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The Health-Care Provider of Last Resort

As officials consider the future of crumbling Cook County Hospital, doctors and administrators debate: How should the hospital be replaced? What role should the county play in caring for the poor and uninsured?



How should health care be provided to the poor of Cook County? The debate is an old one, and it's being heard again in current arguments over the future of Cook County Hospital.

Few deny that the aging hospital is desperately in need of replacement. Like most U.S. public hospitals, County is a "Provider of last resort"--a place where the poor and uninsured know they can receive care when all other doors are closed to them. But the old hospital's physical deterioration is making that care more and more difficult to administer.

As long ago as the 1930s, the venerable facility on the near west side was being called obsolete by its staff physicians. The most recent component of the County Hospital complex, Fantus Clinic, was purchased in 1939; the main structure, where most of the patients are, remains very much as it was when construction was completed in 1913.

By all informed accounts, a new facility has been needed for at least 25 years. Harold Washington's professed dedication to public health recharged the debate over the hospital, Cook County's role in providing health care, and the future of public health-care delivery in greater Chicago. Now that the county appears finally ready to act, the debate has intensified.

A bit of historical perspective may be in order. The Illinois "poor laws" of 1833 established the county as the political unit responsible for assisting the state's poor and indigent. After all possible family resources were exhausted, a "pauper" was eligible to "receive such relief as his or her case may require, out of the county treasury."

In 1837, however, the state act incorporating the city of Chicago gave the City Council the authority to appoint a board of health and to erect, control, and regulate one or more city hospitals. Thus a distinction was forced between assistance to the poor generally and health care specifically. A series of legal battles was waged between the city and the county over who should bear the burden of caring for a poor person who fell ill. Illinois courts ruled consistently that while cities are responsible for preventing the spread of disease, counties must provide medical care to anyone who cannot afford to pay for it.

In 1903, for example, the Illinois Appellate Court ruled: "It is the duty of a county to render medical aid to sick persons who do not come within the definition of paupers but who have not money to pay for such services, and this notwithstanding such county may not have adopted rules and regulations for the giving of such service."

Current Illinois law states: "The General Assembly recognizes that adequate health care is a fundamental right of the people; that there should be no distinction in the availability of quality health care based upon one's inability to pay. . . . Therefore, it is the intent of the General Assembly to establish efficient and economical systems of public health care delivery in densely populated counties throughout the state."

While this act does not specifically mandate a county to establish a health care system, it delegates to the board of commissioners of "counties containing 1,000,000 or more inhabitants" wide-ranging authority either to administer one or to make free health care available under contract. Cook County is the sole Illinois county with more than a million people, and the County Hospital Act is the piece of legislation most often cited by those who are convinced that Cook County is legally obligated to care for the poor.

Actually, it's cited by all sides of the argument. The original issue--who's responsible for the delivery of free health care--isn't debated much anymore. Most people acknowledge that the county is. Now it's the scope of that care that's in question. Representatives of the county feel that Cook County Hospital largely fulfills the county's legal obligations. Critics like Dr. Quentin Young are adamant that the county has the ethical--and possibly legal--responsibility to do much more.

Quentin Young is president of the Health and Medicine Policy Research Group (HMPRG), a Chicago-based health policy think tank. What he sees as the issue transcends the question of replacing the old County Hospital building. He's convinced that there's a concerted effort afoot to reduce public sector involvement in health care. In an age when the dominant philosophy in seemingly every facet of human service delivery is to "privatize"--to encourage business to buy up and transform into commodities erstwhile "public goods" such as health care, education, transportation, even information itself--Dr. Young remains steadfast.

"It is of crucial importance at this time that serious-minded Americans concerned with health policy preserve the public sector," he maintained during a recent conversation in HMPRG's downtown offices. "It has been battered, bashed, dismembered, crushed, and thrown away at our great national loss. We're going to have to reconstruct it no matter what the shape of our future health system is."

The topic of Cook County Hospital is near to Young's heart. In 1947, he began his career there as an intern, and he returned in 1972 to assume the post of chairman of the department of medicine, a sometimes-stormy tenure that ended in 1981. For nearly 40 years, he has been one of Chicago's most outspoken advocates of a strong public health system, even as he has criticized the corruption and inefficiency that have so often characterized the local public sector.

Young and other members of HMPRG have been among the loudest voices in the debate over how the county should proceed in replacing its existing hospital. They are currently embarked on a series of tours to other cities to investigate possible public health prototypes for the Chicago area. They've already been to Boston and Milwaukee; in mid-May, they travel to Seattle and then to Vancouver for a look at how the much-lauded Canadian public health system works at the local level. Denver and Indianapolis, two other cities often cited as examples of how a municipal public health system should work, are possible stops later in the year.

