	Introduction

Emergency departments (EDs) play an important public health role during emergencies and on a regular basis by providing access to emergency care to all patients regardless of their ability to pay (see Text Box 1 ). Although the original intent of EDs was to provide emergency care, this role has expanded, as patients often seek care in an ED when services are unavailable or inaccessible in the community. EDs provide a disproportionate amount of health care to the U.S. population. Specifically, the 4% of physicians who staff EDs are the treating physician in 28% of all acute care visits, and these visits disproportionately involve patients with more dangerous or worrisome symptoms, such as chest pain, respiratory complaints, and abdominal pain. The use of EDs to provide nonemergency care can be costly to payers because services provided in an ED are generally more expensive than those provided in community-based settings. The federal government is interested in the availability of ED services and their appropriate use for several reasons, including its role as a payer of health care services, its role in supporting emergency preparedness, and its role in supporting the health care safety net. Also, the federal government has made investments in emergency preparedness, programs and efforts that support the health care safety net, and efforts that support health care access in general. Given these investments, Congress may be interested in EDs because a well-functioning ED system is necessary to provide surge capacity in an emergency. The function of the ED system, in turn, often reflects its surrounding community's access to health care services; therefore, understanding the use of EDs, evaluating whether such use is appropriate, and examining strategies employed to reduce inappropriate use may all be of policy interest. This report describes EDs, the role they play in the health care delivery system, and current federal involvement in supporting EDs. It then discusses the causes and consequences of three commonly identified and interrelated challenges that EDs face: (1) crowding, (2) providing repeat care to a subset of patients who are frequent users, and (3) providing care to a large population who have behavioral health conditions when an ED lacks the appropriate resources to provide such treatment. The report concludes with policy options that Congress may consider to potentially improve ED functioning and reduce payer costs. EDs Provide Care to Safety Net Populations

ED use is also driven by the availability of community-based health service providers that accept safety net populations, such as the uninsured or Medicaid beneficiaries. Emergency Medical Treatment and Active Labor Act (EMTALA)

The federal government requires—as a condition of Medicare participation—that hospitals with dedicated EDs screen and provide treatment to patients with emergent conditions regardless of a patient's ability to pay. Hospitals in MSAs are more crowded; as a result, they divert more ambulances and have longer wait times. The demand for ED care depends on the volume of patients requiring emergency care and the volume of patients who are seeking care in the ED because it is after-hours or because they lack another source of care (e.g., safety net patients). Effects on Hospitals

Crowding, in general, and boarding, in particular, affect hospital finances by reducing ED and inpatient volume and decreasing revenue earned from serving additional patients. Spending Through Discretionary Programs

Hospitals face a number of challenges related to providing primary and behavioral health care in part because of provider shortages.
Hospital-based Emergency Departments (EDs) are required to stabilize patients with emergent conditions regardless of the patients' ability to pay as a requirement of the Emergency Medical Treatment and Active Labor Act (EMTALA). Given this requirement, EDs play an important part in the health care safety net by serving the uninsured, the underserved, and those enrolled in Medicaid. Open 24 hours a day, EDs provide emergency care, urgent care, primary care, and behavioral health care services in communities where these services are unavailable or unavailable after hours. EDs also play a key role during emergencies, such as natural disasters.
Some EDs are challenged to provide effective care. For example, EDs provide a disproportionate amount of health care to the U.S. population, in general, and to the safety net population, in particular. Specifically, while 4% of all U.S. physicians are ED physicians, they are the treating physicians in 28% of all acute care visits. Some EDs face financial challenges. ED services are costly both to payers, because services provided in an ED are more costly than those provided in community-based settings, and to hospitals, because operating an ED has high fixed costs and because if patients enter with an emergent condition, hospitals are required by EMTALA to stabilize the patient regardless of the patient's ability to pay.
As providers of uncompensated safety net care, some EDs are crowded, in part because hospitals lack staff or inpatient beds to transfer patients from the ED, and in part because of the large number of patients who seek care in the ED because care is unavailable or inaccessible in the community. Crowded conditions have resulted in some patients experiencing long wait times, which, at times, delays access to care and results in worse health outcomes. In addition, hospitals, particularly those in urban areas, are regularly diverting ambulances because they are too crowded to accept new patients.
This report describes EDs and the role they play in the health care delivery system. It also discusses the federal role and interest in supporting emergency care. The federal government is the largest payer for overall health care, through the Medicare and Medicaid programs. Also, the federal government has made investments in emergency preparedness, programs and efforts that support the health care safety net, and health care access in general. Given these investments, Congress may be interested in EDs because a well-functioning ED system is necessary to provide surge capacity in an emergency. The function of the ED system, in turn, reflects its surrounding community's access to health care services; therefore, understanding the use of EDs, evaluating whether such use is appropriate, and examining strategies employed to reduce inappropriate use may all be of policy interest.
This report discusses three commonly identified and interrelated challenges that EDs face: (1) crowding in EDs, (2) providing repeat care to a subset of patients who are frequent users, and (3) providing care to a large population who have behavioral health conditions when an ED lacks the appropriate resources to provide such treatment. Finally, this report concludes with some policy options that Congress might consider to improve ED functioning and reduce payer costs. This report focuses on EDs that are available to the general population; as such, it does not include EDs operated by the Departments of Defense or Veterans Affairs or those operated by the Indian Health Service.