This story originally appeared in Kids Today, Vox’s newsletter about kids, for everyone. Sign up here for future editions. Sahasra Yellepeddi, 16, has lived in Allen, Texas, all her life. Last year, a gunman killed eight people and wounded at least seven in an outlet mall there, one “I’ve been going to since I was born,” she told me. “I realized that these issues that we’re hearing about in the news, gun violence being one, are not abstract, but they’re affecting everyday Americans,” Sahasra said. Sahasra is the development director of the High School Democrats of America, the country’s official high school Democratic organization, and while she won’t be old enough to vote in November, she’s an enthusiastic supporter of Kamala Harris. She appreciates the vice president’s stances on gun reform and reproductive rights, and seeing a Black and Indian American woman in a leadership role “really resonates with me as an Indian American myself,” Sahasra said. Sahasra may be more politically engaged than some of her peers, but according to scholars and educators, lots of kids are paying attention to politics right now — and not in the ways we adults have come to expect. Media outlets (and adults more generally) tend to associate young people with a particular subset of issues such as climate change and the war in Gaza. In fact, teens’ top political concerns look a lot like those of many grownups: They’re just as likely, if not more so, to worry about affordable housing or the national debt as they are about rising sea levels. Indeed, Sahasra listed “the housing crisis and the increased cost of living” alongside climate and safe schools as big issues that matter to people her age. While kids may not be radically different from adults when it comes to their priorities, they are at a different stage of life, coming to political debates with a fresh perspective and not yet exhausted by decades of gridlock and argument. And though they are far from immune to polarization, they may have some lessons for adults about how to have productive and respectful conversations about politics. “They are always surprised how much adults will argue,” said Shari Conditt, a government teacher at Woodland High School in Washington state. Kids crave economic stability right now Children have some concept of government as early as kindergarten, said Christopher Ojeda, a political science professor at UC Merced who has studied how people form their political ideologies. Asked about the government, young kids might draw a picture of a police officer or the White House, he said. In elementary school, children might start voicing support — or distaste — for a political party, but often “they don’t really know what that means,” Ojeda said. “They’re kind of just parroting either parents or peers.” By middle and high school, kids start to have a “deeper understanding of where the parties stand on different issues,” he said. Historically, they’ve mostly gotten that understanding from their parents, but Ojeda thinks parents have gotten less influential since the rise of social media, which allows kids to hear political messages not just from classmates and other peers, but also from influencers and activists all over the world. Kids are getting a lot of their political exposure from TikTok now, said Conditt, who teaches 11th and 12th graders in Woodland, a small town in a purple district of Washington state. Surprisingly, however, they care about a lot of the same things adults do, even the boring policy issues. When Conditt asked her students to write down the top issues for them in November’s election, responses about the economy were by far the most common, with some students listing specific concerns like “affordable housing,” “inflation,” “gas prices,” and even “the national debt.” That’s a lot like what adults tell pollsters every day: The economy was also the top issue in a September Pew poll of registered voters, with 81 percent listing it as very important to them. It’s also in line with polls of 18- to 29-year-olds, who consistently rank the economy as a top concern. Conditt’s students listed “border control,” “abortion rights,” “affordable health care,” and both “gun restrictions” and “gun rights” as key issues for them. Climate change, in another surprise, didn’t come up at all. (Despite record temperatures and the increasing threat of extreme weather, climate is not a top issue for most adult voters this year, either.) “I think that 17- and 18-year-olds want to feel a sense of stability in their world,” Conditt told me. For her students, many of whom are not college-bound, that often means “they want to figure out how to transition into the next stage of their life in a stable way,” and they want to see an economy that makes that possible. Political divides look different for kids Some recent polls have shown young people, especially boys and young men, skewing more conservative than their elders. In one large national survey of 12th graders, about a quarter of boys have identified as conservative in recent years, while under 15 percent identified as liberal — the largest split in decades. Among girls, the results were reversed, with about 30 percent identifying as liberal and just over 10 percent listing themselves as conservative. Among boys, however, the most popular answers in the survey were “none of the above” and “I don’t know.” Some fear this is a sign of political disconnection — the results seem “to show how young men feel alienated from both sides of the political aisle,” Arwa Mahdawi of the Guardian wrote in 2023. “A lot of teenagers and youth have political apathy and tend to not care about politics because they don’t think it affects their lives,” Katie Mirne, a 16-year-old high school junior and the chair of the New Jersey High School Republicans, told me in an email. But there are also signs that kids care about issues that don’t map neatly onto electoral politics. A 2024 survey by the market research group YPulse found that 75 percent of 8- to 12-year-olds were passionate about a social cause or issue. The top issue they cited was animal rights, followed by cyberbullying, poverty, racism, and mental health care. When the child-focused nonprofit Common Sense Media this year asked 12- to 17-year-olds for their top concerns regarding the health and well-being of kids, mental health challenges topped the list, followed by gun violence, the effects of social media, and drug