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Does immigration decrease emergency department usage?

There are many myths in the popular press regarding what are the major determinants of increasing health care costs. Some pundits claim that illegal immigrants that do not purchase insurance are using emergency departments (ED) for primary care services, thus driving up the cost of health care for American citizens (see Science Daily‘s interview with Jack Martin of the Federation for American Immigration Reform).

A study by Peter Cunningham (2006) in Health Affairs found this not to be the case. The author employs the 2003 Community Tracking Study (CTS) to study ED usage in 60 different U.S. sites. The findings are summarized in the chart below.

High ED Usage Low ED Usage
Citizens Non-citizens
Black White, Hispanic
Below Poverty Line Above Poverty Line
Poor Health Good Health
Live near ED Live far from ED
Medicare/Medicaid insurance Private insurance or uninsured
Long physician appt. wait times Short physician appt. wait times
More outpatient visits/physicians Less outpatient visits/physicians
More CHC revenue Less CHC revenue

Surprisingly, non-citizens have an ED visit rates which are 17.2% below those of an average American citizen. Among residents below the poverty line, non-citizens ED visit frequency is 30.3% below that of poor Americans. Also, while African Americans tend to use the ED more frequently, Hispanic ED usage is on par with that of whites.

It is also found that the uninsured have ED usage rates similar to individuals who hold private insurance. People with Medicare or Medicaid insurance use emergency room services much more frequently than the uninsured.

Some of the Cunningham’s conclusions include:

  • HMOs help to reduce ED usage for the poor, but HMO insurance coverage has no effect on ED visit rates for individuals above the poverty line.
  • Increasing Community Health Center (CHC) revenue per poor person in a zip code decreases emergency room visit rates for the poor. Also, longer appointment wait times and more outpatient visits per physician lead to more ED visits. These findings suggests that when communities offer convenient and high quality substitutes for ED visits, patients take advantage of these services. When the patient must wait a long time for an appointment or receive poor care once an appointment is made, then the ED is often the location of choice for medical care.
  • Approximately 25% of the differences in ED utilization rates across sites were due to variation in population characteristics.

As the author suggests, “…reducing ED use defies simple solutions such as expanding insurance coverage or restricting access for undocumented immigrants.”

Cunningham (2006) “What Accounts For Differences In The Use Of Hospital Emergency Departments Across U.S. Communities?Health Affairs. vol 25, no. 5, pp. w324-w336.