The MacNeil/Lehrer NewsHour

MR. MacNeil: Good evening. Leading the news this Thursday, three strong aftershocks hit Northern California as the Bay area recovered from Tuesday's earthquake. The Senate spurned President Bush on abortion and flag burning. Social Security recipients will get a 4.7 percent benefit increase in January. We'll have details in our News Summary in a moment. Judy Woodruff is in Washington tonight. Judy.

MS. WOODRUFF: After the News summary, the California quake is again our lead focus. We have two documentary looks at the human and economic aftershocks. First, Spencer Michels [Focus - Aftershock] on Bay area residents are coping, and then Elizabeth Brackett reports from Santa Cruz, the city nearest the quake's epicenter. Next the overcrowding crisis [Series - Critical Condition - Intensive Care?] We have the second part of a two part series focusing tonight on intensive care. Joining us are two healthcare experts, Uwe Reinhardt of Princeton University and Bruce Vladeck of the United Hospital Fund. We close with a Roger Rosenblatt essay on the nature of man's true colors.NEWS SUMMARY

MR. MacNeil: Three strong aftershocks hit Northern California today as the Bay area struggled to recover from the transportation nightmare caused by Tuesday's earthquake. The new tremors caused some damage to buildings already weakened but no injuries. Life began to return to normal in San Francisco, with power restored in the financial district, airports operating, subways working, and most schools reopened. Across the bay in Oakland, rescuers began removing cars from the collapsed interstate freeway where most of the deaths occurred. They placed wooden and metal supports under the remaining structure in an effort to prevent further damage. In Santa Cruz, near the epicenter of Tuesdays quake, several buildings in the city's downtown district were destroyed. Initial estimates put the damage in Santa Cruz at $350 million. In Washington, congressional leaders received briefings from colleagues on the scene. Afterwards, House Speaker Thomas Foley promised financial aid would be forthcoming.

REP. THOMAS FOLEY: We have an obligation to meet our responsibilities in disaster relief, can't predict these things. So to put it bluntly, if the deficit has to go up, if that's the only way it can be done, the deficit will have to rise. If we have to have a waiver from Gramm-Rudman that'll have to be done. That's not the only way of doing it, but there will be a need to see that these moneys are voted. If a family has a tragedy, a disaster, it may not fit in the budget but it's one of those things that has to be faced when the emergencies occur.

MR. MacNeil: Pres. Bush flies to Northern California tomorrow to survey the damage personally. Yesterday's visit by Vice Pres. Quayle drew an angry response from San Francisco's Democratic Mayor, Art Agnos. He accused the Vice President of turning the trip into a publicity stunt. The Mayor said he was ticked off that Mr. Quayle did not meet with him. Pres. Bush has invited Mayor Agnos and two other mayors to join him tomorrow's tour. There was a major earthquake in China today. At least 29 people were killed and some 8000 homes flattened by tremors registering between 5 and 6 on the Richter Scale. They were centered 135 miles west of Beijing near Datong, famous for its caves holding Buddhist paintings and statues dating back to the 5th century. Judy.

MS. WOODRUFF: The U.S. Senate today refused to go along with Bush's call for a constitutional amendment to ban flag burning. Despite Mr. Bush's urging, only 51 Senators voted in favor of the amendment, 15 less than the 2/3 required for passage. Although the vote was not divided along party lines, the Senate's Democratic leader led the fight against the amendment. The Republican leader supported it.

SEN. BOB DOLE, Minority Leader: To say that the act of flag burning is somehow deeply enshrined in the first amendment is preposterous. You're right. Five justices said that it was so last June, but they were dead wrong. And now we have to decide how to correct the Supreme Court's blunder. And a constitutional amendment is the only way, the only honest way to accomplish this task.

SEN. GEORGE MITCHELL, Majority Leader: We can best protect the American flag by passing a law, as the Congress has already done. We can best honor our bill of rights by leaving it alone, securing the liberties of each and every American.

MS. WOODRUFF: In another act of defiance, the Senate today also voted to expand Medicaid funding for abortions to victims of rape and incest. Pres. Bush has said he will veto the bill which passed the House earlier this week. After little debate on the Senate floor, the vote was 67 to 31 in favor of expanding the coverage. Also today two Senators introduced a bill to cut capital gains tax rates and expand Individual Retirement Accounts or IRAS in an effort to salvage the Bush administration's tax plans. Their move comes as House and Senate negotiators debate whether to remove the capital gains tax rate cut from a compromise deficit reduction bill.

