The gridlock hospital: When acute care becomes a costly social failure

“ You, the feldscher, the superintendent, all the rascals employed in the hospital are immeasurably lower in morals than the worst of us; why, then, are we here instead of you? Where is the logic?"
"It is not a question of morality or logic. It depends on circumstances. The man who is put here, here he stays, and the man who is not here lives in freedom, that is all For the fact that I am a doctor and you a lunatic neither morals nor logic is responsible, but only empty circumstance." ”

“ It is time that the whole problem of social reform should be considered in the light of the best knowledge now obtainable. Medical and sanitary science have much to say to it, and so has political economy. ”

“ The third difficulty is the perplexing problem of determining just how far the self-interest of the individual is consistent with the general good. How much shall freedom of contract be abridged? How much social control shall be exerted over the individual in other directions? How far shall combinations of labor and capital be permitted to go in carrying out their purposes? Amid the complex conditions of modern life, these questions are more difficult to answer than ever before. ”

“ There will be no clearer test of the commitment of this Congress to the anti-inflation fight than the legislation that I will submit again this year to hold down inflation in hospital care.
Over the next 5 years, my proposals will save Americans a total of $60 billion, of which $25 billion will be savings to the American taxpayer in the Federal budget itself. The American people have waited long enough. ”

“ Finally, our deficit will grow and our expansion will sputter if we don't reform our health care system. Health care costs are going up more and more and more than any other part of our budget, not for new health care but to pay more for the same health care. ”

“ Poorly paid labor is inefficient labor, the world over. ”

“ his fluctuations have been between poverty in the extreme, and poverty modified, or, to use his own emphatic language, ‘between nothing to eat and just half enough.’ He is not, as he forcibly remarks, ‘one of those fortunate men who, if they were to dive under one side of a barge stark-naked, would come up on the other with a new suit of clothes on, and a ticket for soup in the waistcoat-pocket:’ neither is he one of those, whose spirit has been broken beyond redemption by misfortune and want. He is just one of the careless, good-for-nothing, happy fellows, who float, cork-like, on the surface, for the world to play at hockey with: ”

“ Every medical man who has often entered the dwellings of the poor, and I can speak on this point from my own experience, knows how sad is the lot of consumptives and their families there. The whole family have to live in one or two small, ill-ventilated rooms. The patient is left without the nursing he needs because the able-bodied members of the family must go to their work. How can the necessary cleanliness be secured under such circumstances? How is such a helpless patient to remove his sputum so that it may do no harm? ”

“ Like begets like, and as the population of any hospital for the insane is chiefly chronic, there being relatively only a limited number of acute cases scattered through the various wards, this evil association must rob society of many a useful and productive citizen by placing him in daily contact with those who mar his chances for recovery. ”

“ The payment of city money to dispensaries should be discontinued, except in special cases where the work done is clearly a proper charge against the public treasury. No money should be paid for the treatment of dependent persons in any private hospital while there is unoccupied room in the city hospitals. ”

“ It stands to reason that so long as there are vacant beds in the city hospitals and the city is at the same time subsidizing private hospitals at a cost greater than the expense of caring for patients in its own institutions, a wrong is being done to the taxpayers. If private hospitals are to receive public assistance at all, payments should be made only at some uniform rate, approximately the same as the cost per capita of maintenance in the public institutions. ”

“ Soon the First Lady's task force will make its recommendations on what we need to do to ensure that every American has access to good, affordable health care, a plan that keeps what's good about our health care system—our doctors, our nurses, our health care providers, our medical research, our great technology—but a plan that changes what's wrong: an increasingly expensive and unjustifiable system of finance, one that's too bureaucratic, one that has runaway costs. ”

“ We decided to begin with an economic plan which puts aside trickle-down economics and emphasizes bringing down this deficit and investing in our people and our economy; to be followed by an effort to control health care costs and provide affordable health care to all Americans; a welfare reform plan to move people from welfare to work; the national service program to open the doors of college education to millions of young people and give many, many of them a chance to pay their college loans back through service to their communities ”

“ How can we keep what's best about our system, our wonderful caregivers, our wonderful medical research system, and fix what's wrong, the fact that there aren't enough places like this Scottish Rite Hospital, that too many people are losing their coverage, that the financing system is a bureaucratic nightmare full of unfairness? ”

“ These problems and many others like them affect us as Americans, not as Democrats or Republicans, and frankly, not as people who consume health care and those who provide it. I talked to doctors and nurses today who are heartsick at the burden of unnecessary paperwork. At the Children's Hospital here in Washington, the doctors told me that $2 million a year is spent on paperwork that has nothing to do with caring for patients, that the average doctor has to give up the chance to see 500 more patients a year just to fill out forms. ”

“ For example, the Federal Government bears the burden of paying billions for the new entitlements mandated by the Medicaid Expansion and federal subsidies for insurance purchases on the exchanges; but it benefits from reductions in the reimbursements it pays to hospitals. Hospitals lose those reimbursements; but they benefit from the decrease in uncompensated care, for under the insurance regulations it is easier for individuals with pre-existing conditions to purchase coverage that increases payments to hospitals. ”

“ The determination of the amount of funding available for such value-based incentive payments under paragraph (7) (A) and the payment reduction under paragraph (7) (B) (i) . ` (iii) The establishment of the performance standards under paragraph (3) and the performance period under paragraph (4) . ` (iv) The measures specified under subsection (b) (3) (B) (viii) and the measures selected under paragraph (2) . ` (v) The methodology developed under paragraph (5) that is used to calculate hospital performance scores and the calculation of such scores. ”

