It was 4:43 on a clear November afternoon when the paramedics found Cynthia Kline, pale and short of breath, slumped against a bedpost in her double- decker Cambridge home. Although Kline was in obvious pain, she seemed keenly aware of what was happening inside her 55- year- old body. One of her blood vessels had closed off, blocking the flow of blood to her heart. Minutes before, she had phoned 911, taken the nitroglycerin tablets prescribed for such an emergency, then waited for help to arrive-an ordeal that stretched out an agonizing extra few seconds while the rescue workers, having found the front door locked, scampered in through an open second- story window. Now, while the paramedics worked busily over her, noting vital signs consistent with cardiac distress, Kline turned to one of them with an anxious plea: "Take me to Mount Auburn Hospital."
Kline, a teacher who worked with special- needs children, had no formal medical training. Yet her instinct about where to go was as sound as a seasoned cardiologist's. Nearby Mount Auburn Hospital, a private teaching facility affiliated with Harvard Medical School, had some of the city's finest doctors and nurses. More important, it had an intensive cardiac care unit that specialized in cases like hers. A few days earlier, staff at Mount Auburn had treated Kline's advanced coronary disease by inserting a balloon into her circulatory system and then expanding it, in order to open up a partially blocked blood vessel. A variant on the very same procedure, "cardiac catheterization," could be used in an emergency like this one, when the flow of blood through a vessel was almost completely cut off. Cardiac catheterization had saved literally thousands of lives across the country.
The procedure had the potential to save Kline's life, too, just as soon as she could get to the hospital and receive it. But getting there was precisely the problem. On the way to Kline's home, the ambulance driver had checked with a dispatcher about hospital availability. Mount Auburn was no- go: the emergency room there was overflowing, with no space to handle new patients. So as the paramedics wheeled Kline into the ambulance, one of them told her they would have to deny her request: "Ma'am, we're going to Cambridge Hospital instead." Kline accepted the news, and maybe for a moment she thought it would be for the best. Although Mount Auburn was less than two miles away, Cambridge Hospital was even closer-just a short trip through the crooked, disjointed streets that surround Harvard Square. It was also a highly regarded medical facility in its own right, with a top- notch medical staff and a recently renovated emergency area fully capable of handling the majority of trauma cases that came its way. Had Kline's condition remained as it was, it probably could have handled her case, too. But just four blocks into the journey, Kline's condition suddenly deteriorated. The instruments tethered to her arm could no longer detect a blood pressure; her heart rate, seventy beats per minute just moments before, was down to thirty-eight. Kline, strapped into a stretcher, was conscious through all of this-and increasingly agitated. At her side one of the paramedics, a kind-looking thirty- year-old, tried to calm her, explaining that the hospital was just seconds away. But as the ambulance made a right turn around one final corner, bringing the tall redbrick facade of Cambridge Hospital into view, Kline began to cry out: "I'm going to die. I'm going to die."
It was 5:04 p.m., just twenty-nine minutes after Kline had first called 911 and about an hour into the heart attack, when the green-and-white ambulance pulled up to the emergency bay. Informed of the patient's newly worsened state, attendants hustled the gurney into the hospital as the medical team began administering intravenous medication to increase Kline's heart rate. For a while it looked like she might pull through. Her pulse went back up to forty- five beats per minute-a far cry from normal but at least not "very low," as it had been in the back of the rig. Her breathing was more regular, too. Soon, however, a cardiology exam confirmed that Kline needed catheterization, something the staff at Cambridge Hospital could not do. A nurse began inquiring about available hospitals, but now it was two hours since the chest pains had first begun-and time, finally, was running out. At 6 p.m. Kline's heart stopped altogether. The doctors began performing the familiar ritual of cardiopulmonary resuscitation (CPR), pumping her chest and using electrified paddles to shock the heart back into a regular rhythm. It made no difference. At 7:03 p.m., the trauma team relented. Cynthia Kline was dead.
Fifty-five- year-old women, particularly those who have a family history of coronary disease, die from heart attacks all the time. So as a forensic matter, at least, Kline's death was unremarkable. But the technology that might have kept her alive existed-and it existed at a hospital that was less than five minutes away from her house. There was no guarantee that Mount Auburn's doctors could have saved Kline. Still, as one source familiar with the case told the Boston Globe, whose story on the matter sparked a state investigation, "Within an hour and a half they would have started to open her artery with a catheter. If you get the artery open there's a 50- 50 chance." None of which would be so troubling if the overcrowding at Mount Auburn on that day in November 2000 were an isolated incident. It wasn't. During a one-week period shortly after Kline's death, a survey of seventy- six Massachusetts hospitals found that sixty- seven of them had used emergency crowding procedures or had diverted ambulance traffic. Massachusetts General Hospital (MGH), Boston's largest medical facility, was closing its emergency room to patients forty-five hours per week. On the day of Kline's heart attack, MGH was the next closest hospital with a cardiac catheterization unit-just three miles away. But it wasn't taking new emergency patients that day, either. And even if Kline was the city's only known fatality from ambulance diversion, there was plenty of reason to think that the overcrowding epidemic was routinely jeopardizing the well-being of patients. In 2000, when the Massachusetts College of Emergency Physicians surveyed the directors of more than sixty emergency room (ER) facilities, four out of five said they'd diverted traffic at some point-and nearly 40 percent said overcrowding had led to "adverse outcomes." Sometimes it was a matter of forcing ambulances to drive longer distances in order to find available hospital beds, or, as in Cynthia Kline's case, of shunting people to hospitals less able to provide advanced treatment. And sometimes it meant that patients who got to the right emergency rooms had to wait many hours before receiving treatment. In some cases, patients actually had to wait inside the ambulances.
