November 27, 2011

 November 27, 2011   The Waitlist


A few weeks ago I was having breakfast with one of the senior physicians of the Cook County Health and Hospital System in Chicago. We were sitting in the wood-walled dining room of Rush University Medical Center the academic medical center where I work as Chief Medical Officer. As we breakfasted at the white linen clothed table, he spoke to me of the problems facing Chicago’s storied County public hospital and health system just down the street from where we sat. The chronic underfunding of this system and public health and safety net health systems around the country have led to wait lists for crucial clinical services. At any given time at the Chicago County Hospital there are four thousand people on the wait-list for diagnostic colonoscopies. These are patients with potential cancers or other serious conditions.  The wait list for a prostate biopsy for a patient with suspected prostate cancer- one year. “The wait list for the eye-clinic is so long,” the physician said as he sipped his tea, “that you could go blind on the wait list!”  The wait list for specialty care is emerging as one of the major problems in US health care. It contributes to premature morbidity and mortality and is likely to get worse with health reform. It’s a form of rationing that will not be fixed with the Affordable Care Act.


Wait lists for specialists are not just a Chicago phenomenon.  Waitlists for crucial medical services have been reported across the United States. And this not just a problem for the 50 million uninsured individuals in the US, though they are the most affected by this. For patients on Medicaid and increasingly for patients on Medicare wait lists for critical services have become the norm. A recent study from the June 16, 2011 New England Journal of Medicine is one of the first to describe the extent of the problem.  A researcher posing as a “secret shopper” called the offices of specialists in Chicago describing an imaginary child with an acute medical problem.  The call to the orthopedic office for the child with a broken arm was emblematic of the problem facing those with the wrong insurance card. If the orthopedic office was told that the child had private insurance then over 90 percent received an appointment. But when the office was told the child had Medicaid, only 20 percent were offered an appointment and these appointments were delayed compared to those with private insurance. The rest were told to “go to County Hospital” where the wait list for critical orthopedic services exceeds that for the eye clinic. The reasons for this are straightforward. The orthopedic physicians get paid better from private insurers so they fill their slots with these patients.


In the 1980’s my colleagues and I described the phenomenon of “patient dumping.”  Patients in need of emergency care who showed up in a private hospital’s ER were transferred to public hospitals because they had no insurance.  A significant number of patients we studied were critically ill or died from their medical conditions.  Our work led Congress to pass the Emergency Medical Treatment and Labor Act in 1986 and patient dumping of emergency patients was ended.  But dumping never really ended.  Hospitals and doctors offices closed in many impoverished neighborhoods leaving few options.  As patients present in increasing numbers to emergency rooms for their routine care, emergency medicine doctors have few options when the patient needs follow-up clinical care.  In cities like Chicago, NY, Atlanta and LA these patients are sent to join wait lists at the public hospitals.   And the situation will likely get worse with the Affordable Care Act.


The Institute of Medicine recently released a frame work for defining “Essential Health Benefits” under the Affordable Care Act. But what good are essential benefits if the physicians who provide the care are unavailable.  Health reform will test access to specialty care in the US.  Health reform promises two major changes: the expansion of Medicaid and the new health exchanges. Both of these reforms will  exacerbate the waitlist problem even while covering more people.  Because most specialists in the US do not take Medicaid, Medicaid expansion will give people cards with limited access.   The health exchanges will offer little relief as well.  The health exchanges have four tiers, platinum, gold, silver and bronze. The bronze and silver options on the health exchanges will likely be lower paying managed care plans which will cater to lower income Americans.  Since not all specialists are enrolled in all plans, this will likely limit specialty access of patients holding these bronze and silver policies as well.


Waitlists like the ones at the County Health and Hospital System in Chicago and elsewhere will be with us into the future without real health reform that aims at providing equality in care, not just expansion of insurance cards that cannot buy the care the cardholder needs.  The only way to provide equal access to all is with a health care system that provides the same card to everybody.  Only with a single payer system, Medicare for All that allows for equal access for all patients and equal pay for specialists, can we hope to end the wait lists for crucial services that the poor and underinsured face.  



