By Marjorie Valbrun
CLEVELAND—Escalated hospital closures in urban communities are raising concern about whether minorities can receive quality health care, especially trauma treatment, when emergency care facilities are miles from their neighborhoods.
Public officials in Cleveland and neighboring East Cleveland are waging a legal dispute with the renowned Cleveland Clinic, which sought to close a local trauma center. Other municipalities nationwide are taking steps to prevent hospitals from closing or moving to wealthier suburbs.
Public health advocates have long decried the steady closures of so-called safety-net hospitals in communities populated by people of color with low or moderate incomes. For at least three decades, these advocates have joined community activists, social scientists and beleaguered city and county officials in warning that this trend threatens health outcomes in communities that need hospitals most. Poor neighborhoods frequently have higher rates of uninsured or underinsured residents with serious health care needs and less access to private health care services.
“This problem has been escalating dramatically and is a consequence of a system where health care is a market commodity that is bought and sold by those who can afford it,” says Brian D. Smedley, vice president and director of the Health Policy Institute at the Joint Center for Political and Economic Studies in Washington, D.C.
“Those who can afford it get it, and those who can’t struggle to get care, often at a lesser quality. It will escalate as the health care crisis worsens and a population that has higher health care needs and health care problems gets worse and worse and ends up in emergency rooms to get treatment at much greater costs that we all will have to bear.”
About half of the nation’s 50 million uninsured are people of color, many with jobs that provide no insurance or just nominal coverage offering very little protection in case of a health crisis or hospitalization.
Smedley says reduced state and federal government subsidies to hospitals have aggravated the closure problem. Although the health care reform law will eventually expand insurance coverage to more people and help hospitals recoup costs for uncompensated care, more cuts to federal payments to hospitals with high uninsured patient loads will pay for the expansion. Additionally, the law doesn’t take effect for three years and would still leave about 18 million people uninsured.
“It’s unclear what the long-term implications will be, but we know it’s better to make sure people get health care and access to local primary care physicians and health clinics and hospitals so they don’t get sick enough to need hospitals,” Smedley says.
Such warnings have done little to slow closures or stem hospitals’ exodus from urban centers to wealthier suburban communities, or from mostly minority suburban neighborhoods to predominantly white ones. Very often, these hospitals were publicly funded or nonprofits whose administrators insisted that other area hospitals would pick up the slack.
Advocates say this has not happened. Hospitals have closed or are planned for closure in Cincinnati, Philadelphia, St. Louis, New York, Washington and many parts of New Jersey. Detroit has lost more than 1,200 hospital beds since 1998 because of closures and has no public hospital. Nor does Philadelphia. Physicians who worked for closed hospitals and had local offices or offered outpatient services locally often leave with them. The Robert Wood Johnson Foundation says closures have created considerable health care gaps for those reliant on the hospitals.
A 2005 report by the State University of New York Downstate Medical Center on hospital care in the 100 largest U.S. cities and their suburbs found that “more public hospitals were lost between 1996 and 2002 (16 percent in cities and 27 percent in the suburbs) than for-profit (11 percent in cities and 11 percent in suburbs) and non-profit hospitals (11 percent in cities and 2 percent in the suburbs).” The authors said the findings contrasted starkly with the relatively moderate decline in the number of hospitals nationwide. The report also found that hospitals underserve high-poverty suburbs while low-poverty suburbs brim with them.
“Public hospitals may become an endangered species,” Dennis Andrulis, Ph.D., the study’s lead author, concluded.
In the late 1990s, researchers at Boston University School of Public Health reviewed data on acute care hospitals in 52 large and midsize U.S. cities from 1936 through the mid-1990s and found that nearly 28 percent of them had closed between 1980 and 1997. They concluded that “the pattern of hospital closings in U.S. cities in recent decades may have damaged access to care generally, may have had an adverse and disproportionate impact on minority Americans specifically, and may even have increased the cost of health care.”
Lynne Fagnani, senior vice president of the National Association of Public Hospitals and Health Systems in Washington, says sustaining urban hospitals requires “state support, but with the recession, they have lost that. With more low-income people getting health care coverage in 2014, we’re going to need a strong safety-net health care system . . . that can serve these populations.”
Until that happens, problems “will get worse not better,” says Ellen Kugler, executive director of the National Association of Urban Hospitals. “Nonprofit safety-net hospitals are very fearful for their future. These are longstanding community hospitals that have stayed committed to and served these communities for decades.
“Many are religiously founded and have a mission to stay and serve . . . . They don’t want to leave, but at some point, you have to be able to pay your staffs, keep electricity on, modernize your buildings and have an electronic filing system. That all costs millions of dollars that they have to find somewhere.”
Kugler says some hospitals have downsized, becoming just drug and alcohol treatment centers, for instance, or long-term care centers. Others have opened branches in wealthy suburban areas with a well-insured patient base to help offset costs at urban locations.