abuse. Conditt, meanwhile, spends a lot of time discussing local politics with her students, like a recent ballot measure to raise money for education. And when it comes to more nationwide issues, she said, her students have learned to keep an open mind when talking to one another, and to “acknowledge the value of the dialogue, versus trying to assert that somebody is right or wrong.” It’s a mindset she’s teaching them, but also one they’ve taken deeply to heart, she said. “My students live in this world where we’re talking so calmly with each other and acknowledging diverse perspectives.” For Sahasra, growing up as a Democrat in a red state has taught her to respect differing opinions. “Living in Texas has shown me the power of politics to facilitate real change,” she said, “but it’s also shown me that politics, at the end of the day, is one aspect of my personality.” What I’m reading Schools are failing to support the victims of nonconsensual deepfake images, according to a recent survey of teachers. A bus driver shortage in New York City is leading to long waits and late arrivals for students, another example of a problem I wrote about last week. More than half of US states have now moved to ban or restrict cellphones in schools, according to a new analysis. Do you want a Skibidi Toilet Halloween costume? Here. At my house we are revisiting Circle, Square, and Triangle by Mac Barnett and Jon Klassen. These books are about three shapes who alternately support and torment one another in an eerie landscape of rocks, waterfalls, and darkness. I think Circle is the best but they are all so good. From my inbox A while back, I asked readers for their thoughts on the proliferation of toys in the lives of kids today. “It’s a part-time job to keep up on sorting them, rotating them, removing from the rotation and keeping hidden from the child until they can be taken to the consignment store/Goodwill,” reader Lynne Marie responded. “Forget trying to remove broken toys, that’s a lost cause. My kid loves to make a ‘nest’ which is a pile of every single one of his possessions which can cover the entire floor of his room and make it impossible to get in and out.” My children have also been known to nest in toys. More on this issue soon! For an upcoming newsletter, I’ll be dealing with the childhood torment that is lice. Do you or the kids in your life have experience with these itchy insects? Get in touch at anna.north@vox.com.

The sweet, odorless gas technically called nitrous oxide has many names: laughing gas, galaxy gas, hippy crack, whippets, even “the atmosphere of heaven.” Nitrous itself has just as many common uses as it does names. Doctors use it as a mild anesthetic, sending patients off into brief and largely pain-free dissociative euphorias before having a tooth pulled or dislocated finger yanked straight. Inhaling nitrous gives a loopy, giddy sort of high that can last up to five minutes. As a pressurized gas, nitrous also powers rockets, race cars, and whipped cream dispensers. The gas is both legal and widely available. It comes in small pressurized canisters intended for kitchen use; large tanks for heavier applications, like medicine or car engines; or even as the gas that shoots out of whipped cream canisters when there’s no cream left (hence: “whippets”). Thanks to being both accessible and cheap, nitrous has been used as a recreational drug for decades, from Grateful Dead concerts in the ’60s to raves in the ’90s. Lockdowns during the Covid pandemic seem to have set off a new wave of recreational nitrous use. Today, “People on Nitrous Gas” has its own TikTok discovery tab, with videos racking up millions of views. Celebrities are putting the risks of abuse on display, from Kanye West and SZA, to Steve-O of the stunt show Jackass fame. The Mormon mothers and social media influencers of “MomTok,” whose faith shuns any drug use, recently said that part of the draw of all the Botox they’ve gotten is getting the nitrous first. “It’s a party,” one said. Inhaling nitrous is considered relatively safe for people who don’t use it often and don’t take too much. But there are definitely risks, and more so in recreational contexts. As recreational use rises, particularly among teenagers, those risks are gaining more attention. The primary one is vitamin B12 deficiency. Nitrous inactivates B12 in the body, which coupled with long-term use can lead to nerve damage across the brain and spine. Without intervention, that can develop into paralysis or brain damage. There’s currently no consensus as to whether nitrous should be labeled an addictive substance. While it doesn’t seem to build the same physical dependency as opioids, it does still carry the risk of habit formation in some cases. And while nitrous doesn’t have a known fatal dose, deaths from use have been known to occur, usually from accidents that can happen while high on nitrous or from asphyxiation. Across the UK, where statistics on nitrous are more detailed, there were just 56 deaths attributed to nitrous between 2001 and 2020, including both recreational and medical settings. (To put that in some perspective, there were nearly 10,000 deaths in the UK attributed to alcohol in 2021 alone.) But while the rise in using recreational nitrous for its brief highs is prompting new concerns, the drug is actually one of the oldest stories in the Western history of mind-altering substance use. Through the centuries of up-and-down nitrous use across the US and UK, you find a rich, at times hilarious, trail left by this so-called atmosphere of heaven. Theaters across the US in the early 1800s filled with members of the public, watching volunteers inhale nitrous on stage and provide a delirious form of entertainment for the crowds. Traveling caravans brought nitrous shows on the road. Poets celebrated a new form of pleasure, while philosophers tried nitrous in Harvard laboratories, frantically scribbling down rushes of insight. [Image: An 1840 engraving of a man dancing after inhaling nitrous oxide. https://platform.vox.com/wp-content/uploads/sites/2/2024/09/2_11557a.jpg?quality=90&strip=all] The history of nitrous use is a history of shifting cultural attitudes about the mind. More specifically, about the value — or rejection — of chemically altered states of consciousness. Today, as the gradual return of legal access to psychedelics is sparking renewed conversation around the potential benefits, and harms, of mind-altering