Two medical professionals, Dr. Nicholas Cozzi and Dr. James Shoemaker, are appealing for immediate legislative and public action to reform the American health insurance system, arguing that insurance company practices are forcing Emergency Rooms (ERs) to become the unintended and most expensive “front door” for routine care.
In a recent op-ed published in TIME, the authors—including Dr. Cozzi, an emergency medicine physician in Chicago—assert that emergency rooms are currently the “last functioning front doors to American healthcare”.
They warn that ERs are increasingly acting as “America’s default outpatient clinics,” caring for patients not only with critical injuries but also those with pressing, non-life-threatening conditions whose insurers have blocked access to care elsewhere.
This systemic distortion is caused by the health insurance industry’s “troubling business model,” which saves millions of dollars when claims are rejected or when doctors are pressured to reject care.
The authors explain that the heavy use of ERs for non-emergency issues stems directly from patients attempting to bypass bureaucratic obstacles. Patients flock to the emergency department because staff can “compress weeks of outpatient work into hours” without having to engage in the “opening battle over insurance prior authorizations”. In the ER, immediate treatment is provided when “seconds count”.
However, this reliance on the most expensive setting for routine care drives up costs and inflicts needless suffering. The authors emphasize that this was never the intended role of the ER.
The crisis in the ER space is cited by the doctors as just one example of how the overall health insurance mess distorts the healthcare system. The key mechanism creating this crisis is the prior authorization process, which requires a doctor to obtain a “permission slip” from the insurer before certain tests or treatments.
What was initially intended to curb unnecessary care “has metastasized into a back-and-forth obstacle course of paperwork” that frequently stalls necessary treatment, increases stress, and raises costs.
The consequences of this model are severe, with denied claims pushing some families closer to financial ruin. The authors highlight that medical debt is a leading cause of bankruptcy in America, plaguing nearly one in five American families.
Evidence of the damaging pace of denials is substantial: internal documents reported by ProPublica show that Cigna doctors denied over 300,000 patients’ care using mass denials, spending an average of 1.2 seconds on each case.
Alarmingly, one in four Medicaid requests—a crucial safety net for children, the elderly, and those in poverty—go unanswered.
A 2023 study focusing on nearly 20,000 Medicaid enrollees found that those who experienced a procedural denial were 20 percent more likely to visit the Emergency Department within 60 days.
To counteract these dangerous trends, Dr. Cozzi and Dr. Shoemaker are appealing for sustained pressure and legislative action. They argue this effort “can’t be a spark that flares and fades; it must spread until the system itself is forced to change”.
The doctors demand “real change” beyond simply relying on social media to amplify cases. They insist on the creation of “federal guardrails to protect patients over needless denials” and propose that states and the federal government must step in when insurers wrongfully block care.
Their specific demands for reform include:
Establishing clear, patient friendly appeals processes and “real accountability”.
Requiring insurance companies to provide transparent, “real time dashboards for denial rates” and time-sensitive appeal portals.
They conclude that every second wasted leaves another patient waiting in a system where insurers can deny care in 1.2 seconds. The authors urge policymakers to “bulldoze the obstacle course the insurance companies constructed”.
The relationship between health insurance coverage and Emergency Department (ED) utilization continues to be a significant focus of health policy research.
Studies indicate that individuals without insurance are more likely to use the ED for non-urgent conditions, often because they lack access to primary care providers. For example, research published in Health Affairs (Gindi, Cohen & Kirzinger, 2012) found that uninsured patients are less likely to have a usual source of care outside the ED, leading to increased reliance on emergency services for both urgent and routine health needs.
Conversely, insured individuals—particularly those with private insurance or comprehensive Medicaid coverage—are more likely to access preventive and primary care, thereby reducing their need for emergency services.
The expansion of Medicaid under the Affordable Care Act (ACA) was associated with changes in ED use patterns; a 2017 study in the Annals of Emergency Medicine (Miller et al., 2017) reported that newly insured populations initially showed higher ED use, but over time, their non-urgent ED visits declined as their access to outpatient care improved.
Despite common perceptions, insurance status does not always correlate directly with lower ED use. The CDC’s National Center for Health Statistics (NCHS Data Brief No. 272, 2017) notes that insured patients also visit the ED for after-hours care or when they perceive their condition as urgent.
Nonetheless, lack of insurance remains a key factor driving non-urgent ED utilization, underscoring the interplay between health coverage and emergency care access.