I spent a night in an emergency department last year — not as a patient, but as a companion for a friend who had fallen off a ladder and needed stitches and imaging for a suspected wrist fracture. We arrived at 8:40 PM. He was triaged at 9:15. He was seen by a physician at 1:20 AM. His X-ray was completed at 2:45 AM. He was discharged at 4:10 AM — seven and a half hours after arrival, for injuries that required twenty minutes of actual clinical care.
During those seven and a half hours, I watched the emergency department operate as a microcosm of everything that is broken in American healthcare. I watched a woman with uncontrolled diabetes whose blood sugar had reached 450 because she could not afford her insulin. I watched a child with an ear infection whose mother brought him to the ER because the earliest available appointment with his pediatrician was three weeks away. I watched a man in his sixties, clearly suffering from a psychiatric crisis, handcuffed to a gurney and attended by two police officers because there were no inpatient psychiatric beds available within 200 miles. I watched a young woman with abdominal pain who had been to two other emergency departments in the previous month for the same complaint and had been sent home both times with reassurance and ibuprofen.
None of these people were in the right place. All of them were there because the right place — affordable medication, available primary care, accessible mental health services, adequate diagnostic workup — did not exist for them within the American healthcare system.
The emergency department as default
The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, requires every hospital emergency department that participates in Medicare (which is virtually all of them) to provide a medical screening examination and stabilizing treatment to anyone who presents, regardless of their ability to pay, insurance status, or immigration status. This law is one of the few universal healthcare guarantees in the United States — and it has, by default, transformed emergency departments into the healthcare safety net for the uninsured, underinsured, and underserved.
Approximately 130 million emergency department visits occur annually in the United States — roughly 40 visits per 100 people, the highest rate in the developed world (CDC, 2022). But the majority of these visits are not emergencies in the traditional sense. An analysis published in Health Affairs found that approximately 13-27% of ED visits could be appropriately managed in primary care or urgent care settings, at significant cost savings (Weinick et al., 2010). A separate study found that the most common diagnoses in emergency departments were not trauma or cardiac events but upper respiratory infections, urinary tract infections, back pain, headache, and anxiety — conditions that are definitively within the scope of primary care (AHRQ, 2017).
The people using emergency departments for non-emergent care are not making irrational choices. They are making rational choices within an irrational system. For the uninsured worker who cannot afford a $200 primary care visit and cannot take time off work during business hours, the emergency department — which is open 24 hours, cannot turn them away, and will bill them after the fact rather than requiring payment upfront — is the most accessible (and sometimes the only accessible) point of healthcare entry. For a parent whose child's pediatrician has no availability for two weeks, an ED visit at 10 PM is not a choice — it is the absence of any other option.
The cost multiplier
Emergency care is, by design, the most expensive setting in which to deliver healthcare. The overhead required to maintain 24/7 physician staffing, trauma capabilities, advanced imaging, laboratory services, and critical care capacity means that every encounter — regardless of acuity — carries a substantial baseline cost.
A study published in the Annals of Emergency Medicine compared the cost of identical low-acuity visits across settings and found that ED visits cost, on average, $2,032 — compared to $167 for the same visit at a primary care office and $193 at an urgent care center (Galarraga & Pines, 2016). The average cost of an ED visit requiring imaging was $3,400; with admission, costs typically exceeded $15,000.
The total annual cost of emergency department care in the United States exceeds $328 billion (AHA, 2022). A proportion of this spending is irreducible — genuine emergencies require emergency care. But the proportion attributable to the failure of upstream systems — inadequate primary care access, unaffordable medications, absent mental health services, untreated chronic disease — represents hundreds of billions of dollars in avoidable spending driven by structural healthcare failure.
The boarding crisis
Perhaps the most visible symptom of emergency department dysfunction is boarding — the practice of holding admitted patients in the emergency department for hours or days because no inpatient hospital bed is available. Boarding has reached crisis levels at hospitals nationwide, with some patients spending 24, 48, or even 72 hours on ED gurneys waiting for beds that never become available.
A study published in the Annals of Emergency Medicine found that the mean ED boarding time for admitted patients increased from 2.4 hours in 2017 to 4.5 hours in 2022 (Rowe et al., 2023). In some hospitals, boarding times routinely exceed 12 hours. The consequences are severe: boarded patients receive suboptimal care (the ED nursing ratio of 1:4-6 is designed for acute stabilization, not the 1:1-2 ratio required for critically ill inpatients), ED capacity is consumed by boarded patients who cannot be moved, new patients wait longer for evaluation, and emergency physicians and nurses work in conditions of sustained overcrowding that degrade care quality and accelerate professional burnout.
The boarding crisis is directly attributable to the closure of inpatient capacity — particularly psychiatric beds and skilled nursing beds — without replacement. The number of psychiatric inpatient beds in the United States has declined from approximately 339 per 100,000 population in 1955 to 12 per 100,000 in 2020, a 97% reduction (Fuller et al., 2020). The patients who would have occupied those beds have not disappeared — they have been redirected to emergency departments, which have become the de facto psychiatric facility of last resort for millions of Americans experiencing acute mental health crises.
The workforce under siege
Emergency medicine is experiencing a workforce crisis that mirrors and amplifies the broader crisis in healthcare labor. Emergency department visits have increased by approximately 30% over the past two decades, while the number of emergency departments has decreased by approximately 11% as hospitals close and consolidate (HSR, 2019). The result is that a shrinking number of facilities and providers are absorbing a growing volume of patients, with predictable effects on quality, safety, and professional sustainability.
