In North St. Louis, Smiley Urgent Care Center is set to close in December because administrators are unable to offset the cost of caring for people without insurance -- the majority of the 16,000 patients it served each year. In 1960, Detroit had 42 hospitals that served about 1.5 million people; today, it has just four hospitals serving 700,000 people, many of them poor, unable to pay or without health insurance to cover the costs. And in Washington, the 2001 closure of District of Columbia General Hospital -- now a crowded family homeless shelter -- has increased the pressure on hospitals and emergency rooms in Maryland.
All across the country, nonprofit hospitals dedicated to serving the poor and uninsured in exchange for tax breaks and federal subsidies are closing money-losing facilities and setting up in more affluent communities where patients are more likely to have health insurance.
That not only means longer emergency response times for gunshot or car-crash victims, the chronically ill elderly or critically injured children, but little or no access to health care for residents who can’t afford insurance and often rely on so-called “safety net” community- or government-run hospitals for primary care. Many of those hospitals -- required by law to treat the indigent -- have chosen to avoid an impossible equation: caring for the urban or rural poor as the cost of that care increases and government reimbursements shrinks.
Caroline Steinberg, vice president of Trends and Operations for the American Hospital Association, said hospitals “are closing, and taking their emergency rooms with them.”
Sager, the Boston University professor, said in neighborhoods like North St. Louis, there isn’t a single functioning hospital, and “there are large expanses in some cities where there are no doctors in private practice.” He cited the closure of Washington’s D.C. General as an example of the chain reaction triggered by a hospital shutdown.
People who lived near that hospital “now go over the county line to [hospitals in] Prince George’s County, Maryland, to get care, which itself has to be rebuilt because they’re losing doctors” to higher-paying jobs in more affluent areas, Sager said. “There’s a domino effect: the hospital that now serves the displaced patients may itself be financially destabilized” by a spike in the number of people who need care but can’t pay the bills.
“We don’t have a competent government or funding model,” Sager said. “When you don’t have one or the other, we call that anarchy.”
And if current population shifts continue -- the 2012 Census showed the rural population is rapidly shrinking, while populations in rust-belt cities like Cleveland and Toledo continue to crash -- the health deserts are likely to expand.
“Unfortunately, we’re in a situation where we’re trying to expand health care on top of a model that’s inefficient,” the Joint Center’s Smedley said. “Clearly, we’re all going to pay for the cost of uncompensated care” when insurance companies offset the costs through higher premiums and fewer benefits.
“It’s hard to quantify, but no doubt people are suffering every day,” Smedley said, noting that access to health care has become a moral argument -- do we want to be the sole top 10 industiralized nation that provides care only to those who can afford it? Are we willing to let people die for lack of it? -- as well as an economic one.
“I hope we don’t have to have more tragedies like the one in Texas,” he said, “before we get it.”
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