How long did you wait the last time you went to an emergency room? And who was there waiting with you -- the uninsured, illegal immigrants? Probably not.

Only a relatively small number of people who use the local ER are uninsured. Chances are your fellow visitors, most of whose needs were not really emergent, were ordinary insured working people looking for a convenient way to get prescriptions refilled, children prescribed antibiotics for sore throats, or an unfamiliar ache or pain diagnosed. As many as 75% of emergency room visits are not for emergencies.

Why do people use the hospital's emergency department so readily? And what does it mean for the future?

Take a good look at this issue and you will soon be looking (again) at the broken health care system as a whole. Because we don't pay for our own health care, our doctors are no longer compensated for the hours and overhead they put in. We all said we hated it when doctors drove Mercedes, but we didn't know how much better off we were under the old system.

In the past, doctors went into business to be healers, and they knew that their sacrifices would be offset by a higher standard of living for themselves and their families. It seemed a great tradeoff for the many years of extra training and the lifelong shortage of leisure time. In the past, doctors knew very little outside medicine -- which is why they were such pathetic failures as investors.

Managed care changed all that. It's the insurance plan that now decides how much doctors will be paid -- not the patient, not the doctor. A "neutral" third party. As a result, young doctors now consider medicine a job -- not a business, not a mission, not a calling. Residents no longer work more than 80 hours a week, or longer than 30 hours on a shift. You may think that's humane, but for the patient it means no continuity of care in hospitals as doctors change shifts like nurses.

So when the emergency room in the hospital is crowded, there may be a doctor shortage, and there's certainly a shortage of specialists in hospitals. They are all on salary, and they stick to the time clock. They are not incentivized to do otherwise.

But at least the hospital ER is staffed 24/7/365. It is always there. Outside the hospital, the care shortage is worse. Primary care physicians and pediatricians are no longer your "real" doctor; chances are they're only gatekeepers who look at you for ten minutes and send you on if necessary. They don't know their patients, who change insurance plans when they change jobs, and neither the doctor nor the patient has any loyalty to the other.

A consequence of this is a growing reluctance of medical students to choose primary care or pediatrics as a career. Why should they? The margins are so much higher on cardiac procedures, or orthopedic surgeries.

That's why you end up going to the emergency room. Something's wrong with your child, and the doctor's office can't see him/her for a week. As a new parent, that's unacceptable. Or you're a senior, and you don't know if you're having heartburn or a heart attack. You call your primary care doc, and he can't see you for days. Or, best case scenario, he can and he decides you need some tests or should see a cardiologist.

The cardiologist can't get you in for a month. And when he does get you in, he simply orders tests, and those take another two weeks. The results don't come back for two more weeks. And that's unacceptable.

The emergency room is the universal short cut to a diagnosis and treatment. Never mind that ERs aren't very good at diagnosing certain conditions, or that you will have to wait twelve hours. That suddenly looks like a better alternative than waiting a month.

Ultimately, this is a self-defeating system. The emergency room is the most expensive place to get medical treatment. The same procedure, the same ten minutes with a physician costs 3x or 10x in an emergency room as it costs in a physician's office. You don't care, because you don't pay. Insurance pays. Your employer pays the insurance.

Ahhhh, but this is all changing. Over the past fifty years, health care has seen all kinds of cost shifts. Costs shifted from the individual to the employer, from the uninsured to the insured. But now there is a new cost shift -- back to the patient. Insurance premiums are going up, and employers can't afford to pay them. Co-pays have gotten higher, and many employers pay only part of the premium for an employee's care and nothing for his dependents.

Slowly, we are starting to feel the rising costs of health care in our pocketbooks. But we all feel the rising cost of gasoline, too, and we don�t give up our cars. What�s wrong with us? The ER doesn�t know.