the emergency care system, but when serious illness or injury strikes, the system they expect to be there may fail them, with catastrophic results. This chapter explains the increasing demands being placed on hospital-based emergency care, describes the nature of the crisis, and explores how it impacts individuals day to day.

In the decade between 1993 and 2003, the United States experienced a net loss of 703 hospitals, an 11 percent decline. The number of inpatient beds fell by 198,000, or 17 percent, and the number of hospitals with EDs declined by 425, a 9 percent decrease (AHA, 2005b). This sharp decline in capacity was largely in response to cost-cutting measures and lower reimbursements by managed care, Medicare, and other payers (discussed below), as well as shorter lengths of stay and reduced admissions due to evolving clinical models of care.

During this same period, the population of the United States grew by 12 percent and hospital admissions by 13 percent. Between 1993 and 2003, ED visits rose from 90.3 to 113.9 million, a 26 percent increase, representing an average of more than 2 million additional visits per year (see Figure 2-1) (McCaig and Burt, 2005). The outcome of these intersecting trends of

FIGURE 2-1 Hospital EDs versus ED visits.

SOURCES: AHA, 2005b; McCaig and Burt, 2005.