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Bailus Walker,* chairman of the Mayor’s Health Policy Council
Testimony to the Committee on Human Services on the
Public Benefits Corporation
September 18, 2000




Dorothy Brizill
Bonnie Cain
Jim Dougherty
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Thank you Councilmember Allen for the opportunity to comment on the District of Columbia Health and Hospitals Public Benefit Corporation (PBC).

Today, we cannot over-emphasize the need for an integrated health care delivery system in the District of Columbia. As health costs and the number of uninsured continue to escalate, and competition increases among providers of care, we must commit ourselves to the full promotion of the health of District residents particularly the children -- a group at risk of disease, dysfunction, and premature death. This means an investment in continuous improvement in the system.

Unfortunately, the pace of change affecting health care is faster than our current ability to monitor or otherwise-track significant developments. Thus, there may be gaps in the data we need to plan and evaluate the District's health services system. What is more, predicting the future of development in medical care and the biomedical field in general is a very inexact science. Therefore, we must sometimes operate on plausible assumptions. It is in this context that the Community Access Hospital proposal is being put forward. The details of that proposal will be discussed by the Director of the Department of Health and I will not labor at the plan in my statement this afternoon. I will however suggest that the fundamental concepts which guided the design of the Community Access Hospital are sound and deserve consideration and support by all stakeholders.

Against that preamble, we submit that the current problems of the District of Columbia General Hospital present this community ----- both public and private sectors -- with formidable challenges and, at the same time, an opportunity to make the system "right."

Having said that, we believe it appropriate to describe the broad context within which the Community Access Hospital proposal must be considered. Failure to consider this context may well have many unintended consequences.


First, it is clear -- even to the most casual observer of the health care scene -- that the health care system is like a fabric woven from many different threads. One cannot work on the fabric one strand at a time. This approach is not productive.

So we urge that the whole fabric, of which DC General is one strand, -- be kept in mind as we hastily seek solutions to the economic and managerial issue of the hospital. Unfortunately, in previous years study group after study group has failed to recognize the fundamental principle of systems -- whether they are physical, biological, or mechanical systems. That principle is that all elements of a system are connected. There can be no development in one part that does not affect the rest of the system.

What happens or does not happen to DC General is bound to affect the rest of the DC health care system. A particular concern is the health care safety net which in Washington, DC describes a broad range of providers, services, and populations.

The population served by safety-net providers range from the uninsured and Medicaid population to a broad array of vulnerable populations, including persons with AIDS, substance abusers, the frail elderly, low income children and pregnant women, the homeless, and the mentally ill.

Unfortunately, it is difficult for the public to understand what is to be gained in preserving safety net "utility" services such as trauma, neonatal care, and specialized drugs for patients with AIDS. Few citizens have contact with these services. Most healthy people never consider their vulnerability to injury or catastrophic illness. But sound health services planning requires sustained attention to these vital programs.

By any reasonable criteria, the safety net is under stress due in part to a number of developments: diversion of Medicaid revenues to managed care organizations, the pressures of a competitive marketplace affecting cross subsidy for charity care, to name only two factors. It is an issue that requires more discussion.

Although any provider can participate in the safety net, urban public hospitals, community health centers, the DC Department of Health, and teaching hospitals are by and large the core safety net institutions. These organizations assuredly provide a great share of services to the poor.


In the District,. basic measures of the need for safety net services include the number of persons without health insurance. An estimated 100,000 people in the District are uninsured or under insured. This estimate translates into one in every five District residents. A public health, social, and economic, concern is that the uninsured are less likely to get preventive care.

The prevalence of disease is another measure of the need for a safety net. Consider the following:

  1. The District ranks number one in the nation with death rates due to all cancers at 258 per 100,000 population and the Department gets reports of new cases monthly.
  2. Cardiovascular (heart ) disease is the leading cause of death in the District accounting for approximately 30 per cent of all deaths.
  3. Stroke is the third leading cause of death in DC (57.9 per 100,000 population).
  4. The risk of infectious diseases is an increasing concern of the public health and medical community of the District. While there is no evidence of the West Nile virus in the region, the distance from here, to New York, where the incidence of the disease is increasing, is not far. In fact, thousands of people move between New York and the District hourly.

