Covid-19 was exploding in Maryland. Eighty-six reported cases jumped to 108 within 24 hours. Seven days later, there were 581.
Hogan’s virus task force soon zeroed in on Laurel Regional Hospital, a long-troubled facility that was downsized to a medical clinic in 2019 and, if reopened, could provide 135 beds. Across the country, governors from California, Pennsylvania, New Jersey and elsewhere also were turning to hospitals closed for lack of use or in bankruptcy, hoping to clean and reequip dusty, empty rooms and wards to prepare for an expected influx of coronavirus patients.
The moves are essentially reversing — at least temporarily — a national wave of closures that cut the number of hospitals in major cities nearly in half over the past five decades. The dramatic drop in hospital beds, usually carried out in the name of saving money and concentrating services in bigger, more advanced facilities, has left the country ill-prepared for a pandemic, experts say.
One leading hospital facility design firm, Array Advisors, released grim projections this month suggesting that the country’s intensive-care-unit beds could be full by the end of April, and all other medical-surgical beds may be full by mid-May.
“The health-care system across the country contracted as a result of trying to provide more efficient care . . . but if you contract the system, then when you have a surge, you are squeezed,” said David Marcozzi, a professor and physician who is leading the covid-19 response for the University of Maryland Medical System. “You don’t have lots of beds open and nurses waiting to provide care.”
So far, hospitals in the D.C. area have not been overwhelmed by virus patients like facilities in hard-hit New York and Washington state. Neither has reopened old hospitals, but New York Gov. Andrew M. Cuomo (D) is setting up four 250-bed field facilities, and mobile military hospitals have been promised to Washington.
In California, where officials say facilities could soon be at capacity, Gov. Gavin Newsom (D) committed $30 million to lease a shuttered hospital in Los Angeles and one near San Francisco that was about to close to provide nearly 500 more beds.
Maryland is also turning to non-hospital spaces, creating a field hospital inside the Baltimore Convention Center and the adjacent city-owned hotel. Virginia and the District are ramping up as well, canceling elective surgeries to free hospital resources and establishing emergency triage tents to add capacity should coronavirus cases spike.
Hospital building boom
The building of major, modern hospitals in the United States kicked off in 1946 with the passage of the Hill-Burton Act, which provided federal grants that paid for up to one-third of hospital construction or renovation, according to Alan Sager, director of the health reform program at the Boston University School of Public Health.
The legislation aimed to spark construction in rural and underserved areas and to create a national average of 4.5 hospital beds for every 1,000 people.
The launch of Medicare and Medicaid in the 1960s also increased hospital construction. But by the mid-1970s, just as the country was approaching the desired bed ratio, building slowed amid a recession.
Over the next two decades, widespread closures continued. Medical advances were one reason: Patients could manage an increasing number of conditions through regular doctor visits, rather than long hospital stays. And cost-conscious hospital companies sought to consolidate facilities to more completely capture the market and avoid overlap.
Doctors also began relocating their practices to the suburbs, where their patients were moving, and affiliating with newer hospitals there, triggering a sharp drop in revenue for many urban hospitals.
“These hospitals were like a car with good tires and a good engine but no transmission,” Sager said. “And doctors are the transmission, they keep the hospitals running.”
The United States has just 2.8 beds per 1,000 people, according to the international Organization for Economic Cooperation and Development. Rural and low-income minority areas, where patients are more likely to rely on Medicare and Medicaid, have been particularly affected.
“This is what has happened if you look at the eastern half of D.C.,” Sager said, ticking off long-shuttered facilities that once served the indigent. “You had Eastern Dispensary, Providence and D.C. General.”
Now, governors and local officials are working to get facilities back online.
In California, Newsom is asking hospitals throughout the state to add 30,000 beds to their capacity and says the state will provide 20,000 additional beds on its own. The closed hospital in Los Angeles and the facility just outside San Francisco were owned by Verity Health System and had fallen into bankruptcy.
Across the country, in hard-hit New Jersey, the state health department is working to reopen Inspira Medical Center in Woodbury. New Jersey Health Commissioner Judith Persichilli said it will take between three and four weeks to get the facility up and running with 300 beds.