One thing was certain, though. The crowding problem made little distinction among patients of varying status, wealth, or influence. Bob Maher was the chief executive officer of Worcester Medical Center in central Massachusetts when he had a heart attack in November 2000, during an airplane flight to Boston. Paramedics met him at the airport, but his connections weren't good enough to get him into MGH, which was, once again, on diversion. So the ambulance took him to another hospital several miles away. A woman named Nancy Ridley had her own troubles in the ER in May 2001. Suffering from a high fever and a hacking cough, she spent five hours waiting to be admitted for pneumonia at the Lahey Clinic in nearby Burlington. Ridley suffered no major health setbacks because of the wait, but the all too typical delay was the kind of problem she might have reported to the Massachusetts Department of Public Health-if only she hadn't already been working there, as its assistant commissioner. Boston, in other words, had an emerging public health crisis on its hands. And it wasn't alone. In Atlanta, an ambulance crew carrying a patient in respiratory distress had to pull over and wait on the side of a highway for eighteen minutes because the nearest hospital was full and the paramedics were busy trying to find an alternative. Only when the patient went into full arrest-that is, he stopped breathing altogether-did the closest hospital find a way to take him. That patient lived, but others were not so fortunate. When the mother of a forty- year-old Cleveland man with liver failure called the local community hospital, staff there referred him to the MetroHealth Medical Center, which had more advanced lifesaving facilities. But when the ambulance arrived, MetroHealth was on diversion. The man ended up back at the community hospital, where, fifteen hours later, he died. In suburban Houston, when a twenty- one-year- old man was hit by a car, the local trauma centers turned him away because they had no room. He ended up on a helicopter ride to the next closest trauma hospital-in Austin, more than 150 miles away-and died shortly after arrival…
The United States has not had a serious political discussion about health care reform since the early 1990s. But if the situation in our emergency rooms is indicative, then perhaps it is time for another one. Overcrowding in ERs, according to most experts, is actually a symptom of other systemic problems now plaguing medical care-from the downsizing of less profitable hospital ser vices such as psychiatric wards, where emergency rooms must frequently send patients who need admission, to the swelling ranks of people without health insurance, whose untreated chronic conditions are more likely to become serious medical crises. To the casual observer, these trends might seem unrelated. But they are all consequences of the way Americans pay for their medical care-and of how that system is now falling apart.
It's a system of public and private insurance programs, supplemented by private charity, that dates back to the late 1920s-the time, not coincidentally, when medical care first became so expensive that large numbers of Americans literally could not afford to get sick. And it's a system that has survived for as long as it has because, by the late twentieth century, it had financed a massive industry dedicated to medical care while putting its services within reach of the majority of Americans. As critics have repeatedly noted, these arrangements have never met everybody's needs; the poor, in particular, have frequently struggled to find medical care either through doctors or through safety- net hospitals. But the U.S. health care system has generally worked well enough-or, more precisely, it has worked well for enough people-to withstand efforts at redesigning it.
Probably never was this more conspicuous than in the early 1990s, when President Bill Clinton proposed his now infamous reform plan. Under Clinton's proposal, the government would have made certain everybody had insurance coverage and, along the way, refashioned the whole health care industry-doing for Americans what the Canadian, Japanese, and western European governments have long done for their citizens. But Clinton's gambit failed. And while many critics would later blame its demise on either Clinton himself or the special interests that fought him, a more crucial impediment to reform may have been public ambivalence. Most Americans, after all, still had health insurance in the early 1990s and rather liked it the way it was. When they needed medical care, they got it. To these people, the possibility of losing insurance and the consequences that might follow just didn't seem real enough to warrant such a sweeping overhaul-particularly if it would be at the hands of the government, an institution few people believed was capable of such a massive and complicated undertaking. "I've got pretty good health care and 80 percent of the country has pretty good health care," said one caller on a CNN show in August 1994, summing up a national mood that had turned decidedly against comprehensive reform. "Why are we doing the wholesale changes?" And yet if Americans truly believed they had rejected radical change with Clinton's health care plan, they were in for a surprise. The arrangements for financing medical care, from the private insurance workers got on the job to the public insurance programs that provided for retirees, were already faltering, because they could neither control nor keep up with the rising cost of medical care. The strain was building not just on emergency rooms, but also on charity clinics and public hospitals. Sooner or later, something was going to give.