UnitedHealth’s $32 Billion Avoidable ER Figure Hides Facility Fees

UnitedHealth Group still circulates a $32 billion estimate of avoidable emergency room visits, drawn from 2018 claims and a 2019 brief. The figure treats a hospital extra charge as waste and a cough as a placement error. It does not count how long it takes to see a family doctor, or the federal rule that keeps the ER open when other clinics are closed.

The price gap in that brief is real. The story it tells about patients is thinner than the headline.

The $32 Billion Figure Is Seven Years Old

In July 2019, UnitedHealth Group published a two-page brief titled as a warning about 18 million avoidable hospital ED visits a year among people with private insurance. The company said those visits add $32 billion in costs. It priced 10 common complaints at a hospital ER, a doctor’s office, and an urgent care clinic, using UnitedHealthcare commercial claims from 2018.

The average ER bill for those complaints was $2,032. The same mix cost $167 in a physician office, which the brief called 12 times higher on the hospital side, and $193 in urgent care, about 10 times the ER price. UnitedHealth Group put the gap at more than $1,800 per visit and multiplied that reduction by 18 million visits to reach $32 billion.

WHAT UNITEDHEALTH COUNTED IN 2018

Those dollars are 2018 commercial averages for a short list of diagnoses, not a 2026 census of every ER trip. The volume count behind the 18 million visits was not even a 2018 tally. The methods note applied the company’s claim mix to CDC estimates of privately insured ER use from the 2016 National Hospital Ambulatory Medical Care Survey.

By 2022, CDC FastStats counted 155.4 million emergency department visits across all payers, or 47.3 visits per 100 people. About 17.8 million of those visits, 11.5 percent, ended in a hospital admission. That is a different universe from the privately insured slice UnitedHealth Group priced. The $32 billion number has still been cited as if it were a live meter.

Two-Thirds Avoidable, After Dropping 19 Million Visits

The brief’s most repeated line is that two-thirds of hospital ER visits by privately insured people are avoidable, “18 out of 27 million.” Read the footnote on the same page. UnitedHealth Group said 27 million of 46 million privately insured ER visits could be classified as primary care treatable or ER needed. The other 19 million were not classified.

The methods paper is blunt about what got dropped. Analysts ran 2018 employer coverage claims through the New York University hospital ED algorithm, which sorts discharge diagnoses into four buckets: non-emergent and primary care treatable, emergent but primary care treatable, ER needed but preventable, and ER needed and not preventable. Visits tied to injuries, behavioral health, and other categories were excluded. Those exclusions are the 19 million.

Two-thirds is 18 divided by 27, the visits left after that cut. Against the 46 million privately insured visits in the same brief, 18 million is about 39 percent. Both shares can be true. They are not the same claim.

The algorithm does not watch someone walk in with chest pain. It reads the diagnosis written on the way out. UnitedHealth Group said each of the 10 priced conditions was primary care treatable between 75 percent and 94 percent of the time, after that retrospective sort.

THE 10 DIAGNOSES IN THE PRICE TAG

• Chest and airway: Bronchitis, cough, flu, sore throat, strep throat, and upper respiratory infection.
• Pain and balance: Headache, low back pain, and dizziness.
• Stomach: Nausea.

John Billings and colleagues at New York University built that tool from Bronx hospital records in 1994 and 1998. They said at the time that it was a way to look at populations, not a switch for paying or denying a single visit. A January 2024 commentary reviewing later tests of the method quoted that limit in full.

the algorithm is not intended as a triage tool or a mechanism to determine whether ED use is appropriate for required reimbursement by a managed care plan.

John Billings, New York University, as quoted in JAMA Network Open

Researchers who tried an updated version on 2018 and 2019 records could prospectively sort only 12.4 percent of visits into a specific urgency category with high accuracy, the same commentary noted, work associated with Theodoros Giannouchos. The original team had already said the tool was not intended as a triage tool.