These trips are HMPRG's latest effort to refine and promote its ideas about the future of health care delivery in Cook County. Dr. Young, Professor J. Warren Salmon of the University of Illinois, and their colleagues at HMPRG already have developed a master plan, "Toward a Cook County Public Health Delivery System: A New Vision," that calls for an expanded county system including a network of approximately 30 county-owned, community-based primary care clinics. The clinics would feed into two or three "mega-clinics."

The mega-clinics, probably the most controversial component as well as the cornerstone of the plan, would be constructed by the county. They would operate 24-hour-a-day emergency care services, be equipped to diagnose and treat most patients sent to them, and provide surgery and birthing services. Those patients in need of more intense or specialized care would be transferred to a public full-service hospital: under this proposal, the county would purchase a community hospital on the south or west side and also construct a new--and smaller--Cook County Hospital. Also proposed is the establishment of a taxing authority to finance and oversee the system.

This plan was unveiled in April of 1986 at an HMPRG symposium. It's since been hailed for its idealism and imagination; it's also been criticized for being fuzzy in detail, for being too broad in scope, for ignoring the astronomical amounts many say such a system would cost, and for suggesting that the county bear the full burden of what many see as a joint city, county, and state responsibility.

Regardless, it remains the most far-reaching idea yet set forth for a working public health system in a county whose infant mortality rate is among the highest in the Western world, and whose number of medically indigent patients--those with no health-insurance coverage whatsoever--continues to grow. It also addresses a larger policy issue that many observers, including HMPRG, feel has been neglected or sidestepped. It's an issue much greater than the immediate problem of replacing the old Cook County Hospital building.

At first glance, the question here seems simple: what should the role of the county be in providing health care to its citizens? But it can be framed in extremely different ways. Spokespeople for the county tend to put it like this: what is the county's (minimum) legal obligation to its indigent population? The answer tends to be simple: it's to own and operate a hospital. Others like Young up the ante: how can the county best meet the health care needs of its citizens, especially the poor and indigent? Their answer, predictably, involves much more than what's currently available on the near west side.

Most projections suggest that the health care needs of the poor and indigent will rise as the population ages, AIDS takes a greater toll, and economic conditions worsen among our poorest citizens. We see now the widely reported phenomenon of "dumping," private hospitals refusing to treat uninsured patients and sending them instead to Cook County Hospital, sometimes in medically unstable condition.

Meanwhile, the hospital continues to deteriorate. Accreditation by the joint Commission on Accreditation of Healthcare Organizations, an important measure of a hospital's quality and ability to attract top people, is in constant jeopardy, largely because of physical plant shortcomings. The popular perception of County is also a problem: the hospital is habitually portrayed as a crumbling, chaotic place where patients wait for hours in antiquated wooden wheelchairs before they can be seen.

Terrence Hansen, director of Cook County Hospital, bristles at some of these stereotypes. He feels that the hospital's image as a M*A*S*H-like war zone, bursting at the seams with patients lying in hallways and harried physicians chasing from floor to floor and bed to bed in a vain attempt to keep up with the volume, has been perpetuated by sensationalist media coverage at times of crisis.

"The projection for 1989 is [an average occupancy of] 670 beds [out of approximately 1,100]," Hansen says calmly, in response to the bursting-at-the-seams stereotype. "The projection for 1988 was 711, average daily census. We won't make 711, so demand is down. Current occupancy rate is about 65 percent.

"The dumping stories are very difficult to deal with because, number one, a patient who does not have the economic wherewithal and who is stable, according to the Metropolitan Health Care Council guidelines adopted by all hospitals in Chicago, should be transferred to County. That's why we're here. Economic transfers are sanctioned by that policy. So whether you like it or dislike it, you out there who are criticizing it, it's why we're in existence, first and foremost.

"So number one, I don't believe in the use of the word 'dumping' for economic reasons. That policy is in effect; that's why the state established us. Number two is the issue of stability; there are certain clinical services that feel that if you're stable you can be transferred, and there are other clinical services that feel if you're unstable, and you're an indigent patient, then maybe you are better off coming to a tertiary-care [full service] hospital right away, and quit horsing around; get you here quickly. So they're willing to accept you [at County] in an unstable condition.

"Those who write the articles that are the most prolific generators of the written word critical of dumping happen to believe in criticizing hospitals who transfer for economic reasons. I'm not quite sure what their alternative is. They're very good at criticizing; they've really been pretty poor at coming up with an alternative."

