History and Health Policy in the United States: Putting the Past Back in

Beatrix Hoffman

So what you're saying is, you're sick,
you're broke, you're unemployed and un-
insured—yeah, sure, come on over.

Frank, desk clerk on NBC's ER
(aired February 6, 2003)

In the face of its unwillingness to guarantee health care to all, the United States has increasingly depended on the emergency room as a de facto safety net for people with nowhere else to go. Since the public knows that ERs are a place where "they can't turn you away," hospital emergency departments have become crowded, not only with true emergencies, but with people seeking routine medical attention. Hospital advocates insist that they are in the midst of an emergency-care "crisis": overworked doctors and nurses toiling in overcrowded ERs with little or no hope of being reimbursed for much of the high volume of care they provide.

This chapter will examine how emergency rooms developed into an unintended response to the inadequacies and limitations of the U.S. health-care system. The ER's status as a doctor's office for all types of patients, from the poor and uninsured to the middle class, emerged in piecemeal and mostly unanticipated ways, long before the issue was addressed by law or policy. Many argue that using the ER as a health-care safety net is irrational both medically and economically, since it encourages the most expensive type of serv

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