October 02, 2011


October 2, 2011   Universal Health Care a Mandate or a Right?


The requirement that most Americans buy private health care insurance or face a tax penalty is the centerpiece of the health care law passed by Congress and signed by President Obama in March 2010.  The constitutionality of this “mandate” will be decided by the US Supreme Court this session.  The fact that the future of the Affordable Care Act will be decided on the question of the constitutionality of the mandate raises a key question about universal health care in the US.   Should universal healthcare be mandated or should it be a right?


Twenty five years ago, my colleagues and I published a paper depicting the adverse impact of hospitals “dumping” uninsured patients on public hospitals, in this case Chicago’s Cook County Hospital.  We made the case that emergency medical care had to be a right or financial considerations would get in the way of sound medical decision making ( Transfers to a Public Hospital, New England Journal of Medicine Vol. 315, 27 Feb 1986.)  Congress responded by passing EMTALA, the Emergency Medical Treatment and Active Labor Act making the right to emergency medical care and care to women in active labor the only form of universal health care in the United States. The practice of “patient dumping” ended overnight.


Fast-forward to the current health care debate.  In order to achieve maximum coverage under private insurance, the Affordable Care Act mandates both employers and individuals to participate or face a fine.  Under this legislation universal health care is mandated, not a right as under EMTALA.  Under the law, there's a big difference between participation in a government health program funded by taxes and privatizing such a program, with individuals forced to purchase private health insurance.  This is a major weakness of the Affordable Care Act which has the expansion of private insurance as a core strategy to get to universal coverage in the United States.  Compare this to publically funded universal health care. There is no need for a mandate because healthcare would be a right legislated by Congress.  No one could opt out on payment which would be in form of a payroll or other tax as is currently the case with Medicare and Social Security.  Since taxation involves representation, which is the case when Congress appropriates money there could be no challenge to a health care law that had an expansion of universal governmental coverage at its core.


In 1965, the passage of Medicare represented a major advance in the governmental funding of healthcare in the US giving most seniors and the disabled the right to basic healthcare coverage.  Despite its detractors, Medicare has been highly regarded by participants at both ends of the political spectrum.  Had Medicare expansion or some other form of governmental single-payer health option been allowed to proceed as part of the Accountable Care Act, the fate of universal health care in the US would not be in the hands of the nine Supreme Court Justices now.  Until we decide as a nation that universal health care is a right for all and not a mandate we will continue to struggle to achieve health coverage for all.        


September 17, 2011

September 17, 2011


Walter maneuvered the empty school bus down the narrow car-lined street on the hard-knock West-side of Chicago when he saw the man pummeling a woman with his fists.  Walter slammed the brakes, shoved the gear into park and bolted out the door.  It was just the way he was. Walter was a railroad man; a fifty year-old tough guy.  He moonlit as bus driver for extra dough.  The railroad had good benefits especially the gold-plated health insurance policy he never used.  But his life was about to change and he would soon confront the cruel realities of health care in America.  Where the health care a man received depended on the health insurance card in his wallet.


Walter bounded towards the fracas and placed himself between the brute and his bloodied victim.  Walter never saw the gun.  The bullet ripped through his upper chest, shattered his clavicle, collapsed his lung and lodged into the nerve that controlled his right arm.


I met Walter three weeks later in my primary care office after he was discharged from the rehab center at my inner-city hospital.  The lung damage from the bullet had worsened his emphysema. He needed oxygen at night. His right arm throbbed in pain and was weakened from the nerve damage.  He would never work again despite his many attempts. He would never live without pain.  He soon lost his railroad job and the insurance card that came with it.  He went from Good Samaritan to No Insurance. He stopped coming to see me because he could not pay.


Months later, I met Walter by the front desk of my office. He needed a refill of his pain medications.  He had lost his home and camped on the couches of family members and friends.   A deep depression overcame him.  He began to drink and contemplated suicide.  I convinced Walter to see me and promised to treat him for free.  It took six years many letters and phone calls to convince the state to provide Wallace with a Medicaid card.


