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Dead Canaries

by Emily Friedman

First published in Hospitals & Health Networks OnLine, August 5, 2008

It was once common practice in mining to take a caged canary into a mine. If the bird died, it was time to evacuate. As some of the nation's great public hospitals -- and some private hospitals -- go the way of unlucky mine canaries, it's time to ask: Are we allowing the backbone of the health care system to be destroyed?

Emily Friedman
Emily Friedman

It was a simple concept, pioneered in U.S. mines in the early 1900s. One reason mining is so dangerous is the buildup of methane gas. Methane is highly combustible if it is present in more than small quantities; it can also cause suffocation. Canaries (and other small animals, which were also used in the mines) are far more sensitive to methane than are human beings, so the practice was simple, if not very humane: Take the bird or other critter into the mine. If it dies, there is too much methane and the miners must run for it.

Methane is odorless and tasteless and was thus undetectable; it was a silent killer. A miner can die of slow suffocation as methane fills the mine, or can die instantly if methane ignites and explodes. It hardly matters; death is death, no matter what the means.

We are seeing the same pattern with some of our country's most important and necessary hospitals.

A Familiar Pattern -- with a Difference

This is not the first time there has been a wave of closings of hospitals that largely serve poor and vulnerable neighborhoods and people. Philadelphia General Hospital, one of the country's oldest public facilities, closed in 1977. Several county hospitals have been closed in California over the years; they were among the 70 acute care hospitals in that state that closed between 1993 and 2003. The two public hospitals in St. Louis closed in 1979 and 1987. In Detroit, according to Professor Alan Sager, Ph.D., of the Boston University School of Public Health, who has been tracking urban hospital closings for decades, "there are essentially four hospitals or clusters of hospitals remaining open" in a city of nearly 140 square miles with a population of over 850,000. That is, he says, "not a lot of hospitals for a city with a large geographic area, where many residential side streets are not plowed in the winter."

So in one sense, hospital closings in lower-income urban neighborhoods are not news. However, in the past few years, the pattern has changed. Many of the hospitals that closed in earlier times were in dicey shape, financially and in terms of their physical plants; had low patient volumes; and, frankly, had been slowly starved to death -- that was certainly the case with Philadelphia General. The quality of care was not always optimum. And there were many other hospitals around to carry the load that was necessarily redistributed by the closing.

But recently, hospitals that anyone other than totally obsessive market-economics zealots would characterize as needed -- and in some cases irreplaceable -- have either been closed or have seen their mission and/or governance shifted in a way that raises questions about what will happen to the patients they traditionally have served.

Everyone Has a Story

These hospitals are (or were) key to the health of their communities. The public Charity Hospital of New Orleans, battered and bruised by Hurricane Katrina in 2005, has not reopened, and plans to build a new teaching hospital in its place envision a private, nonprofit facility.

District of Columbia General Hospital, also public, closed in 2001, leaving a large tract of our nation's capital with insufficient hospital capacity. The private hospital that was supposed to take over its patients, Greater Southeast Community Hospital, ran into serious financial trouble and was sold to a for-profit chain. Greater Southeast (now named United Medical Center) does not offer the same range of services as the public hospital did.

In South Central Los Angeles, after years of controversy, accusations of mismanagement and serious incidents of poor care, Martin Luther King Jr. -- Harbor Medical Center closed in 2007, robbing that metropolitan area of yet another trauma center in a city where several others had already shut down. The New York Times ran an article in the wake of its closing titled "A City Where Hospitals Are as Ill as the Patients."

Grady Memorial Hospital in Atlanta, that city's only public hospital, was transferred from public to private nonprofit control earlier this year. Governance of the storied Cook County Hospital (officially named John H. Stroger Jr. Hospital of Cook County) was also transferred this year to an independent board that observers hope will be free of the county's legendary politics.

There's a story behind every one of these closings. Charity Hospital was devastated by a storm. District of Columbia General was closed in what was essentially a political coup d'état. King -- Harbor was victimized by just about everyone. The county officials who controlled Grady were encouraged to transfer it to private hands by the local Chamber of Commerce, despite community opposition and fears of future underfunding; those fears were temporarily allayed, in part, by a recent grant to the hospital of $200 million from a private foundation. Still, Grady has the only Level 1 trauma center in the city and is the largest public hospital in the South; if it falters, the consequences will be grave.

As for Cook County/Stroger Hospital, well, "political football" wouldn't begin to describe the politics swirling around that august institution, and the transfer of its governance to a nonprofit board was supported by a truly strange set of bedfellows, ranging from county commissioners to leftist political advocates to leaders of other hospitals. (Indeed, the board is dominated by individuals with extremely close ties to nonprofit facilities in the city.) However, if the transfer proves to be a way for the county to avoid its obligation to properly fund the hospital, it would be a disaster for low-income uninsured Chicagoans and patients needing burn and trauma care, among others.

