“Barbaric” and “Humiliating:” Americans Are Waiting Days for a Hospital Bed

HARI SREENIVASAN: Bianna, thanks. Dr. Elisabeth Rosenthal, thanks so much for joining us. You had a recent piece in the Atlantic titled “A ‘Barbaric’ Problem in American Hospitals is Only Getting Bigger.” What’s the problem?

DR. ELISABETH ROSENTHAL: Well, the problem is people who are admitted to the hospital, but there are no beds available. So they end up lying in the emergency room in a hallway, or actually out of the emergency room in a hallway or in an ER overflow area, where it’s not clear who’s responsible for them. And you just don’t have the normal care that an inpatient needs. And I think everyone knows, who’s cared for an older relative or a sick relative, that this happens and everyone’s frustrated by it. But as one of the ER doctors said to me, it’s a problem that nobody – everybody knows about, but nobody cares enough to fix, which I think is the tragedy.

SREENIVASAN: Yeah. You wrote about this in a very personal way too. You were writing about your husband who was dying of esophageal cancer at the time, and you write, “After we went to an emergency department near our home in New York City, he lay trapped on a hard stretcher with its rails up for more than 36 hours, amid the alarms and calls for the code team without any clues of whether it was day or night, and with access only to the few toilets shared by the dozens of patients and visitors in the emergency room.” Tell us a little bit about, you know, I think people forget that the impact that the setting itself has, You don’t know what’s happening and the lights are the same, and you don’t know who’s coming in to do what.

ROSENTHAL: Yeah, no, it’s a scary place. It’s a noisy place. It’s – I called it cacophonous. You know, it’s – there are two or three bathrooms for everyone. You know, I think, you know, and in that particular admission where Andrej sat in the ER for a couple of days, he had altered mental status. And, you know, if you have – who wouldn’t have altered mental status, by the end of those two days, you know, he thought I was – the doctors were out to get him like CIA people or something.

SREENIVASAN: Oh, no.

ROSENTHAL: And I was their paid conspirator trying to keep him there. So, you know what, what happened over the course of his illness, and he didn’t have many ER boarding stays, was because a lot of times when he should have gone to the emergency room, he refused. He said, I’m not going there because I know what’s gonna happen to me. I’m gonna sit in the hallway. It’s humiliating. The stretcher is not a bed. You know, rails up is rails up. There are monitors, there are noises. You don’t know who your neighbor is. You’re in a hallway. You know? So it’s humiliating as well as not good care.

SREENIVASAN: You know, unfortunately, your husband’s care is not the exception. According to a study published in Health Affairs back in 2025, it looked at across 46 million emergency department visits and 15,000 hospitalizations – and this was between the years 2017 and 2024 – during non-peak months – so not even the months where it’s worse – more than 25% of the admitted patients waited four hours or more for a bed. And during winter months it was even higher. So why are patients waiting for a bed for so long? Why do we see human beings in the hallways of hospitals next to emergency departments?

ROSENTHAL: Well, I think the thing is, you know, that that four hour rule, more than four hours, any emergency room physician will say, or a nurse will say, that’s a joke. Everyone waits more than four hours. You’re lucky if it’s you know, less than two days. I mean, we’re talking days and nights for many people. And it’s kind of a – it’s a system problem. It’s the way we finance care in America and the way hospitals, even not-for-profit hospitals, think about care. And it’s our lack of resources for people who are older, sicker, or at the end of life. So it’s a multi-dimensional problem.

You know, when – I was an ER physician for seven or eight years before I became a convert to journalism. And I worked in a very busy New York City emergency room. There were rarely people who boarded. But then the hospital always had some beds open to move people upstairs. If there were not – if there was not space in the emergency room, we could go on diversion. We would cancel elective admissions if there was no room. Now hospitals run like airlines, you know, they want every bed full all the time because an empty bed is a money loser– you know, if you’re thinking about medicine as a business, an empty bed, like you’re paying for nurses, you’re paying for the heating, the cooling, the…. And you’re not getting anywhere revenue back. And more than that, I think you want those beds filled with revenue producing patients, so –

SREENIVASAN: Explain that.

