Overview of 2025 RAND Report: Strategies for Sustaining Emergency Care in the United States

A groundbreaking study by the RAND Corporation, funded by ACEP’s EMPI, analyzing over 50 million emergency department (ED) professional claims across four years reveals an alarming trend: The ED safety net in the U.S. is unraveling and unsustainable.

• In-network reimbursement dropped nearly 11%.
• Out-of-network reimbursement plummeted by almost 48%—a period that spans both before and after the No Surprises Act.
• Meanwhile, uncompensated care—including bad debt and financial assistance—has soared to nearly $47 billion.

This data signals a clear warning: the viability of hospital-based emergency care in the U.S. is in jeopardy.

The Evolving Landscape of Emergency Care in the U.S.

Over the past decade, the emergency care system in the United States has undergone significant change. Emergency departments (EDs) and their healthcare professionals have been on the front lines of major national challenges—including the opioid crisis, rising gun violence, and the COVID-19 pandemic. These pressures have come alongside a notable increase in patient acuity and complexity. At the same time, reimbursement for emergency care has declined to unsustainable levels, threatening the financial viability of EDs and the vulnerable patients they serve.

This report explores:

1. The current value of emergency care,
2. Key challenges to its sustainability,
3. Trends in emergency care payment, and
4. Alternative funding models.

To inform their analysis, the authors convened a study advisory board, conducted interviews and focus groups, launched a survey, developed case studies, reviewed relevant literature, and analyzed administrative data.

Findings: Emergency Care Delivers Critical Value but is at risk

Emergency departments are foundational to the U.S. healthcare system:

• They are among the few healthcare settings where care is guaranteed, regardless of a patient’s ability to pay.
• EDs provide critical, unscheduled, and time-sensitive care, 24/7/365.
• They offer immediate access to diagnostics and treatment, often preventing delays in diagnosis and care.
• EDs enhance both system-wide and community resilience, particularly during public health crises and disasters.
• Many also contribute to public health surveillance and intervention efforts.

Challenges Facing Emergency Care

Despite their value, EDs face growing pressure:

• ED visit volumes nearly returned to pre-pandemic levels by 2024, after steady increases since 2020.
• Patient acuity and complexity have risen, with many patients presenting with intricate medical and social needs.
• Demand for critical care in EDs is increasing.
• Overcrowding, staff burnout, long wait times, and increased violence against staff are escalating concerns.

Payment Declines Are Jeopardizing Emergency Care

Payment per ED visit is dropping:

• From 2018 to 2022, inflation-adjusted Medicare and Medicaid payments to ED physicians declined by 3.8%—physician compensation is not indexed to inflation.
• Payments for commercially insured visits fell more steeply—by 10.9% for in-network and 47.7% for out-of-network care.
• Revenue cycle data reveal that insurers and patients often underpay or deny large portions of what they owe.

Policy Recommendations

To stabilize and sustain emergency care, the authors recommend:

• Fund the EMTALA mandate: ACEP and partners should push for dedicated funding to support the federal requirement to provide emergency care regardless of a patient’s ability to pay.
• Invest locally: City and local governments should allocate funds to support EDs, especially for services like mental health and substance use care that benefit the broader community.
• Create fair compensation benchmarks: Develop standards for compensating care provided to uninsured and underinsured patients.
• Expand primary care and address crowding: Increase primary care access and pursue strategies to reduce ED overcrowding.
• Protect healthcare workers: Pass state or federal laws that impose tougher penalties for violence against ED staff.
• Expand and equalize Medicaid: Push for Medicaid expansion in holdout states and advocate for payment parity with Medicare.
• Fix cost-sharing and No Surprises Act issues: Require insurers—not providers—to collect patient cost-sharing amounts, and fix legislative loopholes to ensure timely, full payment of dispute resolution outcomes.

How Ventra Health Supports the Future of Emergency Medicine

At Ventra Health, we are deeply committed to safeguarding the future of emergency medicine. We recognize that a robust, well-resourced emergency care system is not only vital for patient outcomes—it is foundational to the stability and effectiveness of the entire healthcare ecosystem.

That’s why we proudly partner with leading Emergency Medicine associations and Emergency Medicine Strategic Advisors to champion policies that protect our specialty.  From lobbying lawmakers for fair and sustainable reimbursement models to advocating for the staffing and resources emergency departments need, we are on the front lines of ensuring that emergency medicine remains strong, resilient, and ready to meet the needs of every community.

But we can’t do this alone.  We invite you to stand with us—to raise your voice, engage in advocacy, and be a part of the solution.  Together, we can preserve the integrity of emergency care and guarantee that patients continue to receive timely, high-quality treatment whenever and wherever they need it most.

Join us. Advocate with us. Let’s shape the future of emergency medicine—together.

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