Recent studies do paint dumping as a problem. One of them was conducted by a research team led by Dr. Arden Handler of the Center for Health Services Research at the University of Illinois School of Public Health. Examining the pattern of transfers to Cook County Hospital of medically high-risk mothers and infants, Handler and her colleagues found transfers for economic reasons occurring on a regular basis. There was evidence that some of the women transferred were in active labor when they reached County, a violation of federal regulations. The researchers concluded that "transferring a high risk pregnant woman from a tertiary-care center for financial reasons cannot be in the best interest of her or her infant."

Hansen does admit that obsolete conditions result in unhealthy compromises, and that a new hospital is essential. "We've had people in the hallways," he asserts. "We've had trauma patients in the third floor corridor because we don't have enough space to do trauma.

"This place is inefficient because of the way it is laid out. It is inefficient because you've got three buildings; it is inefficient because you've got critical-care units in all three of those buildings; it is inefficient because for each of those critical-care units to function appropriately, you need a laboratory right next to it. So you've got seven satellite labs with seven critical-care units, as well as a centralized laboratory system. That just on its own is three and a half million dollars a year in operating costs. You eliminate the seven satellite labs over a 20-year period of time, $60 million in savings. You cannot function in those critical-care units without the satellite labs, the way it's laid out right now. That's what makes it so ridiculous, so inefficient."

For a while recently, the basic problem posed by the old, inefficient hospital building appeared on its way to being alleviated. After more than 60 years of running its own nearby hospital, the University of Illinois announced that it was thinking seriously of getting out of the hospital business. Michael Reese Hospital on the south side would take over the university hospital's medical training functions.

Then things got more complicated: Rush-Presbyterian-Saint Luke's Hospital stepped in with its own offer to absorb the university's training responsibilities, and on March 9 the university trustees voted to postpone a final decision on the issue for at least a month. But it's likely that the hospital, only a block from Cook County Hospital, will eventually be vacated. And when this happens, the building could be leased to the county.

Quentin Young is one of many who originally hailed the idea of taking such a step, but at second glance it didn't look so good. Eventually HMPRG released a position paper with its reservations to the entire U. of I. deal. One concern is that the county might exploit the university hospital as an excuse not to build a new Cook County Hospital; another is that the substantial state subsidy for indigent care ($15 to $20 million a year) that has been provided to the university hospital might be discontinued if the university's medical school associates with a private institution.

A third concern is the effect of closing the university hospital on the regional perinatal system. Ten Illinois hospitals, six of them in metropolitan Chicago, have been designated by the state as perinatal care centers. Each presides over a network of area hospitals that serve pregnant women during the second half of pregnancy and then serve both women and infants following birth. Many of these patients are poor and uninsured. Cook County, Presbyterian-Saint Luke's, and the University of Illinois Hospital all happen to be perinatal care centers, and it's not clear that the first two could absorb the university hospital's load. Michael Reese apparently cannot. In Chicago, a city with one of the highest infant mortality rates in the Western world, any diminution of perinatal care could be disastrous.

Then there's Provident Hospital, which closed in 1987 after accumulating over $40 million dollars in mortgages and debts. Until recently it appeared as if the county would soon acquire it at terms falling somewhere between the best-case scenario laid out by County Commissioner John Stroger--the county gets Provident for nothing, and the federal government forgives all public debts--and the $12 million the federal receivers were quoted as asking for it. But then County Board Chairman George Dunne said that unless Provident could be acquired free, the county did not want it.

On March 16, a south-side community group called the New Provident Community Hospital Association purchased the hospital for $7.5 million at a government auction, outbidding the U.S. Department of Housing and Urban Development by $50,000. The county did not participate in the auction.

The New Provident Community Hospital Association, however, was unable to come up with the required $750,000 deposit, and ownership of Provident shifted to HUD, the only other bidder. Apparently Dunne had gambled that one way or another, HUD would wind up with Provident. Now the poker game between Cook County and the feds over how much the hospital will cost the county can begin in earnest.

But regardless of whether the county takes over either or both of these two abandoned hospitals, the question remains: At a time when increasing numbers of medical procedures are being performed in outpatient settings and community-based health care is seen by policy analysts as the wave of the future, should Cook County ride the rising tide? Should it begin to implement what Quentin Young and others feel could be a radically new and improved public health system?

