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.
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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
- Statistics
- 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
- China
Episodes Mentioned
Repurposing public space to impart wisdomBut public schools are still open
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