Essay by Ed Quillen
Medicine – April 2005 – Colorado Central Magazine
THE HOT TOPIC in Salida these days is a new hospital. It’s a topic for Central Colorado as well, since the facility is not just the “Salida Hospital” of days gone by, but the “Heart of the Rockies Regional Medical Center” whose region includes all of Chaffee County, Saguache County down to Villa Grove and Saguache, and into the Howard area of Frémont County. That’s the “Hospital District,” which has an elected board to collect property taxes and oversee operations.
This issue won’t be decided in a public election. If the hospital were to issue “general obligation bonds” to finance a new building, then an election would be necessary because the bonds would be secured by every parcel of property in the district. State law says people get to vote on encumbering their real estate.
But the district plans a “revenue bond,” secured only by hospital income, and that’s a decision the directors can make on their own.
Even though there won’t be a bond election on this issue, there’s still plenty of discussion in Salida diners and tap rooms, and it boils down to two questions:
1) Does the district need a new hospital building?
2) If so, where should it be built?
I UNDERSTAND WHY the district wants a brand new building, rather than one that started in 1899 as a replacement for an 1885 building that burned down. The hospital has been extensively remodeled and expanded since then, but old buildings take a lot of maintenance.
And at some point, the cost of maintenance will grow to exceed the cost of amortizing a new building. Or to put that another way: if you’re spending $500 a month to keep your old car running, and the payments on a new car are $400 a month, the new car starts to look like a decent investment.
I don’t know if that’s the case at the hospital, and even if they had the numbers, I’d be skeptical. That’s because these figures are often contrived to justify what people want to do anyway. Whenever I want a new computer, I tell myself that I’ve been spending $50 or $60 a month to upgrade and maintain the old one, and that a new one –which has all of the latest bells and whistles I think I need — will only cost $750 and will thus pay for itself in a year, and being new, it won’t require replacement parts, upgrades, and the like.
But on the other hand, I used to justify driving an old car, a 1965 Dodge Dart GT, well into this millennium by pointing out that it cost about $50 a month to maintain. Most of that – tires, wiper blades, headlights, etc. — was stuff that any car would need from time to time, be it old or new, and a newer car might require payments of $300 a month for a year or two. That represented a considerable increase in our household overhead, especially for people who drive less than 6,000 miles a year, and besides, I’d rather my money went to Pete Salerno’s garage than to some lending company.
But even though it seems easy to jiggle the numbers in these matters, it is legitimate to consider whether it’s wise to spend money to keep an old building up to rising standards. At some point, a new building will be cheaper. Although I don’t know whether our hospital has reached that point, if it hasn’t, it will. That much we can know for sure.
That, however, is not the only issue related to the current building. Its core goes back to 1899. There are a lot of things that hospital rooms have now – electronic monitoring, oxygen pipes, private baths – that hospital rooms didn’t have in 1899. Sure, they’ve installed new piping, plumbing, and wiring, but the old part of the hospital wasn’t built for that.
I’ve got the same problem where I live and work. Our house, which is also the world headquarters of Colorado Central, was built in two stages; the back portion dates to 1885, and the front to about 1905. Electricity, telephones, and indoor plumbing were novelties then, and they’re sort of patched into the house, rather than being part of the design. It wasn’t built for computer networks, electronic entertainment, and natural-gas heat. Nor was it built for us modern people who seem to need a lot more closet space than our grandparents did.
I cherish the high ceilings, wood-burning stoves, and Victorian woodwork. But I curse the place every time I have to snake some wires through some tight space that was created long ago, before people gave much thought to household wiring.
Medicine has changed a lot since the hospital was built (the X-ray was discovered only in 1895), and a new building, designed for modern methods, should work a lot better than the continued adaptation of an old building. It’s not that the handsome old building is useless; it could do many jobs well through this century, but it was never designed to do what hospitals do now with high-tech laboratories, magnetic resonance imaging, etc.
That’s another part of the talk I hear. When I moved to Salida in 1978, the hospital had something like 60 beds. Now it has 25. So if it’s shrinking, why do they need a big new building? Why aren’t they closing off a wing?
Bed-count doesn’t give a real accurate picture, because hospital stays have been decreasing in length. In 1930, the average stay was 11 days. It was 7.8 in 1970, and 4.9 in 2001. Do the math, and you can see that a hospital with 100 beds in 1930 would need only 45 beds to serve the same number of patients today.
Even so, there’s probably some numerical gamesmanship involved with the current bed count. There are federal grants available to assist “Critical Care Access Hospitals” in rural areas – the theory is that they need some assistance so they can attract qualified people with modern facilities. The upper size limit used to be 15 beds, and there’s no practical way HRRMC could cut back that far. But it was recently raised to 25 beds, a number HRRMC could meet, which probably explains why it’s now a 25-bed hospital.