In Philadelphia, city officials want to reopen Hahnemann University Hospital, an empty building with capacity for 496 beds that went bankrupt and closed last year after serving mostly Medicaid and Medicare recipients for decades. But city officials are sparring with the property owner over the price, publicly accusing the company of trying to profit off the pandemic.
In Chicago, officials reached an agreement with Metro South Medical Center, which closed last year, to reopen with 200 beds. The city also plans to rent 1,000 hotel rooms to isolate those exposed to covid-19 or mildly ill from the virus.
The logistics behind a reopening are considerable, said Robert Bonar, director of the master of health administration program at George Washington University’s Milken Institute School of Public Health.
“You have to have a terminal clean,” he said, referring to a hospital-grade disinfecting process, “and then there is the staffing. You can bring in staff that have gone part time, ask them to go full time. You can even call back retired staff members. But how long will that be sustainable?”
An old facility reborn
The Laurel facility, located between Baltimore and the District, is the first hospital in the Washington region slated to reopen to deal with the coronavirus. Hogan said Laurel was chosen because of its location — Prince George’s County and neighboring Montgomery County lead the state in positive cases — and because the building could get back in shape faster than facilities that had been closed for longer.
In a March 18 letter to the University of Maryland Medical System, which owns the facility, state Health Secretary Robert R. Neall said the state will cover all costs, including mobilizing staff, preparing the space and obtaining beds.
D.C. officials earlier this month discussed reopening the shuttered Providence Hospital in Northeast Washington, but authorities concluded that it was “not suitable for inpatient or residential care.”
The decision to close Laurel Regional as a full-service hospital and transition it to an ambulatory facility, with an emergency room and space for patients to stay for up to 72 hours for observation, led to union protests and heated debates in Annapolis.
At the time, the hospital was owned by Dimensions Healthcare System, which struggled financially and faced complaints from residents about quality of care. Dimensions said downsizing the facility was necessary to halt operating losses that stood in the millions.
Eventually, the company sold the Laurel facility and Prince George’s Hospital Center in Cheverly to UMMS, which is replacing Prince George’s Hospital Center with a larger regional hospital that is under construction in Largo.
The new hospital is supposed to anchor commercial development in Prince George’s and bring top-flight doctors to the county, along with patients who have been leaving the county for heart surgery and other expensive procedures.
The project was not approved by state officials until the number of beds was reduced because of concerns from the state’s health-care commission that plans were too expensive and unrealistic in today’s market. The opening of the hospital, originally scheduled for 2017, has been pushed to 2021.
UMMS also bought other struggling local hospitals over the past 15 years, downsizing several of them. The $4.4 billion system has 28,000 employees and 13 hospitals, including the state’s flagship trauma hospital.
Marcozzi, the UMMS official who is leading the network’s covid-19 response, said parts of Laurel that had been shut down will be deep-cleaned in preparation for reopening, and officials are working to gather supplies, assign staff and create standard operating procedures. They are still deciding which parts of the facility to reopen and how to keep coronavirus patients separate from those receiving treatment at the medical center for other emergencies.
“We won’t be bringing anything on until it is ready,” Marcozzi said.
Bob Atlas, who heads the Maryland Hospital Association, said the sharing of employees and resources in some ways makes large systems like UMMS and Johns Hopkins Health more prepared than smaller hospital systems to deal with a possible surge.
He said that staffing is his biggest concern, citing accounts from peers in New York who say their own models did not fully take into account what would happen when physicians and nurses started getting sick themselves.
Maryland state Sen. James C. Rosapepe (D-Prince George’s), who fought the closure of the full-service hospital in Laurel for years, said he applauds the decision to reopen the facility. But he said the discussion shows “that our health-care system is really screwed up.”
“The costs are too high, and the emergency capacity is too low,” Rosapepe said. “We have to be able to walk and chew gum — we have to think about short-term efficiencies and long-term need.”
Mark Kreidler in Davis, Calif.; Nick Keppler in Pittsburgh; Shirley Wang in Iowa City; and Jennifer Oldham in Denver contributed to this report.
