11/18/2008 05:12 am ET Updated May 25, 2011

If You Doubt That There Is a Healthcare Crisis, Come to Michigan

Before my present gig, I taught public health at University of Michigan. I and my colleagues were involved with several ventures to address that state's urban poverty and related health ills. It's not news that Flint, Detroit, and other urban centers have struggled. Despite serious economic challenges, Michigan was relatively fortunate to have a strongly unionized workforce, well-financed retirees, strong philanthropy, and other assets that somewhat buffered the health system against from the worst consequences of deindustrialization. I left Michigan in 2003 to do similar work in Chicago. It's not entirely my fault, but things in Michigan have worsened since my departure.

My former UM public health colleague Paula Lantz and UCLA political scientist Mark Peterson note in Friday's Free Press, that one million Michiganders are uninsured. They note the large hole Medicaid is placing in the state budget.

Earlier this week, the excellent, real-newspaper part of the Wall Street Journal had an amazing story about hospital closures in Detroit.

The title speaks for itself: "Nonprofit Hospitals Flee Cities for Suburbs, Leaving Poor Behind." The Journal's opening paragraphs captures the raw emotion I encountered many times within the economically and racially segregated environment of greater Detroit:

After nonprofit giant Ascension Health closed the doors on Detroit's Riverview Hospital, the only hospital on the city's blighted east side, some residents directed their anger at St. John Hospital and Medical Center, the system's lone remaining outpost in the Motor City.

In renovations at St. John, the local Ascension subsidiary moved the lobby so that it overlooked the wealthy and almost exclusively white suburb of Gross Pointe Woods rather than Detroit, which it had faced for more than 50 years. William Anderson, who had directed medical education at Riverview, told the WSJ that he believed the health system was saying, "We do not want to be in Detroit where there are so many poor, black people." The hospital system denied that charge, saying the change was dictated by the particulars of the site.

You can imagine how that went over in Detroit's hyper-segregated environment.

Of Detroit's 42 hospitals that operated in 1960, four remain. Locals know a thing or two about the agony of auto plant closings. Local hospital closings are also a heavy blow. A hospital is more than a site of care. It provides employment to hundreds or thousands of people ranging from brain surgeons and nurses to the telephone operators and custodial staff. Hospitals provide an economic anchor for local medical offices, pharmacies, and sandwich shops. Hospital security personnel generally outnumber city police in the immediate vicinity, providing needed protection from crime. Hospital closures are especially demoralizing when they come to symbolize a community's economic decline.

Retaining healthcare providers is becoming more difficult with each passing year. Within a $2.4 trillion healthcare system, providers have opportunities to make money. Few of these opportunities are in stressed locations like east Detroit. One in four people in Detroit lack health coverage. Many of the rest have Medicaid, on whom hospitals often lose money. If you are a hospital executive, locating in a poor Detroit neighborhood is not a marketing advantage when you are trying to court well-insured suburban yuppie patients.

Hospitals, for-profit and nonprofit too, have generally responded the way big institutions do. Ascension's local subsidiary shut down three Detroit hospitals in the past decade. Meanwhile, Ascension opened a new $224 million hospital in a nearby suburb. Ascension does provides significant charity care. The Journal pointedly notes the church-based nonprofit chain makes a lot of money. It owns 67 hospitals, and reported a net income of $351 million last year.

Detroiters are understandably bitter. Ascension has indeed behaved rather shabbily. Yet the underlying problem is not the refusal of some chain to retain a money-losing facility. The real problems reside in a public and private insurance system that makes it very, very hard for hospitals to survive in this environment.

I recently visited Detroit on a research project examining HIV screening in emergency care. In many ways, Detroit gets a worse rap than it deserves. When I tell my friends I am going to Detroit, they have visions of Kurt Russell's travails in Escape from New York. "Don't go roaming around," my mom tells me with some concern.

With time to kill, I violated Mom's advice and walked around. I passed the Detroit Institute of Art, the Museum of African-American History, the Symphony, and much else. Like Chicago, Detroit features great architecture and a beautiful housing stock. Yet there's no escaping that Detroit has fallen on hard times. Its Amtrak station is so run-down it barely supports a candy machine. City government is under-funded, demoralized, and performs very poorly by virtually any measure.

I stopped into the huge General Motors building. Completed in 1923, it is an official National Historic Landmark, a renowned architectural achievement of Albert Kahn. I passed underneath opulent ceilings and a beautiful old Cadillac parked for display in the lobby. The complex is now called Cadillac place. They don't do much with cars there anymore. Most of the place is now used for welfare offices and other public services.

I don't know how to reverse such profound industrial decline. I do know that we can give health insurance to every American citizen. I know that we can ensure that every American city has the fiscal resources to operate effective hospitals.

My experiences in Detroit and Flint taught me something else. The Journal quotes my Michigan colleague Rich Lichtenstein on the litany of sad statistics regarding Detroit's poverty, HIV incidence, and infant mortality. The statistics would be much worse, were it not for Paula and Rich and so many others on the ground who have spent years improving breast and cervical cancer screening, enrolling kids in SCHIP, getting the word out on diabetes and hypertension, helping to link pregnant women to prenatal care, helping incredibly stressed young mothers be better, and sometimes safer, parents to their children.

This is the hard, often overlooked world of social services and public health. People who read my pieces know that I'm alarmed about the nation's dilapidated public health infrastructure, so oddly neglected alongside our nation's colossal thirteen-digit investments in personal medical services.

As we enter the election homestretch in a time of economic crisis, our nation reevaluating how we do things. This comes through both choice and hard circumstance. I'm sure many readers are wondering how they (you) should change your lives to match this moment.

If all goes well on election day, some of my students and colleagues will go to Washington to enact needed change. That's one terrific road, but you don't have to go that far. You can go to Detroit, or Chicago, or Cleveland, or New York, or LA, one of hundreds of other places and make a real difference.

Maybe you even want to go to school with those clowns or at our shop to learn how to do this stuff right. It brings many frustrations, but it's a good life. You make change on a human scale, one life at a time. These days, we certainly need the help.

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