The authors assess the current value of emergency care in the United States, evaluate challenges to sustaining emergency care, measure trends in emergency care payment, and identify alternate funding strategies for emergency care. They find that emergency departments (EDs) offer many types of value to stakeholders but that, because of the stresses EDs have faced over the past decade, the viability of emergency care as we know it is at risk.

Strategies for Sustaining Emergency Care in the United States

Mahshid Abir, Brian Briscombe, Carl T. Berdahl, Kirstin W. Scott, Sydney Cortner, Daniel Wang, Rose Kerber, Wilson Nham

ResearchPublished Apr 7, 2025

Over the past decade, much has changed in the emergency care landscape in the United States. Hospital-based emergency departments (EDs) and the health care professionals who provide care in them have been at the forefront of responding to the opioid and gun violence epidemics and the coronavirus disease 2019 (COVID-19) pandemic, with reported increases in patient acuity and complexity. During the same time frame, there have been unsustainable declines in payment for emergency care, putting the viability of EDs at risk.

In this report, the authors (1) assess the current value of emergency care, (2) evaluate challenges to sustaining emergency care, (3) measure trends in emergency care payment, and (4) identify alternate funding strategies for emergency care. To achieve these objectives, they sought expert input in the form of a study advisory board and conducted interviews and focus groups, a survey, case studies, an environmental scan of peer-reviewed and gray literature, and analysis of administrative data.

The authors find that EDs offer many types of value to various stakeholders in the United States but that, because of the stresses EDs have faced over the past decade, the viability of emergency care as we know it is at risk. The authors offer policy actions that need to be taken on multiple fronts to preserve emergency care.

Key Findings

EDs are the safety net of the U.S. health system

  • EDs are one of the few health care settings in which care is provided regardless of an individual’s ability to pay.
  • The ED is the main location where patients seek acute unscheduled medical care and care for time-sensitive conditions.
  • EDs provide 24/7 access to advanced diagnostics and treatment in a one-stop shop, increasing timeliness of care and potentially improving outcomes by preventing diagnosis and treatment delays.
  • EDs bolster both health system and community resilience by adding care capacity routinely and during mass casualty incidents, disasters, and public health emergencies.
  • Many EDs play a role in public health threat prevention, detection, and intervention.

Despite the value that the emergency care system provides, it faces many challenges

  • In 2024, ED visit numbers almost reached prepandemic numbers nationally, with a consistent rise between 2020 and 2024.
  • Patient complexity is on the rise, with EDs managing patients with complex medical and social needs.
  • ED patient acuity is rising, translating to an increase in demand for critical care services in the ED.
  • Increases in demand and insufficient capacity can lead to ED crowding, longer wait times, and violence toward ED staff.

Payment to physicians per ED visit is falling

  • Medicare and Medicaid payments to ED physicians fell 3.8 percent in real (inflation-adjusted) payment per visit from 2018 to 2022.
  • Reductions in payments for commercially insured patient visits were much steeper, dropping 10.9 percent for commercial in-network and 47.7 percent for commercial out-of-network visits over this period.
  • Payment data from revenue cycle management companies confirm that both insurance administrators and patients regularly underpay or deny payment for significant portions of the allowed amounts they are obligated to pay.

Recommendations

  • The American College of Emergency Physicians (ACEP), health care organizations, and other stakeholders should advocate funding for the Emergency Medical Treatment and Labor Act mandate, which guarantees access to emergency care regardless of an individual’s ability to pay.
  • Local governments and other stakeholders should pursue policies to allocate city and local funds to ED care and related activities that confer value to the broader community, such as care for substance use disorders and mental health conditions.
  • ACEP, health care organizations, and other stakeholders should develop uninsured and underinsured patient compensation benchmarks so that EDs are compensated commensurate with the level of indigent care they provide.
  • Health care organizations and legislatures should invest in expanding primary care capacity and develop and implement strategies to address ED crowding.
  • Legislatures should institute state or federal laws that protect health care workers by increasing the legal consequences for violence against health care workers.
  • ACEP, patient advocacy groups, and other stakeholders should advocate Medicaid expansion in states that have not adopted it yet and should advocate Medicaid parity with Medicare.
  • Legislatures should require insurance entities, not the emergency care professionals or hospitals, to collect deductibles and copays from their enrollees and should implement a legislative fix to No Surprises Act flaws so that payers must pay in full any independent dispute resolution judgments to the prevailing physicians within a preset time frame.

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Citation

RAND Style Manual

Abir, Mahshid, Brian Briscombe, Carl T. Berdahl, Kirstin W. Scott, Sydney Cortner, Daniel Wang, Rose Kerber, and Wilson Nham, Strategies for Sustaining Emergency Care in the United States, RAND Corporation, RR-A2937-1, 2025. As of April 30, 2025: https://www.rand.org/pubs/research_reports/RRA2937-1.html

Chicago Manual of Style

Abir, Mahshid, Brian Briscombe, Carl T. Berdahl, Kirstin W. Scott, Sydney Cortner, Daniel Wang, Rose Kerber, and Wilson Nham, Strategies for Sustaining Emergency Care in the United States. Santa Monica, CA: RAND Corporation, 2025. https://www.rand.org/pubs/research_reports/RRA2937-1.html.
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This research was funded by the Emergency Medicine Policy Institute and conducted within the Payment, Cost, and Coverage Program in RAND Health Care.

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