MR. MacNeil: There was more evidence today that inflation may be moderating. The government reported that consumer prices rose a slight .2 percent in September. The news marked a midday rally on Wall Street. The Dow Jones Industrial Average ended the day with a 39 point gain. The government also announced that the nation's 39 million Social security recipients will get a 4.7 percent benefit increase in January to offset inflation. The average check will rise about $25 a month. The cap on Social Security payroll taxes will also rise. Workers will now pay taxes on the first $50,400 of income, up from $48,000.

MS. WOODRUFF: A national group today charged that poor children are not being served well by the federal government's medical assistance program. The National Association of Children's Hospitals charged that half of all poor children are denied Medicaid eligibility and are in danger of falling through the so- called "safety net". The group's report said that children are literally losing a battle with the elderly for scarce government funds. While Medicaid spending for the elderly rose almost 29 percent over the six years prior to 1984, Medicaid spending for children fell more than 14 percent.

MR. MacNeil: In the Soviet Union, a military transport plane crashed in Azerbaijan, killing 57 soldiers and crew. The victims were among thousands of paratroopers sent to the area after repeated ethnic clashes over disputed territory. In London, Britain's chief justice, Lord Lane, today quashed murder convictions against three Irish men and a woman for IRA bombings. He said they had been wrongfully sent to prison for 14 years as the result of a police frame-up. The almost unprecedented turnaround has shaken the British legal system. The four exonerated today are expected to qualify for some $400,000 each in government compensation.

MS. WOODRUFF: South Africa today got some breathing room on its foreign debt payments. A group of 14 major international banks agreed to give Pretoria more time to pay off $8 billion of its debt. Members of the British commonwealth meeting in Malaysia had planned to try to block the debt rescheduling. News of the agreement brought an angry response from some of the commonwealth members.

KENNETH KAUNDA, President, Zambia: They're blood suckers. I've no message for them to give other than to say if they don't support our efforts to bring about a change within South Africa, they are fueling the ambers of a bloody revolution.

MS. WOODRUFF: At that same meeting Australia proposed a plan to increase sanctions against South Africa if it doesn't make enough reforms in apartheid. But Britain's prime minister Margaret Thatcher immediately announced her opposition, saying more sanctions would only hurt the poor.

MR. MacNeil: The Nobel Prize for literature was awarded today to Spanish novelist Camilio Jose Thela. At 73, the grand old man of Spanish literature, Thela was the first novelist to emerge from the devastation of the Spanish civil war. His first novel, The Family of Pasquale Duarte, published in 1942, was banned by the Franco Government. But the Academy said today it was after Don Quixote probably the most read novel in Spanish literature.

MS. WOODRUFF: In outer space today the nuclear powered Galileo Space Probe began its 6 year journey to Jupiter. The probe was deployed last night from the orbiting Atlantis space shuttle. The deployment occurred on schedule over the Gulf of Mexico. After clearing the shuttle, Galileo fired a two stage rocket to send it on a path toward Jupiter. The $1.5 billion space probe is the most expensive space vehicle ever built. That wraps up our summary of the day's news. Just ahead on the Newshour, the California quake two days later and the hospital crisis facing America, today Intensive Care. FOCUS - AFTERSHOCK

MR. MacNeil: First tonight we concentrate again on the aftermath of the earthquake in Northern California. We start with a report by Correspondent Spencer Michels of Public Station KQED in San Francisco.

MR. MICHELS: With amazing speed volunteers and organizations on San Francisco sprang in to action to feed victims of the earthquake. A group called Open Hand which provides food for 600 bed ridden AIDs patients today was preparing 7000 meals for people in shelters with food donated by some of the cities top restaurants.

SPOKESMAN: You know, I am not a fireman but if I can do something and all of here can serve a hot mean may be that is something very special that day. And there it is a hot meal does make a difference.

