LOS ANGELES (The New York Times News Service)-- Four in 10 of the patients flooding California's dwindling and overtaxed emergency rooms could be treated elsewhere, but can't wait for an appointment with their own doctor, according to a study released Tuesday.

The report by the Public Policy Institute of California offers a portrait of the state's emergency rooms, which have decreased by 11 percent since the 1990s but have seen a 10 percent increase in visits.

And those most likely to go to the E.R. for conditions that could be treated at a doctor's office or clinic are Medi-Cal patients -- not the uninsured or undocumented, according to the study, which was based on data from 2005, the most recent year available.

"In the ideal world, if we had a better safety net out there, four out of 10 patients could go elsewhere," said Dr. Stephen Jones, medical director of emergency services at Northridge Hospital Medical Center. "Not only are we seeing Medi-Cal patients, but patients with HMO insurance who can't get in to see their regular doctor for whatever reason."

Jones and others say the report is only a snapshot of why Medi-Cal patients are flooding E.R.'s.

A threat by state legislators to cut Medi-Cal reimbursement by 10 percent, a stalled state budget that has limited hours and days of operations at community clinics, a lack of specialty nurses and physicians, a slow economy that contributes to lost jobs, and a growing aging population, along with a baby boom, all contribute to the fragility of California's health-care system, experts said.

"Particularly for Medi-Cal patients, long appointment wait times and fewer available providers discourage patients from seeing nonemergency department providers," according to the report.

"For those on Medi-Cal, their visit could have been avoided if the patient had timely and effective primary care," said Sharon McConville, who co-wrote the study for the PPIC, a private, nonprofit research organization that provides information to state policymakers.

To help solve the problem, the study's authors recommend providing more patient-to-provider telephone hotlines, broadening the network of community health-care centers and expanding urgent-care clinics.

Several hospitals in the San Fernando Valley and beyond, including Providence Holy Cross Medical Center in Mission Hills, report they are serving more of those on Medi-Cal.

Of the 35,602 patients that have come through the emergency department at Holy Cross from January to July of this year, 17 percent were on Medi-Cal.

"We do see more Medi-Cal (patients) because so many people have lost their jobs in this economy," said Kerry Carmody, chief executive at Holy Cross. "They no longer can afford to visit their primary-care physicians and so they come to the emergency department as their first visit to the doctor."

Carmody also said the E.R. is treating more children whose parents are working, but have no insurance.

"This is a crisis in Southern California," he said. "That is putting a tremendous burden on all the Valley hospitals and the medical staffs to meet the volume of need."

At White Memorial Medical Center in Los Angeles, physicians report that among the patients they see in the emergency department, 48 percent are Medi-Cal patients and 25 percent are uninsured.

"If you're a Medi-Cal patient, your options are strictly limited," said Dr. Brian Johnston, medical director of the E.R. at White Memorial. "If you look at the rate of which of Medi-Cal programs pay, the rates are the lowest in 50 states."

At Olive View UCLA Medical Center in Sylmar, a public hospital, the numbers aren't as drastic. About 15 percent of those who use the emergency facilities are on Medi-Cal, said spokeswoman Carla Nino. Of the patients who go there, about 7 percent are considered nonemergency.

"Basically, we have been looking at inappropriate use," she said. "Obviously, we are concerned and want to find (primary doctors) so they don't have to use the emergency room inappropriately."

Among the report's other findings:

-- Immigrant Hispanics and Asians use the emergency departments less than U.S.- born whites, and noncitizen immigrants in particular are among the least likely to report a recent emergency department visit.

-- Medi-Cal patients are more likely than privately insured patients to believe the quality of care they receive in an E.R. is better than in primary-care settings.

"The report lays out some very strong recommendations," said Stan Rosenstein, chief deputy director of health-care programs for the California Department of Health.

He said the challenge has always been to hold on to physicians who accept Medi-Cal, while state legislators hammer out the budget and a comprehensive health plan.

"We're concerned about it and we're asking medical physicians to stay with us," he said.

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