Contrary to popular belief, those without health insurance are not flooding emergency rooms as a consequence of being cut off from routine and preventive care. Actually, frequent visitors to the local ER are far more likely to have insurance according to a new review of 25 studies on ER use published since 1990.

Frequent users account for about 8% of ED patients but 28% of visits. Although frequent users are not a homogeneous group, 60% are white and their average age is 40. Roughly 60% are enrolled in Medicare or Medicaid.

The uninsured do not dominate EDs; 15% of frequent ED visitors have no coverage, the study found. Only about 2% of uninsured adults visit an ED four or more times in a year.

Medicaid and Medicare beneficiaries younger than 65 tend to follow the “if you build it, they will come” economic model of health care utilization. Without insurance, people tend to avoid large health care costs for everything except actual emergencies. Given an entitlement in the form of low cost government health insurance, they tend to seek out care for every ailment like a millipede with a thousand-for-one free shoe shine coupon. This phenomenon was clearly seen in the disaster that was TennCare, Tennessee’s attempt in the later 1990s to expand their state Medicaid program to cover everyone under the age of 65.

It’s unclear why public insurance beneficiaries tend to be ER “frequent fliers” at much higher rates than those with private insurance. Undoubtedly, those in lower socioeconomic standing tend to be in poorer health, have more chronic health problems, and hence be more susceptible to the consequences of risky behavior and poor health decisions. But most of these frequent ER fliers with public health insurance have primary care doctors so having access to care should not be the problem.

Or is it?

Even with public health insurance, these patients are still likely to be victims of poorly designed, underfunded, and overcrowded health care systems in intercity and impoverished rural areas.

Public insurance programs like Medicaid usually pay health care providers a fraction of what private insurance policies do and so there are usually significant shortages of physicians in communities where these patients live. What access does exist tends to be either private clinics where the doctor runs a treadmill style practice of seeing 50 to 60 patients a day for less than five minutes a visit in order to maximize profit or there are public clinics staffed by health care providers on salary who have neither the incentive nor the time to provide quality care for a population that is often plagued by multiple chronic health problems.

Either way, getting an appointment to see a health care provider in an undeserved area for an acute illness is often an exercise in futility. Few of these clinics offer after-hours or acute care same day service so often patients have no choice but to visit the nearest ER, even for something as trivial as a bad cough or travelers diarrhea. Without additional funding incentives to expand urgent care access in these areas, the hospital ERs remain the only facilities that are designed and staffed for this purpose. And it’s only going to get worse.

The Patient Protection and Affordable Care Act, signed by President Obama March 23rd, is going to pour hundreds of billions more into expanded Medicaid, Medicare, and subsidies for health insurance to help cover up to 35 million more Americans. Presumably, many of these patients will enter into the same poorly designed, underfunded, and already overcrowded health care systems, thus worsening the situation, and leading to more ER overcrowding.

That expanding health care coverage would lead to more ER overcrowding is paradoxical until you look at the reasons for why ERs are overcrowded in the first place. The solution to the problem caused by the solution to inadequate health care coverage is to adequately fund community health systems in order to provide incentives for the private sector to build more urgent care and minor emergency centers.

This, in turn, would hopefully take a large amount of the load off the ERs so that they can concentrate on actual emergencies. Unfortunately the Patient Protection and Affordable Care Act seems poised to do exactly the opposite; to provide just enough funding to get more people into these systems but not near enough to expand the infrastructure of these systems.

Chris Rangel is an internal medicine physician who blogs at RangelMD.com.

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