“ The insane asylum, except for the chronic cases, in most states both here and abroad, has passed away and in its place has arisen a hospital to which the patient comes as a sick man to have the kind care and systematic treatment that the word hospital implies. He is received and cared for by nurses trained to the work and is at once impressed with the idea that he is a sick man, so regarded by his fellow men, if not cognizant of it himself, and that he is to have done for him what careful nursing, hygienic surroundings and medical science can do. ”

“ Skillful physicians prescribe for a patient that kind and degree of exercise which is suited to his case—to one a rocking-chair on the south piazza; to another a good round trot out of town on the saddle. Thus, in the evening games, which shall rest the tired worker, or divert the invalid, there is a great opportunity for wise choice in selecting those which are best suited for the purpose in view. ”

“ Price security, we are told, is only a special form of sanitary security; the economic motive is secondary and subordinate; the state intervenes to make its inhabitants healthy, and not to make them rich. On that assumption we are asked to say that intervention will be upheld as a valid exercise by the state of its internal police power, though there is an incidental obstruction to commerce between one state and another. This would be to eat up the rule under the guise of an exception. Economic welfare is always related to health, for there can be no health if men are starving. ”

“ Last Wednesday at the White House, Sister Bernice Coreil, a member of the Sisters of Charity, the religious order which runs the largest nonprofit hospital system in America, spoke about health care in a way seldom heard in the Nation's Capital. She pushed all the politics and complex arguments aside and said health care is about basic human values, about honoring the intrinsic value of every person. ”

“ Places like Scottish Rite don't ask children with severe disabilities or serious illnesses, "Can you pay?" They just ask, "How can I help?" The wonderful team of doctors, nurses, and other hospital workers here take all children in need. That's what we want for all of America. ”

“ I might, as my reader will have anticipated me in recognizing, go on almost indefinitely in this direction; but I have said enough, I trust, to prepare him for the point which I want to make in connection with our modern charities and their mischief. Our modern social order, in a word, has become more complex, more segregated, more specialized. A whole class of people in cities—those, I mean, of considerable wealth—with a few noble exceptions (which, however, in our greater cities, thank God, are becoming daily less rare) , live in profound ignorance of the condition of their fellow-citizens. ”

“ Dissociate a body of men from their fellow-citizens, set up an independent caste by endowing it financially, and the consequences appear even in a country where public opinion is as omnipotent as here. The difficulty of forcing progressive action on our colleges is a sufficient illustration. We live in an age of unparalleled "passion, pulse, and power"—an age with gigantic problems suddenly laid on it; our civilization is chiefly industrial, and the railway, the factory, and labor organizations are the largest elements of our social life. ”

“ So extensive and so numerous are the conditions of modern civilization which certainly affect health, that boards of health generally do not pretend to cover them all. For example, the construction and maintenance of public water supplies and sewerage systems, although undertaken by the public at the public expense, are not conducted by health authorities but by private corporations or special municipal departments. Likewise the collection and disposal of garbage, and even the cleaning of privies, is often done by other than public health authorities. ”

“ Almost every act and occupation and nearly every feature of city life may be construed as having some bearing upon public health and welfare. Before a board of health sets out upon a campaign of more esthetic than sanitary value it should be certain that all its simple and essential duties are being efficiently discharged. There is often much inconsistency in public health work. ”

“ But the general dissatisfaction with the growth of free dispensaries, hospitals, etc., is proof that the medical profession is opposed to both an excessive volunteer service and to a diminished practise. On the other hand, it is unfair to the public because it places upon the poor the stigma of asking for assistance for relief from illness for which he is perhaps not responsible. ”

“ If a nurse declines to do these kinds of things for her patient, "because it is not her business," I should say that nursing was not her calling. I have seen surgical "sisters," women whose hands were worth to them two or three guineas a-week, down upon their knees scouring a room or hut, because they thought it otherwise not fit for their patients to go into. I am far from wishing nurses to scour. It is a waste of power. But I do say that these women had the true nurse-calling—the good of their sick first, and second only the consideration what it was their "place" ”

“ Now, according to a new survey out just this week, physicians believe that when their patients are denied services under managed care, up to two-thirds of the time those denials lead to serious declines in patients' health. ”

“ Yet more abundant are the statistical accumulations pertaining to that fourth and last division of descriptive sociology which treats of the social welfare—of the functioning of society, of the ends for which it exists. ”

“ You know, we've been talking about the budget for months. The American people have heard our deeply held views, and we've had time to listen to theirs. I believe there is an overwhelming consensus on a course that is also the right course for America: a balanced budget in 7 years, because it's wrong to leave a legacy of debt to our children; a budget that protects Medicare and Medicaid, because we owe a duty to our parents, to the disabled, and to our poorest children; a balanced budget that protects education and the environment, because we owe a duty to our children and to future generations ”

“ For the curable cases in the hospital annexes no reasonable expense should be spared. This is true economy regarded either from the philanthropic, economic, or scientific point of view. The curable patients come entirely from the strong people who have earned their own livelihood, and have done their part in the world until, loaded down by ill-health, trouble, or care, they break down and go to a State hospital for treatment. ”