MR. MICHELS: Volunteers atthe food program slept in a nearby park to save travel time and to avoid blacked out areas. Despite the fact that parts of San Francisco are still without power, that after shocks keep rattling the area, that the Bay Bridge is still closed this city began to come back to life again. Traffic increased and people started going back to work but things were far from normal. Throughout the day emergency vehicles raced to problems. None of them as serious as those of two days ago. Electricity came back on in most of the city. Elevators in high rises could finally being a few workers to their jobs. Building inspectors made the rounds in the hard hit Marina District. Soft fill land had given way and collapsed several buildings. What are you going to do?

RESIDENT: Right now I am going to go to a friends tonight and make arrangements to take some clothes and the things that I need right now, That is all I can do right now.

MR. MICHELS: Could you live in the building here

RESIDENT: I don't think it is safe.

RESIDENT: She doesn't think that it is safe. I think you could.

MR. MICHEL: Today more than a dozen structures were order raised but even with the devastation officials are pleased with how well the city has responded.

BILL MAHER, San Francisco Supervisor: This was our worst case. A worst case is a big earthquake on a weekday during rush hour with the City Government out of touch and we were spread all over and half the people were at the ball park and we had a hell of a time. We've come through it very well. We've got a good billion dollars in damage. We've got probably 8 to 1200 homeless people. We've got some real problems but we're managing to cope.

JAMES JEFFERSON, Fire Commission: I mean you feel helpless in a lot of respects but as the same time there is so much devastation and at the same time, you see all the agencies working together. See all the volunteers and it really gives you a warn feeling.

MR. MICHELS: From the very beginning, people started to help each other often feeling their way through the dark but the fear and uncertainty of the first few minutes remains.

RESIDENT: I ran down the street over people's bodies. There were people laying out in the street at that time and the flames had began and I could think about was getting my baby.

MR. MICHELS: Did you?

RESIDENT: Yes. to took a while. My baby had been taken to a safer area that I didn't know about and I couldn't get in to my house and so I banged and banged and screened and finally I turned and there he was in his baby sitters arms coming up the street to me.

MR. MICHELS: Those displaced from their damaged homes were getting food and shelter from the Red Cross at the Moscone Convention Center. Many of these people had been living in hotels for the homeless which had been damaged.

RESIDENT: The motel that we were staying at in Baily City we got a crack over here bed and then we got some sort of weird termites that are only supposed to live in the ground and they were flying around and they swarmed on her face and she got freaked out. So we came here because we knew there was no way we were going to go back in.

MR. MICHELS: Another shelter at Marina Middle School serves a more affluent cliental but the problems of the people were the same.

RESIDENT: Yeah. I'm kind of upset I lost everything. I don't even have my wallet.

MR. MICHELS: Is at home.

RESIDENT: Yeah. I feel fortunate. Well as the paper said I was reading the Chronicle I feel kind of helpless and kind of emotionally stressful. I just don't know what's going to happen to all these people.

MR. MICHELS: Everywhere people were finding friends they were worried about and now they had mutual problems.

RESIDENT: we haven't seen each other

RESIDENT: There is a lot going on you don't know if you have a house or not a house.

RESIDENT: We just have each other.

MR. MICHELS: Do you have a house.

RESIDENT: We hope so.

MR. MICHELS: Estimates are that power may be off in some parts of the city for weeks that the bridge will also be out for weeks but some how San Francisco is bearing up.

MR. MacNeil: Now the situation in Oakland where most of the death toll occurred when a mile and a half stretch of Interstate 880 collapsed. As many as 250 people are thought still buried in between the two levels of the freeway. Oakland Mayor Lionel Wilson talked about the difficult search and rescue operation.

MAYOR LIONEL WILSON, Oakland, California: I believe we have reached about 11 vehicles since last night. Some of those vehicles were empty didn't have passengers in them which indicates to us that those people were probably able to get off and get out of their vehicles safely. We still don't have any count in terms of what is there in terms of the bodies of people. We still don't have anything to offer in terms of specific confirmation by the coroner's office, however, we do know, as I'm certain that anyone looking at it would know that there are bodies up on that freeway. The governor has stated to me that money is of no object and he doesn't want money to stand in the way in any respect in terms of how rapidly we get to the people. The bodies that are still on there. It's been amazing the kind of response from the people all over. I have three pages of people and companies volunteering everything that you can think of from Bectel offering the heaviest equipment that they have all the way down to some of the short order places providing food.

