The proposed list of "downcode" diagnoses will shift costs to other users of emergency services -- to the extent possible. Many patients cannot pay anything and insurers already cap fees.  We are proud of our role in the social safety net, but we have to keep the lights on. This rule will hurt smaller and rural hospitals the most, especially the 7 CAH's in Virginia, because their ability to remain open, at their margin, often depends on Medicaid patient fees. Hospitals may reduce nursing staff hours or supplies quality and availability, but as Emergency Physicians, we will not compensate for these cuts by cutting the quality of care we deliver to anyone. We would not if we could; anyway the civil tort system recognizes no exception to the "standard of care." To at least some extent, emergency care availability is a public good. Reduced capacity means reduced security and increased risks. If this tips any hospital over into closing down ER operations, any savings realized by this will be exceeded by increased costs in health, efficiency, and work force productivity. And don't expect this to incentivize patients to go to doctors' offices instead of the ER; Maryland tried this 35 years ago and it made no difference.