The problem of emergency department (ED) overutilization or “inappropriate” utilization is commonly conceptualized in terms of inadequate access to appropriate primary medical care. Although medical care access is a critical issue, a focus on increased access to medical care as the sole solution to “inappropriate” ED utilization may obscure other, perhaps equally relevant, issues from consideration. This article reports findings from an ethnographic study focusing on heavy users (HUs) of EDs in two inner-city hospitals. Drawing on fieldwork and on interviews with HU patients and ED clinicians, I argue that the emergence of heavy ED utilization as both a clinical and policy problem is a function not merely of unmet medical careneeds for individuals, but of “almshouse” needs in a changing health care context. The emergence of ED overutilization as a problem occurs in the context of market forces that are contributing to shifts in the role of EDs and in the moral boundaries of accepted ED practice. If the problem of heavy ED use is more broadly conceptualized in terms of this role shift, not solely in terms of medical care access, a different set of issues and priorities for research, policy, and clinical practice emerges.