The Volokh Conspiracy

Mostly law professors | Sometimes contrarian | Often libertarian | Always independent


"What Do Full Hospitals Really Tell Us About COVID?"


Prof. Ed Richards, who specializes in (among other things) public health law at LSU law school, wrote this on a discussion list I'm on, and kindly agreed to let me repost it here:

This is a comment about Louisiana, although it applies in varying degrees to other states.

If you are a historian of hospitals in the US, or just an old health policy person, you know that post-WWII the federal government subsidized the construction of a lot of hospitals and created the expectation that every small town would have its own hospital. In the 1970s, health economists raised questions about the costs of running hospitals at 40-50% occupancy. This led to the passage of PL 93-641, the health planning act, and the Certificate of Need Program (CON). CON was intended to have community boards vet new hospital beds, etc., with an eye to reducing costs in the community by reducing excess capacity. CON was mostly a bust—everyone understood in theory why excess beds were a problem, but no one wanted to forgo a new facility in their community.

Market changes did what CON didn't and over the next 30 years squeezed out excess beds so that hospitals could operate at 90% capacity and make a lot more money. It was recognized at the time at time this was also removing the excess capacity that was a buffer for when there was a bad flu season or other outbreak. After 9/11 and SARS1, there were plans to build emergency ICUs outside of hospitals during outbreaks, including tents in the parking lots, to make up for the loss of beds. These plans were based on the assumption that there would plenty of people who could be brought in to staff the beds—sort of misunderstanding the PAN in pandemic.

Louisiana was a leader in the specialty hospital business, having neither an effective CON process or state regulatory system. The public argument for specialty hospitals is more expertise and lower costs because of efficiency. The real model was no emergency room, and thus no way for un- and under-insured people to get into the hospital. All of the financial benefits of being a hospital without any of the responsibilities. So we get women's hospitals, orthopedic hospitals, etc., sucking the profitable work from community hospitals, without taking any of the burden of community care for the indigent. General hospitals are even allowed to close their ERs in Louisiana.

The hospitals in Louisiana which take indigent patients and patients though the ER—pretty much all COVID patients—are slammed. The specialty hospitals have lots of staff and lots of beds and don't have much in the way of COVID patients, if there are any at all. They also do little to help the others. Thus Louisiana has a very small number of general beds that are available for COVID patients. It is a real crisis, but it is as much a crisis in health care resources as in COVID. While the Children's hospitals do have ERs, there are not many of them in Louisiana and there are very few total ICU beds. As another list member observed, you can have all the pediatric ICU beds full and still only have a tiny number of kids who are very sick.

The latest COVID surge is a serious problem, and I hope it prompts people to get vaccinated, since it appears that vaccination helps a great deal (even though it isn't perfect). But I thought that Prof. Richards' analysis was an interesting perspective on why focusing on this one particular metric might give a somewhat incomplete picture of the situation.