The Reveres have been around a long time and we know a lot of public health people in different states. Recently we were talking with a colleague about the problem of hospital surge capacity — the ability to handle a sudden demand for services — and she described her first job working for a state health department in the early 1980s. Her job was to compile a health resources report, essentially a yearly compilation of licensed and operating beds for all manner of health facilities, including hospitals, nursing homes, psychiatric facilities, outpatient clinics, rest homes, group homes and license levels for each. Collecting this information annually was required by state law. Within a few years that activity abruptly stopped. The law is still on the books but it isn’t being carried out. The excuse was that the private sector was already collecting the information. It’s probably true that with some time and effort most of that data could be cobbled together from various sources. But the facility-centered nature of that earlier effort would be especially convenient and timely for pandemic flu planning at this moment. We (members of the public and local health planners) would then be able to see, almost immediately, what kind of demand and reserves were available for facilities in our area and start making contingency plans for various scenarios (doubling or tripling of demand, for example). Abandonment of this legally required activity in the 1980s is just one more example of penny wise and pound foolish public health disinvestment, helped considerably by a “Reagan Revolution” wrecking ball approach to any kind of state services, especially those that the private sector wished to keep private.
Those same tendencies have been sharpened as the cost of health and hospital care has risen dramatically. With pressure on reimbursement rates, hospitals and other facilities are looking everywhere for ways to cut costs, and one of the first places to do that is by eliminating bed redundancy. An empty hospital bed costs money; an empty hospital bed that is staffed costs even more money. Neither is offset by any income or medical benefit to a patient. So we got rid of them. The result is that there is very little redundancy in the hospital and clinic system. For a flu pandemic, that means the most severe pressure points are the emergency department and critical care beds and facilities. However many they are. Wherever they are. It’s not so easy to know, these days.
But not knowing exactly isn’t the same thing as not knowing at all. We know — for sure — that it will take very little to overtop the gunwales (that, I am told is called whelming in ship talk; so you can whelm and you overwhelm, but you can’t underwhelm). That’s because we no longer have any redundancy. Redundancy is expensive. It’s capacity you don’t use, so it’s wasted. Like an insurance premium you don’t cash in because your house didn’t burn down. In profit-driven privatized health care, where burning down the house only costs other people, not the house owners, we don’t invest in insurance.
We could have. We used to have reserve capacity in our medical system. Now all we have is the most expensive medical care in the world in the US. That’s enough for some people. The ones that can pay for it. Now. But in a pandemic, even money won’t be enough to get some people medical care.