^{Posted on May 7, 2001}

After Two Centuries, Washington Is Losing Its Only Public Hospital by

SHERYL GAY STOLBERGÊ

WASHINGTON, May 6 Ñ On the day that federal officials decided to put this city's first and only public hospital out of business, business continued there as usual. A woman, hugely pregnant and a week past her due date, received an ultrasound examination in the sweltering heat, the still air moved about by a fan because the air-conditioning had not yet been turned on.

On the maternity ward, a 14-year-old girl gave birth in a room of peeling wallpaper and cracked paint; the baby swallowed its own stool during the delivery and was rushed to the neonatal intensive care unit for oxygen. On the cancer ward, a nurse made her rounds with dollar bills stuffed in her pockets. She never knew, she explained, when a patient might need bus fare home.

So has it ever been at the District of Columbia General Hospital. Since its founding as an almshouse nearly two centuries ago, D.C. General, as it is known, has embraced this city's sick and poor, most of them African-Americans, when there was nowhere else for them to go. It has trained generations of black doctors; many, committed to serving the underserved, stayed on. But the hospital has also been sorely mismanaged, and it has bled red ink to the point of bankruptcy.

Last Monday, in a move that followed a nationwide trend, the federal control board that oversees the city's financial affairs contracted with a consortium of private health care providers to run the hospital and six separate city clinics. The hospital's own outpatient clinics and emergency room will remain open. But the inpatient and trauma wards Ñ in essence, the hospital itself Ñ will be shuttered.

"We are tossing public health into the trash," said Dr. Michal Young, a neonatologist and president of the hospital's medical and dental staff. "When you lose public health in the capital of the most powerful nation in the world, it is an indicator of what the rest of the country is going to do."

Indeed, it is an indicator of what the rest of the country is already doing. Over the last two decades, as competition has forced hospital mergers and acquisitions, the number of public hospitals has dwindled. In 1999, the last year for which figures are available, that number was 1,197, down from 1,778 in 1980, according to the American Hospital Association. By comparison, the number of private hospitals dropped to 3,759 from 4,052.

Public hospitals offer free care for the indigent, typically at greater levels than private hospitals, and at taxpayers' expense. Some, as in Boston and Baltimore, have been absorbed into nonprofit university hospitals, which remain committed to serving the poor. Others have become private entities; still others, as in St. Louis, have shut down.

And dozens, if not hundreds, of small rural public hospitals have closed, said Larry S. Gage, president of the National Association of Public Hospitals and Health Systems. "In cities and in rural areas, hospitals have an increasingly difficult time making it," Mr. Gage said, "and public hospitals are often the most vulnerable institutions."

Mr. Gage says he is not overly concerned about the privatization of government-run hospitals, so long as what he calls their "safety-net mission" is retained. And in many cases it has been, experts say. But others mourn the loss of the institutions that have historically been the nation's health care providers of last resort.

"These are a treasure and we shouldn't let them go," said Sandra Opdycke, author of "No One Was Turned Away" (Oxford University Press, 1999), about the New York City public hospital system. "They have never had the kind of care and respect that they deserve, and especially now, they are not getting it."

Alan Sager, a professor of public health at Boston University who consulted with the unions at D.C. General in an effort to keep the hospital open, said, "What is lost is a guaranteed open door, a room at the inn."

D.C. General sits in the city's depressed Southeast section, at the end of a forlorn stretch of Massachusetts Avenue, a street that in the prosperous Northwest area is home to the elegant mansions of Embassy Row. The hospital is a collection of mostly aging brick buildings, sprawled over a 68-acre riverfront site that includes the city morgue and jail. At its peak, after World War II, D.C. General had enough patients to fill 1,600 beds.

Last Monday, the patient count was 119, a reflection of staffing cuts, uncertainty about the hospital's future and the reality, faced by all hospitals, that patients today are sent home sooner and often not admitted at all.

The hospital had been in dire financial straits for more than a decade, as was the city, which is why the control board was established in 1995. Michael Barch, until last week the hospital's chief executive (he took that job just six months ago, after his predecessor was fired amid accusations of fraud), said the hospital's budget dance had been the same for several years. Each year, the city offered a $45 million subsidy. Each year, the hospital overspent it by many millions, with the city making up the difference.

Of Washington's 550,000 residents, an estimated 80,000 lack insurance. At the same time, the city's health statistics are abysmal.

