The Tufts Daily (TD): How did you get involved in hospital research?
Alecia McGregor (AM): I first became extremely interested in hospitals when I was doing my postdoc at Princeton [in the school] of Global Health and Health Policy. I was learning about the health care and public policy issues in the state that I was in. I quickly realized that one of the most pressing issues facing civil rights organizations in the state was the issue of hospital closures and access to acute care for vulnerable populations — particularly populations of color. I realized that in Trenton, N.J., the capital … there are no longer any maternity wards left in the city. Now, residents have to travel out to the suburbs to give birth, to have prenatal appointments with their obstetrician, etc. Trenton is a majority-minority city, and when you think about who's most vulnerable to ... high-risk pregnancies and things like that, it's quite an injustice to not have any maternity wards left in that city.
A lot of hospitals were built in the 19th century, at least on the East Coast, and after a while, the story goes, they become outdated in terms of technology; they're taking on a disproportionate share of poor patients. There's a narrative that the hospitals are financially distressed and that some should close. The reality is, the ones that close are in neighborhoods that have higher shares of black and Latino populations and higher poverty rates. So, I decided to teach this seminar tracing the history of hospitals and pivoting to some of the policy, financial and social explanations for why we're seeing hospitals closing, [hospitals] merging and public hospitals converting to private hospitals. What's happening in the hospital sector that is broadly reflective of what's happening in our economy in general, and what are some ways that we can guarantee access to care?
TD: I know you've done research in Brazil, and I was wondering if you had any cross-comparisons between the U.S. and Brazilian hospital systems.
AM: That's an area that I'm hoping to do some future research in, comparing those two health systems even though there are some key differences between [the two]. In Brazil, their constitution states that access to health care is a right, and the state has a duty to provide it. Because of that, there is a system of public hospitals and clinics … that provides care free of cost to anyone in Brazil. Unfortunately, that public system is chronically underfunded. A SUS (Sistema Único de Saúde) hospital … is basically a unified health system. So, going to a SUS hospital you'll find yourself in a very long line and that's sort of what people say about public health systems in other places … But, Brazil probably wouldn't have to have those problems with quality and access if the health system wasn't so underfunded.
So Brazil has, as a result, a mixed public and private system ... so if you're getting private insurance it's for additional care. With a private plan you have access to a number of specialists, access to private beds which are sometimes nicer. In some ways, the United States' healthcare system is a two-tiered system, too. Depending on the type of insurance you have, there are only certain types of care open to you. So there is that similarity but, as you know, we don't have a mandate that says that everyone has access to care, and we definitely don't have one that says it's the government's duty to provide it.
TD: That's strange to think about.
AM: It is strange, a lot of people chalk it up to American exceptionalism. Americans see ourselves as different from the rest of the world … There's a kind of belief in individually driven prosperity. Some of that is rooted in United States' classism, faith in capitalism [and] racial hierarchy. A lot of the reluctance to universalize access to care and create national health insurance in the mid-20th century came from Southern Democrats who wanted to preserve Jim Crow segregation in the South. To universalize care would mean to desegregate hospitals, right? So, sometimes you hear the language of "that's not the American way, to provide care for everyone." There's the question of, “Well, who are these undeserving poor that we don't want to provide care to?"
TD: What are some of the drivers you've found in your research of hospital closures in the United States?
AM: Some of the drivers I've been seeing in the data that I've been analyzing … have been things like payer mix. If you're a hospital and you have a higher proportion of people on Medicaid or uninsured patients who can't pay, you're facing a financial consequence because in our healthcare system, there's something that's known as price discrimination … [in which] each of the different payers will pay different amounts for the same exact procedure. That's why there are some private practices — physicians' practices and such — that won't even accept Medicaid patients because they know that they're going to get reimbursed at a lower rate. Safety net hospitals like Boston Medical Center and Cambridge Health Alliance that take a higher share of lower income patients are often facing these lower reimbursement rates.
