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One of the claims I have frequently encountered in support of government intervention in providing health insurance that is more extensive than Medicare and Medicaid in the US, is that it will reduce the need for patients without insurance to use emergency rooms instead of primary care facilities and that will reduce the cost:

Majority Leader Harry Reid, a Democrat, accused Republicans seeking to repeal the health-care law of trying to “force millions of American families to once again rely on expensive emergency room care—or go without care at all.” (Source)

Emergency room usage (and its associated expense) has been an important argument when healthcare reform is discussed, as in the article Obamacare Has a New Problem: It Won’t Fix Emergency Rooms. Studies have been conducted to attempt to quantify how emergency room use correlates with being uninsured, like the study The Effect of Health Insurance Coverage on the Use of Medical Services.

In this article about an appearance by Mitt Romney on 60 Minutes, the interviewer says "That's the most expensive way to do it—in the emergency room." and the author writes:

This constitutes a dramatic reversal in position for Romney, who passed a universal health care law in Massachusetts, in part, to eliminate the costs incurred when the uninsured show up in emergency rooms for care.

Is the total cost in the US of providing universal health care insurance in addition to the existing Medicaid and Medicare programs much less expensive than the total cost of uninsured people using emergency rooms for care?

I am not asking specifically about the costs of a particular implementation (aka the Affordable Care Act) although data collected since Obamacare has been in effect should be helpful.

I suspect that maybe the costs of additional consumption of services by insured versus uninsured people and the bureaucratic overhead of administering insurance plans (among other factors) may make it more cost effective to subsidize building urgent care centers for the uninsured in areas where the cost of treating people in emergency rooms is high due to demand. I'm looking for evidence to either confirm my suspicion or show me that it's wishful thinking. A recent article on Bakersfield.com claims that

Emergency room visits are up 29 percent in Kern County since 2009 when the Affordable Care Act was passed, running counter to one of the key takeaways from the law: that they would decrease as consumers take advantage of preventive care.

which adds some evidence that increased consumption of healthcare services may not by offset by the "savings" that access to preventive care is claimed to provide.

There is an implicit assumption in the arguments about emergency room usage that treating the uninsured in emergency rooms when they need care is more costly than if we provided them with insurance, but I'm having trouble finding convincing evidence that is true for anything but the most simplistic calculation of cost.

The "expensive emergency room care" claim does not seem to focus on the quality or comprehensiveness of care—just the expense. Access to preventative care is a factor, but access to care is still potentially an issue regardless of whether someone is insured or not.

An example of that type of concern is outlined in Health Insurance Coverage and Adverse Experiences With Physician Availability: United States, 2012:

Almost 90% of general physicians accept new patients with private insurance, but less than 75% accept new patients with public coverage (e.g., Medicare, Medicaid), and the proportion of specialists accepting new patients with Medicare or Medicaid is declining.

There may be a more recent study that shows that trend reversing. Regardless, whether the insurance provided by the government is accepted by care providers (including specialists like mental health professionals and oncologists) would be a factor in comparing the total cost.

I recently came across a comparative study (Insurance + access not equal to health care: typology of barriers to health care access for low-income families) that may be relevant.

Families made a clear distinction between insurance and access, and having one or both elements did not assure care. Our analyses uncovered a 3-part typology of barriers to health care for low-income families.
Conclusions: Barriers to health care can be insurmountable for low-income families, even those with insurance coverage. Patients who do not seek care in a family medicine clinic are not necessarily getting their care elsewhere. (emphasis mine)

