why are hospital visits so expensive

Here's Why Hospital Bills Are So High In The U.S. Health Care System

This is Part 4 of an 11-part series. Read the full series here .

Americans will spend over $4 trillion on health care this year, and the federal government projects that will rise to more than $6 trillion in the next seven years. Health care costs are growing faster than the economy, and a big portion of those bills is paid by employers and those with commercial insurance coverage.

High premiums also mean that employers like Tom Savidge have to keep worrying about how they’ll pay for their company plans.

Ever since Savidge opened his first mental health clinic in Greenville, North Carolina, 17 years ago, he’s struggled to keep up with the cost of his employees’ health care. And one major hospitalization can have a big impact on the bottom line.

“At one point in time, we had an employee who had a heart attack and ended up being in the hospital,” Savidge said. “That year alone resulted in about a 30% increase in just one year.”

Savidge has had to spend a lot more time worrying about health care costs than he first anticipated. He’s offered preventative health programs, and switched insurance providers more than once. He even opened up an on-site pharmacy with lower cost medicines. But he says the bill for employee care has almost tripled since he started out, so he’s had to cut back on other things.

“It definitely impacted raises and bonuses,” Savidge said. “Especially when you had markups of 10, 15, 20, 25% on an annual basis.”

Over the last three decades, the cost of American medical care has more than doubled even after accounting for inflation, according to the Kaiser Family Foundation . And a lot of the burden has fallen on private employers, like Savidge, and those with individual insurance policies, says Gerard Anderson, a health policy professor at Johns Hopkins University. “The private sector is paying four-and-a-half times what the rest of the industrialized countries are paying,” Anderson said, “whereas the Medicare program is paying about one-and-half times.”

The Medicare program sets the rates it will pay based on hospital costs. But private payers have to negotiate with every hospital and doctor. And Anderson says lack of competition is a big part of the problem. Much of the Charlotte region, for example, is dominated by three hospital systems: Atrium Health, Novant Health and the much smaller CaroMont Health. He says that mirrors metropolitan areas across the country.

“If you’re an insurer, you have to have that particular health care system in your network, and so they can charge whatever they want because you, as an insurer, can’t say no,” Anderson said.

Anderson says another problem is that insurance companies may not even be motivated to rein in costs for many large, self-insured company plans because they earn a percentage of the bill.

“They have no incentive — as long as they maintain the business — of getting the lowest price,” Anderson said.

Over the past three decades, hospital systems have been consolidating rapidly, merging with other hospitals and buying up physician practices.

And when hospitals consolidate, prices go up . On average, private insurance plans pay 247% of what Medicare pays, according to the RAND Corp. , a nonpartisan think tank.

And that’s just the national average. North Carolina hospitals charge private payers 273% of Medicare rates, says RAND analyst Christopher Whaley.

South Carolina, where health systems are more highly consolidated, ranks second highest in the country in terms of how much its hospitals charge people with private insurance. On average, hospitals there charge people with commercial insurance 344% of Medicare rates.

“That’s almost a hundred percentage points higher than the national average,” Whaley said.

Hospitals argue consolidation isn’t the problem. Cody Hand, a senior executive with the North Carolina Hospital Association, admits prices for private payers are high, but he said hospitals have to charge them more because Medicare pays too little.

“Medicare is a very low payer across the board,” Hand said. “(For most services) it’s less than 80% of the cost they reimburse. And so because of that, we have to figure out how to collect that difference somewhere else in order to stay open.”

But If that were true, Whaley said, then hospitals with more Medicare patients would have to charge their private patients more. But the data doesn’t show that.

“There’s actually no relationship between a hospital’s share of patients that are on Medicare and Medicaid and that hospital’s prices,” Whaley said.

Another reason prices are high, Hand said, is that hospitals have to spend a lot on salaries and equipment. American doctors and nurses earn more than their counterparts in other wealthy countries. Specialists here make an average of $316,000 a year — more than twice as much as the average compensation in nine comparable countries, according to one 2018 study. And, Hand said, hospitals are willing to pay more to get the top talent.

“The private sector is paying four-and-a-half times what the rest of the industrialized countries are paying, whereas the Medicare program is paying about one-and-half times.”

“ It just goes back to the competition argument,” Hand said. “You know, in order to attract the best you have to pay for the best.”

But studies show large hospital systems are also responsible for pushing up some physician charges. When they buy up doctor practices, hospitals often tack an additional fee onto the doctor’s bill. Hospitals say that additional fee helps cover the cost of operations, but consumer advocates say the charges can run into the hundreds of dollars .

Buying up doctors’ offices can also be very lucrative for large hospitals because those doctors then refer their patients back to the hospital for lab tests and procedures. And Whaley said reimbursement is greater for in-hospital tests.

“If you can move things like lab tests and MRIs from outside the hospital to inside the hospital then you can increase how much you get paid ,” he said.

Duke University law professor Barak Richman said large hospitals can use their market dominance to become even more dominant. As an example, he points to a contract the former Carolinas HealthCare System required insurers to sign. Carolinas HealthCare eventually grew into the 42-hospital system Atrium Health.

“Atrium said, ‘If you’re going to contract with us at all, you have to promise us that you will not steer your patients to lower-cost hospitals,’” Richman said. “So this basically is a contractual provision in which Atrium was exercising its market power. And the Department of Justice thought it was an abuse of its market power and it was anti-competitive.”

After the Department of Justice sued in 2016, Atrium agreed to eliminate the clause. It issued a news release at the time saying it hadn’t broken the law and that the contracts in question were created “as long ago as 2001.” But Richman said that by the time the clause was finally eliminated almost 20 years later, Atrium had become a big player.

Big players can push up costs. Even if they do good things with that income, like invest in medical research, Richman said that it amounts to a tax on everyone with private health insurance.

“It falls on every premium payer like a flat fee,” Richman said. “A family that is earning $40,000 is paying the same in premiums as a family that’s earning $ 4 million.”

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I read 1,182 emergency room bills this year. Here’s what I learned.

A $5,571 bill to sit in a waiting room, $238 eyedrops, and a $60 ibuprofen tell the story of how emergency room visits are squeezing patients.

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For the past 15 months, I’ve asked Vox readers to submit emergency room bills to our database. I’ve read lots of those medical bills — 1,182 of them, to be exact.

My initial goal was to get a sense of how unpredictable and costly ER billing is across the country. There are millions of emergency room visits every year, making it one of the more frequent ways we interact with our health care system — and a good window into the health costs squeezing consumers today.

I started my project focused on one specific charge: the facility fee . I found this charge for walking through an emergency room’s doors could be as low as $533 or well over $3,000, depending on which hospital a patient visited and how severe her case was. I also learned that the price of this charge had skyrocketed in recent years, increasing much faster than other medical prices for no clear reason.

But given the volume and diversity of bills I received, I’ve learned so much more.

I’ve read emergency room bills from all 50 states and the District of Columbia. I’ve looked at bills from big cities and from rural areas, from patients who are babies and patients who are elderly. I’ve even submitted one of my own emergency room bills for an unexpected visit this past summer.

Some of the patients I read about come in for the reasons you’d expect: a car accident, pains that could indicate appendicitis or a heart attack, or because the ER was the only place open that night or weekend.

Some come in for reasons you’d never expect. Like the little girl who swallowed a coin to hide it from her sister, the 12-year-old boy who was hit by a home run ball at a professional baseball game (who, incidentally, was given a $60 ibuprofen at the local children’s hospital), and the adult who ate an entire bag of chocolate candy … without realizing it was edible marijuana. Rest assured, they are all fine!

From our series: A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill.

In so many ways, patients find themselves in a vulnerable position during these encounters with the health care system. The result is often high — and unpredictable — bills. Hospitals are not transparent about the cost of their services, their prices vary wildly from one ER to another, and it’s hard to tell which doctors are covered by insurance (even if the hospital itself is covered). In many cases, patients can’t be certain what they owe until they receive a bill in the mail, sometimes weeks or months later.

I’ve also learned that there is a lot of interest in fixing these types of situations. Since we started this project, multiple senators have introduced bills to prevent surprise emergency room bills — including one directly inspired by our project .

I’ll stop collecting emergency room bills on December 31. But before I do that, I wanted to share the five key things I’ve learned in my year-long stint as a medical bills collector.

1) The prices are high — even for things you can buy in a drugstore

One bill that left an impression on me came from a woman seen in the emergency room the day after her wedding. Her eye was irritated from the fake eyelashes she’d worn the night before, and she worried that her cornea might have been scratched.

The providers checked out her eye, squeezed in some eyedrops, and sent her home. She later got a bill that charged $238 for those eyedrops, a generic drug called ofloxacin. According to GoodRX , a website that tracks drug prices, an entire vial of this drug can be purchased at a retail pharmacy for between $15 and $50.

This is something that I saw over and over again reading emergency room bills: high prices for items that a patient could have picked up at a drugstore.

From our series: Toe ointment, a $937 bill, and a hard truth about American health care

I see this a lot, for example, with pregnancy tests. They happen in emergency rooms for good reason: Doctors often need to know whether a woman is pregnant to determine her course of care. But the prices I’ve seen for pregnancy tests are really high.

The bills in our database include a $236 pregnancy test delivered in Texas, a $147 pregnancy test in Illinois, and a $111 test in California. The highest price I saw? A $465 pregnancy test at a Georgia emergency room. For that amount, you could buy 84 First Response tests on Amazon.

Or look at the price of a common antibiotic ointment called bacitracin (you might know it better by its brand name, Neosporin). The bills in our database show that one hospital in Tennessee charged a patient a pretty reasonable $1 for bacitracin — while another hospital in Seattle charged $76 for the exact same ointment. Since prices aren’t made public, it was impossible for these (or any) patients to know whether they were at a hospital that charges $1 for a squirt of antibiotic ointment or one that charges 76 times that amount.

These bills submitted to our database were in situations where there was not a life-threatening emergency, where a provider presumably could have sent the patient to a place where their drug is available cheaper, often over the counter. But that doesn’t seem to happen. Perhaps emergency room providers don’t know the price of the care they provide, either. Instead, patients are getting drugstore items in the emergency room at a significant markup — and paying higher bills as a result.

2) Going to an in-network hospital doesn’t mean you’ll be seen by in-network doctors

On January 28, 34-year-old Scott Kohan woke up in an emergency room in downtown Austin, Texas, with his jaw broken in two places, the result of a violent attack the night before. Witnesses called 911, which dispatched an ambulance that brought him to the hospital while he was unconscious.

Kohan, who submitted his bill to our database, ended up needing emergency jaw surgery. The hospital where he was seen was in network; he Googled this on his phone right after regaining consciousness. But the jaw surgeon who saw him wasn’t. Kohan ended up with a $7,924 bill from the surgeon, which was only reversed after I wrote about his bill in May.

Kohan’s case is something I see regularly in our database: patients who end up with big bills because they went to an in-network hospital but were seen by an out-of-network doctor.

Here’s how that happens: When doctors and hospitals join a given health insurance plan’s network, they agree to specific rates for their services, including everything from a routine physical to a complex surgery.

Doctors typically end up out of network when they can’t come to that agreement — when they think the insurance plan is offering rates that are too low but the insurer argues that the doctor’s prices are simply too high.

Unless states have laws regulating out-of-network billing — and most don’t — patients often end up stuck in the middle of these contract disputes.

Read more about Kohan’s case: You can’t avoid surprise medical bills, even with a “PhD in surprise billing.”

Academic research has shown that most of these types of bills actually originate from a small number of hospitals.

These bills “aren’t randomly sprinkled throughout the nation’s hospitals,” one New York Times article from July 2017 noted. “They come mostly from a select group of E.R. doctors at particular hospitals. At about 15 percent of the hospitals, out-of-network rates were over 80 percent, the study found.”

These surprise bills appear to be especially common in Texas, where Kohan lives. As many as 34 percent of emergency room visits lead to out-of-network bills in Texas — way above the national average of 20 percent.

And, much like the bills with high prices, these bills are really hard to prevent. Out-of-network doctors won’t often mention that they don’t accept the patient’s insurance; they might not even know. And patients often have little choice about where to receive their care — like Kohan, who needed emergency jaw surgery due to his attack.

3) You can be charged just for sitting in a waiting room

Before I started reporting this project, I knew from my decade as a health care reporter that America has sky-high medical prices. But what I didn’t know was that patients can face steep bills even if they don’t see a doctor or have their ailment treated. They can decline treatment and still end up with a hefty fee.

I learned about this from a bill sent to me by Jessica Pell. She told me about going to an emergency room in New Jersey after she fell and cut her ear. She was given an ice pack but no other treatment. She never received a diagnosis. But she did get a bill for $5,751.

