Hospital officials and health care experts say ER crowding is a sign that the nation's medical system is stressed and its safety net for the poor is weakening.

Area hospital officials say their ERs are busier largely because more uninsured people are using them as they have more trouble finding primary care.

At University Hospital, for example, charity trauma and emergency cases for Jefferson County rose 11 percent in fiscal 2003 over the previous year, officials said. But not all the crowding is linked to the uninsured.

Officials at Jewish Hospital, where ER visits rose 17 percent in seven years, said there's also a growing number of insured patients using the ER to avoid rising co-payments at doctor's offices that require immediate payment. The ER treats people even if they don't pay.

"More and more people are using the ER as primary care," said Carol Ormay, vice president of membership services at the Kentucky Hospital Association.

For patients, the trend has meant visits to emergency rooms routinely stretch beyond four hours and sometimes reach eight hours or longer, although at times a patient may be seen immediately.

For health care workers, it has meant more stress and burnout.

"There's a balance between the satisfaction of helping people in the emergency department and just being overwhelmed," said Dr. Dan Danzl, an attending physician in University Hospital's ER.

On a recent afternoon, a crowd filled the waiting room at University Hospital's emergency department, six people lined up at the registration desk and all 27 treatment bays were full. "That's a pretty routine day," nurse Jessica Sumner said.

Wendy Ward, executive director of getCare, a nonprofit organization that helps uninsured adults in Louisville find primary care, said public health clinics are too busy to handle all of the region's uninsured all the time.

"We've got a lot of clinics for people to go to, but those clinics are beyond capacity," she said. "People go to the ER because they have nowhere else to go."

Mary Parker-O'Toole, 53, of Louisville, who is unemployed and has no health insurance, went to University Hospital's ER when she sprained her hip about a month ago. She figured she couldn't get into a clinic to see a doctor quickly enough.

An ER doctor examined her almost immediately and she had some tests, she said. But then she waited for several hours as seriously injured patients were brought in, she said.

"I was there for 13 hours," she said.

About 45 million people were uninsured in 2003, up from 43.6 million the year before, according to the U.S. Census Bureau.

Anna Smith, director of emergency services at the hospital, said, "If it's a choice of paying your rent or getting insurance, most people pay their rent."