Three-quarters of emergency physicians say they’ve seen ER patient visits surge since Obamacare took effect — just the opposite of what many Americans expected would happen.

A poll released today by the American College of Emergency Physicians shows that 28% of 2,099 doctors surveyed nationally saw large increases in volume, while 47% saw slight increases. By contrast, fewer than half of doctors reported any increases last year in the early days of the Affordable Care Act.

The above quotation is from an article in USA Today. Both the ER docs and the press seem puzzled by the increase in ER visits coincident with an increase in health insurance. This confusion stems from a lack of understanding about how medicine is practiced today and how the ER fits into current practice habits. No  one is surprised when the press is confused about anything. The ER physicians are befuddled because they are not primary care doctors and thus don’t know how primary care is delivered in the US in 2015.

If you are seeing your doctor at regular intervals because of an ongoing problem everything works reasonably well. But if you get an acute illness or other health problem that doesn’t coincide with a scheduled visit and call your doctor he will likely tell you to go to the ER. He does this because he’s fully booked and can’t squeeze in any more patients. The more patients with insurance, the more with regularly scheduled appointments, the tighter his schedule, and the more likely that he will direct you to the ER. Below is a study from Health Affairs in 2006 examining ER use across the country. Here’s the abstract:

Increases in the use of hospital emergency departments (EDs) might contribute to crowding at some EDs, higher health care costs, and lower-quality primary care. This study examines the extent to which differences in populations and health system factors account for variations in ED use across U.S. communities. Contrary to popular perceptions, communities with high ED use have fewer numbers of uninsured, Hispanic, and noncitizen residents. Outpatient capacity constraints also contribute to high ED use. However, high ED use in some communities also likely reflects generic preferences for EDs as a source of care for nonurgent problems. [Health Affairs 25 (2006): w324–w336; 10.1377]

What the study shows is that the typical patient with health insurance is the typical patient in the ER (ED in the HA study). So why be surprised when more patients who now have insurance end up in  the ER for a problem that could be handled by a routine visit to their primary doctor were he not too busy to see them?

The emergency room has become the default site for the delivery of unforeseen medical care that arises at inconvenient times. There is no reason to think this situation will change over the near future and it has been a fact of medical life for decades. Nobody expects the Spanish Inquisition even when they call for an appointment.

Differences in the Use of Hospital Emergency Departments (Complete paper)