“It’s for the ice pack and the bandage,” Pell said of the fee. “That is the only tangible thing they could bill me for.”

Read more: She didn’t get treated at the ER. But she got a $5,751 bill anyway.

After I saw Pell’s bill, I started looking through our database and finding similar bills from other patients. They all ended up with significant medical bills, in the hundreds or thousands of dollars. These fees were often on top of additional fees from another health care provider where they ultimately did receive treatment.

This is all due to the key fee I’ve been investigating this year: the ER facility fee. This is the fee that ERs charge for walking in the door and seeking care, something akin to a cover charge at a bar.

Hospital executives often argue that these fees help them keep the lights on and doors open for whatever emergency might come in, anything from a stubbed toe to a stroke patient.

But experts who study emergency billing question how these fees are set and charged, noting that they are seemingly arbitrary, varying widely from one hospital to another. A Vox analysis of these fees, published last year, shows that the prices rose 89 percent between 2009 and 2015 — rising twice as fast as overall health care prices.

“It is having a dramatic effect on what people spend in a hospital setting,” says Niall Brennan, the executive director of the Health Care Cost Institute, which provided the data for that analysis. “And as we know, that has a trickle-down effect on premiums and benefits.”

4) It is really hard for patients to advocate for themselves in an emergency room setting

Since I started working on this project, one of the questions I get most frequently is: How do I avoid a surprise ER bill? Or how can I get my ER bill lowered?

I wish I had a good answer, but I don’t. Patients are usually at the mercy of the hospital when it comes to ER billing.

I have talked to some patients who have successfully negotiated down their emergency room bills. Most of those people applied for financial aid, requested a prompt pay discount, or found an error on their bill.

From our series: An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay.

Some especially savvy patients have even had luck arguing that their facility fee charge was coded incorrectly — that the hospital used a billing code that should be reserved for really intense, complex visits when their visit was actually pretty simple. I’ve noticed that these patients tend to have a doctor in their family who can help them make this type of argument.

Most patients who have successfully negotiated down a bill tell me it wasn’t easy. Erin Floyd from Florida told me about her experience reducing two of her daughter’s bills — one by 90 percent and one by 45 percent — through a combination of financial aid and prompt care discounts.

On the one hand, she was happy to have the bills lowered. In total, she ended up saving $4,369. On the other hand, the whole process was exhausting. There were lots of phone calls and faxes involved.

“I spent at least three hours on the phone working on this,” she says. “I was scanning, faxing, emailing, all while I was at work.” Over email, she described it as an “incredibly stressful and long process.”

And then there are, as Slate has noted , patients who have had their bills reversed after journalists wrote about them. Our project, for example, has resulted in $45,107 in medical bills being reversed after Vox began inquiring about those charges.

But for all of investigative journalism’s merits, reporters writing about medical bills isn’t a great solution for the health care system’s woes.

What stands out to me is that in all these cases, it’s essentially the hospital that gets to decide whether it wants to negotiate or reverse a bill. And if a hospital says no? If it won’t change the facility fee code, or doesn’t offer a prompt payment discount? The patient is essentially stuck. The hospital has the trump card: It can send the bill to a collection agency, a move that could devastate a patient’s credit. In those situations, there isn’t anything a patient can do to stop them.

5) Congress wants to do something about the issue

As more journalists write about ER bills, there is a growing outcry on Capitol Hill — and more senators on both sides of the aisle who want to do something about it.

There are now two proposals in Congress that would make the types of bills I write about a thing of the past. One comes from Sen. Maggie Hassan (D-NH) and another from a bipartisan group of senators including Sens. Bill Cassidy (R-LA) and Claire McCaskill (D-MO).

“It’s unacceptable”: Sen. Maggie Hassan explains her plan to end surprise ER bills.

While the two bills aim to do the same thing (prevent surprise bills in the emergency room), they take different policy approaches. The Cassidy-McCaskill proposal essentially bars out-of-network providers from billing patients directly. Instead, they would have to seek payment from the health insurer, who would be required to pay a price similar to local market rates. ( I’ve written in greater detail about how this works .)

Will either of these bills become law? It’s hard to tell. On the one hand, the safest bet with Congress is often inaction. But this issue seems to be gaining momentum. Just this week, for example, a large coalition of health plans and consumer advocates put out a statement supporting federal action on the issue. What’s more, there is bipartisan interest in working on this — making it the rare issue that just might bring Democrats and Republicans together on health care.

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Hospitals kept ER fees secret. We uncovered them.

• Emergency rooms are monopolies. Patients pay the price.
• The problem is the prices
• I started collecting ER bills. The American Hospital Association started warning its members.
• “It’s unacceptable”: Sen. Maggie Hassan explains her plan to end surprise ER bills
• Prices at Zuckerberg hospital’s emergency room are higher than anywhere else in San Francisco
• A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill.
• Why a simple, lifesaving rabies shot can cost $10,000 in America
• An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay
• She didn’t get treated at the ER. But she got a $5,751 bill anyway.
• Toe ointment, a $937 bill, and a hard truth about American health care
• He went to an in-network emergency room. He still ended up with a $7,924 bill.
• A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills
• After Vox story, Zuckerberg hospital rolls back $20,243 emergency room bill
• Hit by a city bus — and hit with a $27,660 city hospital bill
• After Vox story, California lawmakers introduce plan to end surprise ER bills
• A spinal surgery, a $101,000 bill, and a new law to prevent more surprises
• How to fight an outrageous medical bill, explained
• After Vox stories, Zuckerberg Hospital is overhauling its aggressive billing tactics
• After Vox reporting, California moves forward on plan to end surprise ER bills

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How much does an ER visit cost?

$1,500 – $3,000 average cost without insurance (non-life-threatening condition), $0 – $500 average cost with insurance (after meeting deductible).

Average ER visit cost

An ER visit costs $1,500 to $3,000 on average without insurance, with most people spending about $2,100 for an urgent, non-life-threatening health issue. The cost of an emergency room visit depends on the severity of the condition and the tests, treatments, and medications needed to treat it.

Cost data is from research and project costs reported by BetterCare members.

Emergency room visit cost with insurance

The cost of an ER visit for an insured patient varies according to the insurance plan and the nature and severity of their condition. Some plans cover a percentage of the total cost once you meet your deductible, while others charge an average co-pay of $50 to $500 .

The No Surprises Act , effective January 1, 2022, protects insured individuals from unreasonably high medical bills for emergency services received from out-of-network providers at in-network facilities. The act also established a dispute resolution process for both insured and uninsured or self-pay individuals.

Cost of an ER visit without insurance

An ER visit costs $1,500 to $3,000 on average without insurance for non-life-threatening conditions. Costs can reach $20,000+ for critical conditions requiring extensive testing or emergency surgery. Essentially, the more severe your condition or issue, the more you are likely to pay for the ER visit.

Factors that impact ER visit costs

Many factors affect the cost of an ER visit, including:

Facility type – Freestanding emergency departments often cost 50% more than hospital-based emergency rooms.

Time of day – An ER visit at night typically costs more than the same type of visit during the day.

Level of care – The more severe your condition is, the more time and expertise it takes to diagnose and treat, and the higher the total ER visit cost.

Ambulance ride – An ambulance ride costs $500 to $1,300 on average, depending on whether you need basic or advanced life support during transport.

Medications – Oral medications, injections, or IVs needed during your stay all add the total cost of your ER visit.

Medical equipment & supplies – Any other supplies used to diagnose and treat you—such as a cast for a broken bone or bandages and sutures to close an open wound—increase the cost.

Testing – Each medical test is typically a separate charge. Tests may include urine tests, blood tests, X-rays, or other more advanced imaging tests.

Insurance coverage:

Out-of-pocket costs may be higher for those with high-deductible insurance plans.

While ER visit costs are generally higher for the uninsured, many hospitals offer discounts for self-pay patients.

ER facility fee by level

An ER facility fee ranges from $200 to $4,000 , depending on the severity level of your symptoms and condition. The facility fee is the cost to walk in the door and be evaluated by a physician. Other services you may need, such as lab tests, imaging, and surgical procedures, are charged separately.

To understand your ER bill: Emergency rooms rank severity levels 1 through 5, with Level 1 being the most severe or urgent. However, most of the billing codes for emergency room visits are reversed, with level 1 being the least severe.

Common conditions and procedures

The table below shows the average ER visit cost for common ailments. Prices vary greatly depending on how much testing and expertise is required to accurately diagnose and treat you.

Emergency room vs. urgent care

An ER visit costs $1,500 to $3,000 , while the average urgent care visit costs $150 to $250 without insurance. Urgent care facilities can treat most non-life-threatening conditions and typically have less wait time than the ER. For more detail, check out our guide comparing the cost of an emergency room vs. urgent care .

Other alternatives to the ER for less serious health issues include primary care, telemedicine, and free clinics. Check with the National Association of Free and Charitable Clinics to find a free clinic near you.

FAQs about ER visit costs

Why are er visits so expensive.

ER visits are expensive because emergency rooms run on a 24-hour schedule and require a large and wide range of staff, including front desk personnel, maintenance, nurses, doctors, and surgeons. ERs also run and maintain a lot of expensive equipment and need a constant supply of medications and medical supplies.

While ER visits can be expensive, ER bills are negotiable. If you receive an unexpectedly large ER bill, ask for a discount and question the coding.

Does insurance cover ER visits?

Insurance typically covers some or all of an ER visit, though you may need to meet a deductible first, depending on the plan. The Affordable Care Act requires insurance providers to cover ER visits for "emergency medical conditions" without prior authorization and regardless of whether they are in or out-of-network.

An "emergency medical condition" is considered something so severe that a reasonable person would seek help right away to avoid serious harm.

When should you go to the ER?

You should go to the ER for any serious, potentially life-threatening symptoms, including:

Trouble breathing

Serious head injury

Sudden severe pain

Severe burn

Severe allergic reaction

Major broken bones

Uncontrollable bleeding

Suddenly feeling weak or unable to move, speak, or walk

Sudden change in vision

Sudden confusion

Fever that does not resolve with over-the-counter medicine

Tips to reduce your ER bill

An ER visit can cost thousands of dollars, even if you have insurance. Here are some guidelines to ensure you are not overpaying:

Determine if you truly need an emergency room. If your health issue is not life threatening, consider going to an urgent care facility instead as the cost for the same care can be much less.

Go to a hospital-based ER. Freestanding ER centers typically cost much more than a hospital-based emergency room.

Call ahead to confirm payment options and the current wait time.

Ask about costs up front. If you are uninsured, consider asking the following questions to prevent you from surprises on your future bill:

Do you have discounted pricing for patients without insurance?

Will it cost less if I pay with cash?

What will the fee be for my specific issue?

Do you think I will need additional tests, and what will they cost?

How much do you charge for X-rays?

If I need medication, how much will it cost?

We use our proprietary database of project costs, personally contact industry experts to compile up-to-date pricing and insights, and conduct in-depth research to ensure accuracy in all our guides.

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The Costs of US Emergency Department Visits

The US population made 144.8 million emergency department (ED) visits in 2017, costing a total of $76.3 billion, estimated a recent statistical brief from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP).

That year, 13.3% of the US population incurred an expense for an ED visit, and more than half of hospital inpatient stays originated with an ED visit. More than half of 2017 ED costs for the entire US, $39.5 billion, were incurred in large metropolitan areas. Aggregate ED visit costs and share of ED visit volume were highest for hospitals in the South. (ED charges were converted to costs using HCUP Cost-to-Charge Ratios based on Centers for Medicare & Medicaid Services hospital accounting reports.)

Read More About

Rubin R. The Costs of US Emergency Department Visits. JAMA. 2021;325(4):333. doi:10.1001/jama.2020.26936

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Health Spending

• Quality of Care

Access & Affordability

• Health & Wellbeing
• Price Transparency
• Affordability
• Prescription Drugs

Emergency department visits exceed affordability threshold for many consumers with private insurance

By Hope Schwartz Twitter ,  Matthew Rae Twitter ,  Gary Claxton ,  Dustin Cotliar,  Krutika Amin , and  Cynthia Cox Twitter

December 16, 2022

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Introduction

The high cost of emergency care may impact patients’ ability to afford treatment , with almost half of US adults reporting they have delayed care due to costs. Almost 1 in 10 Americans have medical debt , and about half of American households do not have the liquid assets to afford an average employer sponsored plan deductible. More than one third of US adults are unable to afford a $400 medical expense without borrowing.

Costs of medical emergencies present an additional financial burden on top of already costly health insurance premiums ranging $1,327 for single coverage and $6,106 for family coverage, on average, for workers with employer sponsored insurance. Variation in emergency department billing may make it difficult to predict the cost of an emergency department visit and subsequent financial liability. Recently, the No Surprises Act legislation aimed to curb unexpected emergency medical costs by prohibiting out-of-network billing for emergency services.

