Anarchitecture

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the built environment of a stateless society

Episodes

Saturday May 16, 2020

ana029: Hospital Space is Inhibited, so Public Space is Prohibited

Saturday May 16, 2020

How does a quarantine affect public space?

Why aren’t there enough ICU beds?

Tim reflects on his experience designing hospitals to explain why the US healthcare infrastructure may be ill-equipped to respond to the COVID-19 pandemic.

Spoiler alert: It’s far from anything resembling a free market.

This stress on the healthcare system has been used to justify unprecedented restrictions on the use of government-owned public space. How would private owners of public space manage infection risk in a stateless society?

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View full show notes at https://anarchitecturepodcast.com/ana029.

Discussion

Our recording schedule is a victim of daylight savings time
Tim’s history with healthcare infrastructure
Peak vs. average capacity
Myopic medical experts
Tradeoffs between deaths from the virus and deaths from economoc destruction
Unique challenges of the COVID-19; patients on ventilators and ICU for weeks
Three constraints
- Rooms
- Staff
- Equipment (Ventilators)
“Flattening the curve” – is it effective? Is it worth the cost?
Ratcheting up the surveillance state
- The “Karen” busybody snitch phenomenon; a key ingredient of dystopian novels
Freedoms being suppressed
- Freedom of movement
- Freedom to work
- Freedom of speech
Transmission of the virus is most likely to occur in a public space
Quarantine means you are prevented from using public space
How could a stateless society mitigate virus transmission risk?
Private ownership of public space – recap of our theory
- Public access should be preserved on privately owned public spaces
- Quarantine conflicts with preservation of public access
- Government owners do not bear liability to users; private owners do
Virus transmission is similar to pollution emissions, however it increases risks to users of public space
Imposing a risk on others can be considered a form of aggression
- What is the proportionate response?
Calculating the risk: “Go” x “Get” probabilities
- Joe was the first in the office to self-isolate
- Policymakers can’t control individual immune responses, but they can reduce transmission by closing public spaces
Owners of public space bear a responsibility to maintain the safety of that space, and balance safety and usability
- Grocery stores as owners of “permissive public space” have responded quickly and effectively
- People are maintaining safe distances voluntarily
- Requirement to wear face masks could be more effective
- Certificate of immunity – creepy under government, less so under decentralized private ownership
- Public forms of ownership allow for public decision making without creating power structures
- Decentralized ownership allows experimentation and rapid discovery of effective responses
History of the USA’s “free market” healthcare system
- Throughout human history, healthcare meant dying in slightly more comfort
- 18th century – Napolean’s military hospitals
- George Washington’s top-notch medical treatment
- Florence Nightingale: shift to healing rather than comfort
- Evidence based medicine, scientific and technological advances
- 1870: Public Health Service and the Surgeon General
- Religious hospitals
- Privately built hospitals
- Municipal hospitals
- Truman’s “Fair Deal” – urban renewal and universal health care
- Hill-Burton Act – federal funding for hospital construction… with strings attached
- Demonstration of economic viability – favored centralized healthcare facilities
- “Reasonable amount of free care” to patients who were unable to pay
- Medicare – shift from health insurance to third party payment
- Emergency Medical Treatment and Active Labor Act (EMTALA) – required emergency departments to treat everyone regardless of ability to pay
- 55% of US emergency care goes uncompensated
- 44% of US medical expenditures from Medicare and Medicaid
- Australia’s “socialized” system: 76% publicly funded
- Whoa, we’re halfway there
- 1980’s: Diagnosis Related Group (DRG) system: hospital reimbursement based on an “episode of care” rather than actual costs incurred
- No market pricing – just like rent control
- Stifling construction and innovation
Case Studies
- Critical Access Hospitals – federal funding, with strings attached
  - No more than 25 inpatient beds
  - Increasing patient volume forces inpatients into ER beds to avoid breaching limit
  - “It’s just some arbitrary number that some legislator pulled out of his ass.”
- Surgery unit expansion –
  - Ambulatory surgery center in separate building
  - Medicare/Medicaid moved the goalposts by changing the criteria for the “hospital owned” outpatient facility reimbursement rate
  - A really expensive medical office building
- “Life in a regulated market can be far more chaotic than it would likely be under a fully free market system”
- “It may be the one industry in America that is the farthest removed from a free market.”
Joe’s Aversion to Hospitals
- Chopping firewood is a danger to all great men
- Australian first aid – “She’ll be right”
- The New Royal Adelaide Hospital (RAH)
- Follow up surgery choice – time or money?
- “ER doctors: Please don’t come to the emergency room if you have a cold”
- Obamacare fail #81627: “If everyone has insurance, people won’t go to the emergency room for a cold”
- Fee based service and real health insurance (as opposed to health pre-payment)
- A complete chaotic mess
Certificate of Need (CON)
- obscure state level legislation that libertarians have dug up to complain about
- Hospitals forced to justify any expansion
- Assessment hearing – competitors whine about competition
- Props up incumbents, preserves status quo
- Avoidance of approval process influences hospital expansion decisions
- Duplication of services – cost reduction through competition, and redundancy
- New York was the first state to enact CON laws, and they have the lowest ICU beds per capita
- Many states have removed CON requirements
70 years of government intervention in the healthcare system
- Consolidation due to “growth ponzi scheme” and administrative costs
- Technology has been improving healthcare, removing profitable services from hospitals
Enter COVID-19
- Patients need an “airborne infection isolation room” with negative pressure to prevent germs from getting out
- Typical rooms have positive pressure to prevent germs from getting in
Temporary solutions
- Convert existing hospital rooms to infection isolation rooms
- ASHRAE guidelines to retrofit existing rooms
- Army Corps of Engineers guidelines
  - Arena to Healthcare – difficult to get ICU quality treatment
- China building 1,000 bed hospitals in 10 days
  - Healthcare theater?
  - Chinese government welding doors shut to enforce quarantine?
  - What happens to the excess ICU rooms after the peak has passed?
  - Certificate of need does not apply
- Regional hospitals struggling – extra staff, fewer normal patients
- Hotel to hospital?
- Medical tents (NOT FEMA CAMPS… I hope…)
  - Keeps COVID patients out of main hospital
  - “You’re in a frigging tent.”
  - Evidence based design – out the window (because there are no windows)
- Navy hospital ship
- Now is not the time for a cruise to China
“There are no libertarians in a pandemic”
- ACKSHUALLY…
- Governments have failed on many fronts
- Individuals and businesses have responded quickly and effectively
Is there public space in a pandemic?
- Not under government ownership
“My rights are not subject to your lack of imagination.”