drugs, seeing the many different iterations of nitrous use across history can help us think more expansively about what, if anything, the strange experiences of nitrous mean and what the future of recreational nitrous might look like. “A new pleasure for which language has no name” In late 18th-century industrial Britain, the air was foul. Coal smoke and the odor of feces were abundant. Respiratory diseases were rampant, like tuberculosis, which had come to be known as “the robber of youth.” The deadly air inspired the founding of the Pneumatic Institution in 1799, a medical facility in Bristol intended to study whether gasses could be used as medicines, too. It was there that the first experiments with nitrous began in earnest. The chemist Joseph Priestley discovered nitrous oxide in 1772, but dismissed it as toxic. Humphry Davy, a young lab assistant at the Pneumatic Institution, had a hunch that Priestley’s discovery had been confused with a chemically similar but highly irritating compound: nitric oxide. In April, Davy repeated Priestley’s experiment, and wrote to a friend afterward that he had “made a discovery which proves how necessary it is to repeat experiments,” prefiguring the role of replication in science today. Nitrous oxide, when purely synthesized, was perfectly breathable. Davy then set out to breathe as much as he possibly could. He sealed himself inside a box that was designed to boost the inhalation of gasses. He sat for over an hour while a steady flow of nitrous oxide filled the chamber. When he stepped out, he grabbed a giant silk air-bag full of more nitrous and huffed that too, just for good measure. Then, his mind peeled away from his body, and he “lost touch with all external things,” entering a strange, revelatory world of flashing insights. That summer, Davy invited dozens of curious writers, physicians, and philosophers to visit the Pneumatic Institute in the late evenings after normal operations had ceased. They all huffed nitrous, experimenting with entirely new regions of the mind. According to historian Mike Jay, author of Psychonauts: Drugs and the Making of the Modern Mind, nitrous gave Western scientists one of the first chemical means of reliably accessing mystical states of consciousness. Against the banality of our ordinary experience, nitrous delivered a shocking contrast, a state of mind full of unfamiliar pleasures that often carried a sense of insight into the nature of the cosmos. The poet Robert Southey, after his first hit of nitrous, wrote to his brother that “Davy has actually invented a new pleasure for which language has no name.” [Image: Colored etching by Robert Seymour of his evening with a group of poets composing verses while on nitrous oxide in 1829. https://platform.vox.com/wp-content/uploads/sites/2/2024/09/Gas-living-room-color-1.jpg?quality=90&strip=all] Within a year, however, most who had come to try nitrous lost interest. Its pleasures were new and exciting, but rarely stuck with users once they returned to sobriety after a few minutes. Others who tried the gas just ended up with an upset stomach and the giggles. Davy, who would go on to become president of the Royal Society, stayed with his experiments, eventually producing a hefty book on the chemistry and philosophy of nitrous. He predicted that since nitrous temporarily extinguished pain, it could be useful during surgeries. No form of anesthesia existed yet, so surgeries were very painful, and very dangerous. But the idea failed to gain momentum. Instead, nitrous became something else: entertainment. How nitrous became entertainment, and then medicine Though the early enthusiasm for nitrous fizzled, it was easy enough to produce that, as word got out, chemists learned they could make it in their home laboratories. This turned nitrous into something of a party fixture. “Maybe it will become the custom for us to inhale laughing gas at the end of a dinner party, instead of drinking champagne,” a young German chemist speculated in 1826, after participating in a garden party where guests enjoyed nitrous under the afternoon sun. Public nitrous shows began taking place as early as an 1814 lecture series in Philadelphia. First, a doctor gave a discourse on the effects of nitrous to the assembled crowd. Then, a series of young men volunteered to inhale balloons of nitrous onstage, putting on a raucous spectacle. While Davy and his friends had been interested in the mental side of what being on nitrous felt like, these public shows put a spotlight on the uninhibited bodies that the chemical set loose. After inhaling the gas, volunteers would clumsily dance, fight, sing, or even strike up the occasional fencing match. Sometimes, the first row of a theater was kept empty to protect onlookers from the mayhem. “On stage, the subjective experience was incidental,” writes Jay. “The moment of return to waking consciousness was not interrogated for mystical revelation, but held up for confused hilarity.” Soon, nitrous shows were taken on the road, carried by traveling carnivals to new, hooting crowds each night. Volunteers were charged around 25 cents per huff, bringing in good profit for those who’d invested in the necessary gas tanks, tubes, and breathing bags. One traveling nitrous show, put on by Samuel Colt (who would go on to invent the pioneering Colt firearm), dosed roughly 20,000 volunteers from Canada to Maryland. It was during a show in 1844 that the American dentist Horace Wells witnessed a teenager on nitrous slam into a wooden bench. The boy, Wells noticed, felt no pain, which led him to wonder whether he could give the gas to clients to numb the pain of having a tooth pulled. Wells first tried on himself, inhaling nitrous and having another dentist pull his own wisdom tooth. It was a great success: Wells felt no pain, and proclaimed “a new era in tooth pulling.” He successfully performed the procedure on a few of his patients, before convincing a surgeon at the prestigious Massachusetts General Hospital to let Wells administer the gas during an operation, doubling as a demonstration for a strictly medical audience. It didn’t go well. Nervous in front of a scrupulous crowd, Wells pulled away the nitrous balloon a little too quickly. During the operation, the patient appeared to groan in pain (though it was later deemed an involuntary and unconscious response). Onlookers nevertheless booed Wells out of the theater, and the embarrassment pushed