How long will we accept patients languishing in the ER as normal? (asks a firsthand witness to ‘boarding’ who’s also a distinguished journalist and an erstwhile ER doctor)
A national intervention into emergency-department boarding is overdue. Can the federal government summon the will—and marshal the resources—to finally drive one?
One can only hope, suggests a former ED physician who traded her stethoscope for a reporter’s notepad and an editor’s pen more than 30 years ago.
Boarding is hospital-speak for when patients get left in the ED, typically on gurneys or in wheelchairs, for many hours—sometimes days—because no inpatient beds are available.
The practice has long been a problem in U.S. healthcare. Now it’s widely considered a public health emergency in its own right.
In recent years, EDs have doubled or even tripled in size, writes Elisabeth Rosenthal, MD, in an essay The Atlantic published April 22.
“Even so,” she adds, “patients are piling up.”
Rosenthal fleshes out the coast-to-coast predicament by combining a reporter’s dispassionate findings with a widow’s stoical remembrances of episodes and incidents related to the theme at hand:
Her late husband, Andrej Mrevlje, suffered many hours as an ED boarder before losing his battle with esophageal cancer in February 2025.
Ground gained and lost
Into the story arc of her late husband’s experiences with ED boarding, Rosenthal weaves a loose chronology of recent actions aimed at addressing the scourge of ED boarding.
Holding the timeline together is a promising sense of mounting momentum that, as of April 2026, seems stalled.
Among the developments she names or alludes to:
- December 2023. The Joint Commission releases a peer-reviewed study showing ED clinicians widely beset by ED boarding’s negative impacts on patient safety, care quality and staff wellbeing.
- January 2025. HHS’s Agency for Healthcare Research and Quality (AHRQ) releases a report calling ED boarding a public health crisis. The report, drawn from a 2024 summit of more than 100 experts, diagnoses the problem in detail and offers solid suggestions for addressing if not outright solving it.
- November 2025. CMS focuses a section on ED boarding in its final rule for Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems. The American College of Emergency Physicians applauds the development.
- March 2026. The healthcare performance-analytics company d2i does a nice job explaining the rule’s ramifications for hospitals with ED boarding troubles. In a nutshell, CMS will encourage voluntary reporting of boarding times in 2027, make the practice mandatory in 2028—and roll out reimbursement penalties for poor performers starting in 2030.
Rosenthal also notes the Trump administration’s slashing of funding for AHRQ starting in April 2025. This came as part of a DOGE-led restructuring of HHS.
By August of last year, most of the agency’s staff had been laid off, and all new grant awards and review panels had been shelved.
Notes from a journey through the boarding maze
Rosenthal’s eloquent writing includes many passages that deserve emphasis as well as repeating. Here are a few examples.
> Once they enter ED boarding, patients exist in a gray zone.
“There has been a national push to establish ‘safe staffing’ nurse-to-patient ratios in EDs,” Rosenthal reports. “Even with that, if an ED boarder has a medical complaint that needs quick attention, it’s easy for them to fall through the cracks.”
> Doctors and nurses have complained bitterly about the situation.
One of ED boarding’s worst unintended consequences is compromising on care quality to the point where moral distress becomes inescapable. “But doctors and department heads … are not in control of admissions,” Rosenthal points out. “Generally, a hospital’s administration parcels out inpatient beds, and emergency-department boarding is in many ways a result of today’s business models and pressures.”
> Unfortunately, admitting patients through the emergency room has business advantages.
“The evaluation generates charges that typically run many thousands of dollars,” Rosenthal notes. “[O]nce admitted, my husband was still billed the inpatient rate even for a stretcher in the hall.”
> During one ED boarding experience, while Andrej waited in the overflow area …
“... we were not thinking of any bigger picture” involving the state of U.S. healthcare, Rosenthal recalls. “He was sick, desperate and still waiting for care. He lingered in boarding for four days before he got a bed. Each time he had to return to the ED, each time he faced a painful wait, he hardened his resolve to never go back.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.