THE BEST-KEPT SECRET IN HEALTH CARE
Balter, Michael
The best-hep secret in health care A hospital law s>u're not supposed to know about Michael Baiter In January 1978, twenty-three-old Candida Casas was brought to the emergency room of San...
...As a result, health-rights advocates have been forced to sue in each individual case...
...This "separate but equal" provision, not deleted from the Act by Congress until 1964, gave Federal sanction to hundreds of separate black and white hospitals in the South...
...Often, the states refused to enforce the regulations or simply ignored them...
...They also promise to provide a "reasonable volume" of free care to those unable to pay...
...The best-hep secret in health care A hospital law s>u're not supposed to know about Michael Baiter In January 1978, twenty-three-old Candida Casas was brought to the emergency room of San Diego's Paradise Valley Hospital, suffering from second- and third-degree burns over much of her body...
...Prodded by this and other court defeats, HEW between 1972 and 1974 issued a series of new regulations...
...It is clear that the guidelines will be enforced with no more energy than before...
...The sad fact is that there is no one to enforce even the most favorable court decisions...
...A number of past practices, such as writing off bad debts as "charity care," are now forbidden...
...A series of lawsuits was filed on behalf of people turned away from subsidized hospitals because they did not have enough money, were on Medicaid, or did not have a private physician...
...Because of the new regulations we are having resource problems—we just haven't been able to get to them...
...The battle to hold Hill-Burton hospitals to their promises might have been won long ago if not for the complicity of the Federal Government, which "has been the primary enemy every step of the way," says attorney Armin Freifeld...
...Their request for a preliminary injunction was denied first by District Court Judge Nicholas Bua, and again in the Seventh Circuit Court of Appeals...
...Between 1980 and 1983, for example, 1,030 facilities will be exempted, amounting to approximately $30 million annually in free care lost to the poor...
...The community service obligation remains in effect as long as the hospital is standing...
...Moreover, although the 1979 regulations allow HHS to enter into agreements with the state agencies to monitor the hospitals jointly, only one such agreement has been signed, with the state of California...
...Behind the scenes there are some clever people who are selling out the program...
...Lawyers for the Department of Health, Education and Welfare (HEW), now the Department of Health and Human Services, siding completely with the hospitals, countered that the court had no jurisdiction to order enforcement...
...The 1979 guidelines are a substantial improvement and represent, at least on paper, a limited victory for poor people...
...Health-rights attorneys argued that this policy was exclusionary and violated the community service obligation...
...The New York State Department of Health reported in 1979 that only one of the 151 Hill-Burton hospitals in that state was in full compliance...
...In 1974 the Congress, citing the "sorry performance" of both HEW and the state agencies, phased out the original Hill-Burton Act and replaced it with a new program (Title XVI of the National Health Planning and Resources Development Act...
...A survey of the thirty-eight Hill-Burton grantees in Los Angeles County in February 1980 indicated that thirty of them still required advance deposits for admission...
...The Act evolved from the refusal of Congress to pass President Truman's national health insurance proposals after World War II...
...Accurate records of the care provided must be made public...
...The majority in Congress backed the demands of the hospital industry, represented by the American Hospital Association, for public funding of hospital construction without public regulation...
...The public has seen little return for its money...
...Surgeon General...
...Sometimes greater gains have been made when community activists organize directly against particular hospitals, through actions such as picket lines and demonstrations...
...There it languished in the office of Allen Furey, the program analyst responsible for writing the final report, until December, when it was sent to another section of HHS—even though the hospital, after rejecting Candida Casas, openly credited her first aid and ambulance charges to Hill-Burton Charity...
...A major concession to the industry, however, is a twenty-year limit to the free care provision...
...Written notice that free care is available must be given to every patient...
...In the years following passage of the Hill-Burton Act many "progress reports" were published, describing in intricate detail the numbers of hospitals constructed, the expansion of the program to include nursing homes and chronic disease hospitals, and other accomplishments...
...The case of Paradise Valley Hospital is a good illustration of the HHS attitude...
...District Court in Chicago...
...The agency was required to write more adequate regulations, which it did only after still another court order four years later...
...Only one, Representative Ronald Dellums's National Health Service bill, seriously challenges the power of private medicine, and for this reason, it currently has little chance of passing...
...we will marshal the resources necessary to monitor hospital performance closely and correct noncompliance...
...In fact, the Maryland Bureau has only seven people to monitor the Hill-Burton program nationwide, despite a growing backlog of more than 200 complaints...
...These would be approved by a "Federal Advisory Council" composed of eight members "outstanding in fields pertaining to hospital and health activities...
...Thus, not only will those hospitals completed before September 1959 escape this obligation, but 200 to 300 more hospitals will become exempt each year...
...Nor were the states required to write their own guidelines...
...A hospital had to provide care "without discrimination on account of race, creed, or color...
...Most important are the new community service rules...
...took the word of the states...
...The Government didn't do a thing for twenty-five years to enforce the Act," says Armin Freifeld, staff attorney with the National Health Law Program in Santa Monica, California...
