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Assumptions About Uninsured Patients in U.S. EDs: More Fiction Than Fact

Six commonly held beliefs were either debunked or found to be equally true for insured patients.

Recent physician testimony before Congress asserts that uninsured and underinsured patients unnecessarily drain emergency department medical resources. To evaluate the evidence for this and other common assumptions about uninsured ED patients, researchers conducted a MEDLINE search for citations published from 1950 to 2008 that focused on uninsured adult patients (age range, 18 to <65) who were treated in U.S. EDs. Articles involving psychiatric, dental, and non–patient-care issues were excluded. The researchers reviewed 127 papers to identify assumptions (statements made without supporting data or citations) and then searched peer-reviewed literature, administrative data, and national data sets for data to support each assumption.

Of the six most commonly held assumptions, the following three were not supported by the literature: Uninsured patients present with nonurgent problems, cause ED crowding, and present more often than insured patients. The remaining three (uninsured patients lack access to primary care, are presenting to EDs with increasing frequency, and are more expensive to treat in the ED than elsewhere) were equally true for uninsured and insured patients. The following three additional, less widely held assumptions were supported by the literature: Uninsured patients present with higher illness acuity, delay getting care, and receive less care. According to the Oxford Centre for Evidence-Based Medicine system, the level of evidence that supported, partially supported, or did not support an assumption was strong (1b) for every assumption except the assumption that uninsured patients are presenting with increasing frequency, which was partially supported by a modest (2c) level of evidence. Both insured and uninsured patients reported that they prefer to use the ED for care because they perceive that the ED has more highly skilled practitioners.

Comment: Unquestionably, EDs face enormous challenges, including overcrowding; an aging population; new responsibilities for surveillance and disaster preparedness; and more-complex diagnostic and management strategies for syndromes such as acute myocardial infarction, stroke, sepsis, trauma, and resuscitation. According to this study, conventional "wisdom" about the burden of uninsured patients on some aspects of ED care lacks credibility. Healthcare-delivery policies that are predicated on inaccurate assumptions can further compromise the ability to provide emergency care and unfairly blame an already vulnerable population, with the potential to widen health disparities.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine December 12, 2008

Citation(s):

Newton MF et al. Uninsured adults presenting to US emergency departments: Assumptions vs data. JAMA 2008 Oct 22; 300:1914.

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