A major cause for E.R. crowding is the hospital practice of boarding inpatients in emergency departments. This happens when patients who come to the E.R. need to be admitted overnight. If there are no inpatient beds in the hospital (or no extra inpatient nurses on duty that day) then the patient stays in the E.R. long past the completion of the initial emergency work. This is what happened to Green, and it has become widespread and common. The problem is that boarding shifts E.R. resources away from the new patients in the waiting room. . . .

What hospital would promote such a practice? Potentially, those that profit more from boarding, particularly in poorer communities with high numbers of uninsured and Medicaid patients. Imagine you run a hospital. There are two competing sources for inpatient beds. The first source is patients who come in through direct and transfer admissions. They are more likely to come with private insurance and need procedural care, both of which maximize profits. The second source is E.R. patients, who are more likely to be uninsured or have pittance-paying Medicaid and less likely to need high-margin procedures. Do the math: If you fill your hospital with the direct and transfer admissions and maroon the E.R. patients for long periods, you make more money.

The whole point of EMTALA, the law that mandates treatment of ER's, was to make them a zone within the hospital where ability to pay did not affect quality of care. But given that it was an unfunded mandate, it has had a predictable effect: to gradually starve that one zone of egalitarianism of resources that get diverted to other, more profitable parts of the hospital.