The nation's emergency care system itself is ailing, warns a new health care analysis.

"The emergency health care system's in serious condition. We have a safety net for health care that is frayed," said Dr. Stephen Epstein, an emergency care physician at Beth Israel Deaconess Medical Center in Boston.

Epstein was a member of the American College of Emergency Physicians task force that studied the nation's emergency care. Their report is being released Tuesday.

The panel found a system that is overcrowded, with access to emergency care declining and with poor capacity to deal with public health or terrorist disasters.

"Americans assume they will receive lifesaving emergency care when and where they need it, but increasingly that isn't the case," said Dr. Frederick C. Blum, president of the physicians group.

Overall, California, Massachusetts, Connecticut and the District of Columbia were rated best in emergency care, while the lowest grades went to Utah, Idaho and Arkansas.

The number of emergency departments has declined by 14 percent since 1993 despite an increasing number of people coming to them for treatment, the report said.

Hurricane Katrina showed the critical need for surge capacity in emergency medical care when a disaster occurs, the report noted. In addition, every year people suffering from flu crowd emergency rooms.

The compact District of Columbia, which includes several emergency care centers, ranked first for access to emergency care, along with Connecticut, Maine, Massachusetts, Ohio, Pennsylvania and Rhode Island. No state received a failing mark for access.

Even so, emergency care is one thing and getting a specialist in an emergency may be something else, Epstein noted.

He recalled an incident in which a Massachusetts 8-year-old was hurt in a sledding accident. The emergency physician concluded that the child needed a neurosurgeon, but none was available in that part of the state that day.

The child had to be transported, during a snowstorm, to a Connecticut hospital for treatment.

Emergency patients tend to be sicker and more unstable than others, causing some specialists to be reluctant to see them because of the higher liability and higher malpractice insurance rates, Epstein said.

The result is that some specialists, like neurosurgeons, leave certain states or refuse to provide emergency care.

In addition to access to emergency care the report also looked at quality of care, efforts to prevent injuries and improve public health so emergency care wouldn't be needed and the medical liability climate in states, such as caps on non-economic damage awards and protection for physicians who provide emergency care.