But the drivers that I'm most interested in, in my research, are the ones related to race. We know that race of the surrounding area has a significant effect on whether or not the hospital ultimately closes. So what I'm exploring in my research right now is, what are the political explanations for this? ... So I'm looking at factors like civic participation in a state legislative district and hospital contributions to campaigns. I'm finding that some political factors are predictive of where hospitals close.
TD: When I think about hospitals, I don't necessarily think about the ways that politicians may have a stake in their survival.
AM: Yeah, historically that used to be more visible, especially when there were more public hospitals ... A municipal hospital would often be a place where the mayor would be able to appoint whomever they pleased. It was a form of political patronage to reward supporters by saying ‘oh well you can have this senior position at the local hospital, Cambridge City Hospital or whatever it is,' for example. That was much more commonly seen, but now it's a bit more hidden because the vast majority of hospitals are private. Many of them are technically not-for-profit 501(c)(3)s even though they're highly profitable entities.
TD: Do you have any ideas for how health care can be less focused on profit and more focused on patient care?
AM: I think that's a timely question, considering the health care debate we're having at the national level. I know there was a debate, where Bernie Sanders was debating the sponsors of the Graham-Cassidy Bill and Bernie Sanders ... put forth legislation in the Senate for Medicare for All. There's a total of 16 Democratic cosponsors on the bill, which is huge. For so many Democrats to be coming forth and putting their name on single-payer legislation that doesn't include the private insurance industry, it's saying that ... over a period of some years, Medicare will be expanded from being the program that covers just the elderly to covering 55 and under and then 45 and under...
TD: Right, so incrementally moving it.
AM: Yes, exactly. Now we're having this debate in the public discourse again, which is amazing — we haven't had that in a major way since like the '70s when Richard Nixon proposed his health care reform which some have compared to how Obama's health care reform ultimately looked in terms of its involvement of the private sector and promoting competition amongst private insurers. We haven't had that kind of debate in a while and strangely enough, with Republicans gaining the presidency recently and with a very unusual Republican president in office, it seems like there's a bit of an opportunity for that to happen again. I mean, I think that a return to the social mission of the hospital mission versus the profit-driven business enterprise focus is one way and fundamentally shifting the character of the U.S. health care system. One way to do that would be through Medicare for All, or single-payer. It would remove so many of the intermediaries in the health care system which are known to inflate the price of care. With so many different insurers in the game, that puts upward pressure on health care costs.
TD: That reminds me of driving distance — having so many intermediaries creates so much distance between getting care you need.
AM: It gets in the way of the payer and the patient or the actual provider and the patient, which should be the relationship we're most focused on. We're at a point where the industry is so big. Health care insurance like Blue Cross Blue Shield didn't come about until, like, the '30s, but since then, [it's] grown immensely. Then, we have so many other insurers in this private space that when you think about going from 1930 to now, to the huge chunk of the economy that they make up in terms of jobs... Politically, they're very difficult to contend with.
TD: Do you have any predictions about the future of the hospital business?
AM: Well, I can tell you that the trend of hospitals turning more to outpatient care and other non-hospital entities, like ambulatory surgical centers … is a big change that we've seen. In the short term, we're going to see more hospital closures, particularly in rural areas, particularly in some underserved urban areas... I think unfortunately for the very marginalized populations in the U.S., we're going to continue to see a kind of erosion of access to hospital care. I think we're going to see the continued construction and renovation of hospitals that serve wealthier populations. We're going to see mergers and consolidations even though they've been shown to be associated with higher costs.
Oh, I don't want to fail to mention that there was a hospital that closed in North Adams, about three years ago… Hospitals are supposed to be given a 90 days’ notice before they close, but they did not get that. They got about three days. So the majority [of employees] were left unemployed and they've been advocating to reopen that hospital. North Adams is sort of an old industrial town in western Massachusetts. It doesn't really have its thriving industry presence anymore… And now the nearest hospital that people can go to is in Pittsfield, so that's another fight that's happening right here in Massachusetts.