ROSENTHAL: Well, you know, proceed– we prioritize procedures in healthcare reimbursement. So if you have someone coming in for a hip replacement or you know, a valve replacement or a cardiac procedure, that’s big bucks. If you have someone who’s older or sicker, who’s just needs care, needs their antibiotics administered, you know needs to be turned at night so they don’t get bed sores. They’re not producing revenue. They’re just there.

And the secondary problem, just so I don’t say, oh, it’s the hospital’s fault entirely. Yes, they operate on a business model. So yes, it’s partly their fault. They want revenue, revenue, revenue. But also the problem is they know that if one of those patients goes to a bed, we have an extreme shortage of rehab beds and long-term care beds and hospice beds. So that person will most likely sit there in that bed and not move for days, for weeks, it could be even longer, you know?

SREENIVASAN: You know, how much of this is a demographic shift as well? I mean, we are conscious of this sort of idea of the silver tsunami, the retired population, the boomers now. Over the next 15, 20 years, the population of retirees is gonna go almost up 50% So what happens when more people have these needs and they need places in hospitals or after hospitals?

ROSENTHAL: I mean, we have, as a nation, we have to figure that out. I mean you know, after, since the pandemic hospital beds are down by 20% because, you know – part of it is rational. Like so much more can be done as an outpatient. We don’t need these beds. But the countervailing fact is that you know, there’s an older, sicker population who needs more hospitalization.

Now, whether you know, in the good old days when finance wasn’t king in healthcare, hospitals often had transition units where people who weren’t quite ready to go home but didn’t need full hospital care, would go. But those are money losers. Like, we didn’t pay for that. There was no financial model. And I think, you know, whether it’s in hospital or out of hospital, we just have to figure out better ways. And hey, I, you know, I’m invested in this ’cause I’m gonna be one of those people likely who needs that that kind of system. And boy, when my husband was dying I saw just how terrible it is from the patient perspective.

SREENIVASAN: This was from the Health and Human Services about emergency department boarding, exactly what we’re talking about. Right. This is the end of the Biden administration. It said, quote, “Emergency department boarding is a public health crisis in the United States.” It concluded that “patients who are sick enough to require inpatient care can wait in the ED for hours, days, or even weeks…Boarding contributes to increased mortality, medical errors, prolonged hospital stays, and greater dissatisfaction with care.” I mean, that seems like the bat signal, the fire alarm, the red siren, I mean, whatever you wanna call it. And why did nothing happen after this level of urgency is expressed by HHS?

ROSENTHAL: Well you know, you could blame the change of administrations, but I don’t know if that, what would’ve happened if it was the Biden administration continuing, the panel would’ve been convened. It’s a hard problem to solve, is part of the problem.

One thing that is happening that was suggested by that report is starting in – there’s a new rule that came out of CMS that takes effect this year. But actually, you don’t have to, doesn’t really require the hospitals to do anything ‘till next year. As of 2027, they’re gonna have to report ER boarding times. It’s optional. They are – they can in 2027. In 2028, it becomes required. And then in 2030, it’s – there’s an idea that it somehow should affect Medicare payments. There should be penalties for excessive boarding time.

Now, will that really help? I mean, it’s a start that we’ll know more about the depth and breadth of the problem, but it’s years away.

SREENIVASAN: Tell me a little bit about the money factor here. I think almost 500, 488 hospitals, in the United States, are now owned by different private equity firms. Is there a financial profit sort of pressure here as these hospitals get taken over at the expense of patient care or staffing?

