Emergency physicians are the nation’s healthcare safety net, and emergency departments are often the only place where anyone can walk in, regardless of insurance status or ability to pay, and get the care they need.

Emergency medicine is vital in communities nationwide, and our open-door policy is a moral and legal commitment under the Emergency Medical Treatment and Labor Act. But the physicians upholding this commitment are not paid for more than half (55%) of the time they spend on patient care—failure to close this gap is putting patient lives and physician careers on the line.

Significant resource challenges are straining emergency physicians at a time when demand for emergency care is skyrocketing. The challenges are compounded by persistent violence against health workers, already admitted patients stuck waiting days or longer for care, and systemic dysfunction that takes a real toll on the physicians and care teams who need to be able to focus on patients.

Emergency physicians cannot keep providing care under these conditions, and our communities cannot afford a future without our care.

With cuts to Medicare and potentially Medicaid looming on the horizon, states, hospitals and physicians are preparing for even deeper strain, and the situation is dire.

According to a recent RAND study, from 2018 to 2022, emergency physician payments per commercially insured in-network visit dropped 10.9% and nearly 48% for out-of-network visits. Payments also fell for Medicare and Medicaid patients. At the same time, more than 20% of expected emergency physician payments go entirely unpaid, totaling $5.9 billion annually.

In short, chronic underpayment from insurers is bleeding emergency care dry.

Increasing consolidation is giving insurers unchecked power to lower payments and influence medical decisions that should be made by doctors, not corporations.

Allowing this outsized influence has consequences—when physicians cannot negotiate fair rates, we can’t afford to keep our doors open and we risk being bought out or leaving the profession entirely.

As insurers continue to encroach further into the physician-patient relationship, it should concern everyone that they are denying claims and reducing the value of physician work based solely on their opaque algorithms.

While insurers do all they can to game the system and pay as little as possible, emergency departments are seeing more patients with complex, high-acuity needs—opioid overdoses, mental health crises and chronic illnesses. We are needed now more than ever.

Emergency care is a community lifeline, and it is time for policymakers and regulators to treat it as such.

We need greater scrutiny of consolidation in all parts of the healthcare system. While some claim consolidation improves efficiency, it often eliminates competition, reduces physician autonomy and bargaining power, and increases costs for patients—while threatening access to and quality of care.

Reimbursement reform is equally urgent. Both government and commercial rates must reflect the actual costs of delivering care in emergency settings. That includes adjusting Medicaid and Medicare rates to account for the intensity of emergency care, expanding Medicaid disproportionate share hospital payments to include emergency physicians, and implementing a tiered payment model that fully recognizes the additional critical roles emergency physicians have in our system, such as public health and national security.

Emergency physicians did not choose this field because it was easy. We chose it because we believe in being there for people in their most vulnerable moments. But belief alone will not keep the lights on.

If Americans want emergency care to be there when they need it, policymakers must stop pretending the system will hold without vital funding and stronger support for emergency physicians. We are holding the line. But we can’t do it much longer.

Alison Haddock, M.D., is president of the American College of Emergency Physicians as well as a past chair of its board of directors. She is a clinical associate professor and regional dean for the Everett campus of the Washington State University Elson S. Floyd College of Medicine.