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Long-term ED viability in the US has fallen under threat due to a simultaneous increase in patient acuity and complexity coupled with declining reimbursement.

The long-term viability of US emergency departments (EDs) has been threatened due to a decade-long increase in patient acuity and complexity coupled with declining reimbursement, according to lead author Mahshid Abir, MD, and colleagues in a report published online by RAND.

“Urgent action is needed to sustain hospital emergency departments, which act as a safeguard for patients who use the services and communities that rely on them during a crisis,” said Dr. Abir.

Mounting Pressures

Drawing from expert panels, stakeholder interviews, focus groups, surveys, literature reviews, and administrative data, the report showed that EDs consistently deliver value through round-the-clock access, rapid diagnostics, and acute care, regardless of a patient’s ability to pay. They are also central to disaster response and public health surveillance. Despite their essential role, US EDs currently face mounting operational and financial pressures:

• Operational burdens
  • ED visits in 2024 rebounded to near-prepandemic levels, consistently rising between 2020 and 2024.
  • Patient acuity and complexity are increasing—particularly among those with significant medical and social needs—driving demand for critical care services in the ED.
  • Insufficient ED capacity can result in crowding, delays, and violence toward ED staff.
• Financial strains
  • Between 2018 and 2022, Medicare and Medicaid ED physician reimbursements fell 3.8 percent in inflation-adjusted payments per visit.
  • From 2018 to 2022, commercial insurance payments dropped 10.9 percent for commercial in-network visits and 47.7 percent for commercial out-of-network visits.
  • Revenue cycle payment data confirmed that insurers and patients regularly underpay or deny significant portions of the allowed amounts they are obligated to pay.

Bolstering ED Viability

To ensure that EDs can continue their critical role in the US healthcare system, the report recommended:

• Advocating for dedicated funding for the Emergency Medical Treatment and Labor Act mandate.
• Pursuing policies to allocate funds to ED treatment that benefits the broader community, such as care for mental health conditions and substance use disorders.
• Creating compensation benchmarks for uninsured and underinsured patients.
• Expanding primary care
• Increasing legal consequences for violence against healthcare workers.
• Advocating for Medicaid parity with Medicare, and for Medicaid expansion in states that have not yet adopted the expansion.
• Making insurance entities responsible for the collection of enrollee deductibles and copays.
• Revising the No Surprises Act such that payers would be required to pay in full independent dispute resolution judgments to prevailing physicians within a preset time frame.

Call to Action

“Unless these challenges are addressed, there is an increasing risk that emergency departments will close, more doctors and nurses will leave emergency medicine, and patients will face even longer waits for care,” said Dr. Abir.