"I don't think anybody was very specific at that meeting except me," Terrence Hansen says of the symposium where the HMPRG's "new vision" was unveiled in 1986. "The thing that bothers me is that nobody ever comes up with sample budgets, as to how much it's going to actually cost. And then when you really press them they get extremely irritable with you and say, well, those'll be programmatic decisions that you'll have to make."

Some of Hansen's objections are understandable. The HMPRG plan is, indeed, visionary. If implemented, it would provide Cook County with a comprehensive system that would emphasize prevention, early detection, and delivery of care in the patient's community. In short, it would be everything most public health policy analysts say a health care system should be. Quantifiable cost estimates, however, have not been forthcoming.

When asked the price of establishing the projected network of 30 community clinics, Young is ready with some numbers (although no actuarial study has been conducted to come up with definite projections). "Look at the map; you don't start with zero clinics," Young instructs. He estimates that if the county were to acquire the six clinics currently operated by the city of Chicago, maintain the three it already operates as well as Fantus Clinic, which is the walk-in clinic at Cook County Hospital, and also absorb the dozen or so private not-for-profit clinics that exist throughout the city, "you're talking about add-on, as you measure these things, of 200K, maybe a million, to bring them up to state of the art. Then you have eight more clinics that have to be built. I would say that you're talking a capital investment on the order, generously put, of 30 to 40 million dollars. And voila! You have a dispersed, accessible network of community clinics.

"Sixty-five million dollars have been spent in the last decade and a half just keeping County in code. [Hansen says that the figure is even higher, around $85 million.] That's $65 million that's gone forever. If we had that 65 stashed away ready to go on capital costs, we'd save a bundle on bonding, to add to the bundle that we're saving when we get Provident Hospital, which has a $140 million replacement value."

Dr. Young also says the county should be collecting millions of dollars in medical fees owed it. "Do you know that at this late date in time, County does not have a billing system for anything that happens there? Five percent of a thousand visits [according to Young, 5 percent of Cook County Hospital patients carry insurance], 50 patients, if it's 200 [dollars] a hit, you've just made $10,000. Ten thousand a day, times 365 days, comes out seven figures. Is it irrational to say you collect the money that's due you? Get that billing system going! Take over a big hunk of the U. of I. Hospital, which is all there, another big capital cost saving!"

On the issue of governance, Dr. Young is more vague. HMPRG has suggested a new taxing authority to finance and operate a county health care system. There are currently some 700 active taxing authorities operating within Cook County, ranging from the county itself to a dizzying array of park boards, library boards, suburban school districts, and such public works authorities as the Street Lighting District. The very word "authority" conjures up images of rapacious bureaucracy. How could the notion of one authority more be sold politically?

"I dodge that, and I'll continue to dodge it," Young admits. He still thinks, though, that creating a new authority is theoretically feasible. "If there were some imagination, the authority question would be resolved through some compact, and I have no problem politically, ethically, least of all from a health-care-administration viewpoint, making the county government the center of gravity. It's sanctioned by the statute; it has the virtue of history and tradition."

Questioned more closely, Young says that the idea of a new taxing authority is intended as a jumping-off point for further discussion on the governance issue. "Let's just shake the tree and see what organization will do. It is impolitic to give a set formula, be it a potentially unpopular authority or a forced independent commission. It is absolutely mandatory, given the fiscal reality, that levels of government find a way to come together and work in an agreed-upon formula of interaction."

This "tree-shaking" approach to public policy is what makes pragmatic politicians like Terrence Hansen cringe. Hansen has cold, hard figures at the tip of his tongue, and he fires them out rapidly. He believes that the public has been misled by media descriptions of a report, commissioned by Cook County Hospital and made public in October of 1987, that projected a $500 million cost for constructing a new facility.

Of the $500 million figure, Hansen says, "That's a package. It is $22 million for a new parking facility, it is $30 million for a power plant, that's $52 million right there. We have to build those whether we stay here at 400 beds, 750 beds, or no [new] hospital. West of here on Harrison Street, Harrison and Ogden, we've got an $8.2 million hole in the ground right now; actually, it's got brick two stories up. It's an electrical distribution center. We had to put that up, regardless of what we're doing. So there's $8.2 million already spent out of your 500 million. I can keep going down the line--22 million for the garage, 39 for the powerhouse.

"Does everyone like Fantus? A replacement facility for Fantus, equal to what we think it should be, is around 35 to 40 million dollars. So now I have just spent $100 million of the county's money and I haven't touched one patient bed yet. I wish they'd read the goddamn report; it's obvious that Quentin hasn't! The Tribune still hasn't figured out where to read the report. So what do you want me to do?"

