ana029: Hospital Space is Inhibited, so Public Space is Prohibited

How does a quarantine affect public space?

Why aren’t there enough ICU beds?

Tim reflects on his experience designing hospitals to explain why the US healthcare infrastructure may be ill-equipped to respond to the COVID-19 pandemic.

Spoiler alert: It’s far from anything resembling a free market.

This stress on the healthcare system has been used to justify unprecedented restrictions on the use of government-owned public space. How would private owners of public space manage infection risk in a stateless society?

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View full show notes at https://anarchitecturepodcast.com/ana029.

Discussion

• Our recording schedule is a victim of daylight savings time
• Tim’s history with healthcare infrastructure
• Peak vs. average capacity
• Myopic medical experts
• Tradeoffs between deaths from the virus and deaths from economoc destruction
• Unique challenges of the COVID-19; patients on ventilators and ICU for weeks
• Three constraints
  • Rooms
  • Staff
  • Equipment (Ventilators)
• “Flattening the curve” – is it effective? Is it worth the cost?
• Ratcheting up the surveillance state
  • The “Karen” busybody snitch phenomenon; a key ingredient of dystopian novels
• Freedoms being suppressed
  • Freedom of movement
  • Freedom to work
  • Freedom of speech
• Transmission of the virus is most likely to occur in a public space
• Quarantine means you are prevented from using public space
• How could a stateless society mitigate virus transmission risk?
• Private ownership of public space – recap of our theory
  • Public access should be preserved on privately owned public spaces
  • Quarantine conflicts with preservation of public access
  • Government owners do not bear liability to users; private owners do
• Virus transmission is similar to pollution emissions, however it increases risks to users of public space
• Imposing a risk on others can be considered a form of aggression
  • What is the proportionate response?
• Calculating the risk: “Go” x “Get” probabilities
  • Joe was the first in the office to self-isolate
  • Policymakers can’t control individual immune responses, but they can reduce transmission by closing public spaces
• Owners of public space bear a responsibility to maintain the safety of that space, and balance safety and usability
  • Grocery stores as owners of “permissive public space” have responded quickly and effectively
  • People are maintaining safe distances voluntarily
  • Requirement to wear face masks could be more effective
  • Certificate of immunity – creepy under government, less so under decentralized private ownership
  • Public forms of ownership allow for public decision making without creating power structures
  • Decentralized ownership allows experimentation and rapid discovery of effective responses
• History of the USA’s “free market” healthcare system
  • Throughout human history, healthcare meant dying in slightly more comfort
  • 18th century – Napolean’s military hospitals
  • George Washington’s top-notch medical treatment
  • Florence Nightingale: shift to healing rather than comfort
  • Evidence based medicine, scientific and technological advances
  • 1870: Public Health Service and the Surgeon General
  • Religious hospitals
  • Privately built hospitals
  • Municipal hospitals
  • Truman’s “Fair Deal” – urban renewal and universal health care
  • Hill-Burton Act – federal funding for hospital construction… with strings attached
  • Demonstration of economic viability – favored centralized healthcare facilities
  • “Reasonable amount of free care” to patients who were unable to pay
  • Medicare – shift from health insurance to third party payment
  • Emergency Medical Treatment and Active Labor Act (EMTALA) – required emergency departments to treat everyone regardless of ability to pay
  • 55% of US emergency care goes uncompensated
  • 44% of US medical expenditures from Medicare and Medicaid
  • Australia’s “socialized” system: 76% publicly funded
  • Whoa, we’re halfway there
  • 1980’s: Diagnosis Related Group (DRG) system: hospital reimbursement based on an “episode of care” rather than actual costs incurred
  • No market pricing – just like rent control
  • Stifling construction and innovation
• Case Studies
  • Critical Access Hospitals – federal funding, with strings attached
    • No more than 25 inpatient beds
    • Increasing patient volume forces inpatients into ER beds to avoid breaching limit
    • “It’s just some arbitrary number that some legislator pulled out of his ass.”
  • Surgery unit expansion –
    • Ambulatory surgery center in separate building
    • Medicare/Medicaid moved the goalposts by changing the criteria for the “hospital owned” outpatient facility reimbursement rate
    • A really expensive medical office building
  • “Life in a regulated market can be far more chaotic than it would likely be under a fully free market system”
  • “It may be the one industry in America that is the farthest removed from a free market.”
• Joe’s Aversion to Hospitals
  • Chopping firewood is a danger to all great men
  • Australian first aid – “She’ll be right”
  • The New Royal Adelaide Hospital (RAH)
  • Follow up surgery choice – time or money?
  • “ER doctors: Please don’t come to the emergency room if you have a cold”
  • Obamacare fail #81627: “If everyone has insurance, people won’t go to the emergency room for a cold”
  • Fee based service and real health insurance (as opposed to health pre-payment)
  • A complete chaotic mess
• Certificate of Need (CON)
  • obscure state level legislation that libertarians have dug up to complain about
  • Hospitals forced to justify any expansion
  • Assessment hearing – competitors whine about competition
  • Props up incumbents, preserves status quo
  • Avoidance of approval process influences hospital expansion decisions
  • Duplication of services – cost reduction through competition, and redundancy
  • New York was the first state to enact CON laws, and they have the lowest ICU beds per capita
  • Many states have removed CON requirements
• 70 years of government intervention in the healthcare system
  • Consolidation due to “growth ponzi scheme” and administrative costs
  • Technology has been improving healthcare, removing profitable services from hospitals
• Enter COVID-19
  • Patients need an “airborne infection isolation room” with negative pressure to prevent germs from getting out
  • Typical rooms have positive pressure to prevent germs from getting in
• Temporary solutions
  • Convert existing hospital rooms to infection isolation rooms
  • ASHRAE guidelines to retrofit existing rooms
  • Army Corps of Engineers guidelines
    • Arena to Healthcare – difficult to get ICU quality treatment
  • China building 1,000 bed hospitals in 10 days
    • Healthcare theater?
    • Chinese government welding doors shut to enforce quarantine?
    • What happens to the excess ICU rooms after the peak has passed?
    • Certificate of need does not apply
  • Regional hospitals struggling – extra staff, fewer normal patients
  • Hotel to hospital?
  • Medical tents (NOT FEMA CAMPS… I hope…)
    • Keeps COVID patients out of main hospital
    • “You’re in a frigging tent.”
    • Evidence based design – out the window (because there are no windows)
  • Navy hospital ship
  • Now is not the time for a cruise to China
• “There are no libertarians in a pandemic”
  • ACKSHUALLY…
  • Governments have failed on many fronts
  • Individuals and businesses have responded quickly and effectively
• Is there public space in a pandemic?
  • Not under government ownership
• “My rights are not subject to your lack of imagination.”

