Regulation

Alabama's Dumb Health Care Regulations Helped Create a Shortage of ICU Beds

States like Alabama that give government regulators control over the number of hospital beds tend to have less of them. That's bad even when there isn't a pandemic.

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With COVID infections serious enough to require hospitalization surging, Alabama's Department of Health delivered grim news last week: There are no more available beds in the state's intensive care units (ICUs).

An insufficient supply of ICU beds is one of the acute crisis points of the pandemic. When hospitals run out of room to treat patients who need the most help, doctors and hospital administrators must make difficult triage decisions. This affects not just COVID patients but anyone else who might be in urgent need of medical care—car crash victims or those who've had heart attacks—and it almost certainly means that some people will die who otherwise may have survived.

It's a crisis that has been made worse by outdated and ineffective government regulations—known as "Certificate of Need" (CON) laws—that actually reduce the number of available hospital beds by requiring that hospitals get permission from the state before adding capacity.

In Alabama, which is one of 27 states that subjects the supply of hospital beds to CON oversight by the state, we're now seeing some of the consequences of these rarely thought-of policies. While the surging number of serious COVID cases there and elsewhere across the country is largely the result of unvaccinated Americans being hit by the highly contagious delta variant, a restricted supply of hospital beds is not helping.

Since March 2020, states that use CON laws to regulate the supply of hospital beds have seen an average of 14.99 days per month where ICU capacity has exceeded 70 percent, according to Matthew Mitchell, a senior research fellow at the Mercatus Center who crunched Department of Health and Human Services (HHS) data and shared his findings with Reason. Meanwhile, states that do not have CON laws governing the supply of hospital beds have seen an average of just 8.65 days per month with ICU capacity exceeding 70 percent, according to Mitchell.

Mitchell's findings suggest that either the virus is specifically targeting states with CON laws—highly unlikely—or else those laws might be worsening the crisis.

In Alabama, specifically, there have been 29 days for which bed utilization was above 70 percent in the past month. Over that same period, the average non-CON state experienced just 6.9 days above 70 percent.

The United States has only 2.8 hospital beds per 1,000 people, according to data from the Organization for Economic Cooperation and Development. That's even less than the 3.2 hospital beds per 1,000 people in Italy, where an early COVID outbreak overwhelmed the health care system. In China, the figure is 4.3 beds per 1,000 people. South Korea, whose response to the virus seems to have been one of the best during the pandemic's first 18 months, has a whopping 12.3 beds for every 1,000 people.

CON laws illustrate the importance of having good policy in place before a crisis like a pandemic arises. And it goes beyond the number of hospital beds. Other research conducted by Mitchell and his colleagues have found that states using CON laws to regulate health care have fewer hospitals, fewer dialysis clinics, and fewer surgical centers, among other things.

That translates into higher costs for patients, who also have to travel farther to get treatment. The average 30-day mortality rate for patients with pneumonia, heart failure, and heart attacks in states with CON laws is 2.5 to 5 percent higher even after demographic factors are taken out of the equation.

"Access is the biggest issue," says Mitchell. "It illustrates the difficulty in assessing 'need' from the perspective of a central planner. They have no skin in the game and are typically uninformed on supply, demand, and cost."

Politically connected hospitals can also use CON regulations to smash smaller competitors, often to the detriment of patients. As Reason has previously reported, a CON board in Virginia has blocked a hospital from building a needed neonatal ICU, even after an infant died at the hospital, because a nearby hospital complained about unwanted competition. A similar board in Michigan tried to restrict cancer treatments merely to protect the state's largest health system from competition.

In Mississippi, doctors who wanted to make house calls during the pandemic were blocked from doing so because state regulators had, in 1981, arbitrarily and permanently capped the number of licenses for home health services under the bizarre rationale that no more would ever be needed. If only those central planners had knowledge of a pandemic that would strike 40 years in the future.

At least 24 states have suspended or abolished various CON regulations for health care providers since the start of the pandemic, according to Angela Erickson, a strategic research director for the Pacific Legal Foundation, a libertarian law firm.

Alabama was one of them. In April of last year, Gov. Kay Ivey, a Republican, issued an executive order that temporarily lifted a wide range of regulations including limitations on letting out-of-state medical professionals work in Alabama and CON rules for hospital beds.

Unfortunately, the consequences of decades of bad policy can't be undone by the snap of a governor's fingers. Hospitals in Alabama likely would have had more ICU beds to call upon if those CON regulations had been lifted long ago, or never imposed in the first place. That's a lesson that state officials should remember when the current crisis passes.