One would think that once he had a Medicaid card that life would get better.  And it did to a degree because he could still see me without shame and get medications.  But I was an exception.   Walter like many Americans on Medicaid had trouble obtaining specialty care because many specialists refused to take Medicaid.   Medicaid was not as desirable as his railroad insurance.  And most doctors just refuse to accept it.


The Accountable Care Act will create the opportunity for many other patients like Walter to get on Medicaid.  We know that when poor people are given Medicaid they go to the doctor more and they feel better and are less depressed.   More women get mammograms when insured and more patients take prescription medications.  Walter is living proof of the obvious concept that providing health care to the poor and uninsured is a good idea.   But as Walter discovered the Medicaid card did not equate with access.   A recent study in the New England Journal of Medicine (June 16, 2011)  on access to specialty care in Chicago showed that two thirds of children with Medicaid were turned down by specialists compared to 10% of children with insurance.   Walter is a case study of the inequalities of our health system and of the problems to come when more patients swell the Medicaid ranks in the US in 2014.  More patients will have cards but what good will these cards be if doctors and hospitals will not accept them. 


A better solution- Medicare for All- one payment system for all providers and patients so there can be no cherry picking or denial of patients because of the type of card.  It is fair, it preserves choice and it will end some of the more egregious inequalities in health care that plague the most expensive health care system. So the next patient like Walter can get the health care he deserves.



July 10, 2011



In the 1980s, public hospitals exploded with sick and uninsured patients transferred from private hospitals for economic reasons, a practice called patient dumping.  I was a young physician at Chicago’s Cook County Hospital when my colleagues and I documented the negative consequences of patient dumping and contributed to the passage of federal legislation to ban it.  Fast-forward thirty years.  Urban emergency rooms have been shuttered (Fewer Emergency Rooms Available as Need Rises, New York Times , May 17, 2011) in the most vulnerable communities in America for economic reasons, a practice that could be called, “community dumping.”


Community dumping, the abandonment of high mortality communities by hospitals and clinics, contributes to a deadly epidemic of premature mortality in US cities.  Its victims: working age black men and women.  Black men on Chicago’s South side die eight years earlier than whites while black women with breast cancer have almost twice the chance of dying than white women.  Detroit and Harlem are not much better. The annual toll of the racial mortality gap in Chicago alone is 3,200 excess black deaths, more than died in NYC on 9/11 or  from Hurricane Katrina.


How can US cities be spinning in the wrong direction when it comes to racial inequalities in health outcomes?  Adverse racial health outcomes are not merely the result of bad luck, bad choices or bad genetics.  There are three drivers of health outcome disparity. The first has its roots in the structure of urban communities. Vast swaths of urban neighborhoods are hyper-segregated, with high unemployment, high poverty rates, and poor health outcomes. Most low-income urban blacks in the US live under these conditions – lacking immediate access to the institutions and resources that can, over time, increase their lifespan. Community dumping is not just an issue of poverty.  Over 80% of impoverished whites live in economically integrated white communities and as a result have access to the same grocery stores, schools and health facilities as the more well-off residents of those communities. Low income blacks suffer a triple whammy when it comes to health outcomes- being poor, black and living in a hyper-segregated urban neighborhood. The closing of emergency rooms in these communities is part of a larger pattern of public policy-driven social isolation that contributes to mortality.


 A second reason for the racial health care gap is a lack of access to primary health care. Research shows that in Chicago and other urban areas, over 50% of the black/white mortality gap can be attributed to excessive death rates from treatable conditions – such as heart disease and cancer.   High un-insurance rates limit inner-city black men and women’s access to institutions and specialists who could treat these conditions.