MR. MacNeil: The city nearest the epicenter of the earthquake was Santa Cruz. And there come of the heaviest property damage occurred. Correspondent Elizabeth Brackett reports from that area.

ELIZABETH BRACKETT: In Santa Cruz, the power and horror of Tuesday's earthquake has been brought in to sharp focus by the search for one young women. 22 year old Robin Ortiz was the manager of the Santa Cruz Coffee Roasting Company. She was in the building when much of it collapsed on Tuesday. Her friends have maintained a tense vigil ever since.

ANNE GFELLER: We're so sad. She's been in there almost 2 days now and the first day they called off the search at 1 o'clock in the morning. They said that would be back at dawn and they weren't. They came back at 9. It took them four hours to shore up the walls before they started moving debris out again at 2. o'clock yesterday and then they called off the search again at 6 o'clock.

MS. BRACKETT: 25 people especially trained in searching through demolished buildings shifted through the rubble brick by brick today.

SGT. JOE HABEBE, Santa Cruz Police Dept.: Two earthquake experts came from a station in Canada came down today to assist us. They are in there now physically sorting out the bricks and we have a human chain for them to get the bricks out as fast as we can.

MS. BRACKETT: Last night the search for Robin Ortiz had been called off called off at sundown. Frustrated and angry her friends clashed with police hoping to push them in to continuing the search.

DISTRAUGHT FRIEND: Please find Robin and start God knows when tomorrow morning.

MS. BRACKETT: Police reacted with force.

FRIEND: We're trying to get a meeting with the Fire Department Chief. It is the Fire Department Chief's decision to stop digging tonight. To stop the rescue effort. When the crowd disbands, I can have that meeting. Its not a police decision it is a fire department decision.

VOLUNTEER: The bricks are ready to go at any time. And you have to pull them down one at a time and shore up something else to keep the rest of them in place.

MS. BRACKETT: As the search continued for Robin Ortiz. The rest of Santa Cruz continued to assess the damage to their town. The business community had been hardest hit with the destruction of much of the historic downtown mall. Two sharp aftershocks last night had caused further damage to the unreinforced buildings in the mall.

LARRY PEARSON, Santa Cruz Police Dept.: This Pacific Garden Mall which is on the National Register of Historic Place is our economical and commercial center. As you look at the scene there is tremendous damage but you don't see a lot of buildings absolutely collapsed. Approximately a half dozen total disintegrated . But we're facing significant demolition here. We don't know yet exactly the extent of that. That is what these engineers and structural people are here for. It's conceivable we may lose 1/3 of our buildings here and the cost of reinforcing the other remaining structure to earthquake standards is going to be exorbitant. Many people are not only going to lose not only their property but their business function. They are not going to be in business making money. We are severely compromised economically and much more so then you look now because in three months there may be a great many more holes in this texture then there are at the present time.

MS. BRACKETT: Just outside of Santa Cruze in Boulder Creek it was homes that were damaged.

KAREN MCNALLY: I'm concerned that the smaller areas, lower population along the coastal area may not get as much economic attention and assistance as San Francisco, Oakland Region, Major population centers. I did observe this in 1985, a large Mexican earthquake, Mexico City received much attention, but where the earthquake source actually was along the coastal areas, smaller populations a very difficult time in recovery and assistance.

MS. BRACKETT: Just after noon the search for Robin Ortiz ended unhappily.

MAYOR MANDI WORMHAUT: A third body has been recovered from the mall. The second body in the Coffee Roasting Company. It is the body of 22 year old Robin Ortiz. She did not suffer. You need to know that. She would have been killed instantly. A large beam fell and she never would have known what happened. So all of the assessments of the best way to proceed with this were correct.

MS. BRACKETT: So it will be many months and perhaps years before this town over comes the emotional and economic impact of last Tuesday's quake.

MR. MacNeil: Still to come on the Newshour part two of the crisis in U.S. Hospitals. Tonight intensive care units and a Roger Rossenblat Essay on Autumn Leaves. SERIES - INTENSIVE CARE?

