February 10, 2014

Will Obamacare be a help or a hindrance in the big urban public hospitals that treat the most vulnerable in U.S. society? An emergency room nurse looks at the facts.

BARACK OBAMA'S health care law "is exactly what the doctor ordered" for the Cook County Health and Hospitals System (CCHHS). So said Dr. Ram Raju, the CEO of CCHHS, in a speech to the Cook County Board of Commissioners last October.

Is he right? Will the Affordable Care Act (ACA) help an overburdened public health system deliver care to the hundreds of thousands of people who depend on it? To answer those questions, let's take a closer look at Raju, the public officials he was speaking to last October--and, above all, the real conditions in the public hospitals and clinics Raju presides over.

CCHHS is one of the largest publicly funded health care systems in the country. The heart of the system is John H. Stroger Jr. Hospital, formerly and still commonly known as Cook County Hospital. During 2012, according to a state of Illinois report, Stroger tallied more than 140,000 patients treated by emergency services, more than 10,500 operations, and 767,000 outpatient visits.

Across the entire system of hospitals and clinics, CCHHS employs over 6,700 workers. It has a 2014 budget of about $1.1 billion. Between 2011 and 2013, it received about $250 million each year in funding from Cook County taxpayers--the remainder of the budget came from various government programs such as Medicare and Medicaid.

Raju was speaking to the commissioners in October because he wanted to talk about the projected $76 million decrease in subsidies that CCHHS will ask from Cook County in 2014. He attributes this to the 1115 Waiver, which allowed what is known as CountyCare to early-enroll patients into the expanded Medicaid program established under the ACA.

It was a message Raju knew the county commissioners, always struggling to balance the budget, would be pleased to hear. Of course, Raju didn't mention that his contract allows for a 10 percent performance bonus, based on meeting administrative targets, on top of his already outrageous annual salary of $500,000. But it would be cynical to assume his motivations for the speech were purely financial.

Unfortunately, high salaries are not at all uncommon at the top of a system whose stated purpose is to "deliver health services with dignity, regardless of a patient's ability to pay." Even the Republican-leaning Chicago Tribune found it curious when Raju last year hired as chief of clinical integration--at an annual salary of $400,000--Dr. John Jay Shannon, who had recently been fired from running a Dallas public hospital deemed unsafe for patients.

As for Raju's speech, he started by thanking Cook County Board President Toni Preckwinkle.

Prior to her election as county board president in November 2010, Preckwinle was a five-term city alderman, representing the South Side neighborhood of Hyde Park since 1991. On the City Council, she was a sporadic critic of then-Mayor Richard Daley who spoke in favor of affordable housing and against the city's attempt to delay justice for the victims of police torturer Jon Burge.

But she did support the vast majority of Daley's efforts, including the city's failed bid for the 2016 Olympics and the controversial Tax Increment Financing (TIF) system, which funnels a portion of property tax revenues into a "development" fund controlled by the mayor.

Why would Preckwinkle defend the TIF program? Well, in her former ward, $5.2 million in TIF money--which is supposed to be used to support community development projects in "blighted" neighborhoods--went to construct a Hyatt Hotel near the prestigious University of Chicago.

Penny Pritzker, the billionaire heiress of the Hyatt fortune and now Barack Obama's Commerce Secretary, was a member of the mayoral-appointed Chicago Board of Education at the time. Without the slightest sign of embarrassment, Pritzker's company accepted the TIF money to build a fancy hotel--while school board Pritzker served on approved $3.3 million in funding cuts for seven public schools in the immediate area of the new hotel.

After thanking Preckwinkle, Raju gives high praise for the Civic Consulting Alliance (CCA), a politically connected non-profit that presents itself as doing pro bono work for the benefit of the public, but has definite business interests. The CCA worked closely with Chicago Mayor Rahm Emanuel to implement his neoliberal plans for the city, particularly the closing of public schools in order to expand charters.

Raju credited Preckwinkle for recruiting the "guidance, direction and leadership" of the CCA in restructuring CCHHS. Bain & Company, a "global business consulting firm" and CCA partner, is credited with the management restructuring, which included the hiring of Dr. Shannon.