The third reason for the black/white health care gap is disparity in the quality of health care.  Because of the limited health care choices open to most blacks they are less likely to receive the same quality of care as whites   Blacks are less likely than white patients to receive mammograms and pap smears.  A black patient with cancer is less likely than a white patient to receive evidence-based treatment. Research shows that 80% of Black Medicare recipients are cared for by 20% of the US physician workforce who are less likely to be board-certified and more likely to report chaotic working conditions and difficulty accessing specialists for their patients.  At Chicago’s Cook County Health and Hospital System, many of the conditions that made it difficult for patients and doctors alike to access needed services when I was an intern over thirty years ago, persist today.


How do we begin to solve the racial mortality gap?  We need to reverse “community dumping” by encouraging capital and organizational investments in community based primary and specialty care in these high mortality neighborhoods. Second, we must implement metrics to measure, track and improve the quality of health care by race and ethnicity.  Foremost, we must reform a US health system that segregates patients and communities by insurance status.  While health reform legislation will provide many black uninsured working men and women access to Medicaid or low cost insurance, it could actually perpetuate the racial mortality gap as patients on Medicaid often have difficulty accessing primary care and specialists. Only a universal health care program, such as single-payer that allows all people regardless of community or income, equal access to the best our health care system has to offer, can lessen racial health disparities and reverse community dumping.


June 11, 2011

Election in New York State a Vote for Single-Payer


The improbable May 24, 2011 election victory of underdog Democrat Kathy Hochul in a staunchly Republican district in western New York was widely viewed as a vote against the Congressional Republican’s proposal to transform the Medicare program into an open market voucher program.


In truth, it was a referendum on the US’s only single-payer program- Medicare. Think about the improbability of the vote.  Single-payer health care is often referred to as “Medicare for All.”  It has been derided as a solution to the country’s healthcare problems despite evidence that it the most economical solution to the health care crisis in the US.


 Republican’s faced with a choice of turning Medicare into a free-market program or keeping Medicare as an egalitarian single-payer program switched parties in enough numbers to push Hochul over the top.  Republicans for single-payer? Why not?  In the other western countries with single-payer programs they generally are well received by the population regardless of political party or persuasion.  And as this vote in New York demonstrated, Medicare is popular across the population, regardless of party. Medicare-for-All would be equally popular, if given a chance.

May 16, 2011

“Cook County’s request to convert Oak Forest Hospital into a regional outpatient center was denied Tuesday by the Illinois Health Facilities and Services Review Board. Dozens of people opposed to the county’s plan shouted with joy and hug one another after the vote was announced.”  Chicago Sun Times, May 11, 2011


A conflict has arisen over the closure of an underutilized public hospital in south suburban Chicago. Twice, community and union opposition has kept the Cook County Health System’s request to close Oak Forest Hospital from being approved by the Illinois HealthFacilities and Services Review Board. On the surface, it seemed like an open and shut case. Oak Forest Hospital, one of three hospitals in the Cook County Health and Hospital System, the third largest public health system in the US, is a conglomeration of 41 buildings located on hundreds of acres of oak forested Cook County owned land about 15 miles south of Chicago’s loop.  Originally opened as a poor farm in the 1800s it was transformed into a TB sanitarium at the turn of the 20th century. By the mid twentieth century as TB waned as a public health problem, Oak Forest was converted into a long term facility for the disabled.  More recently it became an acute care hospital for the poor and uninsured of southern Cook County.  Now it was been slated to be shuttered by the Cook County Health and Hospitals System as part of the County’s, “Vision 2015,” a strategic plan which envisions a shift from costly inpatient services to regional outpatient ambulatory care centers. With an average of only 40 patients per day (fewer patients than buildings) Oak Forest cannot run with the necessary efficiencies required of a modern hospital. So why the emotional opposition to its closing?


The Chicago region, like other urban areas of the nation, has experienced an ex-urbanization of poverty from inner-city to far-outer suburban regions.  Suburban Cook County, especially areas south and southwest of the city are home to some of the poorest communities in America with some of the worst health outcomes in the nation.  It is a region of far flung communities and a paucity of health care services.  


