My son was born last month, and for the first time in my career I spent three days inside a hospital as a civilian. I have worked in emergency departments for the whole of my adult life, and I thought I knew what the building was like. I did not. On the labor and delivery floor our nurse was in the room almost constantly, bringing my wife juice, repositioning her, checking the monitor, asking what else she could do. Apart from the hours when my wife was not permitted to eat, we never missed a meal, on labor and delivery or on the postpartum floor afterward. The anesthesiologist arrived within minutes of being paged and stayed to make conversation. The room was spacious and comfortable, with a pull-out bed for me, a view, and a menu. Patient experience advocates rounded regularly to ask whether we were happy and whether there was anything the hospital could do. Everyone was rested. Everyone was bright and cheerful. Nobody was kind because the schedule demanded it; they were kind because they had the time to be.
It was foreign to me. I am used to working in the dungeon, among the wailing and the gnashing of teeth, and this felt like a medical hotel by comparison with the dark where physicians like me and our patients are kept. The contrast was stark enough that I found myself, more than once, contemplating a change of career. Then I went back to work a couple weeks later and walked into my own department, two floors down and a universe away. A patient with chest pain was in a hallway bed because the rooms were full of admitted patients waiting for beds upstairs. The nurse covering him had five others. The waiting room held people who had been there since the previous shift. My colleagues were as competent as the obstetric team, and under the circumstances more impressive, since they were accomplishing it with a fraction of the resources. But nobody had time to be kind, and the patients could tell.
I want to be careful about what I am claiming. I am not claiming that the people upstairs are better people, or that the people downstairs are worse at their jobs. The same nurses rotate between units in many hospitals, and they are the same nurses when they do. What changes is the floor. The hospital has decided, deliberately and rationally, that one of these floors deserves its best, and the other deserves whatever is left over. The interesting question is why, and the answer tells you more about American medicine than any amount of legislation does.
Start with the mother. She chose this hospital, and she chose it months ago. She toured it. She compared it to the one across town, asked her friends, read the reviews, and weighed the parking against the private rooms against the reputation of the anesthesia group. She could have gone elsewhere, and the hospital knows it. A birth is the one episode of hospital care that most families plan, and it arrives with something attached: the mother will decide where her children see a pediatrician, where her husband has his hernia repaired, where her parents are admitted when the time comes. The hospital industry's own consultants describe obstetrics as the front door of the health system and cite survey work finding that roughly three mothers in four receive their subsequent care in the system where they delivered.1 Whether that figure is precise or merely directionally true, hospital executives behave as though they believe it, and they build and staff their maternity floors accordingly.
The money follows the same logic. Commercial insurance pays for about half of American births, and it pays well.2 The Health Care Cost Institute compared employer-sponsored payments with Medicaid fee-for-service payments for childbirth across thirty-eight states and found an average gap of 8,732 dollars per delivery, with employer plans paying more in every state examined.3 A birth on commercial insurance is a scheduled, predictable, well-reimbursed admission of a healthy adult who will leave in two days carrying a newborn and a lifetime of goodwill. From a finance office's point of view, there are few better patients in the building.
The staffing standards reflect the same priorities, and they are explicit. The Association of Women's Health, Obstetric and Neonatal Nurses publishes staffing standards that call for one nurse to one patient in active labor, one nurse at the bedside during the initiation of an epidural, one nurse at the bedside throughout the second stage of labor, and two nurses present at the birth, one for the mother and one for the baby.4 The standards were first issued in 2010, updated in 2022, and treated as a baseline rather than an aspiration; in surveys, the great majority of labor nurses report that their hospitals meet them.5 Emergency nursing has no equivalent. The Emergency Nurses Association's own journal published focus-group research this year in which emergency nurses described a one-to-three ratio as the point at which care would stop being missed, which is to say the point they are not reaching now.6 Nothing in federal law, and nothing in the law of most states, requires an emergency department to staff to any ratio at all.
Now go downstairs and look at the patient in the hallway. He did not choose this hospital. The ambulance brought him here because it was closest, or because the one he preferred was on diversion, or because when you are having chest pain you do not shop. He has no tour, no reviews, no comparison, and no leverage. In any sense that another industry would recognize, he is nobody's customer, and the hospital's obligation to him arises from a federal statute rather than from his choice. The Emergency Medical Treatment and Labor Act of 1986 requires every Medicare-participating hospital with an emergency department to screen anyone who presents and to stabilize any emergency condition it finds, regardless of the patient's ability to pay. The statute attaches no funding to the obligation. It is a condition of participating in Medicare, enforced by the threat of exclusion from the program.7
The consequences for the emergency physician have been measured for decades. Ninety-five percent of emergency physicians provide care under this mandate in a typical week, more than a third provide over thirty hours of it, and a figure the College attributes to the federal government's own regulatory analysis puts more than half of an emergency physician's working time into care that is never compensated.8 The hospital's exposure is larger. American hospitals report having provided nearly 745 billion dollars in uncompensated care since the turn of the century, and the emergency department is where most of it enters the building.9 The payer mix tells the rest of the story. In 2022, patients on Medicaid visited emergency departments at a rate of ninety-nine visits per hundred people, patients with private insurance at twenty-one.10 The floor that the law requires the hospital to keep open is, by design and by statute, the floor where the patients who cannot pay are concentrated.