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  1. We need more government control of everything.

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  2. With COVID infections serious enough to require hospitalization surging

    Were you hoping nobody would follow the link you provided, or are you legitimately too fucking stupid to realize that it provides absolutely no information on hospitalization rates?

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  3. While the surging number of serious COVID cases there and elsewhere across the country is largely the result of unvaccinated Americans being hit by the highly contagious delta variant

    Even though fully vaccinated people make up 3/4 of hospitalized patients in a recent CDC study

    1. People who were the most at risk before being vaccinated are still the people who are the most at risk after being vaccinated? I am shocked!

      It’s almost as if healthy people should just get on with their lives.

    2. Are you quoting a study of a gay hookup party in Provincetown MA as evidence that vaccinated people are more susceptible to hospitalization?

      That’s the dumbest thing I’ve ever heard. Nationwide98-99% of hospitalizations are unvaccinated people

      1. 50 cents well earned

      2. Exactly. The whole concept of using Bear Week as any sort of proxy for anyone else is patently ridiculous. It’d be funny of it wasn’t constantly used to scare the shit out of people who don’t have context for the data.

        Current numbers in my county of 3.5 million, for comparison:
        – 50 hospitalizations vaccinated, 5800 not fully vaccinated

        – 15 deaths vaccinated*, 1250 not fully vaccinated
        *I dont’ know about the last 5, but when there were only 11 deaths a few weeks back 10 of them were with comorbidity (one unknown) average age was well into the 70s.

        Even with delta, like the last few weeks with the surge and everything open, not fully vaccinated are nearly 10 times as likely as vaccinated to test positive, and 34 times as likely to be hospitalized.

        THOSE are numbers from normal people in a normal county, who are living normal Summertime in California lives.

        1. THOSE are numbers from normal people in a normal county, who are living normal Summertime in California lives.

          Israel, Australia and England must be isolated backwaters too, I guess. Interestingly enough, I can source data for my claims. Got a link to yours, or should I just imagine the visage of your asshole, which is where your numbers actually came from?

          1. Just so you know ad hominems like that pretty much mark you as a troll, so mute after this.

            But, since we’re here, the very first bookmark on my list:

            https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_epidemiology/dc/2019-nCoV/status.html

            I have more from several other places in the state that provide good data (OC and San Francisco are worth looking up), and the CDC website, but find it yourself. Because, you know, you’re just here to spread FUD, not to actually understand the data. So this is for people who actually care.

    3. Wrong. That is percentage of cases from one event, nothing whatsoever to do with hospitalizations.

      1. It’s specifically a percentage of cases linked to one event that required hospitalization you dumbfuck. If you don’t like that reference feel free to shove the others that I just posted up your asshole along with your head.

        1. One event that represents nothing about normal American lives. And yet you presented it as if it defined risk for everyday situations. What an untruthful and idiotic thing to do.

    4. Were you hoping that people wouldn’t click on your link, liar?

      1. Which one? I knew with certainty you’d be too stupid to read or comprehend any of them, but I was quite hoping that others with a functional grasp of English and an IQ that occupies more than 2 digits would click on all of them. They say exactly what I said they say. That’s why I quoted from them directly.

        1. You really fucked up, Soledad? Trying to dupe people with a study of a party in Provincetown MA while ignoring all the other data out there that shows more then 90% of all hospitalizations and deaths are non vaccinated people.

          It’s sad seeing dishonest people like you trying to pass off irrelevant information on message boards

    1. The preliminary numbers also indicated that having ED also increased men’s susceptibility to SARS-CoV-2 infection. Men with ED are more than five times more likely to have COVID-19.

      ED clearly causes COVID since correlation = causation.

      He points out that older age, diabetes, high body mass index (BMI), and smoking increase the risk of contracting COVID-19.

      “These are the same as risk factors for ED. Results of our study agree with the pathophysiological mechanisms linking ED, endothelial dysfunction, and COVID-19. Basically, endothelial dysfunction is common in both conditions [COVID-10 and ED].

      Stunning. Fat old men who are more likely to contract COVID and display severe symptoms are also more likely to have ED.

      Do you ever actually read anything you post? What am I saying, you’re still telling us the Mueller report concluded that Trump personally colluded with Vladimir Putin to steal the 2016 election from Hillary Clinton.

      1. Don’t begrudge him a scare tactic that will resonate with minorities. This is the kind of socially conscious science we need in the world today. You can tell from his post that DoL has a lot of concern for the plight of the Southern black man.