Maria Raven and colleagues made the practical problem concrete in an earlier national review. Only 6.3 percent of visits looked “primary care treatable” once a discharge diagnosis was in hand. The chief complaints attached to those visits were the same complaints recorded for 88.7 percent of all ER visits. A person with chest pain who leaves with reflux still needed the workup that ruled out a heart attack. Congress wrote the prudent layperson standard into Medicare and Medicaid managed care in 1997 for that reason: coverage follows the symptoms that brought someone in, not the label on the way out.

Why a Strep Test Costs $2,032 in the ER

If the 10 complaints are ordinary, the bill is not. UnitedHealth Group pointed to two drivers. Hospital facility fees add $1,069 to an average ER visit in that 2018 mix, more than half of the $2,032. Lab, pathology, and radiology services averaged $335 in the hospital and $31 in a physician office.

That extra charge is not a typo for a throat swab. It is how hospitals bill for a department that has to staff a trauma bay at 3 a.m., keep a CT scanner warm, and take whoever walks in. A RAND claims analysis found commercial payments for ER facility care rose 18.65 percent in real terms since 2018, while payments to emergency physicians fell 7.42 percent. About 20 percent of expected payments to ER physicians went unpaid, about $5.9 billion a year in that analysis.

Move the same sore throat to an office and the facility fee disappears. That is the $1,800 the brief wants. It is also why a hospital will not give the fee up without another way to pay for empty standby capacity. Insurers see a markup. Hospitals see the overhead of a door that cannot close.

EMTALA Makes the ER America’s After-Hours Clinic

Since 1986, the Emergency Medical Treatment and Labor Act has required Medicare hospitals with an emergency department to screen and stabilize anyone who comes, whether or not that person can pay. CMS tells patients the hospital may ask about insurance only if the questions do not hold up a medical screening exam without delay.

WHAT EMTALA REQUIRES AT THE DOOR

• Screening: A qualified professional must check for an emergency medical condition, even if the patient has no insurance.
• Stabilizing care: If an emergency exists, the hospital must treat it so the condition is unlikely to get materially worse.
• Transfer: If the hospital cannot stabilize the patient, it must offer an appropriate transfer and explain the risks and benefits first.

Urgent care is not under that duty. It can ask for a card at the desk. It can keep drugstore hours. It can send a complicated case down the street. People who work daytime shifts, and people who cannot pay up front, learn which door still opens. That is not a secret in ER waiting rooms. It is why a lecture about “knowing the difference” between urgent care and the ER keeps missing the people who already know, and do not have a second option at 9 p.m.

Primary care clinics and urgent care centers also point patients to the ER when they lack a lab, an imaging suite, or a lawyer’s comfort with a maybe-cardiac complaint. Liability flows downhill to the one setting that cannot say no. The American College of Emergency Physicians has spent years fighting insurers that try to deny claims from the discharge diagnosis instead of the presenting symptoms. The $32 billion brief is a cost argument. EMTALA is the reason the visits happen at that price.

A New Family Medicine Visit Still Takes 23.5 Days

UnitedHealth Group’s brief said people should use primary care and urgent care instead. Getting onto a family medicine panel is still a wait. AMN Healthcare’s 2025 survey of 15 large metro areas put the average new-patient wait for family medicine at 23.5 days, up 14 percent from 2022. Across six specialties in the same survey, the average wait was 31 days, up 19 percent from 2022. Family medicine waits in that sample ranged from one day to 207 days.

The federal shortage map is worse than a metro average. HRSA counted 340,319 primary care physicians in 2023. As of December 2, 2025, it listed 8,466 designated primary care Health Professional Shortage Areas, covering about 92 million residents, roughly 27 percent of the country, with 63.1 percent of those designations in rural areas. Clearing every designation would take 15,628 more physicians, HRSA estimated. The same agency projects a shortage of 70,610 full-time primary care physicians by 2038.

PRIMARY CARE ACCESS IN 2025

• Family medicine wait: 23.5 days for a new patient in AMN Healthcare’s 15-metro 2025 survey, up 14 percent from 2022.
• Shortage map: 8,466 primary care HPSAs as of December 2, 2025, covering about 92 million people.
• Gap to clear the map: 15,628 additional primary care physicians, per HRSA.
• 2038 projection: 70,610 full-time primary care physicians short, with the squeeze worse outside metro areas.