Boarding is the point at which these two facts meet. An admitted patient who waits in the emergency department for an inpatient bed is called a boarder, and the Joint Commission has held for years that boarding should not exceed four hours. In a study of fifty-six emergency departments across seventeen health systems published in JAMA this year, more than half of all patients admitted to general medical care waited at least four hours for a bed, seventeen percent waited four hours or longer without any inpatient team taking over their care, and nearly one percent waited more than a day.11 The delays were longest at large teaching hospitals and at hospitals serving more Medicaid patients. When thirty-five medical organizations wrote to the White House in 2022 to describe boarding as a national crisis, one of their stated themes was that misaligned economic drivers lead hospitals to reserve staff and beds for lucrative elective surgical patients rather than for admissions from the emergency department.12 Emergency physicians polled at the time told the same story in their own words: one described a hospital that had prioritized transfers and surgical admissions over emergency admissions for budget reasons and was boarding patients for 120 to 200 hours a day.13
Observe what this means. A hospital with a full house must decide who waits. The scheduled surgical patient has a surgeon who will take his business across town, an insurer paying a negotiated rate, and a date on the calendar. The laboring mother has a one-to-one nurse by professional standard and a family that chose the hospital on purpose. The emergency admission has a statute. He waits in the hallway, and his waiting is absorbed by the one department that cannot close its doors, cannot turn him away, and cannot be chosen against, because he never chose it in the first place. The emergency department becomes the hospital's shock absorber because it is the only floor whose patients have no exit.
The strongest objection to all of this is that labor and delivery is itself a money loser across much of the country, and that the lavish maternity floor I walked through is a feature of suburban hospitals with commercial patients rather than of obstetrics as such. The objection is correct, and it deserves the full weight of the evidence. Between 2010 and 2022, 537 American hospitals stopped providing obstetric care, 238 of them rural; by the end of that period more than half of rural hospitals no longer delivered babies at all.14 The Chartis Center for Rural Health counted 267 rural hospitals that closed their obstetric units between 2011 and 2021, nearly a quarter of the rural total.15 Medicaid pays for roughly forty percent of American births nationally and for nearly half of rural births, and the people who study these closures name low Medicaid payment, declining volume, and the fixed cost of keeping a delivery unit staffed around the clock as the reasons the units disappear, at a pace one analyst puts at two rural units a month.1617 Even within the hospitals that still deliver, the staffing is uneven: a national survey of more than three thousand labor nurses found that adherence to the staffing standards fell as the share of births paid by Medicaid rose.18
I accept every word of this, and I would ask the reader to notice what it demonstrates. Where mothers arrive with commercial insurance and the freedom to choose, hospitals compete for them and the floor is beautiful. Where mothers arrive on Medicaid, at rates set by a state legislature and in numbers too small to cover the standing cost of the unit, the hospital does the only thing available to a business that cannot raise its price and cannot select its customers: it stops offering the service. Obstetrics under Medicaid behaves exactly like emergency medicine under the federal mandate, with a single difference. A hospital can close its maternity ward. It cannot close its emergency department without ceasing to be a hospital, and so the emergency department is not permitted the dignity of closure. It decays instead. The rural obstetric unit and the urban hallway bed are the same phenomenon at two different stages, and both are what you get when the government fixes the price of a service, forbids the provider to decline it, and then expresses surprise at the result.
Two further objections remain. The first is that obstetric staffing is driven by liability rather than by love, since obstetrics carries some of the largest malpractice awards in medicine and a one-to-one nurse during the second stage of labor is cheap insurance against a catastrophic verdict. There is something to this, but it proves less than it seems. Emergency medicine is also a high-liability specialty, and nobody has responded by staffing emergency departments to a one-to-one standard. Liability concentrates resources where a bad outcome is both likely to be litigated and likely to be attributed to the hospital, and that is a description of where the paying, choosing patient is, not an alternative to it. The second objection is that the comparison is unfair because laboring mothers are healthy, cooperative, and pleasant, while emergency patients are often none of those things, so of course the atmosphere differs. I have spent enough nights in both places to concede the premise. It is also beside the point. The emergency department's difficult patients are the ones the law assigns to it; the maternity floor's agreeable patients are the ones the market delivers to it. The temperament of the clientele is a consequence of the same sorting mechanism, not an independent variable.
The defender of the present arrangement will reply that none of this is an argument against the mandate. Someone must care for the uninsured man with chest pain, and if the hospital will not do so voluntarily then the law must compel it. I have argued before in these pages that the question is never whether care will be rationed but by whom, and that compulsion without payment does not abolish the ration; it moves it out of sight. The man in the hallway is receiving his care. He is also receiving it from a nurse with five other patients, in a corridor, after a wait that a maternity patient would find unimaginable. The mandate made him an obligation rather than a customer, and hospitals treat obligations precisely as well as they are required to and not one degree better. Every attempt to legislate the warmth of the emergency department into existence, through staffing ratios, boarding limits, throughput metrics, and patient satisfaction surveys, is an attempt to simulate by regulation what the labor and delivery floor gets for free from a mother who can walk across town.