In this analysis, we use 2019 insurance claims data from the Merative MarketScan Commercial Database, which captures privately insured individuals with large employer health plans. We look at the total and out-of-pocket costs of emergency department visits for this group, overall and by diagnosis and severity level. We also look at which services contribute most to the costs of emergency department visits and examine regional variation in emergency department costs. Finally, we look at the demographic profile of consumers who visited the emergency department and the relationship between emergency department spending and annual spending for enrollees.

We find that enrollees spend $646 out-of-pocket, on average, for an emergency department visit. Enrollees with high annual health spending were more likely to visit the emergency department; the majority of enrollees in the top 10% of annual health care spending had at least one emergency department visit during the year. The most expensive components of most emergency department visits include evaluation and management charges, imaging, and laboratory studies, and facility fees make up 80% of the cost of visits. Cost varies by disease, visit complexity, and geographic region.

Large employer plan enrollees’ emergency department visits cost $2,453, on average, with enrollees responsible for $646 in out-of-pocket costs

On average, enrollees in large employer health plans who have an emergency department visit spend $646 out-of-pocket on the visit. There is significant variation in emergency department spending, with 25% of visits costing over $907 out-of-pocket and another quarter costing less than $128 out-of-pocket. These out-of-pocket costs for a single emergency department visit may be more than some people with private insurance can afford and, in some cases, could entirely deplete a consumer’s savings. For example, about 1-in-5 people (21%) with private insurance living in single-person households have less than $1,000 in liquid assets.

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These amounts only include out-of-pocket spending required by the insurer. Before the No Surprises Act went into effect in January 2022, privately insured patients who visited the emergency department frequently had out-of-network claims on their visit, putting them at risk of providers sending them surprise balance bills. The No Surprises Act now prohibits most surprise out-of-network billing, but does not apply to ground ambulances . Any balance bill that a patient received from a provider would not appear in claims data and therefore would have been in addition to the out-of-pocket amounts shown here.

In total, enrollees and insurers paid $2,453, on average, per visit, with one quarter of visits costing $970 or less and another quarter costing $3,043 or more. All the costs described in this analysis are for the emergency department visits only, including professional services and facility fees, and do not include any spending on subsequent hospitalizations.

Facility fees contribute significantly more than professional fees to total visit cost

Emergency department bills are categorized as facility fees or professional fees. Professional fees are for services provided by clinicians, and facility fees include bills for services rendered using equipment owned by the facility, including laboratory or imaging studies. These fees are considered “overhead” for emergency departments and help facilities maintain appropriate staffing levels and technical resources. Evaluation and management charges also have a facility fee component for the equipment, staffing, and administrative resources used by the physician in their management. We find that facility fees make up 80% of total visit cost.

Evaluation and management charges make up the largest share of costs

Including both the professional fee and facility fee components of charges, the largest contributor to spending on a typical emergency department visit is the evaluation and management charge, which accounts for almost half (44%) of average visit costs. Evaluation and management charges are bills for the assessment of a patient that are not related to specific procedures or treatments provided; these services cost over $1,100 per visit, on average.

Imaging charges, including radiologist interpretation fees, make up an additional 19% of the average emergency department visit charge and cost $483, on average. The highest cost routinely performed imaging services include x-rays of the chest and CT scans of the head, chest, abdomen, and pelvis. Over half of visits (55%) include a charge for imaging services. About half of patients (49%) are charged for laboratory studies, including blood tests, which cost $230 on average. Other high cost but less common charges include surgical charges for patients with appendicitis and other conditions requiring surgery without inpatient admission, as well as ambulance charges for transport.

Heart attacks and appendicitis among the most expensive common conditions treated in the emergency department

Costs of emergency department visits depend on diagnosis. We selected nine common reasons to visit the emergency department that vary in complexity of management. More severe conditions, or those with more intervention required, are the most expensive. Of the nine specific diagnoses that we evaluated, the lower-cost diagnoses were those that generally do not require imaging or extensive treatment in the emergency department. These included upper respiratory tract infections ($1,535 total, $523 out-of-pocket), skin and soft tissue infections ($2,005 total, $572 out-of-pocket), and urinary tract infections ($2,726 total, $683 out-of-pocket). While these diagnoses can occasionally require admission to the hospital, in otherwise healthy adults they are typically evaluated with basic laboratory studies and discharged with prescriptions.

The most expensive emergency department diagnosis among those we examined is appendicitis, which, on average, costs $9,535 ($1,717 out-of-pocket) per visit. Appendicitis is almost two times as expensive as the next most expensive diagnosis we looked at, heart attack. 11% of enrollees with a diagnosis of appendicitis had surgical charges associated with their emergency department visit. Surgical costs may be included in emergency department outpatient billing because these patients are often discharged after surgery without being admitted to the hospital. In contrast, other emergency department visits requiring surgery are often admitted to the hospital and have surgical charges during their inpatient visit. Enrollees who had surgery had more expensive visits by over $2,000 compared to those who did not; however even without surgery, visits for appendicitis were almost four times as expensive as the average emergency department visit (and more than twice as expensive out-of-pocket).

Enrollees with emergency department visits have variable annual spending depending on diagnosis

In addition to the costs of the emergency department visit itself, enrollees who visit the emergency department at least once during the year have higher annual health care spending. Annual spending includes the cost of all claims for each patient in 2019, either before or after their emergency department visit. Though appendicitis was the most expensive emergency department visit among the diagnoses we analyzed, enrollees with appendicitis in 2019 incurred an average of $24,333 in additional health care spending, which was comparable to lower cost diagnoses. Enrollees with heart attacks had at least two times more annual spending than any other diagnosis ($52,993), while enrollees with upper respiratory tract infections had the lowest annual spending ($13,727).

These differences in annual costs may reflect spending both directly related and unrelated to the emergency department visit. For example, enrollees with heart attack emergency department visits may have high annual spending because of follow-up, medications, or hospitalizations after their heart attacks. However, their high annual spending may also reflect more comorbidities and higher healthcare utilization at baseline. In contrast, appendicitis, the most expensive emergency department visit, is correlated with relatively lower annual costs; unlike heart attacks, appendicitis often occurs in younger, healthier people and requires comparatively little additional post-surgical follow-up or treatment.

The most complex emergency visits are more than 6 times as expensive as the least expensive visits, but insurers pay an increasing share of the visit as complexity increases

Emergency department visits are coded by complexity during the billing process, from 1 (least complex) to 5 (most complex). Each evaluation and management charge is associated with a procedure code ranging from level 1 to level 5 (99281 to 99285), which are generated by hospital coding professionals based on the physicians’ medical note. Criteria are defined by the Centers for Medicare and Medicaid Services ( CMS ) and based on the complexity of documentation and medical decision making. Patients with level 1 complexity codes require straightforward medical decision making, with self-limited or minor presenting problems, such as rashes or medication refills. Patients with level 5 codes require high complexity medical decision making and present with life- or limb-threatening conditions, such as severe infections or cardiac arrests.

The lowest complexity visits cost $592 on average, with enrollees responsible for $205, or about one-third of the total visit cost. As visits increase in complexity, both out-of-pocket costs and costs covered by insurance increase. For the highest complexity visits, the health plan covers $3,015 on average, or eight times the cost of the lowest complexity visits. On average, patients pay $840 out-of-pocket for the highest complexity visits, which is four times their out-of-pocket costs for the lowest complexity visits.

Higher complexity visits are more expensive for multiple reasons. In general, evaluation and management charges are higher cost for more complex patients. Also, patients with more complex medical conditions generally receive more diagnostic tests, medication, and other treatment, which increases the cost of the visit. For the lowest complexity visits, evaluation and management charges account for almost half (47%) of the overall visit cost. In contrast, evaluation and management charges for the highest complexity visits account for about one-fourth (27%) of the total visit cost, with additional services including tests and treatment making up a larger share of the cost.

Emergency department costs vary by geographic region

We analyzed the top 20 metropolitan statistical areas (MSAs) by population, where data are available. Overall, the San Diego, CA area had the most expensive average ED visits ($3,761 on average). San Diego ED visits were more than twice as expensive as Baltimore, MD, the least expensive MSA in our analysis ($1,645 on average). Expensive MSAs were geographically distributed in all regions of the country including the South, West, Northeast, and Midwest. Within each MSA, there was significant variation in visit costa. For example, 25% of visits in Oakland, CA cost less than $1,236 on average, while 25% cost more than $4,436 on average.

Some variation may be based on the distribution of diagnoses in each area, with more serious or complex diagnoses leading to higher cost visits. For example, if a metro area sees higher than average volume of appendicitis, heart attacks, or other high-cost diagnoses, that would drive up regional emergency department costs.

For common diagnoses, Texas and Florida MSAs are among the most expensive

If we examine costs for specific diagnoses, we can minimize some of this variation in reasons for visits and gain a better understanding of how prices and service intensity affect the rankings. We selected two common, moderate-cost reasons for emergency department visits: low back pain and lower respiratory infections. While these visits can range in complexity and treatment required, they usually do not require hospital admission or high-cost treatment. Low back pain includes patients who present with the symptom of low back pain, regardless of diagnosis. Lower respiratory tract infection includes infectious causes of pneumonia and bronchitis. This analysis was limited to MSAs in which there were >500 cases of each diagnosis in 2019.

Visit costs for both diagnoses in Dallas, TX, Houston, TX, Fort Worth, TX, and Orlando, FL are in the top five most expensive MSAs with >500 cases. For low back pain visits, the Orlando, FL, Fort Worth, TX, Dallas, TX, and Houston, TX areas are each more than twice as expensive as the Warren, MI and Detroit, MI areas, on average. This trend is similar for lower respiratory tract infections. Within MSAs, variation in costs exist for both diagnoses. For example, for low back pain visits, there is more than a $3,000 difference between the least expensive and most expensive quarter of visits in Fort Worth, TX, Dallas, TX, and Houston, TX.

12% of large employer group enrollees went to the emergency department in 2019

We find that 12% of large group enrollees under age 65 had at least one emergency department visit in 2019, and of enrollees with emergency department visits, 80% had only one visit. 20% had more than one visit, and 7% had more than two visits. Emergency department visits were associated with higher annual health care spending, with almost half of enrollees in the top 25% of annual spending having at least one emergency department visit during the year.

We find that the average emergency department visit exceeds the threshold that some consumers can pay without borrowing, and even one emergency department visit in a year may create financial hardship for enrollees in large employer plans. For example, one quarter of emergency department visits for large employer enrollees cost over $907 out-of-pocket. Meanwhile, about 1-in-5 people with private insurance do not have $1,000 in liquid assets, and almost half of US adults report that they would not be able to pay a $500 medical bill without going into debt. Emergency department visits range significantly in cost depending on diagnosis, visit complexity, and geographic area. These variations may present challenges for consumers trying to predict the cost of their emergency department visit prior to going to the emergency department.

Several factors contribute to the variability of emergency department charges. First, unlike other forms of outpatient care including primary care or urgent care visits, emergency departments charge facility fees to offset the cost of keeping emergency departments open and staffed 24/7. These fees vary widely and are increasing at a faster rate than overall health care spending. The facility component represented 80% of total emergency department spending in our analysis. Many hospitals and health care providers consider these costs necessary given their mandate to provide emergency triage and treatment to allcomers. A second contributor to variation is that services are often billed at different complexity levels, and visits that are billed as more complex are more expensive . In some cases, even similar services are billed at different prices by different facilities. Notably, surprise out-of-network medical bills from emergency departments have contributed to high emergency costs for consumers, though the cost of any balance bills would be outside the scope of our claims data. The implementation of the No Surprises Act in January 2022 will generally curb surprise medical billing for emergency care.

As seen in non-emergency spending , we find that emergency department costs vary by geographic area. Among the most expensive MSAs in our analysis were MSAs located in Texas, Florida, California, Colorado, and New York. Interestingly, the most expensive regions for ED care do not align with the most expensive regions for overall health care spending. These comparisons suggest that our findings are not solely related to overall high health care prices in these areas and may reflect other factors including the age and medical complexity of the population or differences in local norms and practice patterns. State-level emergency department regulation may also play a role—states with higher numbers of freestanding , non-hospital affiliated emergency departments (which are associated with higher spending on emergency care) were among the most costly in our analysis.

The financial implications of visiting the emergency department vary widely. Not all the variation in total charges is reflected in out-of-pocket costs, since differences in cost by complexity level are smaller after insurance covers its portion of the bill. However, the most complex emergency department visits have four times higher out-of-pocket costs than the least complex visits. Even the least complex visits, some of which could be treated by a primary care office or urgent care center, cost an average of $205 out-of-pocket ($592 total). Given facility fees and relatively high evaluation and management charges in emergency departments, insurers and patients are paying more when receiving care for these conditions at emergency departments than they would using primary or urgent care. These lower complexity visits may represent a substantial avoidable cost to patients and the health care system at large.   