What HMPRG wants Hansen and the county to do is to expand their interpretation of "legal responsibility." As might be expected, county officials see the issue differently, with Commissioner John Stroger particularly adamant. Not only is it his position that the county's legal responsibility is limited to the provision of in-hospital acute care to the poor; he points out that the county is already doing that and more.

"It's not the responsibility of Cook County to provide [a full-fledged public health care system]," Stroger says. "We're charged with providing inpatient care for the medically indigent, and in certain areas we try to be supportive of those people who are medically underserved and don't have doctors by running our clinics, particularly Fantus Clinic. We run a chronically ill hospital for the senior citizen old and aged in Oak Forest, and we have some clinics also affiliated with Oak Forest to serve the south suburban area where we have a lot of poor people. But I think if the state wants to get into a program whereby the state wants to [expand] what the service should be, then the state should be willing to do that and pay for it. But if the county is going to be responsible, then the county should continue the present program embellished by a relationship with the city of Chicago."

It is Cook County's responsibility, says Quentin Young, and he points to legal opinion buttressing his case. Last summer, HMPRG asked the Chicago Lawyers' Committee for Civil Rights Under Law for an opinion on the county's duty "to provide outpatient care to the indigent population." The Lawyers' Committee is a 20-year-old, civil-rights-oriented group of lawyers that provides free legal services to the poor and disadvantaged. For the last six years, the committee has been focusing increasingly on health care issues. Their response was strongly worded:

"Based on [Illinois law and previous court decisions in similar controversies], we conclude that Cook County has a legal duty to provide adequate, complete health care services, including outpatient care, to poor persons in the county." By participating in Medicaid and Medicare, by passing the County Hospital Act and establishing a public hospital, the state and county established an entitlement, the lawyers argued; and it could not easily be revoked. Cook County "may not reduce or eliminate outpatient services or any other medically necessary services to poor persons; and, in the alternative, that any attempt to modify, reduce, or eliminate outpatient or any other services must be preceded by a public hearing."

In other words, according to Quentin Young: "The constitution and everything else mandates the county to do whatever it thinks necessary to give health care to the poor. It in no way restricts it to a hospital."

Dr. Young is convinced that County Board President George Dunne knows this. Last year, according to Young, Dunne asked the State's Attorney's Office to provide its own legal opinion on the health care responsibilities of the county, then mysteriously withdrew his request when the opinion became available. Young suspects that the request was withdrawn because, in his words, "Mr. Daley, who wishes to be mayor, told Mr. Dunne, 'If I give you an answer it won't be the one you want!'"

George Dunne remembers things differently. He says he doesn't remember the exact details of his exchange with Rich Daley, but adds, "I do recall that we were making an inquiry with regards to what the law specifically stated as to what our responsibility was. And I think, if my understanding of that is accurate, namely that we would operate a hospital for the medically indigent. I think what I said was, when they said that I was correct in my assumption [that this was the extent of the county's legal responsibility], I said, 'All right, fine, forget about it.'"

The disagreement, then, is over what the county must do versus what the county should do. The issue of neighborhood and mega-clinics is instructive in this regard. The county's position, as articulated by Stroger and others, is that the existing city health clinics are sufficient to provide Chicago with a community-based network of the type the HMPRG plan proposes, with no new construction and a minimum of new expense. "I think, right at this moment in history, the way things are now, the city and county should enter into an agreement to use the city's outpatient clinics," says Stroger. "I don't see anything beyond that unless a comprehensive system is developed by the legislature. The city when it was incorporated took on the responsibility for providing for the health and welfare of the people. We've never tried to invade the city's public health department."

Stroger is not opposed to the idea of county personnel providing the care in the neighborhood clinics, so long as the county does not own them. "I think the city should just provide us the clinics, not actually get out and do the work. The city doesn't have the manpower to do that. We have doctors; the city doesn't."

Terrence Hansen puts it more bluntly: "The easiest thing to do is to sit on the sideline and to throw out a proposal that on the surface seems to make a whole lot of sense. For example, the megaclinic. A phenomenal idea; an idea whose time has come. Approximately the same size, and approximately the same level of service, although maybe even more sophisticated than what we provide right now at Fantus Health Center.

"And virtually everyone complains about Fantus for it being too big, overcrowded, long lines, long delays, and long waits. So my first concern is, whatever we haven't done or have learned from Fantus, we should not duplicate again. I really like the idea of a strongly based system of neighborhood health centers, similar to what the city of Chicago has set up.