MS. WOODRUFF: Tonight the second half of our series on hospitals in crisis. On Tuesday, we reported on the squeeze facing emergency rooms in California, where overcrowding has gotten so bad that it sometimes threatens the welfare of the patients. Tonight we look at the situation in New York City, where the problem of overcrowding is among the worst in the nation and the crisis in the emergency room spills over into the intensive care unit. Before Correspondent Elizabeth Brackett went to California to cover the earthquake, she prepared this report from St. Lukes-Roosevelt Hospital. [DOCTOR TALKING TO PATIENT]

MS. BRACKETT: Heart attack victim Jetta Kamer should have been in the intensive care unit at Roosevelt Hospital in New York City, but instead she had been in the hospital's emergency room for eight hours. Kamer was treated when she arrived at Roosevelt at 4 AM. And the ER doctors had hoped to send her on to intensive care. But as is so often the case, the ICU was full. Meanwhile emergency room doctors worked frantically to keep Wing Cho from dying of liver failure. An hour earlier, Cho had been stabilized and should have gone immediately to intensive care, but again no beds. Instead, the overtaxed nurses and doctors in ER tried to provide the same care CHO should have gotten in the ICU. Kamer and Cho were not the only ones waiting for ICU beds. Dr. Stephan Lynn, chief of the emergency department, had two more critically ill patients he wanted to move out for a total of four. How often does it happen that patients back up in the emergency room, can't get into the intensive care unit?

DR. STEPHAN LYNN, St. Lukes-Roosevelt Hospital: Throughout the country on a daily basis, hospitals are backed up. In New York City, where the problem is among the worst in the country, it is a daily routine for most of the emergency departments in New York City to have 10 to 15 patients waiting. The intensive care unit bed is probably the critical link in the system. That's the bed that is most likely to be unavailable when we particularly from the emergency department's perspective really need it. And it's that bed which fills up first and throughout the country my colleagues in the emergency department have found that the lack of available intensive care unit beds is probably the critical factor that causes hospitals to become overcrowded and patients to back up into the emergency department.

MS. BRACKETT: With so many critically ill patients waiting for ICU beds in the emergency room, patients waiting for regular hospital beds wound up in the hallways. This patient had spent 24 hours in an ER hallway.

PATIENT: A real dose of humility. Everything we hear is true.

SPOKESMAN: What is it that you've heard?

PATIENT: What a nightmare.

MS. BRACKETT: No one is immune from the nightmare. Ethyl Giles is an emergency room nurse. Yet, when she got sick, it was no different.

DOCTOR: Even you have to wait for a bed? How long have you waited?

NURSE: Since 5 o'clock yesterday afternoon.

DOCTOR: 5 o'clock yesterday.

NURSE: Yeah.

DOCTOR: You waited throughout your entire shift?

NURSE: That's right, for a bed. Hopefully they'll have one soon, I hope.

MS. BRACKETT: The hours mount for everyone who waits. How long have you been here?

PATIENT: Four hours.

MS. BRACKETT: How long have you been here?

PATIENT: Since last night, 7:30.

MS. BRACKETT: How long have you been here?

PATIENT: About 17 hours.

DR. LYNN: Overcrowding is such a common everyday practice that we've gone so far as to label spaces in our hallway so that nurses and doctors can refer to the patient in bed, hallway 4. I think we're on the verge of a major health care crisis throughout the nation. The crisis is very simple. There are too many patients and there are too few available hospital beds.

MS. BRACKETT: Dr. Lynn says the problem began to reach crisis proportions last year after building for several years. What is different now, say the experts, is that patients coming into the emergency room are much sicker.

DR. LYNN: Why are patients sicker? That's hard to say. One of the reasons is probably poverty. There are an increasing number of patients today with fewer financial resources and less access to healthcare.

MS. BRACKETT: What has the impact of AIDS and drug abuse been on the problem?

DR. STEPHAN LYNN: Substantial. That is a patient population that we couldn't have planned for and didn't expect four to five years ago when the hospital beds that we are building today were in the planning process.