        1. No, he’s looking forward to tapping into the lonely black old women down south.

      2. older age, diabetes, high body mass index (BMI)

        These are the same as risk factors for ED.

        Syndrome X strikes again! Well, will strike again, just give it a few minutes, maybe play with it a little.

      3. “These are the same as risk factors for ED. Results of our study agree with the pathophysiological mechanisms linking ED, endothelial dysfunction, and COVID-19. Basically, endothelial dysfunction is common in both conditions [COVID-10 and ED].”

        “But the authors offer a plausible mechanism by which COVID-19 may impact directly on erectile function,” agrees Pacey. Adding, “There’s more work to be done.

        “I’d also argue it’s a good reason for men to wear a mask, practice social distancing, and take the vaccine when it’s offered to them.”

        Urologist John Mulhall, MD, from Memorial Sloan Kettering Cancer Center, New York City, remarked, “It was a highly preliminary study, but the data are suggestive of a potential link between COVID-19 infection and ED.”

        Cherry picking. Anyway, do whatever you please. I certainly do, without the necessity of viagra.

        1. Lol

          It adds unnecessarily, as if insecure…

          1. I always just assume that people are having sex with their spouse. Until they go out their way to announce it, at which point I assume the spouse is a beard.

        2. Cherry picking.

          Yes, you were. Thank you for quoting more extensively from the article to prove my fucking point you retarded cunt.

  4. Also, even though CON laws are an absolute fucking abomination, this analysis is garbage.

    Mitchell’s findings suggest that either the virus is specifically targeting states with CON laws—highly unlikely—or else those laws might be worsening the crisis.

    Or maybe that’s an idiotic, sophomoric false dichotomy and there’s another lurking variable that might better explain the difference, like population, population density, geography or climate. You can make your case without being a statistically illiterate fuckhead.

    1. You can make your case without being a statistically illiterate fuckhead.

      False dichotomy isn’t a statistical argument. Not to speak too highly of his statistical abilities but, If he’s guilty of the fallacy, he would just be regular illiterate fuckhead.

    2. The CON laws worsening things is a fairly reasonable conclusion. If the crisis is a lack of ICU beds, then it makes sense. If it’s cases, not so much. So it’s really a question of what the major issue is.

      1. I’m guessing, like everywhere else, it’s staffing.

        1. It is, in all likelihood many, many things. As a rule, allowing places to be adaptive, by getting rid of stifling regulations such as these for example, helps. Things are always changing.

          I’m not sure there’s any actual disagreement here though.

          1. My only disagreement was with the false dilemma. CON laws are nonsense on stilts, but trying to gin up a causal relationship without eliminating other variables that could potentially explain the data is lazy and sloppy.

      2. The crisis is NOT actually a lack of ICU beds. On the hospital supply side of things (ie ignoring the virus, vaccination, etc), the bottleneck is:
        a) the labor associated with what we call an ICU bed (ICU nurses, etc) and with this disease (respiratory therapists, orderlies to keep turning patients over) – not the bed itself or the rent of the room.
        b) the velocity/turnover of covid v average ICU patients. Measure it as a bed-day – or how many covid v average patients can an ICU bed handle over the course of a month – rather just a bed.

        1. Left unsaid, of course, is that other parts of a hospital can be used for intensive care for COVID patients should the need arise, which is what happened last year when nearly all of the overflow units and field hospitals deployed across the country at a cost of hundreds of millions of dollars got packed back up without having served a single patient.

    3. Or maybe they can do what you did above: string a couple of anecdotes together and include some small isolated case studies together and call that statistics— all in the service of Dear Leader, of course.

      1. National health statistics from Australia, Israel and the UK are “a couple of anecdotes”. And here I thought those countries were science-followers who correctly placed their entire populace on house arrest for two years and mandated vaccinations and a “papers please” system for ensuring that no one could conduct business without one. What a difference a few thousand inconvenient fully vaccinated dead and dying COVID patients makes…

  5. The United States has only 2.8 hospital beds per 1,000 people, … even less than the 3.2 hospital beds per 1,000 people in Italy, where an early COVID outbreak overwhelmed the health care system.

    Obviously the solution is to mandate 1,000 ICU beds for every 1,000 people, since hospital care upon need is a basic human right.

    1. Yeah, I’m not really certain those stats say much at all. Do we normally have an issue with these amount of ICU beds? Is it actually reasonable to have a larger standing amount of beds in case of emergencies? These are conversations that can be had, but they’re discussions and trade-offs, not some obvious formula to be applied.