The rates of under insured mentally ill persons in the District is another measure of the need for a safety net. While the exact number is difficult to determine, our analysis suggest that the problem is significant and getting worse.

The need for safety net services is also fueled by the culturally and racially diverse population, many of whom are likely to be uninsured and may need special services such as translation and assistance in gaining access to health and social services. It is important to add here that safety net providers offer a range of nonmedical services such as assistance in gaining entitlements, language translation, transportation, referral for housing and employment and day care.

These positive and essential elements of DC General's non-medical services are often overlooked in assessments of that institution's value to the community and we must ensure that these services are not abandoned. They are critical to meeting the broad health needs of our vulnerable population.

It is not necessary to remind you that these non-medical services rarely generate sufficient revenue to cover their cost and are less likely to be provided by nonsafety-net programs. Much evidence has come to the Mayor's Health Policy Council that some non-safety-net providers are not fully prepared to manage patients who are ethnically and culturally diverse, have above-average health risk, and require a broad range of medical and social services. This issue must be addressed at an early date.

The sum vector of the preceding paragraphs is a clear indication that as plans for a future DC General evolve all segments of the community, policy makers, providers -- public and private -- academia, the business sector, the faith community, the health services workforce, and all stakeholders must become far more involved in ensuring a smooth transition from a 20' century system to a 21 St century system consistent with the current changes in the health care industry and the needs of the citizens. While government can provide leadership, it alone cannot address all of the complex multiple dimensions of the DC General problem -- a problem that is a challenge for each of us. A challenge for all of us.


Allow me to comment on medical education which must be an important consideration in any modification of the health services system. Medical education has long been intertwined with the care for the poor, particularly in public hospitals such as DC General, where medical education has provided a critical workforce for the care of indigent patients. DC General is a teaching hospital. It holds a place in the District's pluralistic health care system. DC General has been one of the citadels for medical learning and a place that cares for our most vulnerable citizens. Evidence of this assertion is not hard to find, and any equation or formula for a "new" DC General must address medical education and its related components.


These concerns and related issues emphasize an overarching question which should permeate all discussions about the future of DC General Hospital -- the willingness or ability of the private sector to meet the traditional needs of the public sector population.

This question is being asked in many places and is driven by a number of examples. A case in point was the outbreak of almost 1,100 cases of measles in Milwaukee which was primarily associated with the failure of managed care organizations to immunize Medicaid enrollees. Other similar examples include the failure of private sector providers to screen for lead, treat, and follow-up on childhood lead poisoning cases.

This statement is without rancor and is not intended to indict the health care system, but simply to under score the need to consider a multiplicity of issues when modifying elements of the health care system.


By way of summary, it is worth emphasizing that as we work collectively, as true partners, to address this critical issue, a number of concerns should not be overlooked or blurred in our discussions of the configuration of a "new" DC General Hospital:

  1. The need to have the best available health data/information to inform the decision-making process (e.g., an updated State Health Plan);
  2. The broad spectrum of health needs of the uninsured and other vulnerable populations;
  3. The impact of the changes at DC General on the District's safety net, including its essential components;
  4. The financial investment that other DC agencies already have in the delivery of services for their patient populations at DC General (e.g., correctional health, maternal and child health, school health, health services for wards of the District, substance abuse, and HIV/AIDS services, and nutrition services);
  5. The continuing need for an effective emergency health services system including trauma care; the convenient location of such services is critical in the 21st century;
  6. The access to care and the willingness of private hospitals to accept the uninsured and the impact of the uninsured people on the financial conditions of the private hospitals; and
  7. The long term impact on the evolving primary care system.

We thank you for the opportunity to provide these comments on one of the most critical challenges confronting the District of Columbia. In the final analysis, todays hearing will yield significant dividends to the people of this city.

*Dr. Walker is Professor of Environmental Health and Occupational Medicine and Professor of Health Policy, Howard University Medical Center, Washington, DC.

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