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Bieler and colleagues1 report that frequent visitors (defined as four or more visits per year) to an urban Swiss emergency department (ED) accounted for 4.4% of patients and made 12.1% of visits. This is consistent with other reports summarized in the review by LeCalle and Rabin.2 The review also found that frequent users in the United States were as likely to be insured, but more likely to have government insurance (Medicare/Medicaid), than other patients. The Swiss health insurance plan is similar to that of HB 3200: The America’s Affordable Health Care Choices Act. Insurance is mandatory in Switzerland, and individuals buy it, although they may be subsidized by their employer or the government. There is a set of mandated basic benefits; supplemental insurance is available and people can buy high or low deductible plans.3 Ninety-five percent of the patients in the study by Bieler et al. were insured.1 Noteworthy is that Swiss frequent users were more likely to be socially vulnerable and have substance abuse and psychiatric problems. This is the same population that is likely to be recipients of U.S. government insurance. The evidence seems fairly consistent: insurance will not decrease ED use among frequent users. Most frequent users do so for medical and social reasons, not for economic ones. The 2009 Academic Emergency Medicine consensus conference presented a research agenda for studying ED identification of socially vulnerable patients.4–6 This research could lead to effective ways to direct these patients to care that is more suited to their needs.

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