A patient with a new fever on a Thursday night is not choosing between a $167 office visit and a $2,032 ER visit. That patient is choosing between a clinic that may answer in 23.5 days and a department that has to answer at 2 a.m. Preventive visits and chronic-care management can cut later crises. They do not staff an evening clinic that does not exist.

The Insurer That Counted the Waste Also Runs the Alternative

UnitedHealth Group is not a bystander to the cheaper settings in its own chart. Through Optum, it employs physicians, runs clinics, and has owned the MedExpress urgent care brand since 2015. Andrew Witty, then the company’s chief executive, said Optum employed just under 10,000 doctors and was affiliated with another 80,000.

A 2025 Health Affairs Scholar study of 2023 claims put payer-operated practices at 4.2 percent of the national Medicare primary care market, up from 0.8 percent in 2016. Optum was the largest insurer-owned piece, at 2.71 percent nationally. The national share is small. Local shares are not. The same study found Optum controlling almost 45 percent of primary care in Snohomish County, Washington, more than 40 percent in Contra Costa County, California, and almost 36 percent in Clark County, Nevada. About 10.1 percent of people lived in counties where Optum alone held more than 10 percent of the primary care market.

That vertical stack is the unadvertised context for a brief that tells patients to leave the ER for an office or an urgent care clinic. The same company later pulled back part of the walk-in network it had been pointing toward. UnitedHealth Group said that as of the end of 2024 it no longer operated MedExpress locations in Minnesota. John Rex, then the chief financial officer, told investors Optum had put less emphasis on freestanding urgent care, especially in places where it already ran full clinics.

None of that makes the $2,032 versus $167 math false. It does mean the author of the $32 billion estimate collects premiums on one side of the visit and, in more counties each year, owns the cheaper chair on the other. When that chair is booked out 23.5 days, or the urgent care site has closed, the legally required door is still the ER.

Crowding Starts When Admitted Patients Have Nowhere to Go

The brief’s implied fix is diversion: send bronchitis to clinic, save $32 billion, unclog the hospital. Emergency physicians have been saying for years that a diverted sore throat does not open an inpatient bed. CDC’s 2022 tables show 17.8 million ER visits ending in admission. Those patients wait in hallways when the floors upstairs are full, a backup known as boarding. Ambulance crews then wait at the curb. The next stroke waits behind both.

Injury-related visits alone were 43.5 million in 2022, a volume UnitedHealth Group’s algorithm set aside as unclassified in the privately insured slice. Behavioral health, which the methods note also excluded, has been a rising share of ER work. Neither group is a strep test. Both sit in the same chairs the $32 billion argument wants to free.

Preventive primary care is still worth building. It is the slow way to keep heart failure, diabetes, and asthma from arriving as 2 a.m. emergencies. Coordinated care can cut repeat visits. Those are separate projects from relabeling a 2018 claims file. They need evening hours, same-week new-patient slots, and a payment stream for the standby capacity EMTALA already demands.

As of December 2, 2025, HRSA still listed 8,466 primary care shortage areas covering about 92 million people. The 2019 brief’s own table still starts with a $1,069 hospital facility fee. Until those two facts move, the $32 billion will keep showing up as an ER bill.

Disclaimer: This article is news reporting and analysis of published claims research, federal survey data, and care-access rules. It is for information only and is not medical advice, a diagnosis, a treatment plan, or guidance on whether any person should go to an emergency department, urgent care clinic, or physician office. Readers who are deciding where to seek care, how to interpret a bill, or how insurance covers an emergency visit should consult a licensed physician, nurse practitioner, or other qualified clinician, and, for coverage questions, their insurer or a licensed benefits counselor. Cost figures, visit counts, wait times, and shortage designations come from the dated reports named in the piece and will change as new claims years and survey releases appear.