Uninsured Adults Presenting to US Emergency Departments

Since 1986 when the Emergency Medical Treatment and Active Labor Act was passed, emergency departments (EDs) have had to treat patients regardless of ability to pay or insurance status. The demand for emergency services has increased for this and other reasons, including an aging population, better awareness about the signs and symptoms of heart attacks and strokes, decreased availability of primary care physicians after hours, and other factors. However, assumptions are commonly made that the first factor, an abundance of uninsured patients, is a primary cause of the mismatch between ED resources and demand for these resources.

This study sought to address the validity of such assumptions by examining statements made in published literature about the demands uninsured patients place on EDs and comparing these statements to available evidence on this subject. The authors identified 127 articles, based on inclusion/exclusion criteria, including 13 assumptive statements about adult uninsured patients presenting to EDs. The six most common assumptions were that uninsured patients: 1) present with nonurgent problems; 2) lack primary care; 3) present to EDs with increasing frequency; 4) cause crowding; 5) present more often than uninsured patients; and 6) are more expensive to treat. Other common assumptions included that uninsured patients: 7) present to EDs for convenience; 8) present more acutely; 9) delay care; and, 10) receive less care. These 10 assumptions were assessed individually for supporting evidence and the quality of data on which each assessment was based. The authors found that numbers 1, 4, and 6 were not supported by current data; 8, 9 and 10 often were made together as a set and are well supported by current data; assumptions 2 and 5 also were supported by data; 3 was partially supported; and 7 was difficult to assess the validity of. Several of the supported statements were true of all patients and not only uninsured patients.

Policies made based on these common, inaccurate assumptions have potential to worsen stigmas attached to vulnerable populations, and to exacerbate existing crises in ED care and management.