Emergency physician burnout rates exceed 60% — the highest of any medical specialty. A study published in Academic Emergency Medicine found that the primary drivers of emergency physician burnout were not the inherent clinical demands of the job (most emergency physicians chose the specialty because of its intensity) but rather the boarding crisis, the documentation burden, the staffing inadequacy, and the moral injury of operating within a system that uses the emergency department as a dumping ground for every failure of every other part of the healthcare system (Lin et al., 2021).
Nursing turnover in emergency departments is equally alarming. A survey by the American Nurses Association found that 38% of ED nurses intended to leave their positions within the next year, citing unsafe staffing ratios, workplace violence, and overwhelming patient volumes (ANA, 2022). ED nurses experience the highest rate of workplace violence of any healthcare setting — a study in the Journal of Emergency Nursing found that 76% of ED nurses had experienced physical violence and 100% had experienced verbal abuse within the preceding twelve months (Phillips, 2016).
The violence epidemic
Emergency departments have become one of the most dangerous workplaces in America. The convergence of substance use, psychiatric crisis, pain, fear, frustration with wait times, and the availability of weapons has created an environment in which violence against healthcare workers has become not exceptional but routine.
An analysis published in the New England Journal of Medicine found that healthcare workers experience workplace violence at rates four times higher than workers in other industries, with emergency departments representing the highest-risk setting (Phillips, 2016). In 2022, a physician was shot and killed in the Tulsa, Oklahoma emergency department. In 2023, multiple stabbing attacks on ED staff were reported in facilities across the country.
The response has been inadequate. Metal detectors, which are standard in many urban emergency departments, are inconsistently deployed and variably effective. De-escalation training for staff addresses a symptom rather than the cause. And the underlying drivers of ED violence — overwhelmed facilities, long wait times, untreated psychiatric illness, substance use disorders, and the desperation of people in medical crisis within a system that cannot care for them — remain entirely unaddressed.
What reform looks like
Fixing emergency departments requires fixing the systems that dump patients into them. This means:
Expanding primary care access. When people have access to timely, affordable primary care, ED utilization for non-emergent conditions declines. Oregon's Medicaid expansion under the ACA was associated with a 16% reduction in ED visits for conditions treatable in primary care, as newly insured patients gained access to physician offices and community health centers (Taubman et al., 2014).
Investing in mental health infrastructure. The closure of psychiatric inpatient capacity has transferred the burden of acute psychiatric care to emergency departments, which are poorly equipped to provide it. Rebuilding psychiatric crisis infrastructure — crisis stabilization units, psychiatric urgent care centers, mobile crisis teams, 988 Suicide and Crisis Lifeline response capacity — is essential to diverting psychiatric patients from EDs to appropriate care settings.
Creating alternatives to the ED. Community paramedicine programs, nurse-led clinics, telehealth triage services, and urgent care expansion all provide alternatives to emergency department visits for lower-acuity conditions. A systematic review found that community paramedicine programs reduced ED utilization by 15-30% in participating populations while maintaining or improving care quality (Rasku et al., 2019).
Addressing the social determinants. A significant proportion of ED visits are driven by social rather than medical needs — homelessness, food insecurity, domestic violence, addiction. Embedding social workers, care coordinators, and community health workers in emergency departments — and funding the community services to which they can connect patients — addresses the root causes of preventable ED utilization.
The emergency department I sat in last year was staffed by extraordinary people doing extraordinary work under conditions that should not exist. They were not the problem. They were the last line of defense in a healthcare system that has failed at every line before them. The question is not how to fix the emergency department. The question is how to fix everything upstream so that the emergency department can do what it was designed to do: care for emergencies.
References
- AHA. (2022). Hospital Statistics. American Hospital Association.
- AHRQ. (2017). Emergency Department Use. Agency for Healthcare Research and Quality.
- ANA. (2022). Pulse of the Nation's Nurses Survey. American Nurses Association.
- CDC. (2022). National Hospital Ambulatory Medical Care Survey. Centers for Disease Control and Prevention.
- Fuller, D. A., et al. (2020). Going, Going, Gone: Trends and Consequences of Eliminating State Psychiatric Beds. Treatment Advocacy Center.
- Galarraga, J. E., & Pines, J. M. (2016). Costs of ED episodes of care. Annals of Emergency Medicine, 67(6), 778–782.
- HSR. (2019). Emergency department closures and health outcomes. Health Services Research, 54(1), 11–20.
- Lin, M., et al. (2021). Burnout and its contributing factors among emergency medicine clinicians. Academic Emergency Medicine, 28(4), 456–467.
- Phillips, J. P. (2016). Workplace violence against health care workers in the United States. NEJM, 374(17), 1661–1669.
- Rasku, T., et al. (2019). Impact of community paramedicine programs on emergency department utilization. Prehospital Emergency Care, 23(2), 186–194.
- Rowe, B. H., et al. (2023). Emergency department overcrowding: Causes, consequences, and interventions. Annals of Emergency Medicine, 81(6), 665–678.
- Taubman, S. L., et al. (2014). Medicaid increases emergency-department use: Evidence from Oregon's Health Insurance Experiment. Science, 343(6168), 263–268.
- Weinick, R. M., et al. (2010). Many emergency department visits could be managed at urgent care centers and retail clinics. Health Affairs, 29(9), 1630–1636.