BOSTON — At the great hospitals of the nation's major cities and ballooning suburbs, ambulances are being turned away and patients are stacked in hallways like so much cordwood. America's dwindling capacity for emergency care is being outstripped by Americans' demand for it.
And this time the victims are not just the poor, who have suffered for decades at the country's cash-strapped public hospitals. This time the danger threatens almost anybody who suddenly takes ill or sustains a traumatic injury.
"Rich or poor, black or white, it doesn't matter," said Robert E. Maher Jr., who until recently was chief executive of Worcester Medical Center in Massachusetts. "The capacity simply isn't out there anymore."
Maher should know. When he had a heart attack in November while flying into Boston, he was turned away from the closest hospital, Massachusetts General, because of overcrowding and was forced to take an ambulance across town to find treatment.
The deterioration of the country's emergency care system is a vivid example of the nation's under-investment during the 1990s in the kinds of goods and services that traditionally have served as society's foundation. It illustrates the peculiarly private nature of the decade's long prosperity.
While affluent Americans spent richly on themselves during the 1990s, the nation as a whole devoted a historically small fraction of its expanding wealth to roads and airports, electrical generating capacity and basic medical services on which everyone relies.
One result is that the country is coming off its longest economic expansion in more than a century with fewer emergency rooms than it had to begin with. Accumulating evidence suggests that a second result is that the care being offered by many emergency rooms is worse, not better, than it was earlier in the decade.
Medical specialists generally agree that a key force behind the current crisis is an effort by business and government to let market forces streamline the nation's huge and expensive health care system. This two-decade drive, which peaked in the mid-1990s, succeeded in moderating medical cost increases but at the expense of patient outrage and, now, ER breakdowns.
"We've increased the play of market forces in medicine, but medicine doesn't lend itself well to markets," said James J. Mongan, president of Mass General, one of the nation's best hospitals.
"It's taken some of the resilience out of hospitals and especially the emergency departments," Mongan said. "It's cut the reserves we used to be able to depend on."
The signs of cutbacks are everywhere:
* Emergency rooms are declaring themselves overwhelmed and are shutting their doors to ambulances in spectacular and rising numbers. On average, the two dozen emergency rooms at the heart of Los Angeles County's emergency system were closed more than one-fourth of the time in May and almost one-third of the time in June, according to the county's Emergency Medical Services Agency. The figures are similar for surrounding counties.
Metropolitan Phoenix's 29 emergency rooms simultaneously closed on eight occasions between January and April, according to Dr. Todd B. Taylor, an official with the Arizona College of Emergency Physicians. Metropolitan Cleveland's 22 ERs were simultaneously shut for almost 10% of May, according to Cuyahoga County emergency services manager Murray A. Withrow. Simultaneous shutdowns set off a mad scramble among emergency officials to dole out patients to hospitals that already have said they can't handle them.
* Hospitals are so full that ER doctors can't find room for patients who need to be admitted. A new industry survey of 715 hospitals found that nearly half are running at 90% occupancy during peak periods, drastically higher than a decade ago. In a recent one-week period, metropolitan Boston's 17 major hospitals reported operating at an almost unheard-of 96.2% occupancy rate. High occupancy rates leave no room for emergency arrivals, forcing ER doctors to park patients in hallway beds, sometimes for days at a time.
* For those not critically ill, the wait to see an ER doctor has grown so excruciatingly long that in at least five recent instances in Las Vegas, patients already at the hospital called 911 to be picked up by an ambulance and brought in on a stretcher in hopes of getting quicker care, according to Brian Rogers, managing director of Southwest Ambulance.
"It's a crazy situation," he said.
And, according to a wide array of doctors, administrators and policymakers, it is an increasingly dangerous situation for patients, even affluent and influential ones.
It certainly was for Nancy Ridley, who arrived at the Lahey Clinic in Burlington, north of Boston, on Mother's Day with a spiking fever and painful cough. She had to wait almost eight hours to be admitted with pneumonia. Ridley, as it happens, is the state's assistant commissioner for public health.