THAT RAISES ANOTHER QUESTION that comes up with every hospital expansion or renovation: What kind of hospital should Salida have? Should it be a place for routine medicine like simple baby deliveries and setting skiers’ broken bones, with the equipment and skills to stabilize serious patients until they can be transported to a real hospital in the city? Or should it offer everything this side of heart transplants?
That decision appears to have already been made over the years, with hospital-board elections and bond elections; the majority of the taxpayers of the district want a hospital that is as close to state-of-the-art as possible, with a varied array of specialists and a lot of modern machinery.
In a financial way, that can make sense. Most medical costs are borne by third parties, like insurance companies and the federal government through Medicare and Medicaid. The more of that money that is spent here, rather than in Colorado Springs or Denver, the better for our economy, right? And the hospital has become the largest year-round employer in Salida, with 250 full-time equivalent employees.
WHETHER THAT’S GOOD in a larger sense is another question which raises questions about the entire American model of health care. Right-thinkers often declare something to the effect that “the American health-care system is the envy of the world.”
Now consider that all of the other advanced industrial democracies have socialized medicine. If our system really were envied by other countries, don’t you think that at least one candidate in Canada or Iceland or England or Germany would have campaigned on a promise to “provide an American health-care system”? It hasn’t happened. Even Margaret Thatcher, that free-enterprise believer who served as England’s prime minister in the 1980s, never proposed to do away with National Health.
The truth is, we Americans pay more and get less than in any other developed country. In 2000, we spent 12.9% of our Gross Domestic Product on health care. That’s more than any other developed country, both as a percentage and as an absolute dollar figure – about $1.2 trillion.
And yet, when you look at our public health, we’re nowhere near the top. One common measure is Infant Mortality Rate: out of every 1,000 babies born, how many die before they’re a year old. Our rate is 6.8. We rank 14th, behind nations like Chile, Italy, and the Czech Republic, none of which spends anywhere near as much as we do on health care.
Another measure is life-expectancy at birth. We’re at 77.3 years. We rank 11th, behind countries like Spain, Greece, Iceland, and Japan. They don’t spend as much as we do, either.
But that is not something that a small rural hospital in the middle of Colorado is in any position to fix.
Instead, it’s something that the people who profit from the current inefficient system will spend millions to preserve. Remember those “Harry and Louise” ads when the Clinton Administration proposed some health-care reforms a dozen years ago? That old, sick couple didn’t want the government making their medical decisions. Yet one must assume that Harry and Louise were already covered by Medicare, and thus were at least partially reliant upon government health care. So apparently, what they were really worried about was that our government might start caring about young people, and that would leave less for them.
Our senators and congressmen also enjoy a government-run health-care program, but for some reason they think our moral fiber would diminish if we had one, too.
ANYWAY, I think there’s a plausible case for a new hospital building, providing that the historic parts of the current structure are preserved for some good public use, say as a conference center with lodging. Think of the small conventions that Salida could host with meeting and sleeping rooms at the (old) hospital and the conference facilities at the Steam Plant, connected by a pleasant river walk.
So if they build a new hospital, with 90,000 square feet, where should it go? Nate Olson, the hospital administrator, said that with parking and the like, the facility would need about six acres (the current site is about three acres), and he and the board would like to see at least ten acres, so there’s room to grow.
My personal preference here would be to construct a bridge across the river from the current site, and build a new hospital in the old railroad yards. There’s plenty of room there, and there would still be room for the track if rail service ever resumed.
But it might be difficult to persuade the Union Pacific to go along with that. And there’s not room on the current site for a big new building.
The Cynical Scenario goes like this. Assume you’re a developer with, say, 160 acres a couple of miles out of town. It will cost a mint to put in water and sewer so you can develop the land.
So as a public-spirited gesture, you donate 10 acres for a new hospital site, and the hospital bears the cost of running the water and sewer lines. Now your remaining 150 acres have utilities right at hand, you can subdivide, and make a lot of money, meanwhile appearing to be a public-spirited benefactor.
And that scenario seems to fit with the new Colorado Mountain College property in Buena Vista, which went on 35 acres donated by Ron Southard, who owns about 250 other acres nearby. And suddenly there’s a 1.75-mile $800,000 sewer line that improves property values at the airport industrial park.
But there’s more to the story, according to Jerry L’Estrange, the Buena Vista town administrator. The industrial park already had municipal water, and the town had wanted to extend sewer service out there for the past 18 years. One reason was to preserve water quality in town, a process that is simpler when there aren’t a lot of septic tanks on the edge of town.
CMC was one impetus, he said, which made it easier for the town to get a $484,000 economic development grant. Southard provided some in-kind services for the new sewer line.
So this doesn’t quite fit the Cynical Scenario. It did extend utility services, and the land donor will presumably benefit down the road, but it was land that was already in the process of development, and it was something the town wanted to do anyway.
THEY PAY ME the big money for asking obnoxious questions so I made an appointment and asked Nate Olson, the hospital administrator, about the Cynical Scenario.