him into a depression that culminated in suicide. But the demonstration inspired Wells’s former partner to try a similar procedure, only with a different substance: a solvent called ether. After a few successful experiments using ether as an anesthetic, another demonstration was arranged in the same theater where Wells’s had failed. This time, ether was successfully administered as a pain-vanquishing anesthetic, prompting one of the most significant medical breakthroughs of the century, as well as a revisitation of Wells’s work with nitrous. The hospital theater was renamed “The Ether Dome,” while anesthetic use of both ether and nitrous began to spread across the country. The next 150 years of nitrous The rise of anesthetics like nitrous in medicine was accompanied by a decline in their use as recreational drugs. Physicians began to think of nitrous-induced revelations as gibberish, closer to delirium than real insight. Too much interest in their short-lived pleasures, doctors began to write, could pose a public health risk. Recreational anesthetics like nitrous would “delight the animal sensations, while they destroy the moral sentiments; they introduce their victims to a fool’s paradise; they mock them with joys which end in sorrows.” Jay describes the mid-1800s arc of nitrous as a “shift away from subjectivity,” prefiguring the same trajectory across a variety of disciplines, including psychology. Through the middle of the 19th century, nitrous settled into dentistry while falling out of philosophy, with at least one major exception that ultimately proved the rule: the eccentric American philosopher Benjamin Blood. In 1860, during what he expected to be a very normal visit to the dentist, he awoke from a routine dose of nitrous with the vague sense that he’d glimpsed the essence of all philosophy, the “secret or problem of the world,” as he later wrote. Blood asked dentists and doctors why their gas had given him a spiritual epiphany. He learned two things. First, that “nearly every hospital and dentist office has its reminiscences of patients who, after a brief anesthesia, uttered confused fragments of some inarticulate import which always had to do with the mystery of life.” Across the country, patients returning from anesthesia had been asking their doctors something to the effect of, “What does it all mean, or amount to?” Second, the doctors and the dentists couldn’t care less. Blood received smiles and shrugs, but no explanations. So he spent 14 years reviving the tradition of nitrous self-experimentation, eventually publishing a pamphlet: The Anaesthetic Revelation and the Gist of Philosophy. It didn’t get particularly famous, but it did catch the attention of Harvard philosopher William James. Inspired by Blood’s curious writings, James followed Humphry Davy’s old protocol, heating a beaker of ammonium nitrate in the Harvard chemistry laboratory, capturing the escaping gas, and inhaling deeply with pen and paper in hand. His subsequent experience of “intense metaphysical illumination” informed the rest of his life’s work, where he would go on to become known, today, as the father of American psychology. Meanwhile, innovations in the delivery mechanisms for laughing gas were starting to ramp up its use in dentistry. George Poe, cousin of the poet Edgar Allen Poe, figured out how to manufacture nitrous in liquid form. This allowed for packaging and distributing it in easy-to-use canisters. By 1883, he was supplying 5,000 dentists with canned nitrous oxide across the country. Once nitrous came in a convenient package, people began finding all sorts of new uses for it. In 1914, American rocketeer Robert Goddard filed a patent suggesting it could work as a rocket propellant, where it’s still used today. [Image: Clubgoers at Studio 54 in New York enjoy a tank of nitrous oxide on the dance floor in 1977. https://platform.vox.com/wp-content/uploads/sites/2/2024/09/GettyImages-583937001.jpg?quality=90&strip=all] But the innovation that brought nitrous back into style as a contemporary recreational drug was a little more mundane: whipped cream canisters. It turned out that dispensing cream out of a nitrous gas cylinder delivers the perfectly fluffy whipped cream we can so easily buy in grocery stores today. These whipped cream canisters are also where the name “whippets” comes from, and how we’ve landed in the awkward situation of rising nitrous use among teenagers. Nitrous, today and tomorrow In the neighboring arena of psychedelic drugs, many advocates are pushing for wider accessibility to these mind-altering substances. With nitrous, that accessibility is already here, and now, attracting strong criticism. The UK recently reinstated a shade of prohibition, making possession of nitrous oxide for “unlawful use” illegal. You can still use it to dispense whipped cream and other culinary delights, but if you’re just interested in a giggly high, or even seeing whether it might reveal, as Blood thought, the world’s philosophical secret, that’s unlawful. But prohibition inevitably pushes drug use underground, where it’s guaranteed to be riskier and less well-informed than legal, regulated, and educated use. And with a substance like nitrous that has relatively few risks when used responsibly and occasionally, there’s an opportunity to work on promoting more responsible forms of use through public education (such as awareness that the gas impairs the body’s ability to take in oxygen, so doing whippets in a tight, closed space is probably not as safe as in a backyard). Since nitrous-related substance abuse is such a small problem relative to opioids and alcohol, it hasn’t received all that much study. The past few years of data, however, have prompted a new conversation around whether nitrous should be considered addictive. It doesn’t seem to form a physical dependence, like opioids, and has no physical symptoms of withdrawal. But it does seem capable of forming a more psychological form of dependence (dissociative pleasure basically on tap does obviously pose some habit-forming risk), prompting concerns around how exactly to label it. Either way, ensuring support and harm reduction is available to those who need it may prove to be a challenge. But if we can’t figure out how to handle recreational use with nitrous, it’s difficult to imagine how we’d do it in a world where LSD and psilocybin mushrooms become widely available, too. [Image: Discarded canisters of