MS. BRACKETT: As a result, staff at emergency and intensive care spend hours negotiating for available beds. Dr. David Finley heads the intensive care unit at Roosevelt. [DOCTORS DISCUSSING PROBLEM]

MS. BRACKETT: On the day we were at Roosevelt, Dr. Finley had hoped to move four patients out of the ICU to make room for those waiting in the emergency room. But the conditions of three of his ICU unit patients deteriorated, so by early afternoon only one bed had opened up. That meant three critically ill patients in the ER still had to wait. [DOCTOR TALKING TO PATIENT]

MS. BRACKETT: The case of Wing Cho was much more critical. Cho had begun to deteriorate rapidly. [DOCTOR WORKING WITH PATIENT]

MS. BRACKETT: ER staff hovered over him, but Dr. Lynn would rather have had Cho in the ICU.

DR. LYNN: The problem is we are not trained in the emergency department to provide critical care, we are not staffed, and we don't have the appropriate equipment.

MS. BRACKETT: Does the quality of care drop?

DR. LYNN: I think there is a significant problem in the quality of the care that we offer. However hard we try in the emergency department, we cannot provide care at the quality level that is usually provided in an intensive care unit.

MS. BRACKETT: Dr. Finley returned to the ICU to assess the situation. The reasons for overcrowding here were similar to those in the emergency room, poorer, sicker patients, AIDS, and drug abuse. But Finley had one big additional problem, the chronically ill elderly patient.

DR. DAVID FINLEY: The worst potential patients for ICU management are patients who have been characterized by either progressive, debilitating diseases, diseases for which there is no treatment and no expected recovery, and people whose hospital course has been characterized by progressive deterioration of status despite aggressive care and management.

MS. BRACKETT: And how often do those people wind up in ICU?

DR. FINLEY: Very frequently. We're seeing more and more elderly patients, and yet, they can be supported with the technology and the treatments and the aggressive management of the staff. The system is set up and designed to render treatments. In ventilatory failure, the correct treatment is ventilation. We're doing the treatments; we're prolonging their life. But sometimes survival may not be the best measure of success.

MS. BRACKETT: A critically ill patient's average length of stay in the ICU is about four days. But increasingly Dr. Finley's unit wound up with elderly patients who linger on life support for months, with no hope of improvement. Robert Ackerman, age 82, had been on a respirator for five months since developing complications following surgery for a ruptured aneurysm. While doctors gave him no chance of recovery, his children still hoped he would improve.

DOCTOR: Have you given up?

PATIENT'S DAUGHTER: No.

DOCTOR: You haven't. Why not? What's it take?

PATIENT'S DAUGHTER: Because we think he's going to get up and walk and we know in our hearts, he's not.

MS. BRACKETT: When Robert Ackerman was first admitted his children wanted everything possible done for him. Now they were beginning to think that the treatment was only prolonging his suffering. But having permitted treatment for five months, it was too late for the Ackermans to prove that the treatment against their father's wishes. So New York law now prohibited them from removing him from the respirator. Dr. Finley says if more patients and their families would talk about death, unwanted and often futile treatment would occur less often.

DR. FINLEY: More people are sensible enough to recognize that they are mortal, that we will all die. In my experience in the intensive care unit being dead is never really the issue. Patients don't mind being dead; it's how they die, it's that dying process. And I think what people need is control over their own outcomes and their own fates.

MS. BRACKETT: If patients were more involved, do you think there would be overcrowded situation in ICU's?

DR. FINLEY: I think there'd be less overcrowding. I think certainly there are patients who clearly do not want these treatments and I think that they are insightful and honest about what they do and they don't want. And I encourage people to establish clearly what care and treatment they would want under specific circumstances.

MS. BRACKETT: Elda Dambrosio had made her wishes known. Before illness, she had told her daughter she did not want to be maintained on a respirator if she had no chance of recovery. After a three week illness that caused heart, respiratory, and kidney failure, her daughter struggled to comply with her mother's wishes.

MIRELLA SERVODIDO, Patient's Daughter: I could not stand by and let her suffer any longer and so I have entered a formal request to have the respirator removed, to end this torment, to bring her earthly torment to an end. I have felt all along that we should have done this perhaps several days before this and that to not do it, I felt was a real act of conspicuous cruelty against her and against those of us who love her.