"But if the neighborhood health centers are appropriately operated and appropriately staffed and appropriately organized, do you in fact need mega-clinics? Inherent in that entire suggestion is that something is wrong with the city clinic system. Now tell me what's wrong with it! If you don't like the way it operates, then say so. If you don't like the way its staff is arranged and organized and functions, say so!"

Well, you would need mega-clinics, responds Quentin Young. The mega-clinics would be far more comprehensive than the health centers. But a combination of two or three mega-clinics with a network of neighborhood facilities would give everyone somewhere to go that's close to their homes, which should eliminate bottlenecks.

Then there are the problems Young sees if city-owned, clinics attempt to coordinate with a hospital, or hospitals, owned by the county. First, he claims that the separation of administrative authority between city and county makes for a duplication of services when a patient moves from one system to the other. A patient may go to a city clinic, be diagnosed and receive primary treatment, then be admitted to Cook. County Hospital and undergo the same process all over again.

That's not an insoluble problem, answers Hansen. "Why do you have to subsume it [the city clinic network] into a county system? Can't you do that right now, intergovernmentally? The city and the county sit down, say OK, let's integrate the registration system, have both the city and the county run their registration system off PATCOM [the computerized system currently used by Cook County Hospital]. Medical records? Integrate medical records. Flow of information back and forth? In between clinic and hospital? No problem!"

Hansen claims that County's computer system is to blame for the lack of coordination between county and city, just as it's responsible for the lack of a billing system at the hospital. In 1985 the county entered into a contract with a private vendor to set up a computerized information system for laboratory and radiology data, and to establish an itemized billing system for both inpatient and outpatient services. That system has never become fully operational. Hansen declines to say if litigation is pending, but he adds that "we're in the process of negotiations regarding our assertions that this particular vendor has breached the contract." But once the bugs get worked out, Hansen is confident that the county and city will move into sync.

But to Quentin Young, a unified system run by the county is simply bound to be more efficient. His argument that this system should be organized around a network of clinics is anchored on a theory of what the nature of health care should be.

"It will be looking at the social origins of disease," Dr. Young says, reflecting the thinking of the "social epidemiology" school of public health policy. In this view, disease has its origins in the political and economic realities of people's lives, and must be dealt with by bettering living conditions and empowering communities, as well as through conventional medical intervention. "What informed citizen thinks we're going to make any important dent in teenage pregnancy, low-birth-weight babies, drug and other substance abuse, without community participation? We're not moving in that direction when we think only of the big public general hospital. That's dealing with the failures of the system; you're getting the wreckage, the end-stage cancer, the advanced infection. How much better to nip it in the bud; these are the settings where it must take place."

Dr. Young also sees a system of clinics as an answer to one of the most important issues facing medicine today: the training of primary-care physicians.

"We're overproduced in the specialized services," he maintains. "But the really big issue is how are we going to find that huge army of primary-care physicians and where are we going to train them? The family practice expansion has grown mightily. I'm suggesting that this network of community clinics are precisely the training ground, the internship for a huge fraction of the young doctors who are going to be trained in the Chicago area. We're talking about a setting where they can get good, broad-based primary-care instruction with emphasis on prevention and early detection."

Here, Young raises an issue that's been largely glossed over in the public debate over the future of County Hospital: the role of County as a teaching institution. As a large, urban public hospital, County has long been a place where medical interns and residents are eager to work; one can't find a wider variety of cases, or learn to practice medicine under a greater range of conditions, anywhere else. But John Stroger and Terrence Hansen both maintain that it is now, or soon will be, time for the county to get out of the physician-training business.

Stroger: "I don't think that the trend, is for us to be a freestanding medical program. I would like to see us eventually enter into some type of agreement with one of the major medical schools here. University of Illinois has never been a hospital that was designated a hospital of last resort. The University of Illinois ran its hospital, and still does, for the purpose of training its young men in the medical school, and having a place for them to train after they graduate. [When Stroger spoke, the university had yet to announce it was closing its hospital.] They have taken indigent patients when it was to the advantage of the University of Illinois training program, but that's not its mission. Its mission is education; our mission is to take care of the medically indigent."

Hansen: "I agree with Commissioner Stroger. I think it's just simply waiting, I think that's another sign of the times. I think the requirements that are put forward by the American College of Graduate Medical Education and the residents' review committees are becoming stricter as they seek a higher level of quality, and I think there's more academic requirements that cannot be provided by a freestanding agency like the county which are a natural part of the day-to-day operation of a university. The primary purpose of the county shall be to provide access to health care for the indigent, and the primary purpose for the university shall be training, education, and research leading to a medical education."

