Emergency rooms are on the verge of collapse at many hospitals, raising questions as to their ability to treat victims in a terrorist attack or a natural disaster. That's according to a new federal study [CDC, Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003-04, September 27, 2006 ( PDF)].

About half of all ERs experienced crowding in 2003 and 2004, the study by the Centers for Disease Control and Prevention  found. (An ER is deemed to be "crowded" if ambulances had to be diverted to other hospitals; if average waiting time for urgent cases was 60 minutes of more, or if at least 3 percent of patients left before being treated.)

People can die from these delays. Many apparently do. Autopsies of accident victims who died after reaching ERs in San Diego hospitals suggested that 22 percent of the deaths were preventable. [Crisis Seen in Nation's ER Care, By David Brown, Washington Post, June 15, 2006]

The basic reason for the deadly crunch: increased demand (ER visits rose 18 percent, to 110 million, from 1994 to 2004) coupled with decreased supply (the number of hospitals operating 24-hour ER departments fell by 12 percent over this period.)

Immigrants are culpable at both ends of the supply-demand pincer.

Alas, CDC makes no mention of the role uninsured immigrants and their children play in the ER crisis. (Needless to say, there's no official data on immigrant ER usage specifically.)

But another government study [Income, Poverty, and Health Insurance Coverage in the United States: 2005(PDF)] presents compelling evidence for the immigrant role. In its latest poverty report, the Census Bureau calculates uninsurance rates for 2005, as follows: [Table 1.]

	Native-born:	13.4 percent
	Foreign-born:	33.6 percent
	Naturalized citizen:	17.9 percent
	Non-citizen:	43.6 percent

Of course, the uninsured population is by no means limited to immigrants and their children (often U.S.-born). Their disproportionate impact on its recent growth, however, is strongly suggested by the Census study. Here are the increases in the uninsured population, by race and Hispanic ethnicity, for 2005: [Table 1.]

	Total Percent:	+1,271,000	+2.8
	White, non-Hispanic Percent:	+337,000	+1.5
	Black Percent:	+157,000	+2.2
	Asian Percent:	+241,000	+12.0
	Hispanic Percent:	+618,000	+4.6

While Hispanics account for about 15 percent of U.S. population, they generated nearly half of 2005's uninsured population growth.

Not surprisingly, California ERs are among the hardest-hit. Fox News reports that "Sixty percent of [LA County's] uninsured patients are not U.S. citizens. More than half are here illegally. About 2 million undocumented aliens in Los Angeles County alone are crowding emergency rooms because they can't afford to see a doctor." [ L.A. Emergency Rooms Full of Illegal Immigrants, March 18, 2005 ]

Recent research finds a link between a person's English language skills and the likelihood he or she will visit an ER:

"Survey results indicate that more than a third of English-speaking patients and more than half of primarily Spanish-speaking patients at U.S. public hospitals have low health literacy. One analysis found that Medicare enrollees with low health literacy were more likely than enrollees with adequate health literacy to use the emergency room and to be admitted as inpatients."

 "Patients with reading problems may avoid outpatient doctors' offices and clinics because they are intimidated by paperwork, according to Joanne Schwartzberg, director of aging and community health at the American Medical Association and editor of a textbook on health literacy. 'Emergency rooms are user-friendly if you don't read,' she pointed out, 'because somebody else asks the questions and somebody else fills out the form.'" [ The Silent Epidemic—The Health Effects of Illiteracy By Erin N. Marcus, New England Journal Of Medicine, July 27, 2005]

Implication: Insured immigrants may also share the blame with their uninsured brethren for pushing ERs to the brink.

Public policy has exacerbated the ER crisis. The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, requires every emergency room in the country to treat the uninsured for free. Naturally, this includes immigrants and illegal aliens.

EMTALA was supposed to make ERs more accessible to the uninsured. Talk about unintended consequences:

"Not only did this unfunded mandate contribute to the closure of numerous emergency departments and trauma centers, it also created a perverse incentive for hospitals to tolerate emergency department crowding and divert ambulances while continuing to accept elective admissions. Rather than improving access to emergency care, EMTALA diminished it." [ Crisis in the Emergency Department by Arthur L. Kellermann, NEJM, September 28, 2006]

A modest proposal: cut off ER demand at the border. Finish the wall, enforce the employer sanctions already on the books— and cut off legal immigration with a moratorium.

Edwin S. Rubenstein (email him) is President of ESR Research Economic Consultants in Indianapolis.