A conversation with Ruth M. Rothstein
The director of Cook County Hospital assesses the future direction of health care

Photograph by Bill Stamets Ruth M. Rothstein, director of Cook County Hospital By PAUL F. CUADROS Ruth M. Rothstein was born in 1923 in Brooklyn. After a career as a labor organizer, she landed a job in 1962 as the personnel director of Jackson Park Hospital in Chicago. Fifteen years later, she became president and chief executive officer of Mount Sinai Hospital, which is located in one of the poorest neighborhoods on the city's West Side. I believe, truly believe, that health care is a right and not a privilege. And I believe, other than South Africa, we're the only industrialized country in the world without a national health program. And I think that South Africa will have one before we do.' During her tenure at Mount Sinai, Rothstein created family planning, nutrition and rape counseling programs. And she is credited with rescuing that hospital from closing. Rothstein is also credited with pulling off a similar save at Cook County Hospital, where she became director in 1990. (She now heads the county's Bureau of Health Services as well.) In fact, Rothstein has earned

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accolades from critics as well as supporters for her leadership in reviving and turning the hospital around.

County Hospital provides care to approximately 2,500 people every day — or 912,000 a year. More than 165,000 patients make emergency room visits each year. But, at 80 years old, the building is inadequate to handle the number of patients who come through the door.

As a result, in 1990, County Hospital lost accreditation from a national commission that oversees health care organizations. Two years later accreditation was restored.

Now, Rothstein is on the verge of leading the hospital into a new era, with a new building and a neighborhood clinic system designed to provide needed primary care in some of the poorest areas of the city.

Excellence in public service Ruth M. Rothstein is the recipient of the 1995 Motorola Excellence in Public Service Award. This recognition honors an individual in the city of Chicago, Cook County or the state of Illinois for exemplifying excellence in the public sector because of one's vision, effectiveness, leadership and determination. Sponsors of the award are the Motorola Cellular Subscriber Group, the North Business and Industrial Council, Aon and Illinois Issues. Rothstein will receive the award October 11 at a luncheon at the Four Seasons Hotel in Chicago.

The new Cook County Hospital will be smaller, with 464 beds, and will serve as a hub for a network of clinics in the community. Plans call for a new central plant and parking facilities and an outpatient specialty diagnostic center. The tab is expected to total $570 million. Yet, a 1994 financial study by Coopers & Lybrand estimates the county will save $440 million in operating costs over five years by getting rid of the existing antiquated building.

Meanwhile, as Cook County revamps its health care system in Chicago, other cities are cutting back on services and even considering closing their public hospitals. Los Angeles cut six ambulatory care centers and will close 29 of 39 health centers. In New York, a commission appointed by Mayor Rudolph W. Giuliani recommended that the city close all of its 11 municipal hospitals.

Public health programs in other cities throughout the country also are feeling the state and local budget squeeze. An eroding tax base and increased competition for Medicaid and Medicare patients by private managed care facilities mean even rougher times ahead for the nation's public health care institutions.

Q: WHAT DO YOU think is the mission of public hospitals?

A: I think the mission of public hospitals is to take care of people who come to their doors for medical assistance and to do it with dignity and compassion. The mission of public institutions is also to deal with the population that is probably the most fragile.

Q: MANY OTHER CITIES, including Los Angeles, New York and Washington, D.C., are considering cutting services or even closing public hospitals because of an anti-tax climate and the competition for Medicare and Medicaid patients by managed care providers. What is the future of public hospitals given this wave of cutbacks?

A: I think the question is different. The issue is what's going to happen to the health care system in this country. Not only are public hospitals troubled. Look at all the private hospitals that have already closed in the state of Illinois. So it isn't just what's going to happen to the public health system; it's what's going to happen to the health care system generally.

When you talk about public hospitals, however, you also need to talk about the question of public health. How do we preserve the public institutions so that we can deal with prevention questions and health education questions, in order to preserve the public health of our citizenry?

Now, if you ask me should we downsize, should we be more involved in ambulatory care, should we be joint venturing with other institutions, should we be in the forefront in the fight against tuberculosis, in the fight against sexually transmitted disease, in the fight against gun violence, clearly the answer is yes because that is public health.

And those are the things that we are involved in, those are the things that we have programs to deal with. So yes, the public hospital system should be kept together. The question then becomes how.

Q: THE GOVERNMENT HAS had a great commitment in the past to providing health care to the poor. Critics say this commitment has deteriorated. Have our government leaders lost that commitment to the poor?

A: I think if you look at Washington you wouldn't have to wonder very hard, would you, about what the intent is. The intent is to take us back into the olden days. And the intent is to do what will get you elected.

It is also true that the American people have a great antipathy toward paying taxes — and the government only has revenue based on a tax-base.