High health care costs are of foremost concern for US adults, leading people to skip recommended medical treatment or delay necessary care. Even in the era of new price transparency regulation , which aims to improve consumer access to prices for elective care, emergency department consumers often do not know what testing or treatment they will need, so it is difficult to assess the costs of a visit upfront. Further, in an emergency situation, patients may not be able to choose their provider or facility if they are brought in by ambulance or otherwise unable to direct their care. Lastly, lack of availability and standardization in data may make it difficult for patients to use price transparency data in real time to make decisions about accepting tests and treatment in an emergency. The high and variable cost of emergency department visits represents an opportunity for future policy changes to protect consumers from unaffordable medical bills.

This analysis is based on data from the Merative MarketScan Commercial Database, which contains claims information provided by a sample of large employer plans. Enrollees in MarketScan claims data were included if they were enrolled for 12 months. This analysis used claims for almost 14 million people representing about 17% of the 85 million people in large group market plans (employers with a thousand or more workers) from 2004-2019. To make MarketScan data representative of large group plans, weights were applied to match counts in the Current Population Survey for enrollees at firms of a thousand or more workers by sex, age, state, and whether the enrollee was a policy holder or dependent.

Emergency department visits were flagged if an enrollee had an emergency department evaluation and management claim in the emergency department or the hospital on a given day. If an enrollee had either an emergency evaluation and management claim or another claim originating in the emergency department on the day prior to or after the flagged day, we added the previous and or following day’s outpatient spending to the visit cost. This was to capture all emergency department services for visits that may have spanned overnight or multiple days. Over half (53%) of the spending in this analysis occurred in the emergency department, with another 42% occurring in the hospital, which may occur when a patient receives a test or procedure in a location outside the emergency department during their visit.

Claims were included if they were above $100 and below the 99.5 th percentile of cost. Selected conditions were generated from a literature review of common emergency department diagnoses and defined using ICD10 codes. Enrollees were considered to have a certain diagnosis if the relevant ICD10 code appeared in the “Diagnosis 1” column in one or more claims on an emergency department visit day. While emergency department claims have up to four diagnoses, diagnoses listed in 2-4 were not used to identify relevant conditions because these diagnoses were most often incidentally found rather than related to the reason for presenting to the emergency department. For specific diagnosis definitions: Heart attack includes acute STEMI and NSTEMI, and excludes complications from prior heart attacks or angina; UTI includes acute cystitis, UTI and pyelonephritis; Kidney stone includes renal calculus in any location and renal colic; Lower respiratory infection includes pneumonia and bronchitis. Surgical charges for acute appendicitis include both open and laparoscopic surgical charges. Annual spending was defined as the total spending for each enrollee in the year 2019, which could occur before and/or after their emergency department visit depending on the time of year of the emergency department visit.

This analysis has some limitations. First, there is a chance that we could incorrectly include non-emergency outpatient care (such as a next-day, follow up primary care appointment) in our estimate of emergency department visit costs. Secondly, when accounting for annual spending, we do not control for health status prior to the emergency department visit. Therefore, the increase in annual health spending for patients who visit the emergency department for certain conditions may be because these patients are sicker and higher healthcare utilizers at baseline, rather than specific follow-up costs incurred for the emergency department visit itself. For selecting relevant diagnoses, we only include claims in which a particular diagnosis occurs as the primary diagnosis. Third, the MarketScan database includes only charges incurred under the enrollees’ plan and do not include balance billing to enrollees which may have occurred. Lastly, our findings only represent enrollees in large group employer sponsored plans and may not be generalizable to other groups.

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The Peterson Center on Healthcare and KFF are partnering to monitor how well the U.S. healthcare system is performing in terms of quality and cost.

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The Surprise Hospital Fee You May Get Just for Seeing a Doctor

'facility fees,' common to hospitals, are spreading to doctor practices, clinics, and surgery centers. here's how to fight them., sharing is nice.

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When Dan Sokol saw an orthopedist for shoulder pain in January 2018, he got an X-ray and then a cortisone shot to treat what the doctor said was bursitis. It all took less than 30 minutes at the doctor's office, and his shoulder pain went away.

So a few weeks later when Sokol, a 61-year-old bank credit officer who lives in Los Angeles, got a bill with more than $3,000 in charges from Cedars Sinai Medical Center, a hospital near his doctor's office, he was sure there was a mistake.

His health insurance covered most of the $1,700 charge for the exam, X-ray, and injection. But there was an additional $1,375 fee for hospital operating-room services even though he wasn't treated in the hospital. His insurance covered only a small portion of that fee, leaving him on the hook for $1,039.  

Sokol's insurer said there was no error, though. That's because the doctor he saw works for Cedars Sinai Medical Center, a major hospital in LA. Hospitals can charge a facility fee for services provided by any healthcare provider it employs and at any facility it owns, even if the patient never sets foot in the hospital.

Sokol eventually got the facility fee reduced to $700, which he paid. But he calls the charge outrageous. "If I was told that ridiculous facility fee would be charged, I would have declined having the injection and gotten it somewhere else," Sokol says. 

Steep hospital facility fees aren't new. Federal regulations have long allowed hospitals to charge patients a fee, on top of the tab for medical services, to help cover the high cost of running a hospital.

What is new is that patients are increasingly getting hit with facility fees when they get care outside of a hospital. It's happening because hospitals are rapidly building or buying up not only doctor practices but also urgent-care centers, walk-in clinics, and standalone surgery complexes—pretty much all the places one might go to get healthcare.

As hospitals turn into healthcare behemoths, the ability to choose a doctor or health services provider who is independent from a major hospital system in your region is shrinking.

It's often not obvious to a patient that a doctor is employed by a hospital or that a facility is owned by a hospital, which is why getting billed for a hospital facility fee can be so surprising . It's especially painful for people who must meet high deductibles before their insurance starts to cover some of the bill.

While facility fees vary widely by hospital and service provided, they can add hundreds or thousands of dollars to a medical bill. The fees are often high relative to the cost of the service provided. In an example cited in Health Affairs, an academic health policy journal, a patient was charged $1,100 for a 30-second procedure to determine whether she had fungus under her toe. The facility-fee portion of the bill turned out to be $418, almost 40 percent of the bill.

Hospitals say they need to impose facility fees over their entire network to offset the cost of providing access to care 24/7 to anyone who comes through the doors of their hospital, regardless of the ability to pay.

"The cost of care delivered in hospitals and health systems takes into account the unique social good that only they provide," says Ashley Thompson, senior vice president of policy at the American Hospital Association.

Thompson says a hospital outpatient facility is also costlier to run because these facilities tend to treat patients who are sicker and because they must meet stricter regulatory standards than independent healthcare providers.

But consumer advocates, health policy experts, and regulators say that the fees are poorly disclosed and that it's unfair for patients to pay more than they would at an independent healthcare provider for the same services.

Patients see little benefit when they get outpatient services by doctors or facilities affiliated with large hospital systems, says Aditi Sen, an assistant professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore. Sen is studying how facility fees affect patient care.

"The data we have shows that these big healthcare systems aren't raising quality, but they're raising prices," Sen says. "We have to ask what you are getting for the additional fees."

Why Facility Fees Are Spreading

The revenue from facility fees is a major reason hospitals want to own doctor practices and offer outpatient services, says Christopher Whaley, a health policy researcher at RAND Corporation, a nonprofit policy think tank. Whaley says hospitals also benefit because hospital-employed doctors are encouraged to make referrals to other doctors or to order tests at health service providers owned by the hospital that pays their salary.

Many doctors are happy to leave private practice because of the high overhead and heavy administrative obligations, says Fred Bentley, a managing director at Avalere, a healthcare industry consulting firm. Physicians who are part of a big hospital network deal with fewer of those burdens, and they benefit from being part of a big hospital network with more leverage negotiating prices with private insurers.

The transformation is happening fast. About 45 percent of all physicians work for hospitals today, up from 25 percent in 2012, according to a recent study  [PDF] by Avalere Health and the Physicians Advocacy Institute, a nonprofit organization representing physician groups. The study also found that hospitals own 31 percent of doctor practices, up from 14 percent in 2012.

At the same time, hospitals are aggressively getting into outpatient services because that's where consumers are going. Hospitalizations are declining as consumers seek out less costly, more convenient care in outpatient settings, such as surgery centers, walk-in clinics, and imaging centers, Bentley says.

Hospital outpatient visits have grown from about 600,000 a year in 2000 to 800,000 in 2017, according to the American Hospital Association 's 2019 Hospital Statistics report. At the same time, inpatient hospital admissions have stagnated at about 34,000 annually. 

Hospitals are expanding into outpatient services at a fast pace. HCA Healthcare—the largest for-profit hospital chain in the U.S., with 165 hospitals—has increased the number of urgent care centers it owns by 40 percent in the past two years and doubled the number of stand-alone emergency rooms it operates, to 64, according to Dimensional Insights , a data analytics firm. HCA also runs 113 freestanding surgery centers, the firm says.

Nonprofit hospital systems, including Sutter Health in Northern California and Advocate Health Care in Chicago, are also investing heavily in outpatient clinics.

Federal and state lawmakers are well aware of the controversy over facility fees in outpatient settings. In 2015, Congress passed legislation requiring hospitals to charge Medicare the same fee for outpatient services at its off-site clinics as independent doctor practices. But the law didn't eliminate facility fees and applied only to hospital-owned facilities opened or acquired after 2015.

This year, the Centers for Medicare & Medicaid Services extended those limits by doing away with exemptions for off-site hospital clinics bought or opened before 2015.

Connecticut is aggressively cracking down on outpatient facility fees. It's the first state to require clearer disclosure of facility fees at physician practices and outpatient facilities owned or operated fully or in part by a hospital or health system.

Starting in 2016, hospitals must notify patients who have used a doctor or an outpatient location in the past three years that ownership has been transferred to a hospital. The notice must also include an estimate of the facility fee that may be incurred. For example, when Oncology Associates, based in Hartford, Conn., was acquired by Hartford Hospital in 2017, patients were sent a letter estimating that facility fees could range from $117 to $309.

Connecticut also bans facility fees on certain outpatient services and limits what uninsured patients can be charged. For example, a doctor can't charge a facility fee for new-patient visits.

"So far, only a handful of states have investigated and addressed consumer problems with facility fees," says Chuck Bell, programs director at Consumer Reports, who works on surprise medical bill issues. "Congress and the states should investigate the fees, and ban or restrict their use. If they are permitted at all, the fee amounts should be clearly disclosed well in advance, along with whether they are covered by insurance."

How to Fight Facility Fees

As facility fees proliferate, consumers need to be proactive about finding out whether they will incur one. Here's what to do.

Check with your insurer. Many insurers don't cover facility fees or cover only a portion. Talk to your insurer to find out what its policy is on facility fees.

Talk to your doctor. It's hard to tell whether a facility is hospital-run or whether your doctor works for a health system. When you call to make an appointment, ask whether you will be charged a facility fee. Some doctors may practice at other locations that don't charge one.

If your doctor refers you to a specialist or you need treatment, such as an MRI, at another facility, you also need to find out whether there is a facility fee and what your insurer will charge you if go to a nonhospital provider.

Negotiate. It's difficult to fight a facility fee because it's legal in most places. But you can always talk to the healthcare provider about waiving or lowering the fee. You can also appeal to your insurer to cover more of the cost.  

For more information on how to appeal a medical bill, use this free guide to health insurance appeals from the Patient Advocate Foundation.

What the Fee?!

Are you tired of the endless stream of add-on charges that appear on your bills? On the TV show " Consumer 101 ," Consumer Reports' expert explains to host Jack Rico how to avoid these pesky fees.  

Donna Rosato

I write about the financial challenges of paying for college, managing higher-education debt, and the steep cost of healthcare. I want to help people take control of their finances so that they can enjoy the other parts of their life. What I enjoy: running with friends, kayaking with my husband, and playing Legos with my son. Follow me on Twitter  (@RosatoDonna).

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‘Avoidable’ ER Visits Fuel Health Care Costs

New data shows privately insured individuals are unnecessarily using emergency department services.

‘Avoidable’ ER Visits Fuel Health Costs

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Two-thirds of 27 million emergency department visits by patients with private insurance each year are "avoidable," a new analysis finds.

The staggering amount of money the U.S. spends on health care each year – expected to reach about $6 trillion by 2027 – is being driven in part by patients who get treatment in hospital emergency departments with problems a primary care doctor likely could solve, according to a data analysis released Monday by UnitedHealth Group.