Hospitals “are looking at tens of millions in lost revenue, and it’s hard to see sustainability,” she says. “These hospitals are older, they need more repairs and infrastructure updates. How can you plan for the future, fix a boiler, fix the 50-year-old heating and air conditioning system? How do you get new technology, or a new MRI machine or pay staff?
Community residents and their advocates are organizing neighborhoods, holding protest rallies, enlisting help from civil rights organizations and seeking injunctions to prevent or delay closures. At a minimum, hospital administrators find that they can’t just leave without being accountable to people they served. They’re also more mindful of potential public relations pitfalls.
In September, the University of Pittsburgh Medical Center voluntarily agreed to provide temporary primary and urgent-care services in Braddock, Pa., and neighboring communities after a complaint was filed with the U.S. Department of Health and Human Services on behalf of African-Americans alleging civil rights violations. The complaint said closing UPMC’s Braddock hospital hurt residents’ ability to obtain health care because they depend on public transportation and would face time-consuming commutes to neighboring hospitals.
Cleveland Clinic administrators temporarily delayed closing a local trauma center after the mayors of Cleveland and East Cleveland filed suit in October. Four other local hospitals had shut down over the last decade. The clinic planned to move trauma services from Huron Hospital, which serves neighborhoods in both cities, to a suburban area. The mayors withdrew the suit after clinic representatives agreed to keep the Huron center open while both sides seek a solution “that would continue to meet the needs of area residents.” Each retained the right to return to court if no compromise is reached.
Edward Eckart, commissioner of Cleveland’s Emergency Medical Service Division, says the best solution is to keep the center open.
“The hospital is a significant resource for us and specifically for trauma patients,” he says, noting that 65 percent of trauma injuries treated there originate near the hospital. “ . . .To move the trauma center to a farther eastern suburb that has a very low incidence of traumatic events just doesn’t make sense.”
Meanwhile, the Cincinnati NAACP reacted strongly when Mercy Health Partners announced plans to close two city hospitals and relocate another it had recently purchased to a wealthier suburb. Representatives of Catholic Healthcare Partners, to which Mercy belongs, agreed to attend the NAACP’s local general meeting to explain the rationale for the closures.
“What is currently unfolding before our eyes is Mercy Health System’s urban Cincinnati divestment strategy, weakening safety net services to the poor,” Christopher Smitherman, president of the Cincinnati NAACP, wrote by e-mail to a Catholic Health Partners representative. “This behavior is antithetical to an appropriate community service ethic and contrary to any hospital vision, mission and values statement that I know of, because it injures the poor and those who are most vulnerable in our society.”
David Hayes-Bautista, a professor of medicine at UCLA and director of its Center for the Study of Latino Health and Culture, says current hospital closures echo California’s experience in the late 1960s when about 40 county hospitals closed.
“Since then, public hospitals have been closing at a rapid clip,” he says. “There are no more than five or six counties remaining that operate their own public hospitals. There’s been sort of an implosion of public hospitals, and the counties have been getting out of that business for the last few years.”
When Martin Luther King Jr. Hospital in Los Angeles’ predominately Latino South Central neighborhood closed almost two years ago, Hayes-Bautista says, patient loads but not the budgets of the four remaining county public hospitals increased.
Vernellia Randall, a professor of health care law at the University of Dayton School of Law and author of “Dying While Black,” a book about racial disparities in health care, says the problem of hospital closures in black neighborhoods began in the 1930s.
“Back then, there were more than 200 hospitals located in minority neighborhoods,” she says. “You’d be lucky to find 20 now. The problem is becoming more obvious and getting more attention now because they’re beginning to close hospitals in communities that, although they have large numbers of blacks, also have a large percentage of whites, where before it was primarily in very poor, predominantly black communities.”
Updated research in 2001 at Boston University School of Public Health showed that “about half of the hospitals open in 1936 in neighborhoods that were less than 20 percent African American or Latino in 1990 remained open in 1997, while only about 30 percent of the hospitals located in neighborhoods that were 80 percent or more minority in 1990 remained open in 1997.”
Randall, a former nurse practitioner, says hospitals that left white or diverse urban communities moved to predominantly white suburbs.
“There used to be a time where you could count on government hospitals, but they have been turned over to nonprofits,” she says. “Under the law, nonprofit does not mean charity. They’re not giving away free health care. At public hospitals, they could not turn you away.”
Randall says legal actions such as that against the Cleveland Clinic are counterproductive and bound to lose in court because no law requires hospitals to have trauma centers or be located in certain neighborhoods. “The argument that this has a discriminatory impact is not really legally recognized as a form of racism,” she says. “Our laws are totally inadequate in dealing with institutional racism.”
Randall says cities should complain to a federal civil rights agency that could sue a hospital. States could also pass legislation limiting hospital closures, but their lawmakers have shown little interest in doing so.
Hospital closures are not likely to ebb soon, Smedley says. “If anything, it will continue to grow until the health care law provisions kick in in 2014 . . . until then, we have reasons to be concerned that hospitals will continue operating in the red.”