As emergency physicians look back on the growth of the specialty, we have the opportunity to note significant internal milestones along that path, such as the establishment of dedicated emergency department coverage by physicians in Alexandria, Virginia, in 1961; the formation of the American College of Emergency Physicians in 1968; the first emergency medicine residency at the University of Cincinnati in 1970; and the recognition as a specialty by the American Medical Association and American Board of Medical Specialties in 1979.

Just as important is understanding the external social, political, and financial policies that created the need for emergency medicine and have shaped our profession over the decades. As these forces continue to evolve, so will emergency medicine. Knowing how we got here is as essential as knowing where we need to go.

Genesis of Emergency Departments

In the mid 1940s, with Americans returning from World War II, President Harry Truman signed the Hill-Burton Act, which provided grants and loans for the construction of hospitals and other health facilities, dramatically expanding the U.S. health care infrastructure. This era saw a huge boost in the U.S. population (the baby boom), which continued for a decade. The Hill-Burton Act also placed hospitals in a new area of growth, the suburbs, as growing families moved out from city centers. By 1960, one-third of American families lived in suburban areas.

This act, lasting until the late 1990s, was partially motivated to address lack of access to care in many communities and is responsible for many of the hospitals in which emergency physicians practice today. The Hill-Burton Act stated that funded hospitals would provide care to patients who were unable to pay for free or at reduced cost, making the hospital an access point for all.

As the population boomed, so did the need for unscheduled and acute care, but the medical community could not meet those demands. As a result, the local hospital’s small emergency room became the community access point and a physician on call was assigned to respond. A 1958 New England Journal of Medicine article reported survey responses from 63 hospitals in the Midwest and Atlantic seaboard.¹ It found a nearly 400 percent increase in emergency room visits in the 15-year period of 1940–1955, with a 16.2 percent admission rate.

The driving force for patient visits to the emergency department was limited access to their physicians on nights and weekends, as well as physicians’ concerns that the patients’ needs were more than could be provided for in their offices. The authors noted that, “The study reflects an apparent change in thinking upon the part of physicians and the public and suggests that physicians and hospitals should plan for the future by increasing emergency room facilities. It is believed that this trend is dictated by the public.” The study recommended expansion of dedicated floor space to the emergency room.

A tripling of emergency room visits nationwide occurred between the 1940s and the 1960s. The decade of the 1960s represents a confluence of policy and social changes that lit the match for the creation of emergency medicine and the transformation of the emergency room into the emergency department. By 1961, the first groups of physicians dedicated to providing care in the emergency department started.

Several major events in the 1960s converged to change social thinking and the health care landscape. In 1966, the National Academy of Sciences and National Research Council published the landmark report, “Accidental Death and Disability: The Neglected Disease of Modern Society,” which highlighted the magnitude of the injury problem in America and the poor state of ambulance and emergency services.² Motor vehicle injuries, during a time in which automobiles and highways were also booming, were a matter of particular concern. The report noted that soldiers injured in the Korean War on the front lines were systematically moved to emergency care better and faster than Americans at home injured in motor vehicle crashes. This white paper had a huge impact on EMS and emergency services in hospitals.

Emergency medicine can look back at 50 years of change and recognize that our growth and advancement is underscored by the profession’s commitment to the needs of patients and communities.

Health Care Goes National

In 1965, health care became a national issue. About half of Americans age 65 or older (called “the aged”) lived in poverty and had no insurance. In response to growing public concerns, Medicare and Medicaid were enacted to provide insurance for the aged and money to the states to provide Medicaid to the poor. This was overseen by the Bureau of Health Insurance, which became the Health Care Financing Administration, and then became the Centers for Medicare and Medicaid Services. Hill-Burton–financed hospitals were obligated to accept these new insurances.

The resulting expansion of patients with insurance caused greater demand for care that existing doctors’ offices and clinics could not meet, so people turned to the emergency department for care, often sicker than if they had had routine care.

