The U.S. health care system continues to rely on a diverse and poorly organized health care safety net to provide care for its uninsured and underinsured residents. Last year, the Institute of Medicine (IOM) published a report entitled America's Health Care Safety Net: Intact but Endangered. The IOM cited several threats to the safety net, including inadequate monitoring of safety net function, poor integration of services, financial threats for core safety net providers, and the destabilizing effects of a rapid shift from traditional Medicaid to Medicaid managed care products. This paper reviews the findings of the IOM report, highlighting the key issues for emergency medicine. In response to the IOM's challenges, emergency departments should be used more effectively to monitor local safety net viability and to enhance the integration of community health care safety net delivery systems.