History and Health Policy in the United States: Putting the Past Back In

11. Emergency Rooms: The Reluctant Safety Net

So what you’re saying is, you’re sick, you’re broke, you’re unemployed and uninsured —yeah, sure, come on over. Frank, desk clerk on NBC’s ER (aired February 6, 2003) In the face of its unwillingness to guarantee health care to all, the United States has increasingly depended on the emergency room as a de facto safety net for people with nowhere else to go. Since the public knows that ERs are a place where “they can’t turn you away,” hospital emergency departments have become crowded, not only with true emergencies, but with people seeking routine medical attention. Hospital advocates insist that they are in the midst of an emergency-care “crisis”: overworked doctors and nurses toiling in overcrowded ERs with little or no hope of being reimbursed for much of the high volume of care they provide. This chapter will examine how emergency rooms developed into an unintended response to the inadequacies and limitations of the U.S. health-care system. The ER’s status as a doctor’s office for all types of patients, from the poor and uninsured to the middle class, emerged in piecemeal and mostly unanticipated ways, long before the issue was addressed by law or policy. Many argue that using the ER as a health-care safety net is irrational both medically and economically, since it encourages the most expensive type of servEmergency Rooms The Reluctant Safety Net Chapter 11 Beatrix Hoffman 250 ice and forces hospitals and doctors to provide uncompensated care, especially since the passage of federal emergency care requirements in 1986. However, patients’ insistence on access to emergency rooms for all types of medical care emerged as a relatively rational response to the difficulties of access elsewhere in the health-care system. Emergency rooms are heavily used by both lowincome , uninsured patients and middle-income patients with insurance. Both types of patients seek something they cannot find elsewhere: the right to be seen by a practitioner at any time of day or night. Most literature on the subject assumes that the emergency-room crisis is a recent phenomenon, born of the dramatic upsurge in the uninsured population since the 1980s (Richardson, Asplin, and Lowe 2002). But the crisis began much earlier, in the 1950s, when the use of hospital emergency departments for both urgent and nonurgent care grew at an exponential rate. While ER utilization has continued to rise fairly steadily since 1970, the most dramatic jump came in the twenty-five years after World War II (American Hospital Association 1963–2001). By the late 1950s, the “overcrowding” of emergency rooms—which hospitals blamed on too many patients with seemingly nonemergency conditions—had become the norm. Understanding this earlier “crisis,” as well as today’s, requires examining the historical transformation of the emergency room from a minor hospital function to a centerpiece of U.S. health care. The Rise of the Emergency Room The expectation that every hospital should have an emergency room was a phenomenon of the mid-twentieth century. Earlier definitions of emergencies were quite narrow, referring solely to accidents and trauma rather than disease or other conditions. Most accident victims in the 1800s were rushed to their homes, not the hospital, to await attendance by a physician. Large urban hospitals may have had an “accident room” or “first-aid room” for urgent cases, but these areas, like the rest of the facility, lacked round-the-clock physician coverage, and patients could wait hours to be seen. In order to handle a growing number of factory and railroad accidents, some smaller industrial cities built emergency clinics that later grew into general hospitals (Rosenberg 1987). Most patients taken to first-aid rooms and emergency clinics were travelers or transients, too far from home to call their own doctor, or people who lacked private physicians, such as industrial workers and the unemployed. In the 1920s and 1930s, an increase in accident and trauma cases (mostly due to the automobile) combined with surgical advances and the growing prestige of hospitals led to an expansion of hospitals’ emergency-care facilities. As Emergency Rooms: The Reluctant Safety Net 251 more middle- and upper-class patients chose hospital-based surgery, larger hospitals began to offer after-hours operations for accidents and traumas, and some attending physicians took on the role of “night surgeons.” New facilities adopted new technologies especially suited to emergencies, such as portable operating...