Such a notion appalls Dr. Gordon Schiff, a physician at County and a member of the Committee to Save Cook County (CSCC), a loosely affiliated citizens group that has been one of the more vocal independent voices in the ongoing debate. Schiff and many other members of CSCC see a hidden agenda in many of Hansen's and the county's efforts: to shrink the hospital, and the county's participation in health care, as much as possible.

"The community needs to be alerted to what's going on," says Schiff, "and it's a very dangerous thing. The strength of County has been that it's attracted high quality teaching programs so people, the top trainees over the decades, the top trainees from all the American medical schools vie to get in. You have very high quality professors and supervisors, and that mix of academic interest and state-of-the-art medicine and high quality with services was I think what made County great and what, I think correctly, gives it its high reputation among the community."

Schiff agrees that the hospital's status as a place to learn medicine is falling, but he sees this as a product of its physical obsolescence and of foot-dragging by the county and the hospital administration. "You're attracting high-quality people to work there but it's getting harder and harder every year," he says. "If you operate a hospital, work in a hospital that doesn't have state-of-the-art equipment, that's not air-conditioned, that doesn't have a cardiac cath[eter] lab, doesn't have elevators that work, that doesn't have a lab computer that works, so what we're having now is that we're having trouble attracting American medical graduates. They [the foreign medical graduates] are good doctors, but one of the things that one can say unequivocally is the attractiveness and competitiveness of that training program have slipped markedly, and that's a serious problem. And the thing that concerns me is that people are fiddling while Rome is burning."

Schiff won't go quite as far as his colleague, Dr. Cory Franklin, who noted in a recent opinion piece in the Chicago Tribune that a threatened strike by the nursing staff last October had caused the hospital to eliminate more than 100 beds. Franklin took this as a sign that there may be an agenda on the part of the county to eventually close the hospital altogether.

But Schiff does look with great wariness at any plans to shrink Cook County Hospital significantly, whether by eliminating beds or by building a new, smaller facility. He thinks that a new hospital should have roughly as many beds as the old one, 1,100. Here he differs with Quentin Young, who sees 500 beds as reasonable, given the acquisition of Provident and the network of clinics and mega-clinics, as well as with his boss Terrence Hansen, who proposes a new facility in the 300-to-500-bed range.

"I favor a hospital that's adequate to meet the need," Dr. Schiff asserts, supporting his case with estimates of hospital occupancy that are somewhat higher than Terrence Hansen's figures. "We have 1,100 beds now; the census ranges between 600 and 900. Average censuses have been in the 700s, 800s regularly. It's widely understood in the hospital industry that to have an efficient hospital you have to have some slack; in other words you can't have somebody get into a bed the minute someone else is discharged. The census this year has been in the 700s, but the point you need to understand is that 80 to 85 percent occupancy is considered to be maximum efficiency.

"So if you're talking about a census of 750, you're talking about 900 beds. All the efforts to shrink the current hospital have resulted in severe overcrowding. Terry Hansen took advantage of the nursing strike to close several wards, further shrinking the hospital; there's this constant effort to shrink the size of the hospital."

Most arguments for a smaller Cook County Hospital assume the acquisition of other facilities--the University of Illinois Hospital, Provident Hospital, or HMPRG's networks of clinics and megaclinics--that would take some of the burden off County. Another of Quentin Young's predictions is that neighborhood clinics would eliminate unnecessary overnight stays at County, which he says come about when a patient needing a series of tests can't travel long distances to the hospital several days in a row.

Terrence Hansen bitterly denies this. "Maybe the next thing they'll tell you is that they stay here because it is not centrally air-conditioned, maybe the next thing they'll tell you is they stay here because they like the food! Crescent County [the private agency that reviews services to Chicago-area hospital patients on Medicare and Medicaid] reviews the appropriateness of the stay, the admission, or discharge. We, like every other hospital, fight over our length of stay, and if I was keeping all these people, then why was my length of stay coming down each year over the last five years? Garbage! You do get to the point where you say OK! just give me the names and the particulars, we'll check it out. Nobody ever gives us names, nobody ever gives us particulars, and we never get to check it out."

Gordon Schiff isn't so sure himself about Quentin Young's "unnecessary overnight stay" scenario. "I would say that's an untested hypothesis," he says. "I think one could make an equally strong argument that there's a reservoir of unmet needs out there, that if you put more clinics out in the communities, rather than decreasing the need for County's beds you could potentially increase it. In other words you're going to discover more colon cancers, people are walking around with no health care, there are more heart problems.

