Assisted Suicide?
The Demise of the Clinics
By Alex de Marban, Fri., Aug. 2, 1996
At issue is whether the city should continue as manager of the 13 neighborhood-based clinics, which are now constrained with reduced federal funding. Last year, the State Legislature passed a bill that's expected to cut off much of the city's Medicaid reimbursement at the end of three years, stripping away about $1.7 million, or 10% of the clinic's budget. Moreover, the new bill, called Senate Bill 10, will permit more HMOs to receive a higher level of payment when caring for indigents, a move that is expected to drain the clinic's Medicaid customer base and their federal reimbursements.
The territory ahead looks mighty rough, and Health and Human Services (HHS) Director Sue Milam proposes a full-body physical of the clinics to find savings and management restructuring options. With almost funereal sobriety, Milam marched out an unending litany of foreboding figures at last week's council work session, the gravest projecting a $10 million loss in the next five years, if nothing is done. Milam won't say whether she favors privatizing the clinics -- no doubt concerned about upsetting employees -- but some HHS insiders say Milam is a trigger-happy privatization fanatic. The City Manager Jesus Garza is more vocal, crowing about the windfall of "several million dollars" that clinic privatization could attract.
The actual benefit is uncertain, given the loss of public accountability, and the potential for decreased quality and availability of care. Of additional concern is the future of reproductive services for indigent women at the clinics. If Seton Hospital takes over management of the clinics, as many suspect they will now that they run the city-owned Brackenridge Hospital, certain reproductive services may no longer be made available.
With that in mind, local health-care vigilantes have assembled an informal coalition to keep tabs on the issue, says local clinic expert Rose Lancaster. Lancaster is a member of the council-appointed Federally Qualified Health Care (FQHC) board, which makes recommendations to the council on the clinics. The coalition is against privatization, and would first reform the clinic system from within, maintaining city management but tightening the proverbial belt. She wonders aloud if Milam has presented the clinics' figures in such a way as to predict a doomed tomorrow and the need for a clinic fire sale.
Part of the speculation, no doubt, stems from Milam's apparent faith in the church of privatization. In her dissertation for the University of Texas School of Social Work in 1994, Milam compared indigent care provided by the city's clinic system with that provided by a private, managed care system. Milam found that the private provider, the Positions Corporation of America, saw twice as many patients in the same period of time. Milam says the city's clinic system is slowed by requirements the private sector doesn't have to meet, like legal mandates for purchasing, and council politics and decision-making. Still, she cautions that she's not predisposed to privatization. In fact, she says, HHS will redo the work provided for her dissertation study in a few months, partly to see if it still holds true.
Lancaster and others, including Councilmembers Slusher and Goodman, aren't so sure. Their eyebrows were raised when Milam dourly presented the clinic situation at the council work session on July 24. At meeting's end, almost as an addendum, Milam did wax positive about the clinics and the services they provide. But the FQHC board received the same presentation four days earlier, and as Lancaster notes, there was no positive chaser to mellow the unsavory taste. "The board expressed concern that [the presentation] did not present the clinics in a good light, that it looked like it was geared toward privatization," says Lancaster. "It just showed how much it was costing and didn't talk about the quality of services. When they presented it to the council they added that slide on services, I guess in reaction to our concerns."
If Milam favors privatization, opposing forces could be stifled, since city staff, through recommendations and privileged access to information, can cast the argument in their terms. That's exactly what Slusher is concerned about. At the work session, Milam recommended a 12-member committee of government officials to present options for management restructuring. Slusher is worried "that the committee is there to work out a deal to privatize. It's all government members. There [are] no doctors, no nurses."
Still, the committee is expected to face little opposition at Thursday's council meeting. Only Goodman has joined Slusher in voicing concerns about its membership. Asked if she thinks Milam favors privatization, Goodman replies: "I think so. The way the information was presented was so overwhelming. She doesn't say it flat-out, but I get that feeling."
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The council averted disaster by voting 6-0 (Mitchell was out of town) to settle the lawsuit over the new Bergstrom airport terminal construction contract; the city will pay $190,000 to Aviation Constructors, Inc., the second-lowest bidder for the contract. Aviation alleged that the low bidder, Morganti National, is using two minority contractors who cannot prove their capability to do the job. Morganti will pay Aviation $210,000. Had the suit been pursued, it would have put the May 1999 opening day for Bergstrom airport in jeopordy; city officials said the delay could have cost the city about $140,000 per day in interest from revenue bonds and extra management costs.
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The council also bore witness to an outpouring of community support for the city's electricity conservation program, which provides rebates to businesses and residents for installing high-efficiency air conditioners. More than 60 speakers testified, all but one supporting Goodman's proposal to keep the city's program as is. The city manager recommends a $2.1 million reduction for the coming budget, lowering 1997 spending to $13 million. In the short term, that could help reduce the Electric Utility Department's debt, help the EUD steady rates, and thus help the utility maintain customers when dog-eat-dog competition hits. But in the long term, as most of the speakers pointed out, energy conservation programs will improve the EUD's financial status: A kilowatt saved is cheaper than one produced, especially if another $100 million power plant is forestalled.
To no one's surprise, Ronney Reynolds didn't share Goodman's view. Earlier in the day, he had protested another measure from Goodman, to have the city manager devise a plan for reducing emissions that contribute to the greenhouse effect. Reynolds' basic thesis was the city would be wasting money; nearby cities do little or nothing, so any reductions here would be useless, or so he reasoned. Reynolds didn't support Goodman's energy conservation bill either, raising the banner of moderation by calling for partial reduction to help pay off the EUD's debt and ensure the utility's survivability. That, in turn, will ensure future conservation since it's rarely practiced by the private utilities that could take over the EUD. "If we lose all our customers, you can forget about energy conservation," quoth Reynolds.
His cohorts on the issue, Mitchell and Mayor Bruce Todd, were absent. Slusher, though, seems aligned with them, seeing the rebate program as a rich man's boon at the poor's expense. Beverly Griffith is undecided, too, so the proposal didn't even get into a good stretch, but Goodman promises a resurrection.
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This week in council: Staff proposal to re-privatize the Austin Convention and Visitors Bureau. Expect approval of Milam's committee to study privatizing the health-care clinics. n
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