nitrous oxide. https://platform.vox.com/wp-content/uploads/sites/2/2024/09/GettyImages-1276667241.jpg?quality=90&strip=all] More broadly, though, set against the long history of different approaches and interpretations of nitrous, our current situation isn’t all that new. Today’s social media spectacles of nitrous use are just digitized versions of the same nitrous shows from the 1800s. Back then, some people believed that wild behaviors while on nitrous revealed “the volatility of the democratic masses.” What might it say about our own cultural moment that recreational nitrous use is returning as a sort of performative delirium? As far as the philosophy of nitrous goes, I imagine curious experimenters today are working with different substances, like extended DMT. Maybe someone like Benjamin Blood will come along and make the case that we still have much to learn from nitrous. Maybe dentists will begin to read up on metaphysics and begin engaging with their woozy patients rather than dismissing their experiences. Or, maybe nothing much will happen with nitrous. The social media hype will die down as new drugs take its place, and it will sink back into relative obscurity, propelling rockets and numbing minor surgeries, inspiring the occasional dorm-room conversation about God and the nature of pleasure. At the very least, as its long history shows, nitrous will always remain capable of giving us a great story.

John didn’t start his career mad. He trained as an emergency medicine doctor in a tidily run Midwestern emergency room about a decade ago. He loved the place, especially the way its management was so responsive to the doctors’ needs, offering extra staffing when things got busy and paid administrative time for teaching other trainees. Doctors provided most of the care, occasionally overseeing the work of nurse practitioners and physician associates. He signed on to start there full-time shortly after finishing his residency. A month before his start date, a private equity firm bought the practice. “I can’t even tell you how quickly it changed,” John says. The ratio of doctors to other clinicians flipped, shrinking doctor hours to a minimum as the firm moved to save on salaries. John — who is being referred to by a pseudonym due to concerns over professional repercussions — quit and found a job at another emergency room in a different state. It too soon sold out to the same private equity firm. Then it happened again, and then again. Small emergency rooms “kept getting gobbled up by these gigantic corporations so fast,” he said. By the time doctors tried to jump ship to another ER, “they were already sold out.” At all of the private equity-acquired ERs where John worked, things changed almost overnight: In addition to having their hours cut, doctors were docked pay if they didn’t evaluate new arrivals within 25 minutes of them walking through the door, leading to hasty orders for “kitchen sink” workups geared mostly toward productivity — not toward real cost-effectiveness or diagnostic precision. Amid all of this, cuts to their hours when ER volumes were low meant John and his colleagues’ pay was all over the place. Patient care was suffering “from the toe sprains all the way up to the gunshot wounds and heart attacks,” says John. His experience wasn’t an anomaly — it was happening in emergency rooms across the country. “All of my colleagues were experiencing the same thing.” At times, the short staffing combined with the pressure to churn patients led to deadly shortcuts. John remembers rushing to evaluate one patient and missing his extensive history of alcohol abuse. The patient spent hours getting tests directed at the wrong diagnosis. John could have put together a more appropriate plan if he’d had a few more minutes to sit down and get a better history, but by the time he realized what was going on, the patient was too severely ill. He died in the intensive care unit two days later. “Is that 100 percent because of that staffing? Probably not,” says John. “But if I wasn’t so stressed about jumping into that patient room, making sure my door-to-provider time was less than 25 minutes …” The hypothetical hangs in the air. “Were they going to die anyway? Maybe. But that’s not how I sleep at night. That was four years ago. I think about that guy every day.” [Image: https://platform.vox.com/wp-content/uploads/sites/2/2024/09/240917_xinmei_Vox_ER-Monster_spot1_v2.jpg?quality=90&strip=all] The story of how private equity has been able to so thoroughly debilitate emergency care is one of the more dramatic examples of how corporate interests are corrosive to America’s health care system — and how powerless they leave individual consumers. Today, private equity continues to operate a shocking quarter of ERs nationwide, as of March 2024. Still, there’s some hope: Academics, patient advocates, and doctors say you can make defensive moves to protect your finances and care before, during, and after you or a loved one visits an ER. Understanding private equity’s transformation of America’s emergency rooms is the first step. How private equity sunk its claws into emergency care Modern private equity got its start in the early 1980s, when a free-market acolyte — and former member of the Nixon administration — completed the first major “leveraged buyout.” Using mostly borrowed money, William Simon and his partner bought a greeting card company, extracted huge fees, and then sold it for a massive profit less than two years later. Over the next few decades, what was then called the leveraged buyout industry moved into other sectors. Firms flipped businesses to yield spectacular profits, often cutting corners on the products and services they offered, eliminating jobs, and reducing employee benefits. It was only a matter of time until the industry, now rebranded as private equity, turned its gaze on the US’s $4 trillion health care sector, which was already becoming increasingly commercialized as nonprofit health systems consolidated, paid their executives ever more extravagant salaries, and otherwise played business hardball. Private equity takeovers in health care started around 2000 and have steadily increased since; when several big banks crumbled in the wake of the 2008 financial crisis, private equity’s growth only accelerated. Emergency medicine wasn’t always an appealing target for private equity. Physician staffing in many emergency rooms around the country was