Not Just the Usual Suspects

And it's not just public hospitals. As previously described, United Medical Center in Washington, D.C., has faced bankruptcy and is not in good financial health. In Chicago, 127-year-old Michael Reese Hospital, which shifted from nonprofit to for-profit status in 1998, will close by the end of the year; it turns out that somewhere along the way, the ground on which the hospital stands was sold to a commercial enterprise, and now the city wants to buy the land to build an Olympic Village in case Chicago wins its bid for the 2016 Olympics. (Yes, the city is buying land for an Olympic Village that may never be built. It's Chicago. Don't ask.)

And in a situation that produced national headlines, St. Francis Hospital and Health Center, which is located in a low-income Latino neighborhood in Chicago, was sold to a for-profit entity at the last minute after its owner, SSM Health Care, was unable to find anyone who would take the hospital (which was hemorrhaging financially) off its hands for free. Literally, they couldn't even give it away. SSM had planned to close it.

As Wayne Lerner, president and CEO of Holy Cross Hospital, also in a disadvantaged neighborhood in Chicago, observes, "Even though we have a fair percentage of Medicare patients, our uncompensated care last month went up by a million dollars because we are finding that more and more people who have Medicare cannot afford the co-payments and deductibles. So we continue to play the role of a public good -- we are as much a public good as any entity I have ever seen -- but we are a private institution. We provide services that typically would be provided in the public sector or funded by a public program; instead, they are provided by this little safety-net hospital." He adds that for nearly a 4-mile radius, Holy Cross is the only hospital: "In some ways, we are a sole community provider."

The Underlying Factors

I've been writing about hospital closings for 30 years, and I admit freely that when you've seen one hospital closing, you've seen one hospital closing. Each is unique in terms of the particulars. But this new wave of shutdowns, transfers and changes in mission is clearly a pattern that cannot be explained away by tropical storms or county politics. There are common factors here that are as frightening as they are disheartening.

Among them are:

Market mania. Ever since the Nixon administration and especially since the Reagan administration (including the Democratic years), health policy has been influenced to the point of control by free-market ideologues, who believe that market economics will make the health care system behave and become affordable, accessible and responsive. The fact that the number of uninsured Americans has doubled since this idea was implemented, health care inflation remains two or three times that of the overall economy, and large tracts of this country lack even rudimentary access to hospital care has not swayed those who cling to this philosophy. As a result, the economics of health care, far from being humane, have become Darwinian. And as long as policymakers are more willing to accept a failed ideology than look at the facts, the system will continue to be profoundly irrational -- and unfair.

Richard Thompson, M.D., writing recently in The Physician Executive, observed that Aristotle's concept of "moral intelligence" -- of people seeking to be both intelligent and civilized -- works only in a society "that values decency, courtesy, and respect for others…. Starting a few decades ago, many Americans decided that a world without those values is a preferable world."

Preferences or no, health care is not a normal market, and if you think that it's just fine to have 16 boutique hospitals in every wealthy suburb while people in poor communities die for lack of basic emergency care, well, the system is shaping up very nicely for you.

A lack of anything resembling planning. Older readers of this column will freak out at the very mention of planning with regard to health care, and I can understand why: The failed federal attempt at planning in the 1970s that morphed into silly and sometimes destructive attempts at cost containment -- and that was, as one observer put it, "hijacked" by powerful hospitals to get rid of the competition -- was a flop. However, that does not mean that as a society, we have the right to force vulnerable people to go over the river and through the woods and past Grandmother's house (at $4.50 a gallon, if they have cars, which they usually don't) just to get basic hospital care. We plan golf-course communities, downtown renaissances, parks, transportation systems, Olympic sites and public bathrooms; surely we can find a way to have at least a semi-rational distribution of hospital resources.

A tolerance for extreme tiers. Of course we have tiers in this society, whether in housing, education, food or other sectors. The problem -- which has been pointed out by many analysts -- is that we are willing to tolerate extreme tiering that most countries find unacceptable. The average CEO of a Fortune500 firm earns more in a day than his or her average employee earns in a year; the multiple is 411 to one. No other nation that even vaguely resembles a true democracy allows such a variance. But, of course, the moderating mechanism is usually tax policy, and supporting that sort of thing is a wonderful way to lose an election in this country.

Unfortunately, we tolerate the same variance in health care. You got the money, you get the very best. You don't got the money, you can bleed to death internally while waiting for the bus to the hospital that is 5 or 6 miles away, for all we care.

