Since 2006, the American College of Emergency Physicians (ACEP) has periodically released a state-by-state report card on America’s emergency care environment. In 2014, the third installment of the report card was released. “The information from ACEP’s report card provides clinicians with data on how well emergency care is supported in the United States,” says Jon Mark Hirshon, MD, MPH, PhD, FACEP, who served as chair of the task force that directed the development of the report card.

ACEP’s most recent report card forecasts an expanding role for EDs under the Affordable Care Act (ACA) and describes the harm that is being done from fewer resources and greater demands. It measures conditions and policies under which emergency care is being delivered rather than the quality of care that is being provided by hospitals and emergency providers. The report card grades states on 136 measures in five categories, including:

Most EDs Scored Poor Grades

According to the 2014 report card, the continued failure of state and national policies to support emergency care is endangering patients who require emergent and urgent care. Overall, the United States received a near-failing D+ grade. In a breakdown of the five categories of the report card, the nation received a D- in the access to emergency care category; a C- in the medical liability environment and disaster preparedness categories; and a C in the quality and patient safety category as well as the public health and injury prevention category.


The District of Columbia ranked first in the nation with a B- grade, a mark that surpassed Massachusetts, which held the top spot in the 2009 report card (Figure 1). Massachusetts, Maine, and Nebraska also had B- grades, while Colorado rounded out the top five states with a C+ grade. Wyoming ranked last in the country, receiving an F overall. Arizona was second to last with a D- overall, while New Mexico, Montana, and Kentucky completed the bottom five rankings with an overall D grade.

States continued to struggle with many issues, including healthcare workforce shortages, limited hospital capacity, ED boarding of inpatients, long ED wait times, and increasing financial barriers to care. In the report card, 21 states received F’s in access to emergency care. Ten states received failing grades for quality and patient safety, the medical liability environment, and public health and injury prevention. Also, 13 states received Fs for disaster preparedness.

Improving Emergency Care

The national grade for access to emergency care has not improved since 2009, the last time ACEP’s report card was released (Figure 2). In 2009, the U.S. earned an overall grade of C-. Dr. Hirshon says the lower grade in 2014 reflects a misguided focus on cutting resources for EDs because of perceptions that emergency care is expensive. “Studies show that emergency care accounts for less than 5% of overall healthcare costs,” he says. “America’s grade for access to emergency care was almost an F because of declines in nearly every measure. This reflects that hospitals are not getting the support they need in order to provide effective and efficient emergency care.”

The report notes that there were 19 more hospital closures in 2011, and psychiatric care beds and hospital inpatient beds have decreased significantly despite increasing demands. “Patients are increasingly reliant on emergency care,” Dr. Hirshon says. Other reports have noted that primary care physicians are increasingly advising their patients to go to the ED after hours to receive complex diagnostic workups and to facilitate admissions for acutely ill patients.

A Call to Action

ACEP is calling for legislators and political leaders to make it a national priority to strengthen the emergency medical care system. The report card provides recommendations for improving the five categories that were evaluated (Table). Conditions in the U.S. have continued to deteriorate since 2009 due to lack of policymaker actions at the state and national levels, says Dr. Hirshon. “With the continuing changes in healthcare as well as the ACA,” he says, “it’s clear that emergency care will become even more important in the future. The report card should serve as a call to action to address areas of weakness and make changes that will improve the emergency care environment.”