Public hospitals under the knife

IN THE current issue of the Archives of Internal Medicine, the editorial opens with some frightening statistics about the country's Emergency Departments (EDs):

In the 10-year period between 1994 and 2004, visits increased by 18 percent, while the number of EDs decreased by 12 percent. By 2006, there were more than 119 million visits to the ED compared with 93.4 million in 1994.

More than three-fourths of all urban hospitals are either "at" or "above" ED capacity, which can be seen by increased waiting times, increased diversion (EDs that temporarily "close" to ambulance traffic because they are over capacity), and increased "left before being seen" (patients who register but leave without being seen or treated) rates.

As an ED nurse at a public hospital in an urban setting, this isn't news to me. It doesn't take an expert to know our system is broken and failing. That fact is painfully apparent to anyone who walks into an overcrowded waiting room seeking medical care from Stroger Hospital in Chicago.

Unfortunately for the 5.3 million residents of Cook County, which is made up of Chicago and some surrounding suburbs, a panel of "experts" has recently decided to make things much worse--by drastically cutting health services that primarily serve the working poor.

THE COOK County Health and Hospital Systems (CCHHS) is made up of three hospitals, 16 clinics, a center committed to HIV/AIDS patients, a public health department and a facility at Cook County Jail. The ED at Stroger Hospital alone treats 110,000 patients every year.

The CCHHS is part of a dying breed in the U.S. A 2005 study by State University of New York's Downstate Medical Center showed a sharp drop in public hospitals in 100 major cities and suburbs. These systems are the last existing safety net for the uninsured, a section of the population that is growing every day as unemployment continues to rise.

In cutting 335 jobs and eliminating 700 vacant positions, the CCHHS is claiming to be carrying out an "employee rebalancing effort."

The Cook County Board of Commissioners created the CCHHS Board in 2008 to be an independent overseer of the public medical system. The 11-member board includes six present and former business executives. Two are from industries that have nothing to do with health care--the chief human resources officer at Exelon, a energy utility corporation, and the former CEO of Tupperware.

Some politicians, namely Todd Stroger, the current president of the Cook County Board of Commissioners, have come out publicly against the cuts. He's up for reelection in the Democratic primary that comes in February of next year. Stroger came into the job in 2006, following in his father's footsteps John Stroger--much like Mayor Richard Daley.

Besides nepotism, Chicago politics are also known for corruption. The Cook County Board has such a bad reputation that a judge had to mandate that every single job interview conducted under its authority must have an independent observer present.

Sleazy hiring practices is one reason why the Emergency Network to Save Cook County Health Services--made up of trade unions, health care workers, community organizations and politicians--demanded the creation of an independent overseer for the CCHHS. Established in 2007 to fight an earlier round of budget cuts, the Emergency Network contended that an independent board would better govern the health system.

The CCHHS board hired a former private hospital CEO, Bill Foley, for $500,000 to oversee the changes at CCHHS. Foley then paid $1.7 million of taxpayer money to Navigant Consulting to assess the hospital system, which came up with the suggested cuts.

To those who follow the fate of urban public hospitals, Navigant Consulting is a familiar name. This is the company that was paid $17 million in 2004 to overhaul the Martin Luther King Jr./Drew Medical Center in Los Angeles.

Sandwiched between Compton and Watts, King/Drew was built in response to the Watts uprising of 1965 to serve a heavily African American community. Navigant's efforts ultimately failed, and the hospital was closed in August 2007. As recently as 2004, King/Drew was seeing 178,000 patients per year, and its closure severely impacted the community and surrounding hospitals.

There's no doubt that King/Drew, nicknamed "Killer King," had significant problems for many years. But this doesn't take away from the fact that providing good health care to minorities and poor has never been a priority anywhere in this country. When resources aren't provided to give decent care, it shouldn't be surprising when decent care is not given.

WHILE CCHHS may not be in as bad a shape as King/Drew, there are certainly things that could be done better there to meet the needs of patients.

There's no question that wait times in the ED are excessive and that openings at the specialty clinics are insufficient to meet patients' needs. Access is also a common concern, as people with significant disabilities are forced to take long bus and train rides just to see doctors.

Yet the Navigant report, though couched in language about improving patient care and access, is really about increasing productivity. This trend of getting more from workers while paying them less has been part of the attacks in the private sector for many decades.

Navigant wants to bring these same practices to CCHHS. Under a section entitled "Physician Productivity," the company's report states, "The unfortunate reality is that physicians who are employed [at CCHHS] produce 13 percent less work than private physicians and perform 30 percent fewer procedures." Under a section labeled "Union Contracts Requirements," the report laments how "the County assumes approximately 95 percent cost versus 5 percent employee contribution," and is responsible for a "very liberal Pension Plan."

Except for doctors at one of the hospitals, unions represent almost all of the non-management workers in the CCHHS. Contracts expired in November 2008, and negotiations are ongoing. The unions rightly see these cuts as an attack on their members, and have mobilized against them.

Inter-union collaboration will be necessary if these cuts are going to be successfully fought. Unfortunately, solidarity between the unions has been lacking due to organizing wars between the Service Employees International Union and California Nurses Association/National Nurses Organizing Committee. While raiding campaigns at the CCHHS came to an end earlier this year, work remains to be done to rebuild relations between the two unions.

Meanwhile, the CCHHS has held several town-hall meetings, supposedly to gather input from the community regarding changes to the system. One of the meetings actually took place the day after pink slips were handed out to hundreds of workers. All the meetings were filled with angry community members and workers, who testified how the cuts will only hurt them. While they were originally organized to give an appearance of democracy, they ended up turning into venues of protest.

A rally was also called outside Stroger Hospital November 4, and more than 200 workers, patients and community members protested. Those opposing the cuts have also called their own town hall meeting on November 18 at the Teamster City union hall at for 5:30 p.m.

Because of the public outcry, CCHHS officials have decided to re-examine some of the suggestions put forward in the Navigant report, but they say they're going to move forward with layoffs regardless.

There's nothing inherently wrong with reorganizing a hospital to meet the needs of patients. The problem here is that the patients and the people who actually provide the care haven't been consulted about what to do. There is plenty of work for people to do, and the system could be reorganized without layoffs.

But for the oversight board and CCHHS bureaucrats, the changes are about streamlining a public hospital to make it look more like an assembly line. The CCHHS serves a purpose for the rich and powerful who run Chicago, since it provides "free" health care at taxpayers' expense. The people who own the factories and businesses like the fact that they can avoid providing health coverage, knowing workers can go to County. The powers that be just want this done more cheaply--which is why they're cutting jobs and increasing production.

The fight in the CCHHS must also been seen in the light of the current debate on health care reform. If health care was run to meet human need and not corporate greed, it wouldn't be a question of cost, but how to best take care of people with the vast amount of resources we know exist.

In a sane world, there would be a clinic in every neighborhood, so that health issues could be taken care of early on when they are manageable, not when someone is at death's door, fighting their way to the front of the line at an overcrowded--and underfunded and understaffed--emergency room.