Emergency Response: A Systemic Approach to Diaper Rash, Chest Pain, and Medicaid in the ED

In an effort to rein in health care costs, states have focused on non-emergent use of the Emergency Department (ED) by people with Medicaid coverage, although this is an issue that cuts across payor groups. Particularly in light of the Affordable Care Act insurance expansions, I argue for a system-based approach that views ER overutilization as less a reflection of poor judgment on the part of patients and more a consequence of poor access to primary care and poor systems for managing the complex circumstances of high utilizers. I describe a state program of seven “best practices,” and argue that sustainably reducing non-emergent ED use — by those with Medicaid and those with private insurance — will require effective implementation of primary care supports found in the ACA and in other initiatives, public and private. This systemic approach is in contrast to the misguided, individualistic approach reflected in proposed state policies that would restrict payment based on the urgency of the diagnosis. The legal, ethical and practical problems of payment-restriction policies are compounded by their failure to directly target the root causes of ED overuse or support transition to a health care system that does