      I feel like something else is being hidden there as well, some other error or thing being overlooked.

      1. In Italy they originally threw ALL covid patients into the hospital, even the ones who didn’t really need to be there. And, of course, mixing covid patients with the at-risk.

  6. Mitchell’s findings suggest that either the virus is specifically targeting states with CON laws—highly unlikely—or else those laws might be worsening the crisis.

    Mr. Mitchell, what you’ve just suggested is one of the most insanely idiotic things I have ever heard. At no point in this incoherent suggestion are you even close to anything that could be considered a rational thought. Everyone in this room is now dumber for having listened to it. I award you no points, and may God have mercy on your soul.

  7. Oh sure let’s pick on Alabama again, look I know your raging hatred of conservatives leads you down to dumb conclusions that some archaic state hospital regulation made covid worse, but please try to actually investigate something like oh say the origins of covid and how Chinese propaganda and state control over information made the situation much much worse. I know avoiding all Chicom topics is de rigueur here at liberaltarian central. And we all know why. Maybe break out of that mind prison and like most of the Twatters out there who keep blaming a pandemic on those with zero political power.

    1. Well Alabamans sure do make it easy to pick on them, nothing but inbred, bible thumping, conspiracy mongering, anti-science rubes.

      1. Says the branch covidian who gets all its talking points from TOP MEN who always manage to be wrong…

      2. Sarcasm or condescension?

        1. Retardation.

  8. Pretending that Alabama’s bed shortage has anything to with something other than the millions of folks who have been duped into thinking vaccines and masks are bad is just irresponsible journalism.

    Alabama is one of 27 such states… and yet somehow their vaccination rate is much lower and their outbreak much greater. Wow

    1. Yea, those vaccine mandates for nurses to work, and the consequent staffing shortages, are the height of genius…

    2. It’s not an either/or here. Last year NYC had issues related to it’s sclerotic health care system too, and things like this are a part of that.
      It’s true that increasing numbers put a crunch on open beds, but so does a law that effectively limits the number of beds. There’s nothing silly or disingenuous about pointing that out.

  9. I have nothing bad to say about the people in the state of Alabama. I have done remote work there and these are some of the nicest hard working folks I have ever worked with.

    That being said. The government structure is outdated and difficult to work with. I am talking about the medical side of it. They really need to update. Ground level providing care is not the problem. The government is.

    1. Well if they let echospinner work in the state, they’re definitely fuck ups

  10. “libertarians” simping for larger and bigger government. Enjoy the cocktail parties

    1. Eliminating CoN laws would be a reduction in the size and scope of government…

  11. Like just in time delivery for logistics, just enough beds in the hospital works until it doesn’t.

    1. Like just in time delivery for logistics, just enough beds in the hospital works until it doesn’t.

      That’s the case for just about everything.

      There’s always going to be a conflict between max capacity required vs the average capacity needed for day to day. There is no simple solution — there needs to be ways to quickly scale up — but then you need to quickly scale back down and find something to do with the over production once the demand surge has worn off.

      Not to mention that once that happens, someone will inevitable be attacked for that overproduction / leftovers in response to anticipated surge.

      Look at the criticism Chicago received when they converted McCormick Place into a hospital in anticipation of need due to COVID. After the fact, when people realized that they weren’t needed lots of people criticized Chicago for the decision. But what would have happened if the beds were in fact needed, but they weren’t available. Chicago would have been criticized for not being prepared or anticipating.

      In many of those cases it’s damned if you do and damned if you dont

  12. I was hospitalized at the height of the pandemic last year. The place was pretty empty.
    The nurse confirmed there were no covid patients there. I was in the PCU. The few of us there were moved to the ICU so some of the staff could be sent home.

  13. And NYs dumb healthcare directives …

    Ah, forget, Jake, it’s Reason.

  14. Hopefully everybody has noticed that there’s been no real push in America to actually increase capacity of the healthcare system. Even the ‘healthcare is a right’ people understand we’re going to need massive amounts of new doctors and nurses to pull of their system, so why don’t we get rid of some of the stupid rules that artificially cap our capacity?

    Spoiler: Because this isn’t about a virus.

    1. Hopefully everybody has noticed that there’s been no real push in America to actually increase capacity of the healthcare system

      A big part of that is the fact that the licensing boards are made up of people who might wind up making less money if more doctors are licensed.

