EMTALA clearly changed the role and mission of the ED. In 2007, the Institute of Medicine published a study of emergency care in America detailing the challenges of a high demand and inadequate system capacity, and offering recommendations to improve ED efficiency, organization, care access, and care delivery (Table 120-6). The report notes that from 1993 to 2003 the U.S. population grew by 12%, hospital admissions increased by 13%, and annual ED visits rose from 90.3 to 113.9 million patients. During that time period there was a net loss of 425 EDs, creating the challenges common to all EDs today. The report describes the aggregate result of this imbalance between public demand and hospital capacity as an epidemic of overcrowded EDs, patients frequently waiting in the halls of the ED for an inpatient bed (“boarding”), and ambulance diversion. Another study demonstrated an increase of 16% in the average length of stay in the ED between 2001 and 2005 for all patients, with a 37% increase (79 minutes) in the average wait in the ED for critically ill patients. Since the release of the report with the subsequent downturn of the U.S. economy starting in 2008, the issues have become even more pervasive and acute. A 2009 report by the Government Accountability Office (GAO), Congress's investigative arm, found that emergency patients who should have been seen immediately waited nearly half an hour. Subsequent studies have demonstrated that ED crowding leads to adverse patient outcomes and contributes to racial disparities in care. Health care reform in the future will likely affect health care coverage and ED crowding. Likely, more patients will have insurance coverage in the future, and insured patients utilize EDs more frequently than the uninsured.