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HSC Researcher Testifies at Senate Hearing on Emergency Department Use

Uninsured Play Relatively Minor Role in Increased Use of Emergency Departments

News Release
May 11, 2011

Alwyn Cassil (202) 264-3484 or

WASHINGTON, DC—While there is a common perception that emergency department crowding is driven primarily by uninsured people, most of the growth in emergency department volume between 1995 and 2008 was driven by insured people, Peter Cunningham, Ph.D., a senior fellow at the Center for Studying Health System Change (HSC), told Congress today.

Americans made a total of 124 million visits to hospital EDs in 2008, the latest year for which data are available from the National Hospital Ambulatory Medical Care Survey—the most authoritative and cited source of information on emergency department utilization, Cunningham testified at a hearing of the U.S. Senate Health, Education, Labor and Pensions Subcommittee on Primary Health and Aging on “Diverting Non-urgent Emergency Room Use: Can It Provide Better Care and Lower Costs?”

“Only 8 percent of visits—a total of 9.9 million—were classified as nonurgent. Trends in the relative number of nonurgent visits have actually decreased slightly since 2000, when 10.7 percent of visits were classified as nonurgent. In sum, most visits to hospital emergency departments are neither true emergencies requiring that patients be seen almost immediately nor are they clearly nonurgent problems that could be addressed in other primary care settings,” Cunningham testified.

In his testimony, Cunningham made the following points:

  • Emergency department use has increased substantially over the past 15 years, mostly because of increased use by people with private insurance and other health coverage. While ED crowding is often attributed to the uninsured, their use of emergency departments is considerably less than privately insured people. Increases in ED visits by the uninsured account for only a small share of the overall increase in emergency department volumes.
  • Most ED visits are neither clearly nonurgent nor truly emergencies. Determining whether these visits could be shifted to primary care settings is difficult because the appropriate use of the emergency department for health problems often depends on factors other than their urgency, including the time of day and day of the week when care is needed, the availability of other providers, such as urgent care clinics, and the ability to get same-day appointments with primary care physicians.
  • Increases in ED visits reflect a more general increase in the demand for ambulatory care—physician office visits have increased at an even higher rate than ED visits. As office-based physicians struggle with growing practice capacity constraints, some of the excess demand is spilling over into hospital EDs. For their part, some patients prefer going to the emergency department—even when they have a primary care physician—because emergency departments are open 24 hours a day, seven days a week.
  • Many EDs are expanding to accommodate the increased demand, as well as to increase revenues from resulting inpatient admissions and procedures, particularly for privately insured and Medicare patients. Far from perceiving emergency departments as money losers, most hospitals have little financial incentive to discourage emergency department use by privately insured and Medicare patients—including for nonurgent health problems—which could complicate efforts to shift some nonurgent visits to more-appropriate community settings.
  • Despite recent increases in utilization, hospital emergency departments represent a relatively small part of the U.S. health care system in terms of both utilization and costs. Reducing the use of EDs for nonurgent health problems may generate much lower cost savings than is commonly assumed. However, because Medicaid enrollees have by far the highest per person use of hospital emergency departments, the potential cost savings to the Medicaid program could be more substantial.  

Cunningham’s testimony is available online at

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is affiliated with Mathematica Policy Research.


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The Center for Studying Health System Change Ceased operation on Dec. 31, 2013.