Just like the political landscape in the United States is changing, the landscape of healthcare is shifting as well. The print, television, and internet media has noticed. For the past several months, election coverage has given us daily reminders about the status of American healthcare. During the recent election of Barack Obama, Americans reported that healthcare was one of the most important issues the country faced. The facts don't lie; it was recently reported that a total of 75 million working adults were either uninsured or underinsured in 2007.

So where are these underinsured and uninsured Americans going? To the emergency department, of course! Over the last decade, emergency department (ED) visits have increased by 26%. Although this increase in emergency department usage is good for those of us in the specialty, it is not necessarily good for patients. Between 1997 and 2004, emergency department wait times increased by 36 percent. Longer wait times mean that sick patients have to sit in the waiting room. A sick patient with a true emergency may need to wait for hours to see emergency specialists who are occupied by patients who could be seen elsewhere.

To illustrate this point, recently some central Ohio hospitals are no longer accepting certain types of Medicaid. Medicaid is the United States health program for individuals with low incomes. It is funded by the states and federal government to serve low-income patients, children, seniors, and people with disabilities. At my shop, this change in Medicaid acceptance has led to a 46% increase in the number of Medicaid patients seen at The Ohio State University Medical Center. Needless to say, we have been busy Buckeyes of late.

The reason for this nationwide increase in emergency department volume is likely multi-factorial. A recent report of the Institute of Medicine made national news in June of 2006 when it reported a crisis in emergency care. ED visits are on the rise while the number of emergency departments has begun to fall. Many emergency departments have been forced to close their doors because of the high cost of uncompensated care. According to a recent press release from the American College of Emergency Physicians, from 1996 to 2004, only 35 percent of emergency department charges incurred by uninsured patients were reimbursed. In the past, hospitals shifted costs to insured patients to make up the difference. They can no longer do this because of tighter restrictions from managed health plans. The next report on emergency care is due out in December of 2008. Stay tuned to see if we made any improvements...

So what does this mean to the emergency physician? It means job security, the ability to make a difference, and a stake in the future of health care in this country. The emergency department represents the last arena of health care that sees all-comers regardless of their ability to pay. In the United States, there are 2 jobs for every one graduate of an Emergency Medicine Residency Program. Americans, both with health insurance and those without, are going to emergency departments for their injury and illness. This trend does not look like it is going to change anytime soon. So get a comfortable pair of Crocs, another cup of coffee, and free up some patient gurneys in the emergency department hallways. The sick are coming. Where will you be working when they arrive?

• The American College of Emergency Physicians (ACEP). Medicine's Front Line. www.acep.org/40th; June, 2008.
• ACEP Press Release. ACEP Reminds Americans During Cover the Uninsured Week: Emergency Medical Care for the Uninsured Affects Everyone's Access to Lifesaving Emergency Care. Released April 28, 2008.
• Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health Care System. Hospital Based Emergency Care: At the Breaking Point. Washington, DC: National Academy Press; June 2006.
• Steven Reinberg. 25 Million Americans Are 'Underinsured'. www.healthday.com; accessed June 12, 2008.