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Dire prognosis for poor
Planned budget cuts threaten already fragile system at hospital that serves county's neediest

Sunday, January 07, 2007
Chicago Tribune
by David Goldberg

The patients in my practice at Stroger Hospital are mostly middle-aged and older. They are ethnically diverse. They come from all corners of the county.

I started to see many of them when they fell through the cracks of the health insurance system in spite of their years in the workforce. Many never expected to use the county health services but found they had no other choice. Others went to different facilities but complain they were treated poorly.

They have learned to live with the long waits at nearly every step in their medical care, anchored by a deep-seated trust in county doctors and nurses.

Now things are about to change--for the worse.

Cook County Board President Todd Stroger has asked for a 17 percent cut in the health-care budget--as well as from other county department budgets--to counter a shortfall that the County Board failed to fully anticipate.

The drastic cuts risk undermining the integrity of a vital public health institution. Politicians appear to think the poor and uninsured should suffer for the lack of political oversight and their administrative blunders.

No one knows what the cuts will look like. But we know there will be fewer of us to do the work and fewer services. Community clinics will be closed, and those that are left will be far more crowded.

Taken together, these cuts will deny access to many, extend waiting times and make the tasks of delivering health care to those who remain in the system--and are so dependent on it--so much more difficult.

The hole about to be ripped in the medical safety net, in a metropolitan region with more than 1 million uninsured individuals, will lead to unattended illness, productivity losses and premature deaths.

It is a crime.

I am a son of Holocaust survivors, and I grew up in the civil rights era. My desire for a just and humane society is deeply ingrained. To me, quality medical care is a basic human right. When I came to Cook County Hospital as a medical student 25 years ago and then stayed on as a resident physician, I discovered my calling: combining medicine and social justice.

Nobody turned away

At County, I found something unique: Though many patients failed the "wallet biopsy" administered during their financial interviews at private hospitals or they did not qualify for insurance because of pre-existing conditions, we never turned anyone away. We just cared for people as best we could.

With time, I saw that poverty and disease often are intertwined. Diseases as different as diabetes, cancer and HIV are major health problems that strike particularly hard at poor patients like those we treat.

The doctors I've met at the county's hospital are as passionate as I am about working at the intersection of health care, social justice and human rights.

Together we have made the hospital my medical home.

It has not been an easy road for us. In the old County Hospital building, we saw threats to our accreditation, a power outage in a building that left intensive-care patients dead after their ventilators failed, and burst pipes raining water down into the old building.

No high point was as remarkable as watching the new hospital--Stroger Hospital--rise and open in December 2002. Those of us who had spent years working in the antiquated hospital building pinched ourselves as we encountered the many ways a modern hospital building improved care. Patients marveled at the new facilities too.

But certain problems have persisted. Some reflect the sheer volume of unmet health care needs. In the new hospital emergency room, the waiting time for those deemed sub-acute leads many patients to leave without being seen. The new hospital does not have enough beds, so admitted patients may have to wait more than 24 hours in the emergency room before being transferred to an inpatient unit.

Some of the problems reflect national issues. If not enough mammographers or endoscopists are available nationwide, disproportionately fewer are available to serve the poor.

The results are predictable. We face a backlog of 11,000 mammograms.

Long ago we stopped offering screening colonoscopies, and those without insurance must wait half a year for routine colonoscopies.

Administrative neglect

Many of our problems are local, reflecting administrative neglect. Throughout my tenure, pharmacy service has been erratic. In the summer of 2005, news reports documented the long lines and two-week waits for prescriptions.

Under public scrutiny, pharmacy problems were quickly solved. For a year, prescriptions were available the next day, and the lines of elderly and infirm patients disappeared. But the fix was temporary and the lines are back; wait time for a prescription is now one week. It is an ominous sign.

When I introduce myself outside of medical circles as a county doctor, I can tell that many of those I meet don't understand county health care's importance and strengths.

If you have stable health insurance, you may not realize that on any given day, you interact with the uninsured. That waitress or busboy, retail clerk, security guard or car attendant likely receives health care from a county facility.

They experience the personal and financial burdens illness can bring.

I work with dedicated colleagues who are among the most astute clinicians and best teachers I have known. They are innovators in areas such as HIV care and palliative medicine, substance-abuse screening and treatment, and trauma care.

Proposed solutions

The public health system has productive years left if we support it the right way. In the absence of a single-payer national health program, I offer the following prescription:

-Develop a 2007 budget based on needs. County health care is too important to be a matter of political expediency.

-Lobby for payment from Medicare and Medicaid. A county report has shown that failure to bill or collect from those two federal programs accounts for a large part of the health budget shortfall.

-Calculate the cost of care given to uninsured residents from other counties and lobby for payment from those counties as a steppingstone to a regional health plan.

-Solicit donations from foundations and the corporate sector, recognizing that many of their employees or people who serve them are uninsured and receive county health care. Many corporations donate to private sector hospitals; there's no reason they couldn't do the same with county facilities.

-Develop an effective billing and revenue collection system, one that focuses on the likeliest revenue sources and remains sensitive to low-income, uninsured patients.

-Improve the Bureau of Health Services' administration.

-Finally, consider a temporary tax hike.

Let's turn this crisis into an opportunity and build a stronger county health system.

David Goldberg is a general internist at Stroger Hospital.



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