Carolyn N. Graham, the D.C. regulator who is to decide this week whether Capitol Hill Hospital will remain open, is at the center of a complex struggle with consequences beyond the fate of one small health care facility.
If a hospital wants to convert to a nursing home, as Capitol Hill does, the owner must apply to the city for approval. Graham is supposed to decide on the application, after considering the health needs of District residents and listening to the recommendations and comments of health care experts, community leaders and ordinary citizens.
She has received plenty of comment: from the owner seeking to convert the hospital into a nursing home, from the union workers trying to preserve 700 jobs, from the new mayor struggling to keep the hospital as it is, and from her own health care advisers arguing that the planning process should be above politics.
"In most of my decisions, I could look at facts and figures," Graham said. "They were very rational and absent a lot of emotionality. But this one has really cut very deep. I think it is the toughest decision I have had to make."
Because Graham is a city employee, she also faces the problem of defying Mayor Sharon Pratt Dixon if she approves the hospital conversion, or defying her own advisory council if she denies it.
"I would not like to see the planning process made into a political football," said Jesse Barber, a physician and member of the advisory council, which endorsed the conversion plan. Graham won't comment on that issue.
The city's planning agency is part of the Department of Human Services. Dixon has appointed Vincent C. Gray to head the department, and Graham will report to Gray.
"Ms. Graham is sitting on the hot seat," said John H. Niles, former president of the D.C. Medical Society and a member of the advisory council.
"But I would hope that this kind of situation would be a stimulus for us to address the generic problems of the hospitals," he said. "Hospitals are in desperate straits."
Graham has until tomorrow to rule on Capitol Hill Hospital under the regulations of the District's State Health Planning and Development Agency, which she has directed since 1988.
On one side of the argument is the Medlantic Healthcare Group, the region's largest health care provider and the owner of Capitol Hill Hospital. Medlantic says the hospital, one of the city's smallest, is losing about $1 million a month, primarily because of a shrinking number of paying patients.
To stop the financial drain, Medlantic proposes to close the hospital's emergency room and surgical-medical beds and transform it into a nursing home with a psychiatric center.
One argument for the conversion is based on the health plan developed by Graham's agency. The plan shows that the city has 223 more hospital beds than necessary but could use an additional 549 nursing home beds.
On the other side is the Coalition to Save Capitol Hill Hospital, a group of workers and community residents who have staged protests, filed lawsuits and commissioned audit reports contending that the hospital can be financially viable if managed properly.
As a candidate for mayor, Sharon Pratt Dixon supported the coalition. After taking office in January, she launched an aggressive effort to keep the troubled hospital open.
She warned that "thousands of area residents will suffer tremendous loss as a result of the termination of acute-care services" at the hospital.
The mayor assigned a representative from her office to work with Medlantic to find a buyer for the hospital, as an alternative to the nursing home proposal. Two potential buyers have expressed interest in the hospital, but no deal has been worked out.
At stake are 700 jobs and a facility that last year provided primary care to 27,000 people, many of them from the low-income neighborhoods near the hospital, at 700 Constitution Ave. NE. The hospital's emergency room also serves victims of the city's drug and violence problems who arrive by ambulance.
But the implications of Graham's decision on Medlantic's application for a certificate of need, so it can convert the hospital, extend beyond the District line.
Maryland health care providers also are monitoring the Capitol Hill case.
"It's a microcosm of the confusion and chaos that occurs in many parts of America when you are trying to sort out community need versus financial health of the institution," said Richard Wade, a spokesman for the Maryland Hospital Association.
Wade said Maryland providers have a practical as well as an academic interest in District health care.
"When there is a hemorrhage in the system there, ultimately there is an effect on Maryland, because we have a lot of District poor people in Maryland hospitals," he said.
The D.C. Hospital Association has taken no position on the Capitol Hill case but believes it illustrates the overregulation of health care, said association President Howard T. Jessamy.
He said he believes that Medlantic should be able to decide, based on its financial needs, whether to keep the hospital open.
"If a facility is going bankrupt, it can't carry out its mission," Jessamy said.
District hospital administrators generally describe the city's health planning process as the most onerous in the area and among the most complex in the nation.
"We would like to have the certificate-of-need requirements phased out," Jessamy said.
The Virginia Hospital Association takes a much more positive view of the certificate-of-need process. The association voted in November to request that the state continue its certificate-of-need requirements rather than drop them as had been proposed earlier.
"There were fears that entrepreneurs would come in and set up free-standing ambulatory centers and take away the hospitals' paying patient base, leaving the hospitals with only those people who couldn't pay," said Donald L. Harris, vice president of the Fairfax Hospital System, the largest such health care organization in Northern Virginia.
The federal act that established the health planning process was repealed in 1987 under the free-market influence of the Reagan administration. Since then, health care regulation has been in turmoil, with some states abolishing their programs and others strengthening theirs.
Maryland, Virginia and the District still require a hospital to obtain approval to convert to a nursing home, and Graham now must make such a ruling.