...The regulations did, however, reaffirm one section of the Hill-Burton Act which allowed the building of segregated hospital facilities...
...In most cases the state agencies simply took the word of the hospitals that they were complying...
...The past thirty-five years, since the defeat of President Truman's national health plan, have made this clear...
...None of these hospitals will have to make up for past violations...
...Since 1946, it has provided upward of $4 billion in outright Government grants to more than 7,000 hospital construction, expansion, and renovation projects...
...The final legislation contained a few concessions to Congressional liberals: Publicly funded hospitals would be available to everyone, and, at the suggestion of Senator Robert Taft, a "certain percentage" of free care would be provided to the poor...
...District Court in Chicago to have them thrown out...
...They must admit Medicaid and Medicare recipients...
...Reports of continued widespread violation of the Hill-Burton Act are piling up...
...The court ruled against the hospitals, adding that the HEW position was "in disregard of the provisions and intent of the Hill-Burton Act...
...These comments stand in marked contrast to then Secretary of HEW Joseph Califano's promise in October 1978, that "when the final regulations are issued...
...The regulations require Hill-Burton hospitals to provide free care in an annual amount equal to 10 per cent of their total grant level or 3 per cent of their yearly operating costs, whichever is less...
...AHA attorneys argued that the guidelines exceeded HEW's authority and would add $97 million a year to the cost of hospital care...
...With 60 per cent of the grants going to private hospitals, the Hill-Burton program has become a huge subsidy of the hospital industry...
...The individual states were to administer the program, following regulations written by the U.S...
...The practice is more than a breach of medical ethics...
...Health-rights activists call the Hill-Burton Act the best kept secret in health care...
...These are the hospitals built or improved with funds from Title VI of the Michael Baiter, a free-lance writer in Los Angeles, isaformer writer and editor for the University of Southern California School of Medicine...
...The hospital gave first aid, but refused to admit her upon learning she was in the United States illegally...
...So Paradise Valley put her in an ambulance and sent her back to Mexico, where she wound up in a Tijuana hospital unequipped to handle burn patients...
...Yet without change on this scale, more modest attempts to reform health care in the United States are doomed—like the Hill-Burton program—to failure...
...One landmark case involved seven New Orleans hospitals that refused to admit Medicaid patients...
...The state Hill-Burton Agency confirmed the charges in April 1978, but it wasn't until July 1979 that a final report was filed with the HHS Bureau of Health Facilities, Financing, Compliance, and Conversion in Hyattsville, Maryland...
...At Paradise Valley, almost one-third of a $4 million facility added in 1963 was paid for out of Hill-Burton funds...
...A full trial on the legality of the regulations, which took effect in September 1979, is now in progress in U.S...
...The California Hill-Burton Agency cites violations by 182 out of 244 facilities...
...The Surgeon General's regulations, issued in September 1947, not surprisingly gave no guidance to the states about what constituted a "certain percentage" of free services, or how a person would become eligible for them...
...Government-financed hospitals may not deny emergency services to anyone, regardless of ability to pay...
...Immediately after publication of the new rules in May 1979, the American Hospital Association filed suit in U.S...
...Despite the new regulations, Hill-Burton hospitals felt no increased pressure to provide free care...
...nor can they require a cash deposit before admitting a patient...
...No mechanism was provided for the monitoring or enforcement of the hospitals' service to the community...
...This period dates from the completion of construction and is not retroactive...
...1946 Public Health Service Act, better known as the Hill-Burton Hospital Construction Act...
...The new legislation shifted primary responsibility for enforcement onto the Secretary of HEW...
...Now that the concept of aational health insurance has been resurrected, several bills are working their way through Congress...
...for many hospitals, it is a violation of the law...
...Yet next to nothing has been done over the years to enforce the "community service" and "free care'' requirements that go with the money...
...It is ironic that the same hospital industry that demanded the Hill-Burton Act in 1946 now seeks to block all efforts to enforce its provisions...
...But in the early 1970s health-rights advocates began to rediscover Hill-Burton...
...The overall lesson of the Hill-Burton Act is that public health care cannot be provided by massive subsidies to the private health care industry...
...The amount of care for the poor or their increased access to medical services was never mentioned...
...In return for the money, each hospital agrees to serve everyone in the surrounding community regardless of race, creed, national origin, or any other non-medical factor...
...Although Candida Casas eventually recovered from her burns, a complaint against the hospital was filed by the San Diego branch of Cal PIRG (California Public Interest Research Group...
...Each day, private hospitals like Paradise Valley "dump" critically ill people who cannot pay for the treatments they need...
...In turn, HEW...
...But an exception could be made "in cases where separate hospital facilities are provided for separate population groups, if the plan makes equitable provision on the basis of need for facilities and services of like quality for each group...
...For the first time uniform eligibility requirements are spelled out, based on the Poverty Guidelines...
...Although a local hospital will occasionally make some concessions when threatened with a lawsuit, very little has changed overall...
...We haven't been writing many decisions," says Furey...
Vol. 45 • April 1981 • No. 4