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    One thing that seems to be overlooked in the ER vs primary care equation is whether a lot of people actually have those primary care physicians. Now that routine vaccinations and such are available at pharmacies, healthy & child-free people generally have little reason for regular doctor visits.
    – jamesqf
    Feb 6 '17 at 1:36
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    "although data collected since Obamacare has been in effect should be helpful." - The ACA didn't reduce ER visits; there are still additional barriers to accessing health care from a non-emergency provider (e.g. shortage of health care providers in some areas) besides insurance. So even the newly insured under ACA may continue to use ER at the same rate, or higher rate if they were going without care before even when they needed it.
    – ff524
    Feb 6 '17 at 7:34
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    @ff524: Re "still additional barriers", yes, like maybe two weeks to get an appointment. It's interesting that I can generally take my dog to my vet on a day's notice (or a few hours if it's urgent), and my horse vet will drive 20 miles for a corral call on short notice. And they're cheaper than doctors for humans, too.
    – jamesqf
    Feb 6 '17 at 19:32
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    There's a false premise here - "has never been about the quality or comprehensiveness of care—just the expense." - since the most effective and comprehensive treatment is preventative, or early in the course before it becomes a major problem, that impacts outcomes, as well as cost. It has ALWAYS been an argument that waiting until it's bad enough to seek emergency treatment is also lower quality care with poorer outcomes, as well. May 10 '17 at 17:10
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    Which cost do you want to take into account ? If you only want to compare the cost of a visit to a general physician and being treated in the ER, the general physician is for sure less expensive. But, you have to take many side effects into account: general physicians can help on the prevention side too, while the ER will mostly take care of keeping you alive with a functional body. You will generally be in a less good condition if you can only count on the ER. This will probably have an impact on your ability to have a job and contribute to the overal success of your community, etc... Sep 28 '18 at 14:20
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From a 1996 study in Michigan:

The true costs of nonurgent care in the emergency department are relatively low. The potential savings from a diversion of nonurgent visits to private physicians' offices may therefore be much less than is widely believed.

And from a 2014 study in Oregon:

...Medicaid coverage significantly increases overall emergency use by 0.41 visits per person, or 40% relative to an average of 1.02 visits per person in the control group. We found increases in emergency-department visits across a broad range of types of visits, conditions, and subgroups, including increases in visits for conditions that may be most readily treatable in primary care settings.

Finally, we learned this in 2014:

Medicaid expansions were associated with higher rates of insurance coverage, improved quality of coverage, increased utilization of some types of health care, and higher rates of diagnosis of chronic health conditions for low-income adults.

From these reports, I don't think that the argument holds that saying "no" to subsidized healthcare is a way to save money, unless you also don't mind that many people just don't fare as well without the subsidy.

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  • it's not the difference between subsidised and other healthcare, but the difference between the cost of performing basic care in the ER as compared to a GPs office. And the ER is a lot more expensive to run overall, especially if it needs to be expanded because more people use it (which is often the case) in order to still provide the speed of service required. If 10 people with a heart attack are waiting because someone came in with a torn fingernail, that's the problem ERs are facing.
    – jwenting
    Oct 9 '18 at 11:41
  • @jwenting, I see that the exact question of right-sizing the care facility to the issue (i.e. torn fingernails at the clinic, broken legs at urgent care, compound fractures at the emergency room) is one important aspect of this question. But the question is also for the purpose of validating the claim that subsidized care "will reduce the need for patients without insurance to use emergency rooms instead of primary care facilities and that will reduce the cost." Oct 9 '18 at 13:57
  • so? Having people with non-critical issues avoid the ER and use cheaper alternatives instead reduces cost. The main issue here is whether doing so through subsidies to uninsured people will reduce it beyond the cost of those subsidies, THAT would be an interesting thing to find out.
    – jwenting
    Oct 10 '18 at 4:53
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    @jwenting Anyone who has been into an ED with a torn fingernail knows that after triage, you will wait 10 hours until all the emergency cases that came in after you have been seen, you will be diverted to the urgent-care side where a PA will patch you up and tell you to see a real primary-care doctor, or you will be seen by the med student, who will spend the next several hours putting in half-a-dozen stitches. No one going into an ED with a heart attack is waiting, unless all the doctors, PAs, and nurses are already occupied with other similarly life-threatening conditions.
    – xiota
    Oct 10 '18 at 7:23

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