For Kalin Thomas, getting sick is inconvenient. Most urgent care or primary care offices are closed by the time she gets off work, and her morning commute time makes appointments before the workday untenable.

She worries about repercussions from her employer for taking time off, but even when she can find time for an appointment, getting one isn’t easy. After spending a week trying to find a doctor, Thomas was told she’d have to wait three months to be seen.

“At the time I felt the ER was my only after-hours option,” says the 26-year-old Phoenix native, who’s used the emergency room in the past for sprains, anxiety and strep throat, among other things. A recent study suggests that others are doing the same.

That’s according to a survey of more than 1,000 people conducted in 2019 by Kelton Global, a global insights firm, for the digital health marketplace Zocdoc. Just 14 percent of Gen Xers said they view the ER as their primary care provider, while that proportion dipped to 3 percent among baby boomers over age 55. Nearly 70 percent of those surveyed said they didn’t know what the costs of an ER visit would entail, and 90 percent had insurance. “Historically, emergency rooms have been thought of for emergencies,” says Allison Morgan, a communications manager at Zocdoc. But that’s changing as people are accustomed to getting other services on demand even as health care costs and wait times rise, Morgan says.

While primary care providers used to follow patients throughout their lives and across their health needs, medicine has become hyperspecialized, says Dr. Maria Raven, chief of emergency medicine at the University of California, San Francisco. Millennials also move more frequently than older generations — nearly half of those between age 25 and 34 lived in their home for less than two years in 2017 compared to 34 percent who did in 1960, according to research from Zillow, a real estate platform. Starting from scratch to find doctors in a new place can be overwhelming. Even after finding care, the system can be a game of hot potato: “If I have a broken bone, I’m not going to my primary care doctor to tell me that I have a broken bone to then send me to the radiologist to get an X-ray” before the bone is set, says Raven. “Millennials are into efficiency.”

That efficiency can be found, some believe, in the ER, where doctors “have the full diagnostic power of the hospital at their fingertips,” says Dr. Nima Afshar, a San Francisco Veterans Affairs emergency physician and UCSF associate professor. Emergency rooms provide social services, referrals and navigation all in one place, says Raven, who argues that leveraging that is a “very rational decision.” Additionally, the higher stakes and lack of patient history mean that ER physicians must consider all life-threatening diagnoses, so patients get more rigorous testing for acute issues compared to primary care, Afshar explains. Once people taste this convenience and comprehensiveness, many will keep returning as long as they don’t face higher copays. Although ER visits typically cost more than primary care, insured patients often find most of this expense is passed onto insurance companies — though it depends on their plan, Raven adds.

A shortage of primary care providers, who are not compensated as well as specialists, is exacerbating the problem. That shortage is only expected to grow, which means patients like Thomas can face months-long delays in securing appointments, and that doctors who do go into primary care have to juggle more patients to make ends meet.

Those using public insurance like Medicare and Medicaid have long faced stigma for allegedly overusing the ER, driving up health care costs for the public. But contrary to this conventional trope, research shows that the insured and uninsured use the ER at roughly the same rates, according to 2017 research by Health Affairs. Financially speaking, the patients who should avoid the ER whenever possible are the ones who make too much money to qualify for public insurance yet not enough to afford a solid private plan. Uninsured people could be responsible for paying the full cost of ER “superbills” — the maximum cost when an insurance contract isn’t negotiated with the hospital. This is especially risky because hospital procedure pricing schemes are “cloaked in secrecy,” Raven says.

Beyond the money, there are health consequences from elevated ER use. For one, this can lengthen wait times for people experiencing dire emergencies. Diminished “continuity of care” means doctors don’t have patients’ full medical history or context, says Raven, while increased ER visits force emergency doctors to do a job traditionally taken on by primary care doctors: gatekeeping to hospitals. Afshar expects the growth of subscription models like OneMedical (which requires a yearly premium, and comes with same- or next-day appointments) to intensify the primary care physician shortage — although those models only serve patients who can afford them.

As Thomas knows full well, it’s those in the middle who can get squeezed. But when they do, those ER doors will be — for better or for worse — open to them.

Carly Stern

Why Is the ER So Busy? It’s the First Stop for 25% of Millennials