You may have seen the reports this week, on a recent journal article that the crowding we keep hearing about in emergency rooms is not the uninsured poor after all. That doesn't mean that the uininsured aren't going to the emergency room because, all too often, they don't have anywhere else to go. But everyone else is going too. After all, if you call your doctor at night or on weekend, doesn't the voicemail prompt caution you: "If this is an emergency, please go to the nearest emergency room"?

The number of people who visited U.S. emergency departments began to surge in about 1996, and visits have not decreased since then. From 1992 to 2002, the U.S. experienced a 23 percent increase in emergency room visits -- at the same time as the number of emergency rooms dropped by 15 percent. The population, meanwhile, grew by roughly 10 percent.

We've known for some time that emergency room overcrowding is not driven by the uninsured. The recent survey, in fact, found that the uninsured are less likely to visit emergency rooms than either Medicare or Medicaid patients, probably because ER care is expensive and they try to avoid the expense if they can. Communities with the highest emergency room use are not those with the highest uninsured rates but those where people have to wait the longest time for an appintment at a clinic or doctor's office.

The real driver of emergency room overusage as the authors of the Annals paper have found is...everyone. Look around the ER and you'll see Medicare patients, Medicaid patients, privately insured patients, and of course the uninsured. The percentages of these groups visiting ERs has scarcely changed over the decade. It's just that the total visits by all of them have increased out of proportion to the population increase (and remember we have fewer ERs for them to go to).

The people whose reliance on emergency rooms increased was those who actually did have a usual source of care in a physician's office -- but who couldn't necessarily get in when they needed to -- or wanted to. The uninsured go to the emergency room for care when they have no other option. (And yes, of course we need to address their needs through comprehensive health reform, ERs are not the right place for basic care economically or medically.) The insured, however, turn to the ER for convenience or because, like the uninsured, they may have fewer choices than they used to have. If you have a regular doctor, have you ever called his or her office after 5 pm or on Saturday or Sunday? The answering machine usually says, "If you think you have an emergency, go to your nearest emergency room."

The emergency room is a barometer of our whole system's problems. ER overcrowding is the result of an entire nation that is displaced from regular medical care. The emergency room has become the default provider. Can you imagine a less efficient way of delivering health care?