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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 low- or moderate-income people of color. 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.
“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,” said 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.
The struggle of lower-income people, he continued, “will escalate as the health care crisis worsens and a population that has higher health care needs and 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.”
Half Uninsured People of Color
About half of the nation’s 50 million uninsured are people of color -- many with jobs that provide no insurance or only nominal coverage offering very little protection.
Smedley said 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 for hospitals with high patient loads of those without insurance will partly pay for the expansion.
Additionally, the law doesn’t take effect for three years and would still leave about 18 million people uninsured.
Warnings by health care experts 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. For example, hospitals have closed or are planned for closure in Cincinnati, Philadelphia, St. Louis, New York, Washington and many parts of New Jersey. Detroit has no public hospital. Nor does Philadelphia.
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 determined that from 1996-2002, public hospitals closed at a far great rate than for-profit or private nonprofit hospitals. 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.
Lynne Fagnani, senior vice president of the National Association of Public Hospitals and Health Systems in Washington, said sustaining urban hospitals requires “state support, but with the recession, they have lost that.”
Ellen Kugler, executive director of the National Association of Urban Hospitals, said many nonprofit hospitals are religiously founded and don’t want to leave. Some hospitals have downsized, she went on, becoming 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.
“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?” Kugler asked.
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.
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 the 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. The clinic planned to move trauma services from Huron Hospital, which serves 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.
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.
Christopher Smitherman, president of the Cincinnati NAACP, e-mailed 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, said current hospital closures echo California’s experience. Since the 1960s, he noted, “Public hospitals have been closing at a rapid clip. There are no more than five or six counties remaining that operate their own public hospitals.”
When Martin Luther King, Jr. Hospital in Los Angeles’ predominately Latino South Central neighborhood closed almost two years ago, Hayes-Bautista said, patient loads increased -- but not the budgets of the four remaining county public hospitals.
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, said the problem of hospital closures in black neighborhoods began in the 1930s.
“Back then, there were more than 200 hospitals located in minority neighborhoods. You’d be lucky to find 20 now,” said Randall, a former nurse practitioner.
Once, she explained, people could count on government hospitals, “but they have been turned over to nonprofits. 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 believes 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.
Instead, Randall said, 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.
She added, “Our laws are totally inadequate in dealing with institutional racism.”
Smedley emphasized that hospital closures will continue to grow until the relevant health care law provisions start 2014. “Until then,” he said, “we have reasons to be concerned that hospitals will continue operating in the red.”