Links/Resources

Legislation
- Public Health Service (Wikipedia)
- Hill-Burton Act (Wikipedia)
- EMTALA (Wikipedia)
- Certificate of Need
  - Wikipedia
  - On limiting supply of resources (Medium.com)
  - Map of CON by state (Mercatus Center)
  - Tom Woods Show: Episode 1626 discussing CON
Statistics
- 55% of US emergency care goes uncompensated (Wikipedia)
- US medical expenditures from Medicare and Medicaid: 40% as of Feb 2020, from CMS Fast Facts, Feb 2020 version “National Expenditures” table. The 44% figure was a 2004 number reported in the Wikipedia entry for EMTALA (link above)
- Australia’s “socialized” system: “During 2017–18, total health expenditure was $185.4 billion. Of this, over two-thirds (68.3% or $126.7 billion) was government funded (41.6% by the Australian Government and 26.7% from state and territory governments), with the remaining 31.7% funded by non-government sources (Figure 3.1).” from AIHW Health expenditure Australia 2017–18 Section 3
- Map of ICU beds per capita by state (Washington Post)
Regional Hospitals Struggling (MSN)
Temporary Healthcare Facilities
- ASHRAE guidelines to retrofit existing rooms
- Army Corps of Engineers guide to “Alternate Care Sites” (NOT FEMA CAMPS… I hope…)
- Life comes at you fast: Navy Hospital Ships depart ports after seeing few patients (AP)
China
- Drone Surveillance (Slate)
- Welding Doors Shut (Washington Post)
- Building 1,000 bed hospitals in 10 days (Business Insider)