What a concept: A medical center that offers:

* outstanding equipment and doctors;

* exams, treatment and drugs, all available on the spot;

* 24-hour-a-day service.

No wonder the emergency department at Inova Fairfax Hospital attracts many people without health insurance. "Where else are they going to go?" asked Lea Nolan, a senior research scientist at George Washington University's School of Public Health and Health Services. "They can go there and get treated for a sinus infection all the way up to a heart attack. They can get all the labs that they need, all the X-rays that they need. . . . If you're uninsured, you're low-income, you don't have enough money -- you go the emergency department, you'll get a bill. . . . If you do pay that bill, great, but if you don't, the hospitals really can't do anything. . . . There's a perception of very high-quality care, so it a very rational decision."

Nolan was the lead author of a report issued in March on access to health care in Fairfax County. While her team's study looked at several components of the so-called health safety net, much of it focused on the Inova Fairfax emergency department, which handled more than 22,000 patients in the second half of 2002.

"When the emergency department is overcrowded," Nolan said, "it's because people don't have access to primary care -- or they don't know they have access to primary care -- or to specialty care because the waits are long or it's too expensive, or they're uninsured and there's no one who's willing to take an uninsured or an under-insured patient, or even a Medicaid patient. So it really helps to indicate what's going on in the community."

What's going on in Fairfax -- where about a quarter of the county's million residents are uninsured or reliant on Medicaid or similar health plans for the poor -- is not enough, the report found. While the Fairfax health department spends $10 million a year on an ambitious care program based at three clinics, that budget allows only about 14,000 people to be enrolled.

For people with no regular doctor and no insurance, said Elita Christiansen, vice president for community health and cultural competence for Inova Health System, "their safety net is the emergency room." But the report showed that it's not only the poor who are crowding the Inova Fairfax emergency room: More than 60 percent of patients arrive with private insurance; another 10 percent are covered under Medicare. And according to Nolan's report, many of these people are not in dire straits.

"As sad as it is" to admit, said Christiansen, "I think the emergency room is convenient sometimes" for people who have other options but don't want to fight traffic or wait weeks for an appointment. "You can do it after work, you can do it off hours. And if you look at the lives that we all live in Northern Virginia, that's better than trying to get off work and trying to go to a doctor's [office]." -- Tom Graham

The System welcomes comments from patients, providers, insurers and others about the delivery of health care. While we cannot advocate on behalf of individuals, we are looking for examples of problems and solutions that may direct our reporting. Contact us by U.S. Mail at the address that appears below or by e-mail at thesystem@washpost.com. Do not send original documents.