And while the poor and uninsured may be unable to afford or without access to a primary care doctor, the analysis by the health insurer of its own data and claims found that of 27 million emergency department visits annually by patients with private insurance, two-thirds are "avoidable" and " not an actual emergency. " The average cost of such visits for common conditions that could have been remedied through primary care tops $2,000 .

The problem: an inconvenient and perhaps outdated primary care delivery system that's not always open or accessible when people need immediate treatment.

The Top 10 Causes of Death in the U.S.

"The high number of avoidable hospital ED visits is neither a surprise nor a new problem," says a statement from UnitedHealth Group, headquartered in Minnesota . "Uneven access to timely, consumer-friendly, and convenient primary care options is a longstanding problem, and there is a need to bolster and expand primary care capacity through urgent care centers, physician offices, and nurse practitioners."

According to the analysis of UHG data, privately insured patients show up 18 million times in hospital emergency departments each year in visits that aren't necessary, adding $32 billion a year to national health care costs. Noncritical conditions treated often in EDs include bronchitis, cough, flu, nausea, sore throat, strep throat and upper respiratory infection.

"The average cost of treating common primary care treatable conditions at a hospital ED is $2,032," the analysis says, which is "12 times higher than visiting a physician office ($167) and 10 times higher than traveling to an urgent care center ($193)" for help with those same issues.

The upcharge is partially due to "hospital facility fees, which increase the cost of an average hospital ED visit by $1,069, and lab, pathology, and radiology services, which average $335 at a hospital ED – 10 times more costly than at a physician office ($31)."

Unless the primary care delivery system changes – doctors' offices offer extended, nighttime or weekend hours, or more urgent care clinics open – the problem won't improve, UnitedHealth Group officials say. The nation also needs more medical school graduates to go into general practice, the officials say.

In the meantime, absent better options, health care "consumers will continue to visit EDs for primary-care treatable conditions," the UnitedHealth Group statement says.

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Why Emergency Room Visits Cost So Much

How could an ER visit in which a patient receives nothing more than a Band-Aid cost $629? Sarah Kliff, a health policy reporter for 'Vox,' spent over a year reading ER bills and investigating the reasons behind the high costs. Emergency rooms have a facility fee, which can range from the low hundreds to the high thousands, where the patient pays essentially for just walking through the door. Kliff will also talk about the GOP's latest attempts to cut back Obamacare, and what a Medicare-for-all plan would entail. Also, Maureen Corrigan reviews two books about forgotten stories from Hollywood's past, 'The Lady from the Black Lagoon' and 'Giraffes on Horseback Salad.'

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$12,000 for a bee sting? Emergency room visits get even pricier

Sylvia Rosas decided to go to the emergency room after getting stung by a bee in her yard in Valrico, Florida. She had experienced allergic reactions in the past, but didn't have an EpiPen on hand.

However, what really hurt was the $12,000 bill she received for the visit to the ER.

The 53-year-old said she was seen by several doctors, who ordered thousands of dollars in blood tests and an EKG during the 2015 visit that lasted less than two hours. Since the hospital was out of network, her insurer wouldn't cover the visit, and she ended up having to pay the entire bill.

"Never did I think I'd have this type of a bill," said Rosas, a mortgage loan officer who says she's now hesitant to go to the doctor. "I was there for such a short time."

Rosas isn't the only one getting hit with big bills after a trip to the ER.

Spending on an emergency room visit rose to $1,917, on average, in 2016, up more than 31% from four years earlier, according to the Health Care Cost Institute, which analyzes spending and usage of nearly 40 million Americans with employer-sponsored coverage.

The spike in spending was driven almost entirely by an increase in the prices charged by hospitals, even as ER usage remained relatively flat. The spending covers the hospitals' charges for stepping foot in the ER, known as a facility fee, as well as some tests and services. It doesn't include ER evaluations by doctors, who usually send patients a separate bill.

Overall, the soaring price of ER visits, along with steep hikes in prescription drugs and outpatient surgery costs, have helped fuel a 15% increase in overall health care spending, the institute found.

There may be several reasons why it's getting costlier to go to the emergency room, experts said.

The price hikes stem in part from the fact that ERs are seeing a greater number of patients with more severe medical problems, said Niall Brennan, the institute's CEO.

Hospitals base their ER facility fee charge on the severity of the condition they are treating. Folks with simpler issues, such as cuts or fevers, are more often turning to urgent care centers or pharmacy clinics. So emergency rooms are more likely to receive patients with serious problems, such as chest pain or asthma attacks, which are more expensive to treat.

Related: Americans spend more on health care, but have shorter life spans

Also, more emergency rooms now have access to advanced -- and pricey -- technology, such as CT scans and MRIs, said Renee Hsia, professor of emergency medicine and health policy at the University of California, San Francisco. And patients expect to have more testing done in the ER rather than waiting to go to a lab or doctor's office after they are discharged.

The American Hospital Association challenged the institute's study, saying that annual hospital price growth rates are at near record lows. But the industry group did agree that emergency rooms are treating more complex conditions, citing its report from 2013 that showed Medicare patients treated in the ER had more severe illnesses and visited more frequently.

Still, many ER patients are stunned by the bills they receive.

Rick Brown tried to avoid going to the emergency room after he fell into a small hole by his pool in November and hurt his ankle. He tried icing and elevating it, but after a few days the pain was excruciating.

He finally went to the ER near his home in Brick, New Jersey, where he had an X-ray and was seen by a physician assistant. Brown, who arrived at the hospital on his own crutches, learned he had fractured his ankle. The 58-year-old was given a splint, a prescription for painkillers and a recommendation that he follow up with a specialist.

A few weeks later, the bills started coming in -- including a $2,600 for the ER and $5,700 from a physicians' office. His insurance paid half the ER fee, but wouldn't cover the doctor charges because the provider was out-of-network.

Brown, a bartender, was furious, noting that he was twice asked for his insurance card in the ER. Had he known he'd be on the hook for thousands of dollars, he said he would have hobbled out or waited to go to the doctor's appointment he had made for later in the week.

"To have insurance and to be facing these astronomical bills, I get incensed," said Brown. "You're in a lot of pain and you have insurance. You are expecting it to be covered."

Brown plans to talk to the hospital and the physicians' office to try to reduce the charges.

Related: 4 reasons why US health care is so expensive

That's a good move, said Martin Makary, professor of surgery and health policy at Johns Hopkins University. When patients come to the ER, they don't need to sign any paperwork promising to pay in full, Makary said. Federal law requires emergency rooms to screen and stabilize anyone who comes through the doors.

Makary published a study last year that found that hospitals mark up emergency services -- such as suturing a wound or interpreting a CT scan -- by an average of 340% more than what Medicare allows. (The Medicare allowable amount includes what Medicare reimburses, as well as any deductibles or co-pays the patients pay.) So consumers should try to bargain providers down if they get a big bill.

"Prices are highly fluctuant and often negotiable," he said. "As with new cars, people are not expected to pay the sticker price."

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Why Did My Emergency Room Visit Cost So Much?

Emergency room visits are notoriously expensive. Just a few hours in the ER can cost you thousands of dollars, with or without insurance.

But how is your ER visit cost calculated, and how can you tell whether your hospital bill is correct? 

We scored some insider tips from Goodbill medical coding expert Christine Fries, who has analyzed thousands of ER hospital bills for accuracy. Here are answers to frequently asked questions we get from Goodbill customers about how to understand and vet ER visit costs.

Why did I get 2 bills for my ER visit?

Patients are usually surprised when their first ER hospital bill is quickly followed by a separate hospital bill with similar-sounding charges but different amounts. This is normal and a byproduct of how hospitals bill patients for the services rendered at the hospital, Fries says. 

The institutional bill, also known as the facility bill, charges you for the procedures, tests, and administrative costs from the hospital. 

The professional bill, also known as the physician bill, charges you for the work and time of the physician who treated you. This generally includes services from doctors, anesthesiologists, or specialists who are affiliated with the hospital but aren’t employed by the hospital. 

Expect to get two bills from your ER visit — one for facility charges, and the other for professional or physician charges.

For more information on the different types of hospital bills, see our itemized bill guide . Goodbill currently helps patients negotiate institutional bills, not professional bills, so our guidance below pertains to institutional bills only. 

My diagnosis turned out to be minor. Why was I charged so much?

It’s important to remember that your ER visit costs are based on the symptoms you first describe upon entering the hospital, not your eventual diagnosis, Fries says.

When a patient walks into the emergency room complaining of chest pains, for example, the hospital’s objective is to run tests and administer procedures that can help rule out life-threatening conditions. Even if the doctor ends up discharging the patient with a non life-threatening diagnosis like indigestion, the hospital has already spent the resources to rule out more severe possibilities like a heart attack.

Your ER visit costs are based on the symptoms you first describe upon entering the hospital, not your eventual diagnosis.

“Look at your symptoms first, not what you were diagnosed with,” Fries says. “The level of your ER visit is guided by the symptoms you described, and by the tests the hospital thought were needed based on those symptoms.”

Why was I charged for an ‘ER Visit Level’ 3, 4, or 5? Is this based on severity?

Hospitals will bill you for a line item called “ER Visit Level” that is based on the complexity of your treatment. ER visit levels range from 1-5: ER visit level 1 is the most mild, while ER visit level 5 is the most severe. The level also determines how much the hospital can charge you, from least expensive to most expensive. You may sometimes hear ER visit levels described by their corresponding Current Procedural Terminology (CPT) codes of 99281, 99282, 99283, 99284 and 99285. 

To decide the proper ER visit level, hospitals typically follow certain guidelines from the American College of Emergency Physicians (ACEP) . ER level 1-2 visits are reserved for treatment of mild cases like bug bites and sunburns. The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common, Fries says.

“Most emergency room claims will qualify as a 99284, because you only need something as simple as IV fluids to get you there,” Fries says.

The majority of ER visits fall between ER visit levels 3-5, with ER visit level 4 being the most common.

Here’s a simple rule of thumb for determining whether your ER visit level was correctly assigned.

ER Visit Level 4

‍ An ER visit level 4 typically requires a minimum of two diagnostic tests — like a lab plus an EKG, or a lab plus an X-ray. Or, any administration of fluids through IV will automatically qualify your visit as an ER visit level 4.

ER Visit Level 5

‍ An ER visit level 5 typically requires a minimum of three diagnostic tests — for example, a lab plus EKG and X-ray. Or, any type of imaging scan like a CT scan or MRI where a patient must ingest or be injected with contrast material, will automatically qualify your visit as an ER visit level 5.

‍ I’m not pregnant. Why did I get charged for a pregnancy test?

Many female patients get frustrated when they’re charged for a pregnancy test, even when they’re absolutely certain they’re not pregnant. But this is standard practice and a way for hospitals to protect against unknown pregnancies, Fries says. 

If you’re an adult pre-menopausal female, you can count on being asked to do a urine or blood pregnancy test before the hospital will treat you. It’s too risky to both the patient and hospital to administer injections, scans or drugs in the off chance that a patient is unknowingly pregnant. 

If you're a female, expect to get a pregnancy test during your ER visit — even if you're not pregnant.

On your itemized ER bill, your pregnancy test will usually show up with a description like “human chorionic gonadotropin (hCG),” which is the hormone being tested. This charge will generally fall under the CPT codes 84702 or 84703 if it’s a blood test, or 81025 if it’s a urine test. 

What are some other common ER services I might see on my hospital bill? 

Here are a few common procedure names that often show up in your ER visit costs, and what they mean in plain English:

Metabolic panel

‍ This is a bundle of lab tests run from a single blood draw. Patients may get a “basic” metabolic panel under CPT code 80048, or a “comprehensive” metabolic panel under CPT code 80053. These panels cover a set of individual tests that might otherwise be individually charged. For example, a “comprehensive” metabolic panel must include testing for all of the following: 

• Carbon dioxide
• Phosphatase, alkaline
• Transferase, alanine amino
• Transferase, aspartate amino
• Urea nitrogen

Venipuncture

‍ Any time you get your blood drawn through a needle, this charge under CPT code 36415 is the line item that bills you for the needle.

‍ This test under CPT code 83690 measures your levels of lipase, which is an enzyme that helps break down fat in your intestines. Your lipase levels may be elevated if you have pancreatitis, which is an inflammation of the pancreas gland.  

What are some ER visit cost errors I should look out for?

When analyzing a patient’s ER visit costs for errors, Fries says she goes straight to one place first: Hydration services. If you recall being administered fluids through an IV bag, chances are you got hydration services during your ER visit.

“Hydration services should always be questioned,” Fries says.

