US emergency department costs: No emergency

Background. Many perceive emergency department (ED) overuse as an important cause of high medical care costs in the United States. Managed care plans and politicians have seen constraints on ED use as an important element of COSt control. Methods. We measured ED-associated and other medical care costs, using the recently released 1987 National Medical Expenditure Survey of approximately 35 000 persons in 14 000 households representative of the US civilian, noninstitutionalized population. Results. In 1987, total ED expenditures were $8.9 billion, or 1.9% of national health expenditures. People with health insurance represented 86% of the population and accounted for 88% of ED spending. The uninsured paid 47% of ED costs themselves; free care covered only 10%. For the uninsured, the cost of hospitalization initiated by ED visits totaled $3.3 billion, including $1.1 billion in free care. Whites accounted for 75% of total ED costs. The ED costs of poor and near-poor individuals accounted for only 0.47% of national health costs. Conclusions. ED use accounts for a small share of US medical care costs, and cost shifting to the insured to cover free ED care for the uninsured is modest. Constraining ED use cannot generate substantial cost savings but may penalize minorities and the poor, who receive much of their outpatient care in EDs.