traditionally handled by co-op-like groups, run by working doctors, that contracted with hospitals. In the 1990s, ex-physicians and businesspeople began taking ownership of these so-called contract management groups (CMGs). As they did, they started acting more like for-profit businesses, centralizing decision-making and earnings. The easier it was to make decisions that prioritized profits, the more money CMGs made — and the more attractive they became to private equity. Through the mid- to late-2010s, private equity firms swallowed up a shocking number of American emergency rooms, leaving in their wake a generationally hollowed-out system for providing emergency care to people across the country. Private equity firms and other corporate interests owned nearly 9 percent of ER doctor groups in 2009; by 2019, they owned 22 percent. The wave of takeovers and consolidations peaked in 2021 but carries on all over the US, especially in Florida, Texas, and other parts of the South and West where the firms have been most aggressive. Doctors trying to practice medicine the way they’d been trained to — with a priority on patient care, not profits — found they couldn’t outrun the monster. Private equity’s dominance persisted even after the federal No Surprises Act, enacted in 2022, made many of their most profitable practices illegal. Lots of for-profit models are a bad fit for health care, but of all of them, private equity is perhaps the worst, says Eileen O’Grady, director of programs at the Private Equity Stakeholder Project, a nonprofit watchdog group: “It basically takes the for-profit model and makes it so much more extractive and so much more harmful and risky.” Private equity puts profit above all else To understand what makes private equity such a malignant force in health care, you have to understand its uniquely craven and purposefully opaque corporate structure. Imagine you own a lemonade stand, and you want it to make more money. You have a few options: You can plow all your profits back into the business until it grows — what business school types call organic growth. Alternatively, you can get a bank loan. If you’re really ambitious, you can sell shares of your lemonade stand to the general public by promising them a good return on their investment. There’s another option here, one that will make you richer quicker: You can sell all or most of the stand to the rich kid at the end of the street. He’s offering you a lot of money for it — more than you’d get over the short term from the other options. That’s because he’s taken out a huge loan to pay for the deal. But there are a couple of catches: First, if he runs into financial trouble (which he very well might, since he’s been buying up lemonade stands all over town), he’ll sell it off for parts, leaving the neighborhood lemonade-less. This will cost him nothing personally because he used the lemonade stand as collateral for that big loan. The second and perhaps more important catch is that this kid is buying your lemonade stand in order to sell it. He doesn’t care about lemonade or the people who like it. His strategy is to make the stand’s balance sheet look so attractive that a few years later, another investor will buy it at a premium — or if that fails, then yes, to sell it off for parts. A year down the road, odds are high your precious lemonade stand will be a sad shadow of what it once was, or it might not exist at all. That kid is private equity. [Image: https://platform.vox.com/wp-content/uploads/sites/2/2024/09/240917_xinmei_Vox_ER-Monster_spot3_v2.jpg?quality=90&strip=all] When private equity comes for a lemonade stand (or for Toys “R” Us, Samsonite, Mitchell Gold + Bob Williams, or for any of the thousands of businesses these firms have taken over since they rose to prominence in the late 1980s), the result is often a sad story about the decline of a legacy brand — shoddy products and lost jobs. Depressing, but not a life-and-death issue. When private equity comes for health care, though, the result is human suffering: Elderly and intellectually disabled people sitting in puddles of their own waste, sick patients not getting the care they need, worse outcomes for patients. It’s not just lemonade. People’s lives are at stake. The way private equity gets into emergency care is by buying out the CMGs that manage physician staffing — that is to say, the firms only buy the clinicians themselves. It’s a different model than when private equity invests in other areas of health care. When firms buy hospitals, nursing homes, medical practices, rehabilitation facilities, and group homes, they acquire not only staff, but also buildings, land, and medical equipment. In the case of emergency care, “private equity doesn’t pay the hospital rent, they don’t hire the nurses, they don’t pay the electric bills, they don’t provide any of the equipment,” says Robert McNamara, chair of the emergency medicine department at Temple University in Philadelphia. The hospital still handles those finances. “They’re just working the labor force. … The highest-cost thing on their expense side is the board-certified emergency physician.” When emergency rooms first caught the eye of private equity firms, the prospective investors offered the physician owners of CMGs huge payouts. Leon Adelman, an emergency medicine doctor who leads the staffing firm Ivy Clinicians and writes a workforce-focused newsletter, says the owners faced a tough choice: “‘Do I do what is ethical and feels right … and I get a nice going-away party and maybe a watch or something — or do I get $10 million?’” “What they were buying was the ability to charge patients who were consuming a non-shoppable service,” Adelman says — one for which patients are unable to compare prices. If you’re having a heart attack, you’re not going to call around to hospitals to find out who is going to give you the best deal. Hospitals that increasingly have profit on the brain often found private equity a more attractive partner than doctor-owned CMGs. The firms are flush with cash, which means they don’t look to the hospitals to shore up their finances. “They won’t ask you for a penny,” Adelman explains. “They’re making plenty of money.” Once a private equity firm bought an emergency room, there were two levers it could pull to make a profit: It could maximize what it reaped from patients who’d received services, and it could cut what it spent paying the clinicians who provided