That is the lesson I brought back downstairs. The nicest floor in the hospital owes nothing to the hospital's generosity. It is nice because the people on it could have gone somewhere else, and everyone from the chief financial officer to the night nurse knows it. The emergency department will become that kind of place on the day its patients acquire the same power, and on no day before. Until then, I can offer the man in the hallway my competence and my best approximation of patience, and I can tell him honestly that the cheerful floor upstairs is not evidence that the hospital cares. It is evidence of what the hospital does when it has to.
Haskell Editorial Team. Harnessing the Power of the Purse Through Obstetrics. Haskell. October 1, 2019; updated December 8, 2025. https://www.haskell.com/insights/harnessing-the-power-of-the-purse-through-obstetrics/
KFF. State Profiles for Women's Health: Maternal and Infant Health, United States. Births Financed by Medicaid, 2024. https://www.kff.org/interactive/womens-health-profiles/united-states/maternal-infant-health/
Valencia Z, Sen A, Kurowski D, Martin K, Bozzi D. Average Payments for Childbirth Among the Commercially Insured and Fee-for-Service Medicaid. Health Care Cost Institute. June 9, 2022. https://healthcostinstitute.org/all-hcci-reports/average-payments-for-childbirth-among-the-commercially-insured-and-fee-for-service-medicaid/
Simpson KR, Lyndon A, Spetz J, Gay CL, Landstrom GL. Adherence to the AWHONN staffing guidelines as perceived by labor nurses. Nurs Womens Health. 2019;23(3):217-223. https://doi.org/10.1016/j.nwh.2019.03.003
Association of Women's Health, Obstetric and Neonatal Nurses. Standards for Professional Registered Nurse Staffing for Perinatal Units: Executive Summary. https://www.awhonn.org/education/staffing-exec-summary/
Emergency Nurses Association. Study: Emergency Department Staffing Decisions Require More Than a Ratio. January 13, 2026. https://www.ena.org/news-publications/newsroom/study-emergency-department-staffing-decisions-require-more-ratio
Congressional Research Service. Overview of the Emergency Medical Treatment and Active Labor Act (EMTALA) and Emergency Abortion Services. Report IF12355. March 21, 2023. https://sgp.fas.org/crs/misc/IF12355.pdf
American College of Emergency Physicians. The Impact of Unreimbursed Care on the Emergency Physician. https://www.acep.org/administration/reimbursement/the-impact-of-unreimbursed-care-on-the-emergency-physician
American Hospital Association. Fact Sheet: Uncompensated Hospital Care Cost. February 2022. https://www.aha.org/node/451454
Cairns C, Ashman JJ, Kang K. Emergency Department Visit Rates by Selected Characteristics: United States, 2022. NCHS Data Brief No. 503. National Center for Health Statistics. August 2024. https://www.cdc.gov/nchs/products/databriefs/db503.htm
Janke AT, Haimovich AD, Cussen M, et al. Time to inpatient management for boarding emergency department patients. JAMA. 2026;336(11):976-979. https://doi.org/10.1001/jama.2026.13302
American College of Emergency Physicians. Regs and Eggs: November 10, 2022. https://www.acep.org/federal-advocacy/federal-advocacy-overview/regs--eggs/regs--eggs-articles/regs--eggs---november-10-2022
Cerutti E. ED boarding: 10 things to know. Becker's Hospital Review. December 31, 2024. https://www.beckershospitalreview.com/care-coordination/ed-boarding-10-things-to-know
Kozhimannil KB, Interrante JD, Carroll C, et al. Obstetric care access at rural and urban hospitals in the United States. JAMA. 2025;333(2):166-169. https://doi.org/10.1001/jama.2024.23010
Chartis Center for Rural Health. Rural America's OB Deserts Widen in Fallout From Pandemic. December 19, 2023. https://www.chartis.com/insights/rural-americas-ob-deserts-widen-fallout-pandemic
KFF. State Profiles for Women's Health: Maternal and Infant Health, United States. Births Financed by Medicaid, 2024. https://www.kff.org/interactive/womens-health-profiles/united-states/maternal-infant-health/
Vollers AC. 'Expensive and complicated': Most rural hospitals no longer deliver babies. Stateline. June 11, 2025. https://stateline.org/2025/06/11/expensive-and-complicated-most-rural-hospitals-no-longer-deliver-babies/
Simpson KR, Spetz J, Gay CL, Fletcher J, Landstrom GL, Lyndon A. Hospital characteristics associated with nurse staffing during labor and birth: inequities for the most vulnerable maternity patients. Nurs Outlook. 2023;71(3):101960. https://doi.org/10.1016/j.outlook.2023.101960