Coding guidelines require that the two CPT codes for this service, 96360 and 96361, meet a minimum time requirement of 31 minutes in order for one unit to be billed. These 31 minutes must also be “stand alone” — meaning that the administration of the service cannot overlap with any other type of infusion service. Often, hospitals don’t meet these requirements, rendering the charge unbillable.

Hydration services are a common source of errors in ER hospital visit costs. You can tell if you're being overcharged by checking your medical record.

To verify whether you’re being charged properly, you’ll need your medical record, Fries says. Look for hydration service “start” and “stop” times, which are usually included in the Medication Administration Report (MAR) section of your record. If the hydration service duration is less than 31 minutes of standalone time, you have a strong case to dispute the charge with your hospital. To find out how to get your medical records online, visit our Medical Records guide .

I don’t see any CPT codes on my bill. How can I get them?

CPT codes are the common language used across all hospitals to describe a certain procedure. They’re what enables our medical coders at Goodbill to analyze hospital bills for errors, line item by line item. They also help us compare prices apples-to-apples across hospitals.

CPT codes are the standard language used to describe a certain procedure across all hospitals. They're key to helping you identify errors or inflated charges in your ER hospital bill.

Unfortunately, the hospital bill you get in the mail is most likely a consolidated summary of your ER visit costs and won’t include CPT codes. You’ll need an “itemized bill” from your hospital to get a line-by-line breakdown of each charge, complete with the CPT code and cost. 

The good news is that you’re legally entitled under HIPAA to get access to this information. To learn more about your patient rights and how to obtain your itemized bill, check out our Patient Right of Access guide .

Are there other topics you’d like us to cover? Email us at [email protected] and let us know.

Guides, news, and articles to help you tackle hospital bills.

How to Negotiate Your Hospital Bill

Read our expert tips on how to negotiate your hospital bill to save up to thousands of dollars.

Itemized Bill: Your Key to Negotiating

Itemized bills provide key details that can help you negotiate your hospital bill.

Can Hospital Bills Affect My Credit?

You have time before your bill can go to collections or affect your credit.

Negotiating hospital bills has never been this easy.

Building trust and confidence into every health care transaction.

© 2022  Goodbill, Inc.

Hospital wait times will still be bad this year, even with labor gains

• The US is recovering from a physician shortage and worker numbers remain below pre-pandemic trends.
• Small businesses are seeing labor growth this year, but hospitals still have staffing shortages.
• One reason why is that workers in the healthcare sector have seen "soft wage growth" recently.

The US may be recovering from a physician shortage , but don't expect to spend less time in hospital waiting rooms this year.

Healthcare worker numbers are steadily growing but remain below pre-pandemic trends, according to a Bank of America report published in April. The bank's data and analysis firm, The Bank of America Institute, based findings on internal workforce data collected between 2019 and 2024.

US Bureau of Labor Statistics data shows that the healthcare sector is 1.6% behind on growth based on pre-pandemic projections. Outpatient care centers are 9.4% behind on growth, while the hospital labor force has seen small gains at 0.3%.

One of the reasons job growth has been behind, according to the Bank of America report, is that workers in the healthcare sector have also seen "soft wage growth" in recent years. Additionally, the report found many employees are still underpaid because they tend to interact more with clients and work more labor-intensive hours than employees in other industries.

Between April 2022 and April 2023 — the most recent available data — the national median time patients spent in the emergency department was 162 minutes , according to the Centers for Medicare and Medicaid Services. In the same period between 2020 and 2021, CMS found that time was 149 minutes.

The pandemic worsened an already growing problem, as unemployment rates jumped , more people needed urgent medical care , and reports of doctor and nurse burnout skyrocketed. In fact, healthcare workers made up a significant portion of the people leaving their jobs during the Great Resignation .

Ambulatory care — which includes all appointments and treatments that don't require hospital admission — makes up half of all jobs in the healthcare sector, Bank of America found. Hospitals employ just over 30% of healthcare workers while under 20% of employees work at nursing and residential care facilities.

Bureau of Labor Statistics data shows that the healthcare sector employed about 10% of total US workers last year, a share of the labor force that has remained consistent for the past decade.

This ongoing shortage comes as Americans worry about medical debt , the rising price of prescription drugs , and the staggering costs of emergency medical care . Per KFF (formerly known as Kaiser Family Foundation), three in four US adults say that healthcare is one of their top financial concerns.

Patients will still see labor shortages in ERs and care facilities

Despite labor gains, patients could still experience the impacts of the physician shortage. The US is expected to face a physician shortage of up to 86,000 people by 2036, according to the American Hospital Association .

Related stories

The Bank of America report found that small businesses, defined as healthcare offices with fewer than 20 employees, are seeing the strongest rebound growth. For patients, this might result in more available appointments with specialists and private practice doctors.

Many small businesses hired more full-time healthcare workers instead of temporary contractors in February 2024 compared to February 2023, according to Bank of America.

Still, patients will likely still feel the consequences of labor gaps when they visit the hospitals and long-term care facilitates.

Longer ER stays, for example, are an indicator that hospitals are " understaffed or overcrowded ," according to the Centers for Medicare and Medicaid Services.

There has also slower labor recovery at long-term care facilities. This could lead to longer patient waitlists for residential care.

A report published in March from the nonprofit Peterson Center on Healthcare and KFF shows that the number of people in skilled nursing jobs, retirement care jobs, and roles that provide care for people with developmental disabilities are still below pre-pandemic levels.

Burnout and low pay mean slow jobs recovery

The Bank of America report suggests that a lack of wage growth could be contributing to doctor and nurse shortages. Healthcare workers have labor-intensive jobs, and low pay could be making it more difficult for hospitals and care facilities to attract employees, the report found.

Average wages for healthcare workers have increased overall since the beginning of the pandemic, but KFF said this could be because fewer low-wage workers are employed in industry.

A 2023 National Institute of Health study found that inadequate pay is the most frequently cited reason employees give for burnout and leaving medicine.

Despite the slow gains, the Bank of America's report said it's a good sign that healthcare facilities appear to be hiring more full-time workers in 2024.

"Our finding that contract payments are easing indicates that firms may be under less pressure from labor shortages," the report said. "This could imply normalizing employment growth ahead."

Are you a healthcare worker experiencing burnout? Are you a patient who has experienced long wait times because of hospital staffing shortages? Reach out to this reporter at [email protected] .

Watch: Nearly 50,000 tech workers have been laid off — but there's a hack to avoid layoffs

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BREAKING: In a tense courtroom, two potential jurors in Trump's trial break down crying during selection. Both were excused.

O.J. Simpson, NFL star whose murder trial gripped the nation, dies of cancer at 76

O.J. Simpson , the former NFL star who was acquitted of murdering his ex-wife and her friend in a televised trial that gripped the nation, has died of cancer, according to his family.

"He was surrounded by his children and grandchildren," the family said in a statement posted on X . "During this time of transition, his family asks that you please respect their wishes for privacy and grace."

Reports circulated in February that Simpson had been diagnosed with prostate cancer and was in hospice care as he underwent chemotherapy. He denied that he was in hospice in a video posted on X, but did not address whether he'd been diagnosed with cancer.

“Hospice? Hospice? You talking ‘bout hospice?” he said in the video with a laugh, adding that he doesn’t know who started the rumors. 

Orenthal James Simpson played 11 seasons in the National Football League and was known as "The Juice" to his fans, but his sports legacy was tarnished forever in the 1990s after his ex-wife Nicole Brown Simpson and her friend Ronald Goldman were killed.

Brown Simpson, 35, and Goldman, 25, were found stabbed to death outside her Los Angeles home in 1994.

On June 13, 1994, Goldman was returning sunglasses that the mother of Brown Simpson had left at a restaurant where he worked. The two were stabbed and slashed dozens of times, and their bodies were found the next day.

When Los Angeles police officers went to Simpson's home to speak to him about the slayings, Simpson did not answer the door but officers noticed a trail of blood leading to his car, as well as blood on his car.

Once a revered athlete, Simpson went from a Hall of Fame icon to a murder suspect.

Days later, officials charged Simpson with the murders and he attempted to evade arrest, resulting in an infamous hourslong police chase along Southern California's highways in his white Ford Bronco .

Simpson's case went to trial in 1995 and was broadcast to millions of viewers across the nation. The court case was dubbed the "trial of the century" as it dragged on for months and transformed into a public spectacle.

Feelings over the trial have remained mixed over the years, with many accusing the Los Angeles Police Department of racism in its handling of the case. Others believe that Simpson's ability to retain high-powered attorneys allowed him to get away with murder.

The trial made prosecutors Christopher Darden and Marcia Clark household names, in addition to Simpson's defense attorneys Johnnie Cochran, Alan Dershowitz and Robert Kardashian.

He was acquitted of both murders in a controversial verdict. Two years later, he was found civilly liable for wrongful death in the double homicide case.

Despite his acquittal in the criminal trial, many still believed Simpson was guilty, a belief bolstered by a jury ordering him to pay $33 million to Goldman's family in the civil case — damages that were never paid in full.

Goldman's father, Fred Goldman, spoke to NBC News by phone Thursday and described Simpson's death as "no great loss."

“The only thing I have to say is it’s just further reminder of Ron being gone all these years," he said. "It’s no great loss to the world. It’s a further reminder of Ron’s being gone.”

Bob Costas, the sports broadcaster who worked with Simpson for years at NBC Sports covering the NFL, said Simpson leaves behind “a complicated legacy, to put it mildly.”

“I can’t think of anyone historical or someone that we may have known where the first chapter and the second chapter of their lives are such a stark contrast … revered and then reviled,” Costas said on NBC’s “TODAY” show Friday.

In 2007, Simpson led an armed robbery attempt of a sports memorabilia dealer in Las Vegas. He argued in court that he was recovering his own stolen items, but his defense failed to sway the jury.

He was convicted and sentenced to 33 years in prison, of which he served only nine before he was released on parole .

Simpson spoke to The Associated Press by phone in 2019 , telling them that he was healthy and happy living in Las Vegas. He maintained that he believed his robbery conviction was unfair, but said: “I believe in the legal system and I honored it. I served my time.”

The Simpson murder trial was re-enacted and relitigated decades later in FX’s “The People v. O.J. Simpson,” an installment of the network’s popular “American Crime Story” series in 2016. Released that same year was the Academy Award-winning documentary "O.J.: Made in America," detailing Simpson's rise and fall.

Simpson was born in San Francisco and raised in public housing, going to a local community college before transferring to the University of Southern California. He was part of the school's national championship in 1967 and earned the Heisman Trophy the next year.

He was drafted by the Buffalo Bills in 1969 as a No. 1 overall pick.

According to NBC Sports , Simpson was the first player in the league to rush for 2,000 or more yards in a season and is considered the best running back of his era.

Simpson had three children from his first marriage to Marguerite Whitley, one of whom died in a drowning accident as a toddler.

He also shared two children with Brown Simpson.

Following her murder and his acquittal, Simpson won custody of their shared children and moved to Miami with them. His custody fight with his former-in-laws also drew headlines as the children's grandparents took him to court in a bitter legal battle.

Doha Madani is a senior breaking news reporter for NBC News. Pronouns: she/her.

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The Opening Days of Trump’s First Criminal Trial

Here’s what has happened so far in the unprecedented proceedings against a former u.s. president..

This transcript was created using speech recognition software. While it has been reviewed by human transcribers, it may contain errors. Please review the episode audio before quoting from this transcript and email [email protected] with any questions.

It’s the first day of the Trump trial and just walking out the door in my house. It’s a beautiful day, 6:11 AM. The thing that keeps running through my head is it’s kind of amazing that hundreds of jurors are going to show up at the Manhattan courthouse. And some of them are going to know what they’re there for — probably talking to their friends, their relatives about it.

Some of them are going to learn this morning talking to other jurors in line, asking what all the fuss is about. But I really do imagine that there’s going to be at least one potential juror who, headphones on, getting into court. Here they’re going to be there for the first criminal trial of Donald J. Trump. And just, I mean, how would you react?

[MUSIC PLAYING]

From “The New York Times,” I’m Michael Barbaro. This is “The Daily.” Today, what it’s been like inside the lower Manhattan courtroom, where political and legal history are being made? My colleague, Jonah Bromwich, on the opening days of the first criminal trial of a US President. It’s Thursday, April 18.

Is that his mic? Hi, there.

Hello. How are you?

I’m doing good.

OK. Thank you for coming in, Jonah —

Thank you for having me.

— in the middle of a trial. Can you just explain why you’re able to even be here?

Sure. So we happen to be off on Wednesdays during trial, so.

We being not “The New York Times,” but the courts.

That’s right.

Which is why we’re taping with you. And because we now have two full court days of this history-making trial now under our belts. And the thing about this trial that’s so interesting is that there are no cameras in the courtroom for the wider world.

