For immediate release
Tuesday, July 18, 2006
12:01 a.m. EDT


Christopher Fleming

Hospital Emergency Department Use Varies Greatly Across The United States

Contrary To Conventional Wisdom, Communities With More Uninsured Or Immigrant Residents Generally Have Lower Levels Of Emergency Department Use

Bethesda, MD - Contrary to popular belief, communities with high levels of uninsured or immigrant residents generally have much lower rates of hospital emergency department (ED) use per person than other communities, according to a study by the Center for Studying Health System Change (HSC) published today as a Web Exclusive in the journal Health Affairs.

The study found that ED use in twelve nationally representative communities varied considerably from the national average of 32 ED visits per 100 people in 2003, ranging from a high of about 40 ED visits per 100 people in Cleveland to a low of 21 in Orange County, Calif.

Despite common perceptions that high rates of uninsured and immigrant residents contribute to higher ED use, communities with the highest levels of ED use generally did not have the highest numbers of uninsured, low-income, racial/ethnic minority, or immigrant residents. For example, Cleveland -- where ED use was high -- had low rates of uninsured (7.9 percent) and noncitizen (3.2 percent) residents. In contrast, Orange County -- where ED use was low --had high rates of uninsured (18.2 percent) and immigrant (15.6 percent) residents.

“The findings are surprising and make it clear that reducing emergency department use defies simple solutions such as restricting access for noncitizens or expanding insurance coverage,” said study author Peter J. Cunningham, a senior fellow at HSC, a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation (RWJF). The study was funded by the WellPoint Foundation with support from RWJF.

Cunningham also noted that although a rapid influx of immigrants may contribute to ED crowding in some individual hospitals -- particularly along the U.S.-Mexico border -- immigration is not a major contributing factor to ED crowding nationally, even in many communities that have a large population of Hispanic immigrants.

“Hispanic immigrants -- a high proportion of whom are uninsured -- are not heavy users of EDs compared to other individuals, including whites with private insurance,” Cunningham said. “And their numbers are still too small in the vast majority of communities nationwide to have a major impact on the health care system in those communities.”

For example, in 2003, noncitizens had about 17 fewer ED visits per 100 people than citizens, on average, while uninsured people had 16 fewer visits than Medicaid patients, about 20 fewer visits than Medicare beneficiaries, and roughly the same rates as privately insured people, on average.

The Health Affairs article, titled “What Accounts for Differences in Use of Hospital Emergency Departments across U.S. Communities?,” is based on HSC’s nationally representative 2003 Community Tracking Study household survey, which includes information on about 46,600 people. The study also linked secondary data sources to the communities studied, including the American Hospital Association annual survey, the HSC physician survey, and the Health Resources and Services Administration Uniform Data System.

Along with an in-depth look at ED use in the twelve communities, which included Boston; Greenville, S.C.; Little Rock; Syracuse; Indianapolis; Seattle; Lansing; northern New Jersey; Miami; and Phoenix, in addition to those already mentioned, the study found similar ED use patterns in the sixty communities included in HSC’s household survey. Other key study findings include the following:

-- Outpatient capacity constraints contributed to high levels of ED use in some communities, as reflected by longer waits for physician appointments.

-- Greater enrollment in health maintenance organizations (HMOs) and greater availability of community health centers (CHCs) were associated with lower levels of ED use, particularly for lower-income people.

-- Despite the large number of population and health system factors that contribute to ED use, differences in these characteristics explain only about 40 percent of the variation in ED use between high- and low-use communities.

The study concluded that much of the variation in ED use across communities is not explained by differences in population and health system characteristics, which suggests that high ED use in part reflects patients’ preferences for using EDs, regardless of income and insurance status, as well as practice patterns among physicians and other providers that favor greater use of EDs.

You can read the article by Cunningham and coauthors at


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at


©2006 Project HOPE–The People-to-People Health Foundation, Inc.