I am not particularly concerned about how cushy the top tier is; Bill Gates and Warren Buffett are going to get whatever they want, and that's how it is. But I worry about the floor, about what we consider to be the most basic level of decency and civilization below which we will not allow others to fall, and increasingly, it appears that there isn't one. The people of New Orleans learned that in 2005.

Racism. Many studies have shown that hospitals tend to vacate the premises as neighborhoods become predominantly African-American -- a pattern that is not true of many Latino, Asian-American or other minority areas. Professor Sager reports, "In the 52 cities I have been tracking, involving 1,200 hospitals since 1936, decade after decade, hospitals that serve African-American neighborhoods have been much more likely to close, controlling for everything else, and the trend shows no sign of stopping." Obviously, the interaction of poverty, perceived lack of safety, inability to recruit staff, patients' insurance status and other factors is complex, to say the least; but it does seem that African-American neighborhoods are particularly disfavored -- despite the fact that Latinos and Native Americans are more likely to be uninsured.

No voice for the community. Charlotte Collins, an attorney who is director of public policy and advocacy for the Asthma and Allergy Foundation of America, and who previously served in several capacities for public hospitals, observes that "what is missing in this whole equation is a seat of power, a voice for patients." Although health care is hardly unique in this regard, she is nevertheless correct: Hospitals and clinics and physicians come and go, and people in the neighborhood cope as best they can, but they have long since ceased to believe that they have any influence over what happens to their health care infrastructure. And as a rule, they're right.

Abrogation of government responsibility. One reason that communities do not think they have a voice is that their elected leaders are supposed to speak for them. But in many cases, they don't. Faced with the need to start paying on the bonds they floated in fatter times, or with the consequences of having depended on the auction bond market, or with the siren call of private buyers looking to acquire the beautiful new physical plant that was built with taxpayers' money, many local and state authorities just give in to temptation and try to get out from under. Although it is an understandable move, it is less easy to understand the abandonment of people who are dependent on the hospital from which the politicians are seeking to flee.

So Who Cares? (Literally)

In an economy that is shedding jobs like dandruff while food, fuel and just about everything else cost more and more, one might say that things are tough all over. And they are.

But we are talking about the backbone of the health care system, about our infrastructure, about basic access to hospital care regardless of insurance status or other factors. We are talking about the guts of what health care is, or should be, about. As Chris Capito Burch, executive director of the National Association of Public Hospitals, says, "The key issue is the ability to serve the uninsured at a time of declining resources at the local, state and federal level. Communities need to look at ways to continue this critical mission."

Communities may not do that, or may not want to do that, or may not know how to do that. But the hospital community should. Wayne Lerner of Holy Cross Hospital in Chicago asks the obvious: Why should "have" hospitals care about "have-not" hospitals? He points out that although some nonprofits have marvelous bond ratings and that the sector as a whole isn't looking too bad, the gap between the "have" hospitals and the "have-nots" is growing significantly in terms of revenue, margins and access to capital. In the end, he says, it's a question of whether luckier hospitals feel any obligation to those that are vulnerable.

It is a profound question, one that speaks to the visceral issue of whether there is a hospital community, of whether the marketeers and the profiteers and the Darwinians have drilled so deep that they have seized the heart of what hospitals are supposed to be and have hardened it beyond redemption.

It is sad -- if not tragic -- that the most generally acceptable argument one can make in favor of "have" hospitals supporting "have-not" hospitals is a pathetic and, in the end, a morally dishonest one: that the hospitals that have been able to avoid low-income, uninsured, minority and otherwise "inconvenient" patients might inherit them, anyway, if the safety net continues to dissolve. It's a persuasive argument, but, given where hospitals are located (and where they aren't), and the blind eye that most regulators turn toward hospitals that pick and choose, and the prevailing "survival of the fittest" mentality, the risk is not great. Most of those patients will never find their way to the doors of hospitals that don't want them.

But something else may well happen: As the safety net collapses, and nobody cares, then the next tier of hospitals struggles and goes down, and nobody cares, and eventually access to favored services for the fat and sassy starts to disappear, it may well be too late to stop the dying. And from some destitute city neighborhood, the ghost of a dead canary of a hospital will whisper, "I tried to warn you."

As Pastor Martin Niemoller (1892-1984) wrote about his experiences in Nazi Germany,

First they came for the Socialists, and I didn't speak up because I wasn't a Socialist.
Then they came for the trade unionists, and I didn't speak up because I wasn't a trade unionist.
Then they came for the Jews, and I didn't speak up because I wasn't a Jew.
Then they came for me, and there was no one left to speak up for me.

The great American poet E.E. Cummings said it more simply:

I am also a you.

First published in Hospitals & Health Networks OnLine, August 5, 2008

© Emily Friedman 2008

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