There’s no audio recordings. So all we really have is and your eyes and your notebook, maybe your laptop. And so we’re hoping you can reconstruct for us the scene of the first two days of this trial and really the highlights.

Yeah, I’d be happy to. So on Monday morning, I left the subway. It’s before 7:00 AM. The sun is just rising over these grandiose court buildings in lower Manhattan.

I’m about to turn left onto Center Street. I’m right in front of the big municipal building.

And I turn onto Center Street. That’s where the courthouses are.

I’m crossing.

And I expected to see a big crowd. And it was even bigger than I had anticipated.

Here we go. Here we go. Here we go. Now, I finally see the crowd.

You have camera banks. You have reporters. You have the beginnings of what will eventually become a protest. And you have this most New York thing, which is just a big crowd of people.

[CHUCKLES]: Who just know something is going on.

That’s right. And what they know is going on is, of course, the first trial of an American president.

All right, I’m passing the camera, folks. Camera, camera, camera, camera. Here we go.

Let’s start with Sharon Crowley live outside the courthouse in Lower Manhattan.

I want to get right to ABC’S Aaron Katersky who’s outside of the courthouse.

Robert Costa is following it outside the courthouse in Lower Manhattan. Bob, I saw the satellite trucks lined up all in a row. Good morning.

Talk to us how we got here exactly.

So this is the case that was brought by the Manhattan district attorney. So prosecutors have accused Donald Trump of covering up the actions of his former fixer, Michael Cohen, after Cohen paid hush money to Stormy Daniels. Stormy Daniels had a story about having had sex with Donald Trump, which Trump has always denied.

Cohen paid her money, and then Trump reimbursed Cohen. And prosecutors say that Trump essentially defrauded the American people because he hid this information that could have been very important for the election from those people when he reimbursed Cohen.

Right. And as I remember it, he also misrepresented what that reimbursement was. Claimed it was a legal fee when, in fact, it was just reimbursing Michael Cohen for a hush money payment.

Exactly, yeah. He definitely didn’t say reimbursement for hush money payment to Stormy Daniels. It’s a cover up case. It’s a case about hiding information you don’t want people to see.

Right. And of course, the context of all this is that it is in the middle of a presidential election. It’s 2016. Trump wants to keep this secret, prosecutors allege, so that the American public doesn’t know about it and potentially hold it against him.

Right. And prosecutors are telling a story about election interference. They’re saying that Trump interfered with an election. And Trump himself is also using the phrase “election interference.” But he’s painting the trial itself as election interference as he now runs again in 2024.

Fascinating.

And because we’re in Manhattan, and because the jury pool is going to be largely Democratic, and the judge is a Democrat, and the district attorney is a Democrat, Trump keeps claiming he cannot get a fair shake. This is democrat central. And in democrat central, Trump doesn’t have a chance.

OK. So, what happens once you actually enter the courthouse?

Outside, there’s all this fanfare. But inside, it’s a little bit business as usual. So I go up to the 15th floor, and I walk into the courtroom, and I sit down, and it’s the same old courtroom. And we’re sitting and waiting for the former president.

Around 9:30, Trump walks in. He looks thin. He looks a little tired, kind of slumping forward, as if to say with his body like let’s get this over with. Here we go.

The judge walks in a little bit after that. And we think we’re all set for the trial to start, but that’s not what happens here. And in fact, there are a series of legal arguments about what the trial is going to look like and what evidence is going to be allowed in.

So, for example, prosecutors ask that they be allowed to admit into evidence headlines from “The National Enquirer” that were attacks on Trump’s 2016 opponents — on Ted Cruz, on Marco Rubio, on Ben Carson.

Because prosecutors are in some sense putting Trump’s 2016 campaign on trial. These headlines are a big part of that because what prosecutors say they show is that Trump had this ongoing deal with “The National Enquirer.” And the publisher would promote him, and it would publish damaging stories about his opponents. And then crucially, it would protect Trump from negative stories. And that’s exactly what prosecutors say happened with Stormy Daniels. That “The National Enquirer” tipped Cohen off about Stormy Daniels trying to sell her story of having had sex with Donald Trump, which he denies. And that led to the hush money payment to her. So what prosecutors are doing overall with these headlines is establishing a pattern of conduct. And that conduct, they say, was an attempt to influence the election in Trump’s favor.

And the judge agrees. He’s going to admit this evidence. And this is a pretty big win for the prosecution. But even though they win that one, they’re not winning everything.

They lose some important arguments here. One of them was that after the Access Hollywood tape came out, there were allegations of sexual assault against Donald Trump. And you know this, Michael, because you reported two of them — two of the three in question at this very trial.

Prosecutors had hoped to talk about those during trial in front of the jury to show the jurors that the Trump campaign was really, really focused on pushing back against bad press in the wake of the Access Hollywood tape in which Trump seemed to describe sexual assault. That was a big problem for the campaign. Campaign did everything it could to push back, including against these allegations that surfaced in the wake of the tape.

But the judge, saying that the allegations are hearsay — that they’re based on the women’s stories — says absolutely not. That is incredibly prejudicial to the defendant.

Interesting.

And that Donald Trump would actually not get a fair trial were those allegations to be mentioned. And so he will not let those in. The jurors will not hear about them.

So this is a setback, of course, for the prosecution, a victory for Trump’s legal team.

It’s a setback. And it also just shows you how these pre-trial motions shape the context of the trial. Think of the trial as a venue like a theater or an athletic contest of some sort. And these pre-trial motions are about what gets led into the arena and what stays out. The sexual assault allegations — out. “The National Enquirer” headlines — in.

OK. And how is Trump sitting there at the defense table reacting to these pre-trial motion rulings from the judge?

Well, as I’ve just said, this is very important stuff for his trial.

Right. Hugely important.

But it’s all happening in legal language, and I’m decoding it for you. But if you were sitting there listening to it, you might get a little lost, and you might get a little bored. And Trump, who is not involved in these arguments, seems to fall asleep.

Seems to fall asleep — you’re seeing this with your own eyes.

What we’re seeing, overall, including our colleague, Maggie Haberman, who’s in the overflow room and has a direct view of Trump’s face — I’m sitting behind him in the courtroom, so I can’t see his face that well.

You guys are double teaming this.

That’s right. I’m sitting behind him, but Maggie is sitting in front of him. And what she sees is not only that his eyes are closed. That wouldn’t get you to he is asleep.

And we have to be really careful about reporting that he’s asleep, even if it seems like a frivolous thing. But what happens is that his head is dropping down to his chest, and then it’s snapping back up. So you’ve seen that, when a student —

I’ve done that.

(CHUCKLES) Yeah. We all kind of know that feeling of snapping awake suddenly. And we see the head motion, and it happens several times.

Lawyers kind of bothering him, not quite shaking him, but certainly trying to get his attention. And that head snapping motion, we felt confident enough to report that Trump fell asleep.

During his own criminal trial’s opening day.

Does someone eventually wake him up?

He wakes up. He wakes up. And in fact, in the afternoon, he’s much more animated. It’s almost as if he wants to be seen being very much awake.

Right. So once these pre-trial motions are ruled on and Trump is snapped back to attention, what happens?

Well, what happens in the courtroom is that the trial begins. The first trial of an American president is now in session. And what marks that beginning is jurors walking into the room one by one — many of them kind of craning their necks over at Donald Trump, giggling, raising their eyebrows at each other, filing into the room, and being sworn in by the judge. And that swearing in marks the official beginning of the trial.

The beginning is jury selection, and it’s often overlooked. It’s not dramatized in our kind of courtroom dramas in the same way. But it’s so important. It’s one of the most important parts of the case. Because whoever sits on the jury, these are the 12 people who are going to decide whether Trump is guilty or whether Trump is innocent.

So how does jury selection actually look and feel and go?

So, jury selection is a winnowing process. And in order to do that, you have to have these people go through a bunch of different hurdles. So the first hurdle is, after the judge describes the case, he asks the group — and there are just short of 100 of them — whether they can be fair and impartial. And says that if they can’t, they should leave. And more than half the group is instantly gone.

So after we do this big mass excusal, we’re left with the smaller group. And so now, jurors are getting called in smaller groups to the jury box. And what they’re going to do there is they’re going to answer this questionnaire.

And this part of the process is really conducted by the judge. The lawyers are involved. They’re listening, but they’re not yet asking questions of the jurors themselves.

And what’s on the questionnaire?

Well, it’s 42 questions. And the questions include, their education, their professional histories, their hobbies, what they like to do whether you’re a member of QAnon or Antifa.

Whether you’re far left or far right.

That’s right. Whether you’ve read “The Art of the Deal,” Trump’s book, which some prospective jurors had.

Right. It was a bestseller in its time.

That’s right. And some of it can be answered in yes/no questions, but some of it can be answered more at length. So some of the prospective jurors are going very, very fast. Yes, no, no, no, yes.

Right. Because this is an oral questionnaire.

That’s right. But some of them are taking their time. They’re expanding on their hobbies. So the potential juror in seat 3, for example, is talking about her hobbies. And she says some running, hiking. And then she said, I like to go to the club, and it got a huge laugh. And you get that kind of thing in jury selection, which is one of the reasons it’s so fun. It’s the height of normality in this situation that is anything but normal.

Right. The most banal answer possible delivered in front of the former president And current Republican nominee for president.

Well, that’s one of the fascinating parts about all this, right? is that they’re answering in front of Trump. And they’re answering questions about Trump in front of Trump. He doesn’t react all that much. But whenever someone says they’ve read “The Art of the Deal —” and there are a few of those — he kind of nods appreciatively, smiles. He likes that. It’s very clear. But because there are so many questions, this is taking forever, especially when people are choosing to answer and elaborate and digress.

This is when you fall asleep.

This Is. When I would have fallen asleep if I were a normal person.

And by the end of the day. Where does jury selection stand?

Well, the questionnaire is another device for shrinking that jury pool. And so the questionnaire has almost these little obstacles or roadblocks, including, in fact, a question that jurors have seen before — whether they would have any problem being fair and impartial?

Hmm. And they ask it again.

They’re asked it again. And they’re asked in this more individualized way. The judge is questioning them. They’re responding.

So, remember that woman who said she liked to go to the club got a big laugh. She reaches question 34. And question 34 reads, “Do you have any strong opinions or firmly-held beliefs about former President Donald Trump or the fact that he is a current candidate for president that would interfere with your ability to be a fair and impartial juror?” She said, yes, she does have an opinion that would prevent her from being fair and impartial. And she, too, is excused.

So that’s how it works. People answer the questionnaire, and they get excused in that way, or they have a scheduling conflict once they reach the jury box. And so to answer your question, Michael. At the end of day one, given all these problems with the questionnaire and the length of time it’s taken to respond to and people getting dismissed based on their answers, there is not a single juror seated for this trial.

And it’s starting to look like this is going to be a really hard case for which to find an impartial jury.

That’s the feeling in the room, yeah.

We’ll be right back.

So Jonah, let’s turn to day 2. What does jury selection look like on Tuesday?

So when the day begins, it looks almost exactly like it looked when the day ended on Monday. We’re still with the questionnaire, getting some interesting answers. But even though it feels like we’re going slow, we are going.

And so we’ve gone from about 100 people to now there’s about 24 the room there’s 18 the jury box. And by the time we hit lunch, all those people have answered all those questions, and we are ready for the next step in the process.

Voir dire. And what it is the heart of jury selection. This is the point where the lawyers themselves finally get to interview the jurors. And we get so much information from this moment because the lawyers ask questions based on what they want out of the jurors.

So the prosecution is asking all these different kinds of questions. The first round of wajir is done by a guy named Joshua Steinglass, a very experienced trial lawyer with the Manhattan District Attorney’s Office. And he’s providing all these hypotheticals. I’ll give you one example because I found this one really, really interesting. He provides a hypothetical about a man who wants his wife killed and essentially hires a hitman to do it. And what he asked the jurors is, if that case were before you, would you be able to see that the man who hired the hitman was a part of this crime?

And of course, what he’s really getting at is, can you accept that even though Michael Cohen, Trump’s fixer, made this payment, Trump is the guy who hired him to do it?

That’s right. If there are other people involved, will jurors still be able to see Donald Trump’s hands behind it all?

Fascinating. And what were some of the responses?

People mostly said, yes, we accept that. So that’s how the prosecution did it.

But the defense had a totally different method of voir dire. They were very focused on their client and people’s opinions about their client.

So what kind of questions do we get from them?

So the lawyer, Todd Blanche, is asking people, what do you make of President Trump? What do you think of President Trump?

And what are some of the responses to that?