In 1966, President Lyndon Johnson, responding to a March report from the President’s Committee for Traffic Safety, made it a priority in his State of the Union address. He championed legislation, the Highway Safety Act, that included driver education, law enforcement, crash prevention, engineering standards, and medical care and transportation of the injured. The Department of Transportation was formed, and within it, the National Highway Traffic Safety Bureau was formed, later becoming the National Highway Traffic Safety Administration (NHTSA). EMS was expanded federally due to the death toll from motor vehicle crashes, which is why NHTSA has always played a large role in EMS and still does today. In 1971, NHTSA’s Office of EMS published the first guidelines for training emergency medical technicians.

In the 1970s, Congress enacted the Emergency Medical Services Systems Act of 1973 to authorize the Department of Health, Education, and Welfare to provide funding for planning and development of EMS systems throughout the United States. The act identified 15 specific components of EMS systems including manpower, training, communications, and data collection and led to the development of more than 300 regional EMS systems across the United States, both extending emergency care to the community and delivering higher-acuity patients to the emergency department.

In 1996, NHTSA brought the various participants in EMS together to create a common vision, The EMS Agenda for the Future, which helped modernize EMS and better integrate it with today’s complex health systems. That vision is currently being revised toward 2050, building upon the remarkable progress of the last few decades.

All of these have collectively placed a greater focus on emergency response and care and became a tipping point for emergency medicine, which began to grow as a specialty in response to needs of the increasingly complex patients arriving to emergency departments.

EMTALA, ACA, and Beyond

Congress inserted the Emergency Medical Treatment and Active Labor Act (EMTALA) into a budget bill in 1986 in response to national media focus on stories of unstabilized insured patients, including inpatients, being sent from private hospitals to public hospitals after a “billfold” biopsy. It was signed into law by President Ronald Reagan in 1987 and placed obligations on all hospitals to medically screen patients to determine if an emergency medical condition exists prior to inquiring about payment or insurance, provide care until stabilized for those with an emergency medical condition, and, if a transfer is required, to make it within the provisions of EMTALA. EMTALA has had many changes over the years, and its effects, both good and bad, are significant. It continues to be a major force in the provision of emergency care and establishing emergency departments and emergency physicians as the safety net for the United States.

The Patient Protection and Affordable Care Act (ACA), in response to a growing number of Americans who were uninsured because of low income or rising costs of insurance, passed in 2010 and was signed by President Barack Obama. It reinforced emergency care as an essential health benefit and expanded health insurance coverage for millions of Americans, either through private insurance or Medicaid expansion by states that chose to do so. Mired in politics and the challenges of change, its lasting effects will continue to play out. Increased coverage has not translated to increased access to care and already stressed emergency departments have seen volumes rise.

Three interconnected trends are reshaping both the emergency department and emergency medicine: the aging of the population, growth of chronic disease, and the move from inpatient to outpatient care. These older patients are more complicated and require complex evaluation and treatment. The disposition mindset has reversed. In the past, we admitted patients to have them worked up. Now, these patients are worked up to determine if they need to be admitted. As a result, emergency physicians are increasingly the decision makers for hospital admissions and have expanded their scope to manage observation units. These trends will likely continue and grow to include more telehealth, telemedicine, admissions to “hospital at home,” and placing satellite emergency departments placed in the communities closer to the patients.

Emergency medicine can look back at 50 years of change and recognize that our growth and advancement are underscored by the profession’s commitment to the needs of patients and communities. It has always been this way and always will be.

Dr. Martinez is chief medical officer for Adeptus Health in Irving, Texas; assistant professor of emergency medicine at Emory University in Atlanta; and an ACEP Now editorial board member.

Reference

1. Shortliffe EC, Hamilton TS, Noroian EH. The emergency room and the changing pattern of medical care. N Engl J Med. 1958;258(1):20-25.
2. National Academy of Sciences and National Research Council Committee on Trauma; National Academy of Sciences and National Research Council Committee on Shock. Accidental death and disability: the neglected disease of modern society. Washington, D.C.: National Academies Press (US); 1966.