"I'm willing to invest resources in preventing people from coming in, but you can't do it backwards. Look at what happened with the closing of the mental hospitals and the homeless. The order has to be you don't close the mental hospitals and then say we're going to put [in] community mental health centers, and when that doesn't happen you end up with a generation of people on the streets. If somebody wants to start building these clinics, then we'll talk about shrinking the hospital if that shows that the need is less.

"What I want to address now is what is the current need? The demographics and the epidemiology of diseases predict that the current demands on County are likely to stay the same or increase. As far as we can predict with the aging population and the changing heart rate patterns and AIDS and the fact that our population is aging and there's going to be more heart disease, there's going to be more lung cancer.

"How much of that will be offset by our ability to manage people as outpatients? People are writing about [complex operations] being done in one day, in and out, but I just don't think that's applicable to our patient population who don't have the kind of resources at home. Some of them don't even have homes, period; there's no food in their home, there's no heat, there's no water, patients have their gas shut off. The shrinking of the hospital is based on a series of untested hypotheses that I think could potentially lead to a very severe worsening of access of people to care."

Hansen is offended by the notion that someone is trying clandestinely to "shrink" the hospital, or that the county wants eventually to shut it down. "I think that's bullshit," he snaps. "I think that's ludicrous. All you have to do is come and look at what the board's done in the last ten years, nine years, eight years, seven years. You know, you'd like to have an intelligent discussion, you'd like to debate the points, but after a while, when you've heard the same wild accusations for five years, you get to a point where you say, 'Oh come on, not again! We're still here, pouring money in like it's going out of style, we're fighting with you over the size of the residency training program because your census is dramatically down, but you don't see doors being closed--Cut the crap fellas, start waking up and looking at what's going on around the hospital!' And I address that to a number of my esteemed members of the medical staff. The county has poured incredible amounts of dollars into this place here, and it would be an instantaneous ticket to oblivion, I think, if that board were to suddenly say, hey, the best thing we could do is close the hospital. I just don't see it."

After a while, the exchange of scenarios, numbers, projections, and accusations numbs the mind. As often happens, the central issue--the health and welfare of the indigent of Cook County--seems in danger of getting lost amid the turf wars and eruptions of long-standing philosophical and political rivalries.

George Dunne and his loyal deputies John Stroger and Terrence Hansen have made their position clear: they recognize the county's statutory duty to own and operate a hospital; they recognize little more. Stroger, in fact, suggests that according to his interpretation of the law, which is certainly not Quentin Young's, the county could not do much more even if it wanted to. "The county does not have the power as the county government to create that type of delivery system," he argues when asked about the comprehensive network envisioned by Young and HMPRG.

One can readily sympathize with the exasperation of policy-oriented activists like Young who want to goad an unimaginative bureaucracy into accepting a "new vision." "For once in our life," Young insists, "let's do a Burnham and make no small plans." But the vagueness of the answers one gets when trying to pin the "new vision" down to specifics--like money, like governance--indicates that it's far from being expressible in concrete terms.

Observers have begun to look warily to other cities--Philadelphia, Saint Louis, Detroit--where public hospitals have closed in recent years; a 1988 article in the journal Medical News and Perspectives documented that 34 county hospitals in California had been "closed, sold, or otherwise disposed of" between 1960 and 1985. California was ominously put forth as a possible "bellwether" state. According to data from the Center for Health Services Research of the University of Illinois, 18 public hospitals have closed in U.S. cities since 1980.

Will that be our eventual fate in Cook County? One hopes not; Terrence Hansen is no doubt sincere in insisting that there is no plan afoot to close the hospital. But the political foot-dragging on Provident, a hospital with an estimated $140 million replacement value that could have been acquired for under $8 million, makes some of the dire predictions of Dr. Schiff and Dr. Franklin seem much more credible. If the county continues to refuse Provident as anything but a free gift, and if mounting pressure to keep the University of Illinois Hospital in the public sector persuades the university trustees to hang onto it, everything will be back at square one: an aging, obsolete hospital on the west side, sagging more ominously every day, as politicians and policy makers try to stick one another with the bill for replacing it.

Meanwhile, the larger question remains. Must political vision in Cook County be forever limited to the narrowest interpretation of legal responsibility? Or is there a place for "new visions"? If such an idea is embraced with enough enthusiasm and imagination, can mechanisms be found to make it work? The future of public health care in Cook County hinges on the answers.

Art accompanying story in printed newspaper (not available in this archive): photos/Mike Tappin, Jon Randolph.

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