Well, there’s this incredible exchange with one of the jurors who absolutely refuses to give his opinion of Donald Trump. They go back and forth and back and forth. And the juror keeps insisting you don’t need to know my opinion of him. All you need to know is that I’m going to be fair and impartial, like I said. And Blanch pushes, and the guy pushes back. And the only way the guy budges is he finally kind of confesses almost at the end that, yes, I am a Democrat, and that’s all we get.

And what ends up happening to this potential juror?

Believe it or not, he got dismissed.

[LAUGHS]: I can believe it. And of course, it’s worth saying that this guy and everybody else is being asked that question just feet from Trump himself.

That’s right. And you might think you were going to get a really kind of spicy, like, popcorn emoji-type exchange from that. But because these are now jurors who have said they can be fair and impartial, who, to some extent, want to be on this jury or at least wouldn’t mind being on this jury, they’re being very restrained.

Mostly, what they are emphasizing — much like that guy just described dis — is that they can be fair. They can be impartial. There’s one woman who gives this really remarkable answer.

She says, I thought about this last night. I stayed up all night. I couldn’t sleep, thinking about whether I could be fair. It’s really important to me, and I can.

What ends up happening to that particular juror?

She’s also dismissed. And she’s dismissed without any reason at all. The defense decides it doesn’t like her. It doesn’t want her on the jury. And they have a certain number of chances to just get rid of jurors — no questions asked.

Other jurors are getting dismissed for cause — I’m doing air quotes with my hands — which means that the lawyers have argued they actually revealed themselves through their answers or through old social media posts, which are brought up in the courtroom, to be either non-credible, meaning they’ve said they can be fair and they can’t, or somehow too biased to be on the jury.

Wait, can I just dial into that for a second? Are lawyers researching the jurors in real time going online and saying — I’m making this up — but Jonah Bromwich is a potential juror, and I’m going to go off into my little corner of the courtroom and Google everything you’ve ever said? Is that what’s happening in the room?

Yeah, there’s a whole profession dedicated to that. It’s called jury consultant, and they’re very good at finding information on people in a hurry. And it certainly looked as if they were in play.

Did a social media post end up getting anybody kicked off this jury?

Yes, there were posts from 2016 era internet. You’ll remember that time as a very heated one on the internet, Facebook memes are a big thing. And so there’s all kinds of lock him up type memes and rhetoric. And some of the potential jurors here have used those. And those jurors are dismissed for a reason.

So we have these two types of dismissals, right? We have these peremptory dismissals — no reason at all given. And we have for cause dismissals.

And the process is called jury selection. But you don’t actually get selected for a jury. The thing is to make it through all these obstacles.

You’re left over.

Right. And so when certain jurors are not dismissed, and they’ve made it through all these stages, by the end of the day, we have gone from zero juror seated to seven jurors who will be participating in Donald Trump’s trial.

Got it. And without going through all seven, just give us a little bit of a sketch of who so far is on this jury. What stands out?

Well, not that much stands out. So we’ve got four men. We’ve got three women. One lives on the Upper East Side. One lives in Chelsea. Obviously, they’re from all over Manhattan.

They have these kind of very normal hobbies like spending time with family and friends. They have somewhat anonymous jobs. We’ve got two lawyers. We’ve got someone who’s worked in sales.

So there’s not that much identifying information. And that’s not an accident . One of the things that often happens with jury selection, whether it be for Donald Trump or for anyone else, is the most interesting jurors — the jurors that kind of catch your attention during the process — they get picked off because they are being so interesting that they interest one or the other side in a negative way. And soon they’re excused. So most of the jurors who are actually seated —

Are not memorable.

Are not that memorable, save one particular juror.

OK. All right, I’ll bite. What do I need to know about that one particular juror?

So let me tell you about a prospective juror who we knew as 374, who will now be juror number five. She’s a middle school teacher from Harlem. And she said that she has friends who have really strong opinions about Trump, but she herself does not. And she insisted several times, I am not a political person.

And then she said this thing that made me quite surprised that the prosecution was fine with having her on the jury. She said, quote, “President Trump speaks his mind, and I’d rather that than someone who’s in office who you don’t know what they’re thinking.”

Hmm. So she expressed approval of President Trump.

Yeah, it was mild approval. But the thing is, especially for the defense in this trial, all you need is one juror. One juror can tie up deliberations in knots, and you can end with a hung jury. And this is actually something that I saw firsthand. In 2019, I was the foreperson on a jury.

How you like that?

Yeah. And the trial was really complicated, but I had thought while we were doing the trial, oh, this is going to be a really easy decision. I thought the defendant in that case was guilty. So we get into deliberations, but there’s this one juror who keeps gumming up the works every time we seem to be making progress, getting a conversation started.

This juror proverbially throws up his hands and says, I am not convicting. This man is innocent. And we talked and we talked. And as the foreperson, I was trying to use all my skills to mediate.

But any time we made any progress, this guy would blow it up. And long story short, hung jury — big victory for the defense lawyer. And we come out of the room. And she points at this juror. The guy —

The defense lawyer.

The defense lawyer points at this juror who blew everything up. And she said, I knew it. I knew I had my guy.

OK. I don’t want to read too much into what you said about that one juror. But should I read between the lines to think that if there’s a hung jury, you wonder if it might be that juror?

That’s what everyone in the courtroom is wondering not just about this juror, but about every single person who was selected. Is this the person who swings the case for me? Is this the person who swings the case against me?

These juries are so complex. It’s 12 people who don’t know each other at the start of the trial and, by the end of the trial, have seen each other every morning and are experiencing the same things, but are not allowed to have talked about the case until deliberations start. In that moment when deliberations start —

You’re going to learn a whole lot about each other.

That’s right. There’s this alchemical moment where suddenly, it all matters. Every personality selected matters. And that’s why jury selection is so important. And that’s why these last two days are actually one of the most important parts of this trial.

OK. So by my math, this trial will require five more jurors to get to 12. I know also they’re going to need to be alternates. But from what you’re saying what looked like a really uphill battle to get an impartial jury or a jury that said it could be impartial — and Trump was very doubtful one could be found — has turned out to not be so hard to find.

That’s right. And in fact, we went from thinking, oh, boy, this is going awfully slowly, to the judge himself saying we could be doing opening arguments as soon as Monday morning. And I think that highlights something that’s really fascinating both about this trial and about the jury selection process overall.

One of the things that lawyers have been arguing about is whether or not it’s important to figure out what jurors’ opinions about Donald Trump are. And the prosecution and, I think, the judge have really said, no, that’s not the key issue here. The key issue is not whether or not people have opinions about Donald Trump.

Right. Who doesn’t have an opinion about Donald Trump?

Exactly. They’re going to. Automatically, they’re going to. The question is whether or not they can be fair and impartial. And the seven people we already have seated, and presumably the five people that we’re going to get over the next few days and however many alternates — we expect six — are all going to have answered that question, not I hate Trump; I love Trump, but I can weigh in on the former president’s innocence or guilt, and I can do it as fairly as humanly possible.

Now, Trump is not happy about this. He said after court yesterday, quote, We have a highly conflicted judge, and he’s rushing this trial.” And I think that he is going to see these beats of the system the criminal justice system as it works on him as he is experiencing it as unfair. That is typically how he talks about it and how he views it.

But what he’s getting is what defendants get. This is the system in New York, in the United States. This is its answer to how do you pick a fair jury? Well, you ask people can you be fair? And you put them through this process, and the outcome is 12 people.

And so I think we’re going to see this over and over again in this trial. We’re going to see Trump experience the criminal justice system.

And its routines.

Yeah, openings, witnesses, evidence, closings. He’s going to go through all of it. And I think, at every turn, it makes sense to expect him to say, well, this is not fair. Well, the judge is doing something wrong. Well, the prosecutors are doing something wrong. Well, the jury is doing something wrong.

But at the end of the day, he’s going to be a defendant, and he’s going to sit, mostly silently if his lawyers can make him do that, and watch this process play itself out. So the system is going to try and treat him like any other defendant, even though, of course —

— he’s not. And he is going to fight back like no other defendant would, like no other defendant could. And that tension, him pushing against the criminal justice system as it strives to treat him, as it would anyone else, is going to be a defining quality of this trial.

Well, Jonah, thank you very much. We appreciate it.

Of course. Thanks so much for having me. [MUSIC PLAYING]

PS, have you ever fallen asleep in a trial?

I have not.

[CHUCKLES]:

Here’s what else you need to know today.

It’s clear the Israelis are making a decision to act. We hope they do so in a way that does as little to escalate this as possible and in a way that, as I said —

During a visit to Jerusalem on Wednesday, Britain’s foreign Secretary left little doubt that Israel would retaliate against Iran for last weekend’s aerial attack, despite pressure from the United States and Britain to stand down. The question now is what form that retaliation will take? “The Times” reports that Israel is weighing several options, including a direct strike on Iran, a cyber attack, or targeted assassinations. And —

Look, history judges us for what we do. This is a critical time right now, critical time on the world stage.

In a plan that could threaten his job, Republican House Speaker Mike Johnson will put a series of foreign aid bills up for a vote this weekend. The bills, especially for aid to Ukraine, are strongly opposed by far-right House Republicans, at least two of whom have threatened to try to oust Johnson over the plan.

I can make a selfish decision and do something that’s different, but I’m doing here what I believe to be the right thing. I think providing lethal aid to Ukraine right now is critically important. I really do. I really — [MUSIC PLAYING]

Today’s episode was produced by Rikki Novetsky, Will Reid, Lynsea Garrison, and Rob Zubko. It was edited by Paige Cowett, contains original music by Marion Lozano, Elisheba Ittoop, and Dan Powell, and was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly Lake.

That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.

• April 19, 2024   •   30:42 The Supreme Court Takes Up Homelessness
• April 18, 2024   •   30:07 The Opening Days of Trump’s First Criminal Trial
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• April 16, 2024   •   29:29 A.I.’s Original Sin
• April 15, 2024   •   24:07 Iran’s Unprecedented Attack on Israel
• April 14, 2024   •   46:17 The Sunday Read: ‘What I Saw Working at The National Enquirer During Donald Trump’s Rise’
• April 12, 2024   •   34:23 How One Family Lost $900,000 in a Timeshare Scam
• April 11, 2024   •   28:39 The Staggering Success of Trump’s Trial Delay Tactics
• April 10, 2024   •   22:49 Trump’s Abortion Dilemma
• April 9, 2024   •   30:48 How Tesla Planted the Seeds for Its Own Potential Downfall
• April 8, 2024   •   30:28 The Eclipse Chaser
• April 7, 2024 The Sunday Read: ‘What Deathbed Visions Teach Us About Living’

Hosted by Michael Barbaro

Featuring Jonah E. Bromwich

Produced by Rikki Novetsky ,  Will Reid ,  Lynsea Garrison and Rob Szypko

Edited by Paige Cowett

Original music by Dan Powell ,  Marion Lozano and Elisheba Ittoop

Engineered by Chris Wood

Listen and follow The Daily Apple Podcasts | Spotify | Amazon Music

Political and legal history are being made in a Lower Manhattan courtroom as Donald J. Trump becomes the first former U.S. president to undergo a criminal trial.

Jonah Bromwich, who covers criminal justice in New York, explains what happened during the opening days of the trial, which is tied to Mr. Trump’s role in a hush-money payment to a porn star.

On today’s episode

Jonah E. Bromwich , who covers criminal justice in New York for The New York Times.

Background reading

Here’s a recap of the courtroom proceedings so far.

Mr. Trump’s trial enters its third day with seven jurors chosen.

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The Daily is made by Rachel Quester, Lynsea Garrison, Clare Toeniskoetter, Paige Cowett, Michael Simon Johnson, Brad Fisher, Chris Wood, Jessica Cheung, Stella Tan, Alexandra Leigh Young, Lisa Chow, Eric Krupke, Marc Georges, Luke Vander Ploeg, M.J. Davis Lin, Dan Powell, Sydney Harper, Mike Benoist, Liz O. Baylen, Asthaa Chaturvedi, Rachelle Bonja, Diana Nguyen, Marion Lozano, Corey Schreppel, Rob Szypko, Elisheba Ittoop, Mooj Zadie, Patricia Willens, Rowan Niemisto, Jody Becker, Rikki Novetsky, John Ketchum, Nina Feldman, Will Reid, Carlos Prieto, Ben Calhoun, Susan Lee, Lexie Diao, Mary Wilson, Alex Stern, Dan Farrell, Sophia Lanman, Shannon Lin, Diane Wong, Devon Taylor, Alyssa Moxley, Summer Thomad, Olivia Natt, Daniel Ramirez and Brendan Klinkenberg.

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Jonah E. Bromwich covers criminal justice in New York, with a focus on the Manhattan district attorney’s office and state criminal courts in Manhattan. More about Jonah E. Bromwich

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