Terry H. Schwadron
May 10, 2020
It seems important that, as we can, we should look at lessons from the worst of the coronavirus experience — and at some of the underlying conditions that have come to light.
Will we look anew at housing and environmental conditions in areas of the Bronx, Queens and other urban areas where immigrant and African American populations have been unduly struck by coronavirus? Will we reconsider what passes as employer-paid health care coverage for most Americans but that omits millions? Will we replenish public health ranks and prepare for the next round of contagion — or are we worried only about re-opening beaches and golf courses as soon as possible?
One item on the agenda: hospital capacity.
Every state made the case that its hospitals could not possibly house the predicted surge of coronavirus patients predicted in the various doomsday models from public health figures. That led to lockdowns and stay-at-home orders that were meant to “bend the curve” downward, a generalized attempt to lower the number of patients. At the same time, New York Gov. Andrew Cuomo led the states in ordering hospitals to add beds, add federally created hospital spaces and equipment searches to handle a threat of triple the number of needed hospital beds.
The states and federal authorities opened convention centers, Central Park, even abandoned buildings and hospital ships to prepare for the worst. In all, we have about a million hospital beds nationally, when the disease was being projected at needing many multiples in sick patients.
This round was bad, but still shy of the total overload Cuomo and others had targeted as necessary. But what happened came about in a rush and expense.
But, as The Washington Post found, “America’s now-disastrous lack of hospital capacity is no accident. It is, in part, a result of consolidation over the past 30 years that concentrated our health-care system in wealthy cities and suburbs, where the prevalence of expensive insurance plans allowed big health systems to rake in profits.”
Every state has seen such mergers — more than 680 in all over the last decade, including mergers between hospital systems, takeovers of rural hospitals, as well as doctors’ offices and outpatient clinics. They may affect rural areas the most, exactly where virus cases are rising and where it is easier to become overwhelmed with virus patients.
There have been good reasons, of course, for consolidation. Without mergers, individual hospitals were moving independently to duplicate expensive equipment, competing for doctors, and were multiplying administrative costs. The general idea was that these practices were leading to higher health costs overall and that hospital beds were going unused, leading to higher costs for hospitals themselves.
There were profit-oriented reasons for merger among the haves of the hospital business.
Since the 1970s, the Federal Trade Commission, which oversees these mergers, has not challenged any merger in which either hospital group has fewer than 100 beds. So lots of rural hospitals are now owned n operated by chains and there are about 15% fewer community hospitals in the United States than in the mid-1970s, or about a half-million hospital beds. Another 120 hospitals in rural areas have shut, and more hospitals are clustered in urban areas.
The availability to more well-care under the Affordable Care Act and the decision in many states against expanding Medicaid payments also increased the pace of mergers, as hospitals found themselves losing money.
But there seems plenty of evidence that urban hospital mergers have been a goal for financial companies that have taken on roles in the hospital conglomerates. The Post study found that investors have pressured hospitals to cut costs, buy their rivals and then raise profits by imposing a largely outpatient health-care model. Outpatient hospital prices have grown four times faster than what doctors charge — a trend that has both reduced beds and propelled hospitals’ frenzied takeover of independent physician groups. Between 2016 and 2018, hospitals acquired more than 8,000 doctor groups.
Mergers affect all kinds of community health services, of course. I live in Harlem in New York City, where hospital chains have chosen to consolidate most of their various competing drug addiction services and methadone clinics. Naturally, our area shows up first in any citywide look at danger spots.
It Doesn’t Add Up
Put it all together and you get fewer hospital beds when a pandemic says you need them.
So that’s why we saw a scramble for hospital ships and field hospitals that are little more than tents with cloth dividers. A great effort, indeed, but perhaps one made necessary by our more general policies.
Cuomo, at least, is requiring hospitals to maintain a 90-day supply now for protective gear, in exact recognition that we need to think ahead.
When Donald Trump has boasted often about the speed of the Army Corps of Engineers and FEMA to erect these field hospitals, perhaps we should be asking why they were necessary in the first place. Clearly government must act to meet the immediate need, but perhaps the government ought to look anew at what results from hospital mergers and how we pay for their services.
Or, perhaps we should be really looking anew at the entire health care system for its health aspects rather than picking off political points for one party or the other and as a profit center.
In any event, if Trump can stop his insulting style long enough to take an actual look, government should hold public health needs in higher esteem. The public good may not best be measured by the best profit margin.