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

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Anarchitecture

Society & Culture


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? Use hashtag #ana029 to reference this episode in a tweet, post, or comment View full show notes at https://anarchitecturepodcast.com/ana029. ----more---- 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) Episodes Mentioned Public Space Series Repurposing public space to impart wisdomBut public schools are still open Contact: Email us: info@anarchitecturepodcast.comTweet us: @anarchitecturep Follow: Website: https://www.anarchitecturepodcast.com/Facebook: https://www.facebook.com/anarchitecturepodcast/Instagram: https://www.instagram.com/anarchitecturep/Twitter: https://twitter.com/anarchitecturep/Reddit: https://www.reddit.com/user/AnarchitecturePodcstMinds: https://www.minds.com/AnarchitecturePodcast Subscribe: iTunes: https://itunes.apple.com/au/podcast/anarchitecture/id1091252412YouTube: http://www.youtube.com/channel/UCWELM_zTl7tXLgT-rDKpSvgSpotify: https://open.spotify.com/show/5pepyQfA25PBz6bzKzlynf?si=4UiD6cLkR6Wd26wJC4S4YQPodbean: https://anarchitecture.podbean.com/Stitcher: http://www.stitcher.com/s?fid=85082&refid=stprBitchute: https://www.bitchute.com/channel/MIq2dOnSaTOP/RSS (all posts): https://www.anarchitecturepodcast.com/feed/RSS (Podcasts only): https://www.anarchitecturepodcast.com/feed/podcast/Other Subscription Options Support: Patreon: https://www.patreon.com/anarchitecturepodcastBitbacker.io: https://bitbacker.io/user/anarchitecture/Steemit: https://steemit.com/@anarchitectureDonate Bitcoin (BTC): 32cPbM7j5rxRu1KUaXGtoxsqFQNWD696p7