In Reply: Dr Epelde contrasts the Spanish and US health care systems and notes that, despite providing universal and free health care, Spain also struggles with increasing ED visits. Universal and free health care does not necessarily translate into easy access to primary care. Thus, issues related to access to primary care and the aging population will need to be explored in Spain as well.
We agree that the more consumerist culture both in the United States and globally, in which “one-stop shopping” is becoming the norm, may contribute to the increase in ED utilization. Indeed, other US studies have shown that patients who have a private physician actually have a higher likelihood of visiting the ED compared with those without a usual source of care.1 Our study provides new insights to the phenomenon of increased ED utilization in the United States by showing that visits for ambulatory care–sensitive conditions have increased, particularly in adults with Medicaid. We concur that the task of providing appropriate care for all patients in the appropriate setting will require a multipronged approach both in the ED and ambulatory care settings, and ultimately the integration of the entire medical care system.