those services. Doing both at the same time has made emergency medicine practically unrecognizable. Burned-out doctors, screwed-over patients Under new private equity ownership, ERs adopted an assortment of unsavory practices. Firms not only pressured clinicians to see patients faster, as illustrated by John’s experience, but to recommend hospital admission for more patients. They also dramatically raised the price tags for a range of emergency services, resulting in back-breakingly large bills for patients nationwide, like ones charging thousands of dollars for glue applied to a half-inch wound. To avoid having to negotiate those astronomical bills with the expert hagglers at insurance companies, firms kept their ERs from participating in many insurance networks. It was easier to collect on a so-called balance bill — the portion of a medical bill not paid for by a patient’s insurer — if the care a patient had received wasn’t covered by their insurance at all. In a study of two of the largest emergency medicine staffing firms in the US, health economist Zack Cooper found costs to patients went up more than 80 percent after a corporate interest took ownership. [Image: https://platform.vox.com/wp-content/uploads/sites/2/2024/09/240917_xinmei_Vox_ER-Monster_spot4_v2.jpg?quality=90&strip=all] Meanwhile, to minimize costs, private equity-owned staffing firms often replaced more expensive physicians with nurse practitioners and physician associates. It was a move likely to worsen patient care: While these professionals do highly skilled work in a variety of clinical settings, the emergency department is one place where care outcomes are more likely to suffer if a doctor isn’t involved. In a demonstration of how deeply invested private equity was in emergency care, these firms set in motion a system to generate cheap labor, trained to private equity’s productivity maximizing specifications. For-profit health care companies, including private equity-invested ones, founded a glut of residency training programs in the late 2010s. A 2021 study projected the move would lead to an oversupply of more than 7,800 emergency medicine doctors by 2030. According to reporting by Lever, the private equity-funded staffing firm American Physician Partners told investors they expected the surplus to eventually save them an expected $20 million in annual payroll costs. There are good reasons to believe that private equity’s soup-to-nuts transformation of emergency care has had a devastating effect on physician morale and patient care — and many emergency doctors say both are true. In lemonade-stand terms, private equity is “diluting the lemonade, but charging six times as much,” Adelman says, and their customers are “dying of thirst.” Emergency medicine has long been among the most stressful physician specialties. However, in recent years, the burnout rate has climbed to 63 percent, according to a 2024 Medscape survey, and the specialty is losing popularity among medical students. Doctors’ decision-making authority is their currency; “To have that taken away because of leadership and ownership models that negate that authority is really disheartening, and leads to burnout and, really, moral injury,” says Aisha Terry, a Washington, DC, emergency room doctor and president of the American College of Emergency Physicians, an advocacy and education nonprofit. Meanwhile, finding concrete data proving patient harms is difficult. Yashaswini Singh, a health care economist who studies changes in physician practices acquired by private equity funds, says linking patient outcomes with private equity involvement is “a Herculean task.” Still, researchers are on the case, and so are legislators — earlier this year, Sen. Gary Peters (D-MI) initiated an investigation into private equity’s effects on the quality of emergency care. Private equity can only do what it does because so many other parts of American health care are so dysfunctional. “Just to be really clear, private equity is not the main harm of health care in the US,” says O’Grady. “I think it’s a symptom of a much bigger problem.” In the US health care ecosystem, private equity is a bottom-feeder, an entity that can only exist because of the bad behavior and misaligned incentives of the bigger players in the marketplace. Private equity’s deep pockets, its willingness to extort patients, its heavy-handedness with telling doctors how to practice wouldn’t be possible — much less an advantage — in the absence of these larger upstream problems. Maybe there wouldn’t be as many opportunities for private equity to make money in health care if hospital budgets were stable; if insurance companies didn’t play hardball with both providers and patients; if pharmaceutical industry players didn’t artificially and unevenly inflate drug prices; if elected officials weren’t so susceptible to powerful lobbies that block comprehensive, loophole-closing health care reform. That’s not the world we live in, however; and because the American health care system is broken in these and so many other ways, private equity thrives within it, often invisibly. Congress tried to fix the problem — but fell short In 2020, Congress threw a huge wrench in the private equity game plan when it passed the No Surprises Act, aimed at saving patients from receiving shocking bills after getting emergency care. When the law took effect in January 2022, it meant that patients who receive emergency care can’t get billed for out-of-network care, even if the care is from an out-of-network facility or doctor. (They do still have to pay whatever deductibles, copays, or coinsurance their insurance plan would require related to an in-network visit.) It also protects people from higher bills if they get routine, non-emergency care at an in-network facility from an out-of-network doctor without their knowledge or consent. Billers — including private equity owners of emergency medicine practices — now have to ask insurance companies to pay the balance of their out-of-network bills. It turns out it’s a lot harder to extract unreasonable fees from insurance companies than from individuals. The act served as the death (or near-death) blow for several emergency medicine groups backed by private equity, which at their peak staffed nearly one-fifth of American emergency departments. That really only means some of these firms are now being run with oversight from courts and creditors, not that all of