Scuttling health care for the poor

THE Reagan administration is about to make it even tougher for the poor to get the hospital care promised them by federal law and in effect legitimize one of the more blatant misuses of public funds in recent history. At issue is the administration's announcement last November that it will exempt publicly owned health care facilities from the regulations applied by the Department of Health and Human Services in enforcing the Hill-Burton Act of 1946. That's the law Congress passed in response to the widespread concern after World War II that many people had no access to basic medical treatment -- but also in response to heavy lobbying by hospital interests eagerly seeking funds for postwar expansion.

What the lobbyists got were federal grants and loans totaling more than $4.4 billion for the construction of public and private health-care facilities. The funds went to almost 60 percent of the country's hospitals, nursing homes and other facilities -- 4,653 of them in all. About half, or 2,444, were publicly owned.

In exchange, the facilities were supposed to provide ``a reasonable volume . . . of hospital service offered below cost or free to persons unable to pay therefor . . . both the legally indigent and persons who are self-supporting but are unable to pay the full cost of needed hospital care.''

Lobbyists agreed to that provision as a way to block passage of a health insurance bill that was introduced along with the Hill-Burton legislation. They didn't much like the compromise, but it was far better than what they would have gotten in the other legislation. It would have provided free or below-cost care to the needy through a national health service that would have greatly weakened the tight control exercised over the health care system by hospitals, physicians and others in the private sphere and threatened their large financial returns.

The federal government kept its part of the bargain, playing the chief role in the massive and constant growth of hospitals and related facilities -- and of their rates and income -- that has occurred since then. But the Hill-Burton Act's promise of care for the poor has been unmet.

Study after study has shown that the private institutions receiving the government construction money generally have treated the poor only in return for the huge sums provided by the government through medicare and medicaid. They have ignored -- and have been allowed to ignore -- their obligations under the Hill-Burton Act.

Few of those receiving construction funds have built facilities in urban ghettos or rural slums. Few have effectively sought out the needy for free or below-cost treatment. Many have turned away those desperate enough to seek care on their own.

Few have even provided the minimal care called for by the Department of Health and Human Services in determining their specific obligations: ``uncompensated service'' equaling 3 percent of their operating cost in any particular year or equaling 10 percent of the Hill-Burton funds they received that year, whichever is less.

As a consequence, millions of Americans in need of medical treatment have been shunted to overcrowded and underfinanced public hospitals and clinics. That includes an estimated 200,000 seriously ill or injured patients who are transferred every year from private to public institutions for no reason other than their lack of money.

Many of the needy have been denied care entirely, even at the public facilities whose very nature presumably commits them to helping anyone in need, even at those public facilities whose acceptance of Hill-Burton funds specifically commits them to providing such help.

Gordon Bonnyman, an attorney in Nashville who has helped lead a nationwide effort by public interest lawyers seeking strict enforcement of the Hill-Burton Act, notes that ``public hospitals . . . are acting like private hospitals.''

Public facilities also are turning away patients who cannot demonstrate an ability to pay whatever those providing care demand. Public facilities also are taking such steps as requiring incoming patients without health insurance -- and up to 20 percent of the country's citizens have no coverage -- to make cash deposits before being admitted for treatment.

Now, thanks to the Reagan administration, the public institutions will be freed from one of the most important of their legal obligations to act otherwise.

Administration officials contend that exempting public facilities from the Hill-Burton Act regulations is merely a move to free them from what Larry S. Gage, president of the National Association of Public Hospitals, calls ``procedural nonsense.'' That includes posting notices, placing newspaper ads, and otherwise informing the poor that care is available and reporting those efforts, the results and similar matters to the government.

Hospital and administration officials insist that adequate care will be provided the poor nevertheless. Obviously, however, they'd rather not have to prove it.

Dick Meister is a San Francisco author.

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