It's also very interesting that when the American people go to the polls — and they don't go in great numbers — a president can be elected with 50 percent of the vote. Or Newt Gingrich can be elected [speaker of the U.S. House] with less than 50 percent and suddenly he becomes a "macher," a macher being a bigshot.

But what happens when the American people say, "We don't want to pay anymore taxes. We don't want to take care of them. We're tired of this." They do say it. But the minute you start to take stuff away from the American people — like cut Medicare, cut certain programs — they don't like it. They say, "No, no, no, that's not what we meant. What we meant is we don't want to take care of them. That's what we meant."

But they forget them is us. Because today there are 41 million uninsured in this country.

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Q: AND ABOUT 1.1 million in Illinois.

A: And as we talk, they add to it by the minute. We're 41 million people in this country without health insurance. And in any given day there's another 10 million who have lost jobs, or changed jobs, and don't have health care. What the American people don't understand is that it's not "them," whomever "them" is. The fact of the matter is that it could be me, it could be you ending up in the emergency rooms because we don't have insurance.

Q: WHAT'S CENTRAL TO your plan for the new Cook County Hospital?

A: We're planning a considerably scaled-down Cook County Hospital. We have to develop a seamless system so that we use all of the community resources, County Hospital being the hub. But more importantly — and the real critical issue — is to develop a strong presence and clinics and doctors' offices in the communities that we serve, where there is a need. There are no real health care facilities in the community. That's where we should be. And unless we do that we will not be able to do the downsizing.

Q: A GREAT MANY people use the hospital as their personal clinic, don't they?

A: But most emergency rooms are handled in the same way.

They use it as their family physician because there are not enough resources in the community. That's exactly the point. You build the resources in the community, and you start to educate communities not to use the emergency room.

Wouldn't it be marvelous if they could run to their family doctor either in a clinic or they had his phone number and then they could see their family doctor like you do or I do? That's what we're trying to do.

Q: WILL IT BE difficult to educate the population to use the clinics?

A: Sure, of course. Isn't it going to be hard to educate you to use managed care?

We're changing the way America uses the health care system, the way the American people have been taught. When you have an earache the first instinct should be to go to your doctor, your primary care physician. You should only go to the ear doctor when you've been sent. And when there is something so wrong that you need a specialist. But that's what we do.

Q: WHAT IMPACT WILL Gov. Jim Edgar's plan to move the state's poor into managed care have on Cook County Hospital?

A: We've been working with them steadily to develop a program that will indeed help to manage the care of public aid recipients.

Whether it's called MediPlan Plus, whether it's called XYZ or PQI, that's the way medicine is going to be delivered in the future, whether it's your care or my care or the care of the person who has insurance through the public aid system, because that's also insurance. It may not be the kind everybody loves, but it's insurance and everybody pays.

I would cover the county with facilities that would enable people to get health care in their own communities

Q: WOULD THE PLAN to move Medicaid patients into managed care reduce the hospital's finances?

A: No, we have a different kind of arrangement for getting paid. We get paid through what is called an intergovernmental transfer. It means the county and the federal government match funds. The state is the conduit through which we get the funds.

Q: CONGRESS IS CONSIDERING providing block grants to the states to design their own Medicaid plan. How will this affect public hospitals?

A: I think it depends whether that change impacts the way we get paid now. I think that block grants can be negative and positive. It depends on how the state — whether it's the state of Illinois, the state of Alabama, or Mississippi — wants to use those funds.

Unfortunately, unless there's strings attached to the block grant funds, then a state might decide to use the money not for health, but to fix a road. So, I'm hoping that, if there are block grants, rather than MediPlan Plus or whatever, that there will be strings attached so that kids won't suffer because someone wants to politically use the funds in another way.

Q: ARE THERE PLANS drawn up for the new hospital?

A: We hired a project manager. Well, we've retained the services of a project manager. We're in the process of retaining the services of an architect and enginneer. And this will start the team going. It's much overdue.

Q: IF YOU HAD a wish list of things you wanted to do, what would it be?

A: I would cover this whole county with facilities that will enable people in their own communities to get health care and not have to use anybody's emergency room.

Q: WHAT HAVE YOU learned from your experiences that can help other hospitals?

A: I think what I brought, more than anything else, was an ability to work with communities. I have a strong identity with neighborhoods and the people who live in them.

I think I brought that well before any other institution started to think about their role based on their geography. I did that way back in the early 1970s. And that was a result of my own background, my own upbringing.

I also bring something that a lot of people may or may not think about. I believe, truly believe, that health care is a right and not a privilege. And I believe, other than South Africa, we're the only industrialized country in the world without a national health program. And I think that South Africa will have one before we do.

Paul F. Cuadros covers health care issues for The Chicago Reporter, an investigative monthly that focuses on urban issues.

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