Austin @ Large: Austin at Large

It wasn't the first time Mayor Pro Tem Jackie Goodman had thrown herself crosswise in front of a City Hall train, but rarely had she seemed more isolated or desperate -- or, if you'd rather, heroic -- than last week, in a council chambers packed to the gills with supporters of the city's deal to, uh, give Children's Hospital of Austin to the Seton Healthcare Network. That troublesome verb -- "give" -- formed a text for Goodman's last-ditch attempt to, if nothing else, change the context of this deal. She asked several people, several times from the dais, "Does this deal mean we're giving Children's to Seton?" She got several variations of the same answer: Well, yes. But we prefer not to think of it that way.

And why not? What's so bad about giving Children's to Seton? Aren't they the health care pros? Aren't we going to get a better hospital at the old airport than the crowded and overburdened facility on the Brackenridge campus? If they're willing to spend well over $100 million of their Catholic money on our health care -- on top of the tens of millions each year in charity care that Seton provides free to Austin taxpayers -- then why are we complaining? Why should we want to spend public money to retain ownership of Children's when we don't have to?

That's a simplistic but essentially faithful summary of the argument Goodman was trying to counter. It's a hard thing to debate from the dais after less than a month of public discussion of a hideously complex and depressingly grave issue.

As with most hideously complex issues that the city faces -- the aquifer wars being the exception that proves the rule -- the opposition to the Seton deal is terribly overmatched, attempting to counter great pyramids of data and expertise and investment with only a vague, if gut-wrenching, sense of unease. Did we agree to this? But that feeling of civic nausea, more than the public's fear of Seton itself, really does make a lot of concerned citizens want to throw up. That's why it was so hard for the dealmakers to tell Jackie Goodman flat out, "Yes! We're giving Children's to Seton, because there is no question that it is in Austin's best interest to do so right now -- maybe not in a perfect world, but certainly in Austin right now." They knew a lot of people don't believe that -- even if they don't know why they don't believe that.

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The Hobson's Choice

What makes people on both sides want to throw up is the degree to which Austin's community health depends on the kindness of the private medical profession. Seton's annual charity care, the losses at Brackenridge that it covers out of its accounts, is just the largest line item. Everyone who provides health care provides indigent health care. When there aren't enough private providers or places to offer that care -- mental health, trauma care, childhood infectious disease -- it simply doesn't get provided, with disastrous results. And despite the philosophical fantasies of the Texas Legislature, the "indigent" are not Other People, poor wastrels who authored their own fate. Many of you, readers, already know you're medically indigent -- that you have too little insurance, if any at all, and are at risk of medical catastrophe. Many more of you are just as indigent and don't know it. Or have just become so thanks to the Lege.

The crisis is grave, and the system we have in place is already being held together by duct tape and plastic sheeting, and it makes people on the inside -- at Seton, at City Hall, and elsewhere -- impatient, if not totally unsympathetic, with what seem like idealistic and forensic arguments about the value of public ownership and control of the health care system. But ever since Seton took over Brackenridge and Children's in 1995, the hospital system has struggled, and more often than not failed, to avoid, or rise above, the political burdens of what is inherently a political role. Witness the fracas over the nascent Women's Hospital at Brack, or over Seton's initial move not only to take Children's away from Brack but to relocate it to outer Pflugerville. Anybody who's going to marry the city -- even if Seton is the "provider" who takes care of poor Austin's needs -- must be more considerate if they want a healthy, long-term relationship.

As of last week, that relationship has become permanent; Seton will be running Austin's public hospital for the rest of our lives, unless we're willing to pony up $50 million in spare change to get out of the deal. This provision was hailed by many as a needed fetter on Seton's hands -- lest they decide that their business imperatives take them elsewhere -- but it likewise binds the city and its citizens. We will never be able to contemplate getting another provider to operate the hospital -- including ourselves, if we should decide that we were wrong in the mid-Nineties and that running Brack as a purely public hospital isn't such a bad idea.

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A Pig Unpoked?

All of this deep, structural stuff -- the questions of principle, of how much control the citizens should have over health care -- will, or should, come to the surface in a big, explosive way as Travis Co. prepares to vote on a public-health financing district, possibly as soon as September. What will a district do? Will its needs and motives as Seton's Brackenridge partner be different from those of the city? Where can it best devote the money -- probably not very much, in the grand scheme -- it will collect? More than likely, the health-district debate will tend to follow none of these threads. It will instead all be about taxes and how much suburbanites in western Travis Co. -- where more than the normal number of people really aren't medically indigent -- are willing to shell out extra for a place to park the ambulance.

This tax jive is so beside the point, a fool's game if ever one was, but it will swell up to fill the vacuum that should be filled with a real public consideration of health care as a social priority. Right now, the citizens of Austin have only the barest conception of what the local health care system actually is, let alone of what it should be in the future within the oversight of a health district. Ignorance, in this case, is not bliss -- as Seton and City Hall have learned, it makes people irritable and nauseated, among other unpleasant side effects. Whether Seton has just received a great gift from the city, or the other way around, until we unwrap the package and see what's inside, too many citizens will feel they've gotten a pig in a poke.