THE INFORMATION above, which is all public, shows the intimate and tangled connections between big capital, political officials and the restructuring of health care through implementation of the ACA, even on the local level. Judging from this, it's no wonder that Wall Street reacted favorably when the ACA was first signed into law, and again when the Supreme Court upheld it as constitutional.

But back to the question: Is Raju's assertion true? Is the ACA what the doctor ordered for public health care systems such as CCHHS?

It's impossible to answer yes, first of all, because of the centrality of political and business interests to determining the content of the ACA, from the inception of the debate on the health care law through its passage in 2010 to the ensuing criticisms, from both sides of the aisle, about its implementation.

Applying the law guarantees the role of the for-profit insurance industry and imposes it on a public system with the stated primary purpose of providing health care "regardless of ability to pay." This is the very definition of trying to fit a square peg into a round hole. To take the analogy further, the use of a hammer to drive the peg in could either drastically change the shape of the hole or actually break it.

Neither the ACA nor CountyCare will cover undocumented immigrants, who make up a significant section of the patient population in CCHHS. Raju, to his credit, has made iot clear that CCHHS will continue to treat all patients, regardless of citizenship status. But treating patients and allowing them to enroll in the insurance program are two different things, and those without papers will not even be able to attempt to access any potential coverage from this system.

One area where the lack of access to health care for the undocumented is most disturbing is with organ transplants. While CCHHS doesn't do these procedures, many other area hospitals perform them routinely. Sarai Rodriguez died at the age of 25 on August 11 of last year after Northwestern Memorial Hospital refused to do a liver transplant in March because she was both uninsured and undocumented.

She died just three days after the conclusion of a 10-day hunger strike organized by the Our Lady of Guadalupe Anglican Catholic Mission, headed by Father Jose Landaverde. Twenty people were on hunger strike, many of them in need of an organ transplant themselves. The strike ended when three hospitals agreed to meet with patients and work out a plan.

Father Landaverde organized a similar action in June of last year, resulting in two organ transplants for three patients who needed them. Unfortunately for Elfego Arroyo, the delayed liver transplant he eventually got was not enough to save him, and he died in July 2013.

That drastic measures such as a hunger strike need to be taken in order to receive health care in the richest country of the world is an indictment in itself. As organs are routinely harvested from the undocumented and given to those in need, there is no excuse for excluding them from being on a recipient list.

Several horror movies revolve around a plot where unsuspecting Americans traveling abroad are murdered so their organs can be harvested. It seems that the reverse is much closer to reality.

AS FOR those who will qualify for coverage under Medicaid as a result of the ACA, the attitude of many people is that something is better than nothing. Some people who are living close to or at the poverty level will have greater access to care--except in states where governors have refused to implement the ACA, out of spite toward Barack Obama and the Democrats.

For those who do qualify, however, it is still unclear how extensive and effective the ACA will be at providing this care. Meanwhile, it's crystal clear who will be better off--the health insurance companies and the hospital industry will profit immensely from the ACA.

Forcing more "customers" to buy coverage from already profitable insurance companies--through the "individual mandate" requiring people to buy coverage or pay a tax penalty--is not the health care law's only boon to corporations. Provisions within the ACA will also allow hospitals to demand increased "productivity" from health care workers. I put "productivity" in quotes, because while health care providers certainly want more effective care for their patients, increased productivity and what is best for the patients' health is usually not the same thing.

As an article by Forbes reports, Neal Patterson, the CEO of Cerner--one of the largest producers of health care information technology systems--has become a billionaire, in no small part because of the passage of the ACA.

At Stroger Hospital, management is implementing the use of barcode scanners for administration of medication, partially because CCHHS will receive federal dollars for doing so and partly to avoid future penalties. While some studies demonstrate that the use of these scanners can reduce error, technology shouldn't be considered a panacea.

Another area where the ACA will bring big bucks to private companies is the financial penalties for hospitals that don't provide "patient satisfaction." The company Press Ganey has contracts with no less than 50 percent of all hospitals for surveying patients regarding their care. Even Forbes, an ardent supporter of the free market and profit motive, thinks that customer satisfaction is a bad measure of a physician's practice.

