Talks between top District officials and three hospitals over how to reorganize health care for uninsured residents have stalled because some hospital leaders dislike the others' proposals and worry that Mayor Anthony A. Williams does not want their institutions to survive.
The discussions have been clouded by suspicion and mistrust, and it isn't clear what will put them on track, participants say.
Since May, Williams (D), financial control board Chairman Alice M. Rivlin and D.C. Council members have been pushing representatives of D.C. General Hospital, Howard University Hospital and Greater Southeast Community Hospital to agree on ways to eliminate duplication in their programs and give basic medical care to 80,000 uninsured residents.
The three institutions provide 79 percent of the District's charity hospital care. In recent years, they have been financially unstable, depending on federal or local subsidies to survive.
Publicly, the hospitals and city officials say they are confident they can reach agreement. But privately, the hospitals criticize each other and express concern about the city's motives in forcing them to combine their programs.
"Everybody is holding onto their own turf, and their focus isn't on what's best for the uninsured," said one doctor who is closely following the talks and asked not to be identified.
Williams sees the safety-net negotiation as an urgent first step toward reorganizing a health care network poorly matched to the city's health needs. At a time when 80,000 D.C. residents lack health insurance and have hit-or-miss access to basic medical care, the city is burdened with excess hospital capacity and duplicative care programs.
The city has 4,441 licensed beds, but only about 3,100 of them are actually in operation because public and private health plans are steering their members toward outpatient care. Some experts have said that even though the District is the hub of a regional hospital system, it needs no more than 2,115 beds.
Many D.C. hospitals are losing money or consuming government aid at a brisk pace. D.C. General and its clinics use $50 million a year in city subsidies. Howard University collects more than $200 million a year in special congressional appropriations, part of which goes to subsidize its hospital.
None of the three hospitals has shown an inclination to yield control.
"If everybody wants to be in charge, then nobody is in charge," said a frustrated city official who spoke on condition of anonymity. "We have to put aside these parochial interests and try to come to the table with a concern for [residents'] health problems."
In a statement, Williams said an agreement among the hospitals is key to improving access to health care for low-income residents.
"The District and the management of our three 'safety net' hospitals are working through very difficult, yet very important, issues," he said.
For decades, the city has been beset with daunting health problems. The life expectancy of black men in the District is virtually the lowest in the country. Death rates from preventable causes, including heart disease, HIV/AIDS, stroke and diabetes, are much higher than national averages.
Officials at city-owned D.C. General, the District's busiest trauma center, fear that Williams wants to shutter the aging facility because it would cost too much to modernize. Julius Hobson Jr., vice chairman of the Public Benefit Corp., the quasi-independent agency that runs D.C. General, said he doesn't want anything to do with the foundering Greater Southeast.
"Someone has offered you a bride and a dowry, except the dowry's got problems, and the bride ain't all that pretty," Hobson said.
Greater Southeast was driven into bankruptcy court protection under the weight of $67 million in debts. To keep the 286-bed hospital from closing and leaving Ward 8 residents far from another facility, the mayor in May promised $8.5 million in loans, advances and grants to Greater Southeast to keep it open through August.
D.C. General officials also are concerned that the city could damage D.C. General's finances if it reassigns city contracts for health services to Greater Southeast.
Howard officials say they are willing to participate but want a leadership role in any solution. University President H. Patrick Swygert has proposed preserving Greater Southeast by making it a Howard-controlled satellite teaching facility. Swygert wants the city to give Howard the authority to take over Greater Southeast and quickly restructure it.
"We are prepared to lead," Swygert said.
But Hobson said D.C. General doesn't want to be led. "They are asking for control. We just say no to that," he said.
Greater Southeast leaders don't rule out working arrangements with either of the other hospitals, but they complained this week that the mayor, after rescuing it in May, isn't keeping his promises.
The city missed the June 30 deadline for providing a management consultant to advise the hospital on how to make further budget cuts, said George Gilbert, the hospital's chief executive. Now, with the last $3.1 million installment of that aid yet to come, the city is pressing Greater Southeast's board of trustees to submit to city control as a condition of receiving it. Gilbert's board has said no, too.
"It's alarming," Gilbert said. "This community and this hospital expect the city to live up to the agreement. We are living up to our end of it. If there's a change [in the rescue agreement] it could be extremely problematic because of our precarious situation now."
D.C. officials are about to make the final installment, but even if that money comes through, Gilbert remains uneasy about what the city wants to happen on Sept. 1. "What's missing is a central figure to reach out and take control of this process," he said. "We don't know what the endgame is."