There are three reasons for the opposition to Oak Forest’s closing- concerns about access to health care, job loss and lack of faith in the Cook County Health System to deliver on its promises to expand ambulatory services in the south suburbs.  Let’s examine them one by one:  


There are huge unmet health needs in southern Cook County and opponents of the plan to close Oak Forest Hospital believe that many people, hard pressed and in need of healthcare will have nowhere to go.  Since Oak Forest is the only public healthcare institution in the region some view the closing of the hospital as an abandonment of the community and the growing uninsured.  A hospital represents more to a community than just patients in beds. Crucial outpatient services like radiology, physical therapy are lost as well as a hospital closes. There is also a 24 hour walk and drive in Emergency Room that fields patients with urgent and non urgent conditions alike.  With a closed Oak Forest Hospital, uninsured patients in need of inpatient or outpatient hospital care will have to go to other local hospitals or be transferred to John H. Stroger Jr. Hospital of Cook County, miles away.  This creates a burden for both patients and families to travel so far from their homes.


Second, the loss of jobs at the hospital is a critical loss not only to the individuals affected but also the surrounding communities.  In many communities, hospitals are some of the largest employers and losing a hospital means loss of jobs, and reduction in economic activity.  At Oak Forest over 250 jobs will be lost when the hospital is closed, jobs the community can ill afford to lose.


Finally, there is deep skepticism that the cash strapped Cook County Health and Hospital System will ever fulfill its promise to build a comprehensive regional outpatient center on the Oak Forest campus.  The southland region of Chicago is in desperate need for primary and specialty care outpatient services and the regional clinic, if fully realized, will address some of those needs. But whether it will get built is a concern. And the Cook County Health and Hospital System is counting on the Oak Forest closing just to balance the budget this year. This is the dilemma that the Cook County Health System Board of Directors (on which I sit) faced when we made the decision to close Oak Forest.  The Cook County Health and Hospital System and the Cook County Board of Commissioners has counted on the savings from Oak Forest Hospital’s closure to build out the clinics and hire the doctors to staff them.


The failure to close Oak Forest and build the regional clinics would be a serious blow to “Vision 2015,” the health system’s strategic plan. While many of us on the board would have preferred to have built out the regional health care centers before closing Oak Forest, there were not the dollars to do so. Some of on the board (myself included) might have preferred to actually expand, redevelop and recapitalize the Oak Forest Hospital campus, but faced with huge budget gaps, and the loss of sales tax revenues this was not an option either.


The conflict over the closure of Oak Forest Hospital is just a skirmish in a larger battle about the financing of the public health sector, not just in Chicago, but around the US.  


In 2007, the Chicago based Center for Tax and Budget Responsibility published a report entitled, Cook County’s Revenue System is Structurally Unable to Support the Public Services it Provides.”

In part, reports like this led to the creation of the independent Cook County Health and Hospital System Board to manage the revenues and expenses of a public health system in decline. But there remains this structural deficit.  Since 2008, adjusting for inflation, the Cook County Health and Hospital System has lost more than $ 300 million in revenue and almost 2000 jobs. And Oak Forest Hospital is one of the first casualties. Everyone knows you can’t cut your way to success in healthcare. Lives are at stake. Communities at risk. There needs to be new revenues to treat the uninsured who will still be with us even if “health reform” survives. 


As this battle over Oak Forest Hospital’s closing demonstrates, independent governance is not sufficient, if there is not also independent financing and taxing authority for the beleaguered Cook County Health and Hospital System. Given the rise in the numbers of uninsured (more than 800,000 in Cook County) the public health system will always be needed as the provider of last resort. But without new sources of revenues, we won’t come close to meeting the health needs of the insured. In the end, Oak Forest Hospital will likely be closed and the regional outpatient center in southern Cook County, built.  The battle lines will be re-drawn. But the structural funding deficit of public health in Cook County and elsewhere will remain until we take bold and dramatic steps to solve it.  


More on this in a future blog.


March 25, 2011

Please leave your comments below. We would love to hear if you worked at County and what it meant for you. We also would love to hear from former patients, activists and anybody who has ever been impacted in one way or another by the venerable institution. Thank you.

David A. Ansell, MD, MPH.

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