Some hospitals have hired companies to assist in the introduction of scripts to govern interactions between nurses and patients. The rationale was laid out clearly in the headline of a web page at the iVantage Health website: "Patient satisfaction? A matter of perception."

For companies like iVantage and the hospital managers who listen to it, whether the health care being given is actually good for the patient isn't as important as the perception of good health care. Obviously, there's nothing inherently wrong with calling people by their name and communicating effectively, as the script companies want us to do. But it becomes a problem when this is prioritized over educating nurses on actually providing better care.

We've had hours-long education sessions in our emergency department (ED), during which extra nurses were brought in to cover the unit while we were in classes on how to provide better "customer service." We've never had a similar emphasis on heart attacks, strokes, diabetic ketoacidosis, seizures or hypertensive emergency.

Though I've never heard of a patient dying from "bad customer service," our patients are affected by these medical problems, and nurses in my department aren't being systematically educated on the latest treatments.

Articles referenced on the website of the Minnesota Nurses Association demonstrate the importance of a different strategy aimed at reducing error and patient mortality--a more important and tangible measure than the ambiguous "patient satisfaction"--increase the number of bedside nurses.

The more-nurses-equals-better-patient-outcomes equation may seem like a no-brainer to anyone in or outside the health care profession, but only one state--California--has legally mandated nurse-to-patient ratios, and that law was fought against tooth and nail by the hospital industry and then-Gov. Arnold Schwarzenegger. A similar bill made it to the Council of the District of Columbia, the legislative body of the country's capital. But the hospital industry was successful in lobbying for the defeat of a bill that would have improved patient care.

AT CCHHS, staffing continues to be an ongoing issue.

Nurses in the emergency department have been struggling for improvements for years. In the spring of 2011, we went to the safety committee with a petition signed by nurses across three shifts and testified about unsafe conditions for patients--the problem was temporarily fixed when management lifted a ban on overtime.

In March 2012, we again had to raise the issue of safe staffing, this time with management's bosses on the Cook County Board of Commissioners. We again brought petitions from across three shifts, and the problem was again temporarily fixed by lifting an overtime ban.

But by September 2013, the problem of staffing was still ongoing, and to make matters worse, the County Commissioners' labor lawyers were proposing contract changes during bargaining with the nurses union that would have negatively affected the formula by which nurses accrue overtime.

Management's over-reliance on overtime became a weak point when ED workers exercised their legally protected right to not sign up for it last September. Coming together across racial and ethnic lines and job divisions--and despite management efforts to cajole and threaten us--we held the line, and none among the 130 who work in the ED signed up to work more than their regular shifts.

While we had originally decided on five days of no overtime, management gave in and wanted to meet at the end of the second day to resolve the issue when it became clear that we weren't going to budge. A similar action took place in operating rooms, and 20 elective surgeries had to be rescheduled.

In the ED, a third of the department had to be closed for the two days. Wait times for patients were affected, but blame for this lies at the feet of those who run the hospital. We not only had made them aware of the problem for years prior, but they must have known something was up when their overtime sign-up sheet was completely blank two weeks beforehand.

In the end, management agreed to expedite new hiring. But since then, only one nurse has been hired on nights, which doesn't even make up for the number who have retired or changed jobs.

Nevertheless, the lesson we learned has been seared into everyone's minds--when we stick together as a unit, our collective power is a force that can't be ignored. Furthermore, news about this spread across the hospital, and if it has to happen again, the no-overtime action won't take place in just two departments next time.

The ACA won't be able to fix a broken health care system because the law preserves the profit motive, and the profit motive is the root of the problem in our health care system, because it prioritizes money over quality patient care. While the ACA may bring in more money to stabilize CCHHS financially in the short term, the law cements and expands the neoliberal changes already being made to the delivery of health care--few of which are actually beneficial to patients.

The health care system needs more radical treatment: profit must be removed from the equation, and the needs of the patients must be put at the center.

Patients and health care workers must be part of a united struggle if this radical reorganization is to take place. Corporations and the politicians they own have much to lose--and we have everything to gain.