ROSENTHAL: Well, of course, the, you know invasion of private equity into healthcare is, to my mind, not a good thing. You know, the goal of private equity is to make something more efficient and then to resell it and make profit, which you know, hospitals have been pushing efficiency for years on their own. But this has happened at not-for-profit hospitals too. I mean, most of the big teaching hospitals are not-for-profit, and they all have huge boarding problems. They work on a kind of, they don’t call it profit, but they think a lot about money. And the administrators are constantly thinking about, are we making money? Are we losing money? They have huge overhead, much of which is medical. But then, you know, the CEOs of these hospitals are get pay packages that are often between 5 and 10 million. So, you know, they kind of act like businesses even though they’re not for profit, and they call their profit surplus rather than profit. But…

SREENIVASAN: Yeah. You wrote a book several years ago called “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.” Now, you probably need to update that book considering, because things haven’t all been fixed, right, since you wrote some of these problems. But I guess the second part of the title, how can we take it back?

ROSENTHAL: How we can take it back for ourselves individually is, you know, there are some, there are a lot of things you can do. You know, you can make more of a fuss when you – you can look at those explanations of benefit statements. You can fight bills. Very few of the insurance denials get appealed because people just don’t know how to do it or can’t be bothered, or that’s not they can’t be bothered. It’s too complicated. Hospitals offer you know, programs that may help people who need discharge find a hospice or, you know, you can get your labs drawn at in-network labs. In some cities, like in New York, it’s hard to find a primary care doctor. Everyone needs a primary care doctor because that way you have an advocate within the system.

But I think globally, what we can do is, you know, in polling that we do at, at KFF you know, voters say healthcare and healthcare costs are one of their major priorities, but people don’t vote their healthcare and politicians haven’t really offered much. Like what is – in 2016, the Democrats were talking about lowering the Medicare age progressively. They were talking about a public option, which is a government provided insurance plan that you could choose if you didn’t like the commercial plans on offer. You know, there were enhanced subsidies, which the Trump administration let expire.

So I’m always surprised that we know everyone is angry about healthcare. Everyone is angry about emergency room boarding. To my mind you know, politicians, God, it’s such a winning issue. If you talk about that, you know, when people talk about gas prices and you know, mortgage rates, I’m like, guys, yeah that’s bad that there’s that kind of inflation. But what’s stealing money from your pocketbook and keeping you sicker is the way our healthcare system is treating you. So let’s vote for that and ask more politicians to, to address that.

SREENIVASAN: In, in the article on near the end of his life you went to the ER for the last time, and you write quote, “I did what I promised myself I’d never do: I called a doctor friend, who called the hospital’s VIP office. Suddenly, Andrej was whisked to a real hospital room with a bed that he could adjust to keep his head elevated, a tray he could eat from, a morphine pump, a tv, a bathroom, and a nurse call button at his side.” Why did you finally do this? And what did that moment teach you?

ROSENTHAL: Well, he was in the emergency room on a stretcher for a few days. And he was miserable. You know, the first thing he asked when he got to the emergency room that night was, did you bring my shoes? Like, he was so sick, and all he wanted to do was leave. And I couldn’t take, he was too sick to have him at home. And we hadn’t been able to arrange hospice yet. So you know, I knew he was dying in that admission, likely. And I was not gonna let him die sitting on a stretcher with rails up in the emergency room with his feet hanging off. You know, it was just too – the opposite of a beautiful, dignified death. And death is never to, as I’ve seen it, you know, a wonderful experience but it was a terrible way to go.

So, and I knew because I practiced in hospitals, that there were these VIP offices. And I knew – because I knew the system pretty well – that I could call someone to make that work for us. But, you know, writing about health policy for my entire life, it was not something I wanted to use. I wanted, I want this to work for everyone, you know, not just calling a VIP office, but you know, when your husband’s dying, you do what you have to do for your loved one.

SREENIVASAN: Author and journalist and physician, Dr. Elisabeth Rosenthal, thanks so much for your time.

ROSENTHAL: Oh, thanks for having me and letting me talk about this important issue.