      It’s almost as if when people are asked to regulate themselves they will do what’s best for them only rather than what’s best for everyone

      1. At least back in the 80s and 90s they were honest about their motives.

      2. It’s almost as if when people are asked to regulate themselves they will do what’s best for them only rather than what’s best for everyone

        I sense sarcasm in what is a literal description of a free market, Adam Smith’s ‘invisible hand’, a cornerstone of capitalism and libertarianism.

        Maybe you could go ask an accountant for Arthur Anderson how easy it was for them to manipulate the FASB and the AICPA after their complicity with Enron was revealed. Oh, you can’t, because the way they managed a single client torpedoed one of the largest accounting firms in the US and now there are only a ‘Top 4’ accounting firms.

        To a profession that relies on personal reputation, the importance of self-policing is self-evident. The medical profession could more easily police itself if it was not for onerous regulations of the industry and the political necessity to continually lobby the elected elite as a counter to lobbying by the legal profession, the insurance industry, labor unions and against the lootocrats in the government itself and the Progressives who would institute universal health care which will lead inevitably to health care professionals as indentured servants of the state.

  15. It’s a crisis that has been made worse by outdated and ineffective government regulations—known as “Certificate of Need” (CON) laws

    The name is the program.

  16. At the end of the day this is simply the effect of hospitals using the government to protect their profits. The CON regulations are nothing but a way to limit competition and make sure that the existing hospitals keep their existing profit levels.

    This isn’t “regulation” this is crony capitalism on full display.

    Since March 2020, states that use CON laws to regulate the supply of hospital beds have seen an average of 14.99 days per month where ICU capacity has exceeded 70 percent, according to Matthew Mitchell, a senior research fellow at the Mercatus Center who crunched Department of Health and Human Services (HHS) data and shared his findings with Reason. Meanwhile, states that do not have CON laws governing the supply of hospital beds have seen an average of just 8.65 days per month with ICU capacity exceeding 70 percent, according to Mitchell.

    Mitchell’s findings suggest that either the virus is specifically targeting states with CON laws—highly unlikely—or else those laws might be worsening the crisis.

    Or maybe… Mitchell’s findings suggest that in states that don’t have artificial or arbitrary caps on the total number of ICU beds, the chances of being over 70% full is significantly lower, due to the fact that there are more total ICU beds in the state. If 2 states with similar populations and similar rates of illness, the state with more beds to start with is obviously going to have a lower percentage of beds in use.

    Since this is March 2020 data, that also doesn’t say anything about how many empty ICU beds are left empty and unused under normal circumstances. Obviously 1 for every resident of the state isn’t feasible…so what is the “correct” rate to ensure that there is enough capacity during a major event while not having a bunch of empty beds taking up space under normal circumstances.

    This issue is more complicated than the author seems to be willing to admit.

    1. There’s not often a huge distinction between regulation and regulatory capture. This is a known thing forever.

  17. Alabama voted for Trump. Therefore Alabama can do no wrong.

    California has not Certificate of Need regulations, therefore Certificate of Need regulations are necessary.

    1. I’m actually kind of surprised that California doesn’t have them.

  18. Sure, the beds are a problem, but even if you have beds, there is no one to staff them. ICU is 1-1 or 2-1 nurse patient ratio because these people are really sick. The gating factor for staff is that nursing schools limit their class sizes and reject plenty of potential nurses because they are .1 GPA under those who made it. How someone is rejected because they got Bs in English or electives is ridiculous. It takes 4 years to graduate a BS entry-level nurse. Universities need to wise up.

  19. Um, in this Forbes article, Alabama is listed as having the higherst number of ICU beds per inhabitant in the country as of 2018:

    https://www.forbes.com/sites/niallmccarthy/2020/05/18/icu-bed-capacity-in-all-50-us-states-compared-infographic/?sh=436ed3a424dc

  20. The article starts from the (incorrect) premise that imperfect allocation of ICU beds by democratically-elected Government is inferior to that which for-profit private interests would

    That there are fewer specifically because government regulates it and says the mattresses can’t contain bedbugs or otherwise be shitty (considerations made for the benefit of patients not profit).

    If we let Hospital Bed Management Corp LLC. handle it they’d do better.

    BULL. SHIT. you brainwashed retards

  21. The article blames Certificates of Need, but at the very end, mentions that Gov. Ivey waived Alabama’s CoN program nearly a year and a half ago. So what have Alabama hospitals done since then to add ICU beds? That statistic was missing from the article.

    1. They do a lot of lying by omission here at Reason dot com.

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