[Editor’s note: Wait, Ed, stop right there. Before you go on: Who pays you the big money? Because whoever it is I want some. But to go on….]
“Sure, we’d prefer donated land to land that we had to pay for,” Olson said. “Who wouldn’t?”
But “the cost of running the utilities that a hospital needs – water, sewer, natural gas, electric – can run into some big money, especially if you’re talking about raw land a few miles out of town. We want a site where the utilities are already present.”
One complexity of hospital siting is access from the rest of the service area. Poncha Springs offers good highway access from Villa Grove and Buena Vista, but it means a run through town traffic for ambulances from Howard. Put it, say, across the highway from Seven-11, and Howard does fine but Buena Vista and Villa Grove don’t. But even if that’s important, it can’t be much of a determining factor, because every site will favor some areas over others. It might be a tie-breaker in favor of convenient access from Buena Vista, though, since it’s the largest town after Salida in the Hospital District.
The new hospital won’t go to Buena Vista, but it might not end up inside Salida, either. Ernest Màrquez is a Salida attorney and one of the five board members, and he told me that “We have to look at what’s best for the entire district in picking a location. Salida can’t just sit there and assume that the hospital will stay in town.”
But I think it’s important to keep the hospital in town, within convenient walking distance for as many people as possible. The more people who can walk or cycle to work, the less traffic. And the more exercise they get, so the healthier they’ll be.
AS NATIONAL TRENDS GO, Americans seem to be on one that’s good for the economy but not for anything else. We build stuff that we have to drive to, which means we have to build lots of roads and cars and trucks which muck up our air and increase our asthma and emphysema problems. And the gas comes from countries which don’t necessarily like us, so we have to go to war, and although wars may be good for the economy, they’re not good for anyone’s health.
And now that we’re so auto-amicable our towns sprawl all over the place, which isn’t good for wildlife; and our kids can’t walk anywhere because there are too many dangerous roads to cross; and there never seems to be enough parking, so we keep putting ugly parking lots everywhere.
Further, the more we drive the less we walk or cycle. So to get the exercise we need, we pay to join gyms. Or else we forgo it, in which case our health suffers and we have to go to a hospital – another contribution to the Gross Domestic Product.
While all of that — wars, illness, excessive weight, and high cholesterol — may be good for the economy, it is not good for us. So if the hospital is concerned about public health, it should sit where the public – and its own employees – can be healthy in the process.
I put that before Olson. He had not done a formal survey of employees to find out how they got to work, but at a meeting with about 70 hospital employees, “I asked if any of them would have a problem if the hospital sat two or three miles from where it is now, and no hands went up.” However, some physicians ride their bicycles to the hospital, he said, “and they want to be able to keep doing that.”
So there’s some internal support for a convenient location, rather than an isolated medical campus surrounded by cow pastures soon to become two-acre homesites.
Most downtown merchants and a large number of Salida residents also prefer an in-town hospital, because they’re afraid that our city will change if we keep moving things out of the downtown district. Local residents are proud of Salida’s old-fashioned, pedestrian-friendly historic district, with its sidewalks, parks, new walking trail and downtown grocery store. But that may not last long if our hardware, video and clothing stores, banks, and clinics all keep moving out to the highway to join what used to be our motel, big box, fast food, and restaurant tourist district; or if the subdivisions keep spreading further and further out of town, dispersing sprawl and mini-marts across the country-side. In that case, Salida may well follow the path of so many cities and end up with an essentially abandoned historic center.
Thus, Salida’s merchants, and city council, and residents, and some doctors support an in-town hospital. But I don’t know whether that will be enough.
When I first heard of a new hospital building, I thought of the Salida school district’s adventures with a middle school. On several occasions, the school board asked voters to approve a bond issue that would have built the middle school out on Holman Avenue, too far for most kids to walk. And on those occasions, Salida voters turned the issue down. Finally the school board proposed a sensible location, near the high school which was easy to walk to, and it passed.
And so, I thought, it might work this way with the hospital. If the board tried to sell us a bad location, we could vote against it, and keep voting against it until they figured it out.
But there won’t be a bond election for the hospital, since it’s a revenue bond.
THE BOARD CAN LOOK at whatever parcels its site-selection committee recommends, pick one, and go from there, all without public participation. About all we can do, if they come up with a bad site, is start a recall election against hospital board members, and there might not be enough time to do that if they start signing contracts a few minutes after approving a site.
The board is a public body, though, and as a community institution, the hospital needs community support for any new site. Already the Salida City Council has passed a resolution urging the board to keep the hospital inside town, and it’s hard to go into a store on F Street without being urged to sign a petition for keeping the hospital inside town.
So let’s apply some pressure and keep it on. As a national study pointed out in 2003, “people living in counties marked by sprawling development are likely to walk less and weigh more than people who live in less sprawling counties. In addition, people in more sprawling counties are more likely to suffer from hypertension (high blood pressure). ”
Sprawl makes us sick, and hospitals are supposed to help keep us well.