In the crowded waiting area of a hospital emergency room in Stony Brook, New York, a young father rocked his ailing infant, attempting to sooth the baby's stomach disorder while they waited to see a doctor.
Nearby, a tearful young woman, frightened and bewildered, complained of blurry vision and pain, the result of an automobile accident earlier that day. Her sister, who was more seriously injured in the crash, was elsewhere in the hospital, in intensive care.
More than 50 miles away, in a Manhattan hospital emergency room, an alcoholic man clutched his stomach and groaned as he whizzed by on a gurney.
These are just some of the faces behind the more than 100 million emergency room visits Americans make every year, according to the Centers of Disease Control and Prevention, according to a growing body of research and experts, they are also the faces most likely to be failed by America's health care system.
Data from the American College of Emergency Physicians, which represents 23,000 ER doctors, paints a chilling picture of a system in decline. The capacity of the nation's emergency systems has decreased by 14 percent since 1993, ACEP says, as more than one thousand hospitals have closed their emergency departments nationwide. Meanwhile, demand continues to increase, with 114 million ER visits reported in 2003, the highest number the CDC has ever recorded.
Earlier this year, a task force of the National College of Emergency Physicians issued the first ever "report card" on the nation's emergency system, sounding an alarm of a system in trouble. American emergency rooms earned a C-minus in the A-F rating system. None of the states studied received an A; 80 percent of the national system received mediocre or failing grades.
Experts say that as the number of patients seeking health care in emergency rooms grows, their likelihood of being failed by an emergency care system in critical condition itself grows as well.
"The system is broken and there are glaring holes in the safety net," warned Dr. Angela Gardner, head of the task force that studied the nation's emergency health care facilities. "It needs to be fixed now," she said.
As the crumbling system struggles to address the nation's daily needs, Dr. Gardner said a more ominous crises looms.
"It is certainly not prepared to deal with a public health emergency or any sort of devastating event such as a terrorist attack," she said.
Much of the demand for emergency care comes from the 46 million Americans with no health insurance, a number that climbs annually. (More than 80 percent of patients without coverage have jobs but no health benefits.)
According to the Kaiser Commission, the uninsured receive less preventive care, are diagnosed at a more advanced stage and, once diagnosed, tend to receive less therapeutic care and have a higher mortality rate. Because they have poorer general health than the insured, they end up in emergency rooms because they have nowhere else to go, when neglected chronic health conditions have become life threatening.
Federal law compels hospitals to provide emergency health care, but does not fund that mandate. Hospitals must absorb the cost of patients who can't pay for treatment, and to offset the losses, they often hit uninsured, middleclass paying patients with bigger bills because the hospital is not bound by the much lower negotiated fees they are paid by insurance companies.
"Congress does not provide a single dime to help pay for the care that it mandated," said Dr. Robert Suter, a former president of the ACEP, in a telephone interview. "There needs to be government funding to make sure that emergency service is sustained," he said.
Because so much of emergency care is delivered to the uninsured, emergency department treatment is often palliative and designed to stabilize a patient. Someone who is uninsured, or with only Medicaid benefits, is not guaranteed the comprehensive care that may be needed.
"The uninsured are often the people we see with congestive heart failure or kidney failure and they are very sick because they have neglected their health for years," said Dr. Suter. "There are plenty of cases where they have kidney failure and need dialysis to survive."
Dr. Peter Viccellio, the head of the emergency department at Stony Brook University Hospital on New York's Long Island, said many doctors refuse to perform surgery on the uninsured or those covered by Medicaid because they are so poorly reimbursed.
"A lot of people show up because they have conditions that are treatable, but in many cases no one will treat them beyond giving them some pain relief because they have no money," said Vicellio, a 27-year ER veteran whose department treats 75,000 people a year. "I see lives destroyed because of the inadequacies of our hodgepodge system. It's pathetic."
Dr. Viccellio has received national acclaim for reducing overcrowding in emergency departments by transferring stabalized patients to other floors of the hospital where they can continue to be monitored.
"At a time when emergency department visits are going through the roof, the number of emergency departments has declined because hospitals have found it more economically attractive to close the emergency department than keep it open and lose money, "said Dr. Frederick Blum, president of the ACEP, which represents more than 23,000 members.
Dr. Suter warned that some of the biggest emergency departments in the country face closure because of the money crunch. The shutdown of emergency facilities endangers everyone, he pointed out.
"If the emergency room closest to you shuts down, we all suffer, even if you are Bill Gates, because it will take longer to get to an emergency room."
Funding, however, is only one part of the problem. Emergency rooms also face a shortage of doctors, though economics is at the root of that problem as well.
The soaring cost of medical malpractice insurance has forced many doctors to give up their practice and has shrunk the number of specialists, such as neurosurgeons, who are available to emergency departments. One doctor said he had 20 specialists on call five years ago. Today he has four. This is true in many hospitals throughout the nation.
Many specialists refuse to work in emergency departments because of the heightened risk of malpractice suits. They cannot be compelled to work in emergency departments.
Because of this shortage of specialists in emergency rooms, there are countless cases where urgently needed special care is not available in an entire region. The patient must be transported to another city.
For example, a patient in need of a neurosurgeon following an accident in Houston had to be flown to Dallas to get the care needed to save his life because this was quicker than waiting for a neurosurgeon to become available in a Houston emergency room. The shortage of specialists and the need to transport patients long distances often results in delayed care that can have catastrophic consequences.
"The sooner a patient is treated for a serious trauma, the more likely the patient will survive," said Dr. Thomas Neparst, an emergency department physician in Manhattan's New York Downtown Hospital.
Neparst's hospital, which is four blocks from the site of the World Trade Center, treated more than a thousand people injured in the collapse of the Twin Towers on Sept. 11, 2001.
Overcrowding also forces emergency departments to divert incoming ambulances to other hospitals. Overcrowding and diversion of ambulances were cited in the task force report card.
"There are some cases where patients are diverted a number of times," said Suter. "Ambulances sometimes have to bypass a number of hospitals before they find a hospital that will accept the patient."
Doctors interviewed for this article unanimously decried the deterioration of emergency care and see a single-payer universal health plan as the answer. They point out that government programs could meet important health needs and operate with less overhead than private plans designed to make profits and satisfy stockholders.
For example, according to Dr. Viccellio, Medicare operates with a 3 percent overhead compared to private insurers who spend 30 percent on overhead.
Stony Brook University Hospital spends $15 million dollars a year on billing because the private plans are so different and criteria for payment so complex. A single payer system would eliminate the need for each hospital to operate its own billing department.
"I could vaccinate a lot of kids with the $15 million our hospital would save," said Dr. Viccellio.
However, the medical community is itself divided on this issue of universal health care.
In August 2003, the prestigious Journal of the American Medical Association proposed a national health insurance program that had been endorsed by more than 8,000 doctors, including two former surgeons general.
The American Medical Association, the largest medical organization in the United States, immediately distanced itself from the article. It said that while JAMA was associated with the AMA, the publication is editorially independent. The AMA has historically opposed a national health insurance system.
AMA president Donald Palmisano, responding in 2003 to the JAMA proposal, acknowledged that "a solution is desperately needed." However, he said that a national health care system would "ration care, increase bureaucracy and demoralize doctors and patients."
Doctors who support a national health care plan acknowledge that a prerequisite for adoption of universal health care in the United States is a fundamental change in attitude by Americans.
"The commitment to health care is a commitment by an entire society," said Gardner. "I think at the moment Americans struggle with how much they are committed to health care for everyone."
Donald Snyder was a news producer at NBC for 27 years and has been a freelance writer since his retirement. He specializes in Germany and Eastern Europe.