Imagine you’re planning to open a business. Your community desperately needs what you provide — so much so that lives will literally hang in the balance based on whether you can keep your doors open. You apply for a loan and begin building your financial forecast.

As you research market conditions, you discover three sobering facts:

• You will not be paid by roughly 20 percent of your customers.
• About 50 percent of your customers will pay through a government program that reimburses at a rate far below fair market value.
• Only 30 percent of your customers will pay rates that approximate the true cost of your services, and even those payers have reduced reimbursement by a range of 10.9 percent to 47.7 percent over the past five years.

No bank would approve that loan.

Yet this is the business model of emergency medicine.

This is not hyperbole. It is the reality outlined in the 2025 RAND report, Strategies for Sustaining Emergency Care in the United States.¹ Even though emergency medicine has always operated under this strain, the system is now approaching a breaking point. I began to feel it acutely in 2023, when inflation surged and a Medscape analysis of 2018–2023 data showed that emergency physicians’ real wage growth, adjusted for inflation, fell by 12.1 percent.²

We are now at a moment when we can no longer afford to ignore the elephant in the room: EMTALA is an unfunded mandate. Every day, emergency physicians expend physical and cognitive energy — often while facing violence, moral injury, and communicable disease — to care for patients who cannot pay. Ten years into practice and one pandemic later, it struck me that no other profession is routinely required by federal law to provide complex professional services for free.

Out of curiosity, I asked ChatGPT whether any analogous situation exists.* It could not identify a true parallel. The closest examples were public defenders, jury duty, and the military draft.  Even then, it noted:

• Compensation: EMTALA does not guarantee compensation, whereas public defenders, jurors, and draftees receive at least some payment.
• Nature of Work: EMTALA obligates private actors to provide potentially extensive, resource-intensive services creating a direct economic burden unlike those other examples.

Let that sink in. We are federally mandated to work. We are unpaid for roughly 20 percent of that work. For at least half of what remains we are paid far below market value. In effect, we are required to provide professional labor without fair compensation.