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.

For decades, physician groups have lobbied for higher Medicare and Medicaid payments. Yet given federal and state deficits, and the political volatility surrounding entitlement programs, the likelihood that public payer rates will catch up to fair market value in the foreseeable future is slim.

The RAND report proposes that ACEP develop compensation benchmarks. I believe this should include establishing a fair market value for emergency physician services. From there, we could pursue a pragmatic solution: Any care provided below that benchmark would generate a tax or student loan credit for the individual physician.

While the exact percentage varies by your practice’s payer mix, approximately 50 percent of the patients that emergency department (ED) physicians see are Medicare or Medicaid patients. With an aging population, it is reasonable to expect the percentage of Medicare patients to increase in the years to come. With reimbursement flat for years and unlikely to rise meaningfully, emergency medicine now faces a sustainability crisis that threatens recruitment, retention, and patient access.

To illustrate, assume — imperfectly — that commercial insurance approximates fair market value. In reality, ACEP and stakeholders would need to define a standard benchmark, particularly as private payers also erode rates. Using chest pain as an example, with average reimbursed used for illustration:

• • Fair market value (average of the top three commercial insurers): $370 for a level 5
  • Example formula: (Fair Market Rate – Public Payer Rate) × Units Billed
  • Level 5 Medicare chest pain visit: ($370 – $220) × 1 = $150 in below-market care

Multiply that across thousands of encounters per year, and the magnitude becomes clear.

Regardless of employment model — contractor, employee, or partner — there is a clear billing trail tied to each physician. At year’s end, alongside a W-2, 1099, or K-1, physicians could receive a statement quantifying the uncompensated and below-market care they provided. That amount could then be applied as a tax or student loan credit. The principle is simple: When we work, we should be compensated.

Under the current federal tax code, pro bono professional services cannot be deducted. Expenses associated with providing the charitable service, for example, travel, uniforms, and equipment, can be deducted.³ Deducting professional services for emergency medicine would require a change to the tax code to enact, yet it may be a more viable strategy than increasing entitlement spending.

This is not a cure for the system. American health care is on a collision course: Nearly 18 percent of the country’s gross domestic product (GDP) is spent on health care, yet we lag behind peer nations in life expectancy, maternal mortality, and infant outcomes. This is simply a stopgap aimed at preserving our health care workforce.⁴  

If 20 percent of our patients cannot pay, then in a 10-hour shift, roughly two hours are “donated.” Because this care is federally required, a tax or loan credit simply acknowledges that emergency physicians function, in part, as an extension of the public workforce, much like AmeriCorps or public defenders.

Critics may argue that this problem is already “baked in” through the Relative Value Scale Update Committee (RUC), convened by the American Medical Association and composed of representatives from medical specialties, including emergency medicine. The RUC advises the Centers for Medicare & Medicaid Services (CMS) on how much each service should be worth in relative value units (RVUs). The CMS ultimately determines Medicare reimbursement.⁵

In theory, this process accounts for the intensity and complexity of medical work. In practice, it has long privileged procedural volume over cognitive labor. Surgical and interventional specialties dominate the committee, and the work most central to emergency medicine — rapid synthesis, diagnostic uncertainty, risk stratification, de-escalation, social complexity, and safety-net care — has repeatedly been undervalued.

As our population ages and medical care becomes increasingly intertwined with behavioral health, housing insecurity, addiction, and social vulnerability, more of what emergency physicians do is cognitive. Yet these services are precisely the ones most vulnerable to RVU compression. When I asked a billing expert how much uncompensated care is effectively “recovered” through the RUC and RVU system, the answer was blunt: It is impossible to calculate, but his best estimate is pennies on the dollar.

More importantly, the RUC was never designed to solve an unfunded federal mandate. EMTALA compels emergency physicians to provide complex, resource-intensive care regardless of a patient’s ability to pay. No amount of internal RVU recalibration can make up for a structural requirement to deliver large volumes of free and below-market care. This is not a valuation problem; it is a public policy gap.

This is not about emergency physicians carving out a larger slice of the existing RVU pie. It’s more like giving us a tax credit to pay the electric bill so the oven can keep running and bake the pie.

The same formula proposed here — quantifying below-market care and converting it into a tax or student loan credit — could apply across specialties. And in doing so, it could meaningfully improve access to care upstream, reducing unnecessary ED utilization.

We all recognize this scenario: A specialist declines to see a patient in clinic because “they won’t get paid,” and the patient is sent to the ED instead. A hand injury. A dental abscess. A complex wound. A psychiatric crisis. The ED becomes the default because it is the only location where federal law guarantees health care regardless of the ability to pay.

If that same hand surgeon could also receive a credit for below-market care, the economic barrier to seeing that patient in the clinic would shrink. Health care could happen in the right setting, at the right time, by the right physician, without the ED serving as the financial shock absorber for the entire health care system.

Emergency medicine is simply where this fracture line is most visible.

Simply because physicians are high earners does not mean our time is free. The longer we normalize unpaid and underpaid professional labor, the more we devalue the work we do. And when emergency medicine becomes unsustainable, access for patients will be the first casualty.

Dr. Austin is the emergency medicine program director at FSU-Pensacola, a Vituity site. She is the author of Revitalized: A Guidebook to Following Your Healing Heartline and host of “Heartline: Changemaking in Healthcare.” She is the current Chair of the American Association of Women Emergency Physicians (AAWEP). www.andreaaustinmd.com @andraaustinmd.

Disclaimer: This essay was developed through iterative drafting and analysis with the assistance of ChatGPT (OpenAI), which I used as a research and writing partner to explore policy analogies, test economic framing, generate illustrative tables and formulas, and refine clarity and flow. All arguments, interpretations, and conclusions are my own.

Opinions in this piece are my own and do not represent the views of any entity I work for or with, and do not reflect AAWEP or ACEP opinion or official policy

References 

1. Abir M, Briscombe B, Berdahl CT, et al. Strategies for Sustaining Emergency Care in the United States. The RAND Corporation. Published April 7, 2025. Available at https://www.rand.org/pubs/research_reports/RRA2937-1.html.
2. Adelman, Leon. Decreasing Real Wages for Emergency Physicians. Emergency Medicine Workforce Newsletter. Published April 28, 2023. Available at https://emworkforce.substack.com/p/decreasing-real-wages-for-emergency.
3. Internal Revenue Service. Charitable Contributions. Publication 526 for use in preparing 2025 returns. Available at https://www.irs.gov/pub/irs-pdf/p526.pdf?utm_source
4. Centers for Medicare & Medicaid Services. NHE Fact Sheet. Accessed March 23, 2026. Available at HYPERLINK “https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet
5. The American Medical Association/Specialty Society Relative Value Scale Update Committee. An Introduction to the RUC. Accessed March 23, 2026. Available at https://www.ama-assn.org/system/files/introduction-to-the-ruc.pdf