them are out of business: They’re largely still standing, and many have since only expanded their footprint in emergency care. [Image: https://platform.vox.com/wp-content/uploads/sites/2/2024/09/240917_xinmei_Vox_ER-Monster_spot2_v2.jpg?quality=90&strip=all] The No Surprises Act did some good for people, but it’s far from perfect. Many people simply are unaware when they’ve been incorrectly billed. Clinicians and the facilities they work for occasionally don’t follow the legislation’s rules, or inappropriately ask patients to waive their protections. Insurance companies don’t automatically absolve patients of responsibility for a surprise out-of-network bill, and the appeals process is complicated and time-consuming. And there are loopholes: Out-of-network ambulances and urgent care facilities aren’t covered, and neither is the follow-up care people get after an emergency room visit. The emergency medicine profession, meanwhile, will take a while to recover from private equity’s onslaught. John’s colleagues are the kinds of doctors who will drive a patient home if they don’t have a ride, he says. Many of the people who seek care in American emergency rooms live on the poorest and most marginalized fringes of society; emergency medicine doctors know this, and for some of them, it’s an important reason they chose the work. “This is not about pay for us,” he says. “This is just about being fair and letting us practice how we want to practice. And that’s gone.” --- What to do when you need emergency care It has to be said: Patients shouldn’t have to be shrewd when navigating a system that’s supposed to care for them at their most vulnerable, or risk both their life and their finances. And yet, that’s the health care system the US has. It’s hard for people to tell when a private equity firm has taken over a local emergency room. It’s not like the firm slaps its logo on the side of the building. Patients usually don’t even know until they get a bill that an investment company had a hand in determining who saw them in the emergency room and what kind of workup they ordered, says McNamara. Given that reality, anyone who may one day visit an emergency room in the middle of a crisis — that is to say, nearly everyone — should know how to protect themselves, says Patricia Kelmar, who directs health care campaigns for the Public Interest Research Group (PIRG). There are things you can do to ensure you don’t end up with an astronomical bill. Know where to go and who is treating you Some situations don’t permit much decision-making about which emergency room you’ll go to or how you’ll get there. Still, it’s worth making an advance plan for where you’ll go if you have the option. Cooper, the health economist, says an emergency room’s ownership isn’t the only thing that matters in deciding whether to go there in an emergency. If a private equity-owned ER sees a higher patient volume than others and is affiliated with an academic institution, it may still be the best option. Even with the No Surprises Act in place, care from in-network doctors at in-network hospitals is far less likely to result in unpleasant bills. So before you need an emergency room, check with your insurance company to see which ones are in network and nearest to you. Once you’re at an emergency room, Cooper suggests asking to see an in-network physician. Make a plan for how to get there Ambulance transport is unlikely to be cost-free for most Americans, so if you need to get to an emergency room and you’re in stable condition, it’s worth trying to get there in other ways. Air ambulances are covered by the No Surprises Act, but ground ambulances are not, and are unfortunately often out-of-network for many people. The ones owned by private equity are especially likely to be wildly expensive. Nevertheless, many states have laws to protect consumers from outrageous ambulance bills — but only if their plan is state-regulated, which means about 60 percent of insured people are still unprotected. You can figure out if yours is one of them by contacting your state’s insurance department. You can also work with your insurance company and the ambulance company to negotiate big bills; legal aid organizations can also provide assistance. Understand what you’re signing Non-emergency hospital departments (for example, the ones that would take care of you if you had to stay in the hospital for more care after an ER visit) are allowed to ask you to sign away your No Surprises Act protections. The form they use to do this is, totally unironically, called a Surprise Billing Protection Form. Emergency rooms, however, aren’t allowed to ask you to sign this waiver. If they do, say no and report the violation to the No Surprises Help Desk by calling 1-800-985-3059. Almost every US hospital still has to provide care for you under US law. If you get a wonky bill, file a complaint If you do still end up with a nonsensically large bill, you can push back and appeal decisions — again, by reaching out to the No Surprises Help Desk. Additional guidance on your medical billing rights is available on the PIRG website, and legal and other help may be available from organizations like Dollar For and local legal aid groups. Demand better from community leaders and elected officials There are better approaches to solving emergency medicine’s problems than by doing hand-to-hand combat with private equity’s worst practices. Reducing the overall harm requires change on a systemic level. Zirui Song, a Harvard health economist and internist who studies private equity in health care, says those changes include better enforcement of the laws we have aimed at preventing consolidation, fraud, and abuse; closing tax loopholes and other laws that allow private equity firms to conduct business while taking on minimal financial risk; and requiring transparency around private equity health care acquisitions and health care prices. These are all subjects you can contact your elected officials about. You can also ask to join the board of your local hospital, says McNamara. At nonprofit health systems in particular, these groups are required to include people from the community. As a member, you could learn more about how private equity works and say, “We don’t want private equity in our community.” --- This story is supported by a grant from the National Institute for Health Care Management. Vox Media had full discretion over the content of this reporting.