It’s 3 a.m. in the emergency department (ED), and an elderly homeless man sits quietly in a corner. His breathing is labored, his clothes tattered. Tonight, he arrives not because of an immediate, life-threatening emergency but because, for people like him, the ED is the only option left.
As an emergency physician in a busy emergency department, I witness daily how America’s fragmented healthcare system creates preventable crises. Every shift, I encounter individuals whose medical issues fall outside the realm of emergency medicine. Patients arrive with chronic conditions—unmanaged diabetes, untreated mental health concerns—that would be more appropriately managed in a consistent outpatient setting if they had access to usual care.
The emergency department has become America’s healthcare safety net, primary care office, mental health clinic, and social service agency – not because it’s the best place for these services, but because we’re the only place that never closes our doors. However, the Emergency Department is fraying under the burden of healthcare’s systemic failures and the inaccessibility to timely care and adequate resources.
Emergency departments have long served as the safety net for millions who lack insurance, primary care access, or consistent support systems. These are the spaces where people turn when no other avenue remains.
However, that safety net is fraying.
Emergency departments across the nation are strained beyond their intended mission, and their capacity to address the mounting needs of the most vulnerable is diminishing. As primary care access, mental health services, and housing support have not expanded to meet the needs of the communities that need it most, the ED has become the final destination for those who would otherwise have no entry point into the healthcare system.
In 2024, one in four Americans skipped medical care due to costs and nearly 30% of Americans reported not having a usual source of medical care, forcing them to rely on emergency departments for basic health needs. The result is an unsustainable level of demand for care, long wait times for admission (also known as boarding), overcrowding, and a deepening gap between the ED’s mission and its present reality. Furthermore, when emergency rooms are filled with patients needing basic healthcare, resources are diverted from those in immediate crisis. Wait times grow, resources become strained, and the quality of care suffers.
Although resources are scarce, our emergency department does what it can. Our care coordinators build trust and navigate complex systems. Our social workers find creative solutions for seemingly impossible situations. Our substance abuse counselors offer hope and practical support. But they— and we— cannot create resources that don’t exist or make services accessible that aren’t there.
To bring stability to the emergency department, we must enact meaningful systemic reforms. We need local, state, and federal-level buy-in from policymakers to bring better social support to communities. This includes housing support for those facing homelessness, implementing crisis workers for mental health crises, and providing better support for community health workers to engage with the communities that they serve. Most importantly, it is critical to improve access to preventative care services and screening tests, such as mammograms, pap smears, and colonoscopies Failing to address these challenges will leave our EDs overwhelmed and jeopardize the health of those who rely on them, as well as the viability of our healthcare system as a whole.
To be sure, we cannot realistically expect to overhaul the entire healthcare system, especially given the existing financial, political, and logistical barriers. However, the frequent reliance on EDs for such purposes reflects broader systemic failures: a lack of affordable primary care, insufficient mental health services, and an absence of unified healthcare infrastructure capable of addressing needs proactively rather than reactively. Without serious change, individuals like the elderly man in the corner will continue to depend on the emergency department as a last resort.
This is an urgent matter. It is time to mend our fraying safety net so that those most in need are not left to seek help in spaces that were never meant to serve as their sole refuge. The health and stability of our society demand it. Until we do, the emergency department will continue to be the only option for too many—and that’s a prescription for failure we can no longer afford to fill.