In Washington, DC one of the most persistent challenges is ED use for low-acuity, non-emergency visits (LANE). Some years, LANE visits have risen to as high as 65% at some hospitals. This is compounded by a generous 911 policy that enables anyone for any reason to secure an ambulance ride to an ED. Many cities wrestle with this challenge and interventions to interrupt these patterns have only achieved modest success, at best, I.e. 10-30% reductions, which may or may not be sustainable. Prevailing wisdom about explanations for this intractable problem suggests people choose the ED due to lack of access to primary care. A recent study in Washington, DC by JSI highlighted adequate and in some cases, an over abundance of primary care access yet low utilization of primary care. How might we better think about and design primary care and preventive services that address this problem?