Links/Resources

• Legislation
  • Public Health Service (Wikipedia)
  • Hill-Burton Act (Wikipedia)
  • EMTALA (Wikipedia)
  • Certificate of Need
    • Wikipedia
    • On limiting supply of resources (Medium.com)
    • Map of CON by state (Mercatus Center)
    • Tom Woods Show: Episode 1626 discussing CON
• Statistics
  • 55% of US emergency care goes uncompensated (Wikipedia)
  • US medical expenditures from Medicare and Medicaid: 40% as of Feb 2020, from CMS Fast Facts, Feb 2020 version “National Expenditures” table. The 44% figure was a 2004 number reported in the Wikipedia entry for EMTALA (link above)
  • Australia’s “socialized” system: “During 2017–18, total health expenditure was $185.4 billion. Of this, over two-thirds (68.3% or $126.7 billion) was government funded (41.6% by the Australian Government and 26.7% from state and territory governments), with the remaining 31.7% funded by non-government sources (Figure 3.1).” from AIHW Health expenditure Australia 2017–18 Section 3
  • Map of ICU beds per capita by state (Washington Post)
• Regional Hospitals Struggling (MSN)
• Temporary Healthcare Facilities
  • ASHRAE guidelines to retrofit existing rooms
  • Army Corps of Engineers guide to “Alternate Care Sites” (NOT FEMA CAMPS… I hope…)
  • Life comes at you fast: Navy Hospital Ships depart ports after seeing few patients (AP)
• China
  • Drone Surveillance (Slate)
  • Welding Doors Shut (Washington Post)
  • Building 1,000 bed hospitals in 10 days (Business Insider)

Episodes Mentioned

• Public Space Series

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