In recent days we have seen how militarizing policing in the aftermath of the 1960s uprisings has exacerbated tensions and fueled unrest. Less visible is how flaws in our health care system that have been evident since the beginning of the covid-19 pandemic are also rooted in the response to the very same uprisings. Recognizing these shared roots illuminates how today’s protests against police brutality and injustice are historically linked to the ongoing pandemic.
Even before this weekend’s unrest, American institutions were showing signs of strain. Not only has the covid-19 death toll topped 103,000, but the nation’s health care system is collapsing. As hospitals have pivoted to treat covid-19, many are unable to stay financially afloat because of the dramatic decrease in patient volume and voluntary procedures. This conundrum — the collapse of hospitals at a time of unprecedented need for medical care — shows just how over reliant our country is on a costly acute and emergency health care system that is better at addressing rare and singular diseases that afflict individuals than doing low-cost preventive health care that could support and sustain the public good.
That’s because since the 1970s we have valorized expensive drugs, technology, invasive procedures and intensive labor arrangements to save us when we are at our sickest rather than address nonmedical and public health approaches that prevent the onset of serious disease when we are at our healthiest. This shift toward an acute-care and emergency-focused system, however, was not inevitable but a result of decades of public policy, rooted in the aftermath of the 1960s uprisings.
In the 1960s, policymakers hoped that antipoverty programs and expanding access to health care would alleviate racial tensions and address inequality. A series of laws was poised to expand health care access to more Americans than ever before. Medicare, Medicaid and President Lyndon B. Johnson’s Great Society anti-poverty programs meant that more people would be able to pay for health care. In addition, Johnson’s Heart Disease, Stroke and Cancer Acts also fostered large research and capital-intensive academic medical centers to raise health standards and innovate medicine. Theoretically, these laws would help establish community hospitals in neglected neighborhoods and connect them regionally with large, cutting-edge hospitals to continually raise the quality of care across the board.
But, it didn’t work. Los Angeles County Supervisor Kenneth Hahn realized soon after the 1965 Watts Uprising that nothing could convince private hospital owners or voters to build a hospital in every community, especially in troubled black neighborhoods like Watts. Indeed, even after John McCone, Chair of the California Gubernatorial Commission on the Watts Uprising, recommended building a Watts hospital to prevent a future uprising, Los Angeles’s majority white electorate rejected a 1966 ballot referendum designed to fund it. Fearing another uprising, Hahn acted anyway; he convinced fellow members of the Board of Supervisors to build a hospital, eventually called King-Drew Medical Center, from public funds.
Although he couldn’t build hospitals everywhere, Hahn knew that people in rural areas and inner-city neighborhoods without a hospital close by, needed health services, and would continue to register their frustration if they were forgotten. So he arrived at a creative solution, investing in one of the first paramedic systems in the nation in 1967.
Instead of building a health access point in every community across the vast county, Hahn connected patients in far flung neighborhoods to large medical centers by ambulance units refurbished from fire department “rescue vehicles,” outfitted with modern medical technology and trained medical personnel. This system could shrink the distance between people and the lifesaving care they needed.
Before these mobile care units, patients transported in ambulances were lucky if their drivers knew basic first aid and the sight of them pulling up to a doorstep was usually interpreted as a sign of impending death. Before the 1970s many funeral companies operated or sponsored ambulance companies as a local service to feed into their businesses. But with Hahn and others revolutionizing the ambulance industry, patients could receive treatment en route to advanced hospitals and be more likely to survive.
As ambulances connected distant people to medical centers, hospitals transformed their emergency rooms to receive patients with urgent needs. Doing so made Los Angeles not only the birthplace of one of the first modern paramedic systems but also home to the first academic medical program to train emergency physicians in 1971 at Los Angeles County-USC Medical Center.
Similar to modern mobile care units, emergency departments and trauma centers were a radical transformation from emergency rooms of old, which were associated with inferior care, moonlighting physicians and poor patient populations. Medical centers now marshaled already expensive labor, expertise and technology found elsewhere in the hospital and from military settings devised during the Korean and Vietnam wars for use around-the-clock in newly redesigned emergency settings. Emergency Medicine thus amplified the costs of specialized acute care services already present within large hospitals.
Americans became acquainted with this new form of medicine and fell in love with it when a popular television show, “Emergency!,” began airing in 1972 that showcased emergency medicine’s seeming ability to treat anyone for any affliction quickly and effectively.
By the 1980s, rural and suburban municipal leaders across the U.S. began to see EMS systems attached to emergency departments as a better investment than supporting the construction of multiple lower-cost health service points in every community. In many cases, politicians built EMS systems by transferring public health money once allocated to public clinics and acute services to large medical centers with fancy emergency departments and trauma centers. Especially after the mid-1970s establishment of 9-1-1 services integrating police, fire and hospital services together into one system, investment in EMS was also seen as an important investment in public safety.
President Ronald Reagan gutted public health budgets in the early 1980s. Yet, he also signed the Emergency Medical Treatment and Labor Act (EMTALA) in 1986, an unfunded federal mandate prohibiting hospitals from turning away citizens seeking emergency services. In Los Angeles, the County Supervisors responded by prioritizing resources for its publicly-funded EMS systems, prisons, police and fire departments, while defunding public hospitals, clinics and health education programs. This essentially subsidized state-of-the-art facilities for privately insured Americans.
Such cannibalization of “safety net” health services since the 1980s resulted in the “super acute” health system we have today — a system fantastic at caring for patients who are either close to death or wealthy and able to afford advanced, but expensive procedures and treatments but ill-equipped for taking care of people with basic health needs, even if neglecting basic health leads to far more expensive, urgent health needs down the road.
Ironically, most people do not associate emergency departments with white rural and suburban voters but with poor people of color who seek emergency medicine care because it is the only option available to them. The stigma of using emergency medical services often leads many poor people, immigrants and people of color to forgo basic care until it is too late. The racialization of emergency room utilization thus ignores the fact that white suburbanites do not access emergency services any differently than anybody else, but they rarely suffer the same stigma or negative social consequences. Shifting taxpayer resources away from low cost preventive health care since the 1980s toward public safety and EMS systems thus created a system that deepens inequality between wealthy, largely white communities, and communities of color.
For decades, policymakers have redistributed public health resources, investing in cutting-edge, high-tech solutions and an emergency medicine system that has been a poor fit for the general health of many Americans, especially the poor and uninsured who lack adequate facilities and basic care in their communities. This has followed a parallel track to our investment in police forces and systems of incarceration, expensive “solutions” that do little to promote people’s safety and well being and that disproportionately harm African Americans.
Today’s uprisings have been a response to generations of structural racism, particularly in policing. But they come amid the covid-19 pandemic that also has killed African Americans at a shocking rate. As we work to manage the spread of coronavirus and to treat the ill, we will need to be more creative in addressing the larger ongoing crisis that coronavirus is only a small part of. The lives of people left behind by our resource rich acute care health system depend on it.