Hospital-based emergency departments across the United States are facing mounting pressures that have led to longer wait times, overcrowding, workforce shortages, clinician burnout and closures of rural and community facilities, according to healthcare policy experts and a recent RAND Corporation study.
The fundamental issue is a mismatch between demand for acute unscheduled care such as strokes, heart attacks and trauma versus the capacity available to deliver it. Unlike other medical specialties, emergency departments cannot reduce services when resources decline because they are legally required under the Emergency Medical Treatment and Active Labor Act (EMTALA) to treat all patients regardless of ability to pay.
A RAND study found that closures affect multiple stakeholders: health systems lose acute care capacity, primary care physicians lose an on-demand resource for complex patients, communities lose a hub for care coordination, insurance companies lose a guaranteed network of emergency physicians, and public health entities lose standby capacity during emergencies. Randy Pilgrim, chief medical officer at SCP Health, outlined a three-part approach to address these challenges: immediate stabilization through payment reform, medium-term prevention of further deterioration, and long-term systemic solutions.
What the Right Is Saying
Conservative healthcare policy experts argue that regulatory reform and market-based solutions offer better paths forward than increased federal spending. The American Enterprise Institute has published research suggesting that certificate-of-need laws and scope-of-practice restrictions contribute to emergency department closures by limiting competition and flexibility in staffing.
Senator Mike Braun of Indiana, a member of the Senate Finance Committee, has pushed for Medicare physician payment reform through budget reconciliation rather than new mandatory spending. Conservative commentators at The Heritage Foundation have argued that tort reform and malpractice liability changes would reduce defensive medicine practices that strain emergency departments. Republican healthcare advisors have also advocated for allowing nurse practitioners and physician assistants to practice independently in rural areas as a cost-effective alternative to requiring physician staffing ratios.
What the Left Is Saying
Progressive healthcare advocates argue that emergency department closures disproportionately harm vulnerable populations and require increased federal investment. Senator Sherrod Brown of Ohio has advocated for rural hospital protections, stating that rural communities cannot afford to lose their sole point of access to acute care. The American College of Emergency Physicians, representing a predominantly Democratic-leaning specialty, supports legislation such as the No Surprises Act implementation and has called for inflation-adjusted Medicare physician payments.
Organizations including Families USA and the Center for American Progress argue that insurance companies should bear greater responsibility for emergency care costs. They point to data showing that 20 percent of emergency physicians' services go entirely unreimbursed, arguing this represents a systemic failure of the private insurance market to support the healthcare safety net. Progressive groups have also called for expanding Medicaid reimbursement rates and funding community health centers as an alternative to emergency department overuse.
What the Numbers Show
According to data cited by the American Medical Association, Medicare physician pay has declined 33 percent since 2001 when adjusted for inflation. The RAND Corporation study documented that both insurance companies and commercially insured patients are paying incrementally smaller portions of reimbursement obligations owed for emergency services. Healthcare industry analysts estimate that 20 percent of emergency physicians' services go entirely unreimbursed, the highest proportion of uninsured care delivered by any single medical specialty.
During 2020 alone, 30 percent of all emergency department visits were for mental health issues, reflecting limited availability of outpatient behavioral healthcare. The Medicare Payment Advisory Commission has noted that hospital-based emergency departments face unique financial pressures because they cannot reduce patient volume even when reimbursement fails to cover costs, unlike surgical centers or specialist practices that can limit services.
The Bottom Line
Healthcare leaders across the political spectrum agree that emergency department sustainability represents a critical policy challenge, though they disagree on solutions. Pilgram and other emergency medicine advocates argue that immediate payment integrity reforms requiring insurers to provide prompt, appropriate reimbursement for emergency care under EMTALA and the Prudent Layperson Standard would stabilize struggling departments.
Congress is expected to consider Medicare physician fee schedule reforms during upcoming budget negotiations, where proposals to add inflation adjustments and prevent absolute cuts face uncertain prospects. Long-term solutions including expanded access to primary care, behavioral health services and specialty care could reduce preventable emergency department utilization, according to healthcare economists studying the issue.