"We have a life expectancy for African-American men that is 59, the lowest in the country," said Dr. Ivan C. A. Walks, the city's health commissioner. The infant mortality rate, 12.5 per 1,000 births, is nearly double the national average.

The city in 1996 put the hospital and the city clinics under the auspices of a new body, the Public Benefits Corporation, which was supposed to act like a business. That strategy worked in Denver. But it failed here.

The corporation "never integrated the clinics with the hospital," said Alice M. Rivlin, an economist at the Brookings Institution who is chairwoman of the federal control board. Some clinic doctors were not qualified to admit patients to the hospital. Nurses at the clinics and the hospital earned different salaries. Antiquated computers made it impossible to track patients.

The hospital's financial records were a mess. Sixty percent of D.C. General's patients were insured, Mr. Barch said, yet often they were not billed. "It was a culture that said, `We're here to serve patients, not to harass them about paying,' " he said.

In January 1999, a new mayor, Anthony A. Williams, took office. "We talked," Ms. Rivlin said, "and I urged him to get on top of the hospital problem."

Mr. Williams, previously the city's chief financial officer, is regarded here as something of a technocrat and politically na•ve. At a recent news conference, his press secretary had to remind him to look at the cameras. He did not expect the deep resentment he would engender by stepping into the hospital's affairs.

"Thank God for four-year terms," Mr. Williams said in a recent interview.

By last year, city auditors had warned that the hospital was about to run out of money and would soon be forced to shut down. "We were in a crisis," Ms. Rivlin said. The solution, the mayor and his staff concluded, was to get the city out of the health care business.

"We began looking around the country at other jurisdictions," said Dr. Walks, the health commissioner. "San Diego, Detroit, Tampa. What we found is that if you do these transitions correctly, you can expect three things: increased access, increased quality and cost savings."

According to a 1999 report by the Kaiser Family Foundation, for every 100 public hospitals in the United States, one closes and two convert to private ownership or management each year. But for Washington, finding a private partner was not easy. About 200 people turned out for a bidder's conference, Dr. Walks said. Two bids were submitted.

One came from a group led by Mr. Barch, who proposed building a smaller hospital on the site of D.C. General. That plan was rejected. The other came from a consortium led by Greater Southeast Community Hospital, a Washington hospital that went bankrupt in late 1999 but has been bought and turned around by an Arizona company.

For $90 million each year from taxpayers (the Public Benefits Corporation spent $120 million last year), Greater Southeast has promised to increase medical services Ñ including hospital admissions, surgeries and primary care Ñ for uninsured patients by 34 percent.

The big question, of course, is whether it can live up to that commitment. The company's financial history leaves many residents as well as the City Council, which voted unanimously to oppose the privatization, uneasy.

Mayor Williams is confident that the uninsured will get more, and better, care. "I'm going to sleep like a baby at night," he said, "because I've done the right thing."

But Dr. Sager, the Boston University professor, says the mayor underestimates the intimate relationship between patients and hospitals. When a hospital closes, he said, 30 percent of its patients simply cease seeking care for a time.

"Hospitals are not interchangeable parts in some health care machine," Dr. Sager said. "It takes a while to reweave a connection."

That connection is keenly felt at D.C. General, by both patients and doctors.

"I feel that I was led by the Lord to come here," said Dr. Steven Tucker, director of obstetrics and gynecology, who arrived three years ago. Once, he had dreams of renovating the maternity ward. "This institution," Dr. Tucker said, "has never been given a fair shake."

To whites in Washington, the hospital symbolized everything that was wrong with the city. But to blacks, it stood as a symbol of culture and history. With its privatization, conspiracy theories abound. Some blacks say they believe the mayor, who is himself African-American, wants the riverfront land for redevelopment.

"The eradication of D.C. General is a statement that there is no place for the black community, for the low-income residents, the people that have lived here through thick and thin, ups and downs," said the Rev. Graylan Hagler, pastor of the Ply mouth Congregational United Church of Christ. "Not only is the hospital being removed, but those populations are being removed."

But more than a symbol, D.C. General was a medical home for the disenfranchised. Last month, a homeless man became ill during a court hearing on misdemeanor charges and died a short while later in a holding cell. While he was still in court, gasping for breath, he begged of the judge, "Just take me to D.C. General."