MS. BRACKETT: The decision to withdraw life support is gut wrenching even for the medical staff who must carry it out. [STAFF DISCUSSING LIFE SUPPORT REMOVAL]

MS. BRACKETT: Dr. Finley supported Mrs. Dambrosio's daughter in her difficult decision. The doctor acknowledges that such painful choices can shorten suffering in terminal cases and enable other patients to receive desperately needed care.

DR. FINLEY: In that 3 week period there have been six hospital admissions that have been blocked by her use of that bed and those resources have been applied to her in a setting in which no one really expected that she would recover or benefit. When she expires, then the patient in the emergency room will be admitted to that bed. Until she expires or until there are other beds that become available, he will be kept in the emergency room. This obviously foreshadows a very difficult night in the emergency room.

MS. BRACKETT: One of those patients waiting for a bed in the ICU would not make it. After being brought back to life twice by the ER staff, Wing Cho died. It was left to Dr. Lynn to help a young intern break the news to the family.

MS. BRACKETT: Meanwhile, Jetta Kamer was still waiting for a bed in intensive care. Hospital renovation plans call for doubling the number of beds in the intensive care unit. But the head of the IC says more beds will not solve the problem. What is needed, he says, is better management of the beds they have.

DR. FINLEY: I don't believe there is a shortage of ICU beds. I think that there is an adequate bed availability. The issue really is access. Studies have been done that suggested that a large percentage of patients are admitted to the ICU who are not sick enough to warrant that level of care and that resource investment. And another significant percentage of patients are too sick to benefit. And they think that our interest and our research should be directed to assure that when you have a limited resource, the people who benefit the most are actually the patients who have access to those resources.

MS. BRACKETT: Dr. Finley spends much of his time both on rounds in a classroom trying to teach younger staff members how to best utilize the scarce number of intensive care beds. [CLASSROOM SESSION]

MS. BRACKETT: But the man who must deal with the huge backup of patients in his emergency room every day says better management alone cannot solve the problem.

DR. LYNN: My fear is that the problem will grow substantially worse and that fear is based upon the fact that a large part of the problem is due to poverty, to AIDS, to drug abuse, to lack of staff availability, particularly nurses, and lack of hospital bed availability. None of those problems is going to be solved in the short-term future. It will take years, if not decades, before any of those problems can be appropriately resolved.

MS. BRACKETT: Fortunately, one of Dr. Lynn's immediate problems was resolved. After 12 hours of waiting, Jetta Kamer finally got her bed in the intensive care unit. But there was still one more patient waiting in the emergency room. The ER staff was dreading a busy Friday night, knowing that the ICU would not be available. Most of the staff here would have agreed with their chief, the crisis is severe and it may take many years to solve.

MS. WOODRUFF: To consider solutions to these problems of overcrowding in emergency rooms and intensive care units in the nation's hospitals, we turn now to two experts. Bruce Vladeck is president of the United Hospital Fund, a non-profit research, educational and philanthropic organization. Uwe Reinhardt is the James Madison professor of political economy at Princeton University, and a frequent commentator on American health policy. Gentlemen, we've seen, you all have just seen this report, and I understand you both have seen the report we aired Tuesday night on overcrowding in emergency rooms and now in intensive care units. I want to ask both of you if this is a pervasive problem across the country, or is it a problem that is occurring primarily in our major cities in Los Angeles and in New York City. Mr Vladeck, what is your view?

BRUCE VLADECK, United Hospital Fund: It's primarily a big city problem. There are other problems, some of them more severe in healthcare in rural areas. But one of the things that's happened in the last decade is that we've become less and less like one another from one part of the country to another. The emergency room problem is largely a big city problem.

MS. WOODRUFF: Dr. Reinhardt.

UWE REINHARDT, Medical Economist: I think the social pathology of these two cities is quite different. In New York, you have a shortage of beds and hospital capacity all around relative to the need for beds. In Los Angeles, for all you know, you have excess capacity but the shortage is driven by hospitals who close emergency rooms because emergency rooms are a conduit of patients who are uninsured. And the situations are quite different in my view.

MS. WOODRUFF: You're saying the hospitals in Los Angeles taking that action make the difference?

DR. REINHARDT: Yes.

MS. WOODRUFF: And the second question, on the intensive care units, is it the same situation, Mr. Vladeck? Is it a problem just in the big cities, or is it a problem pervasive across the country?

MR. VLADECK: The pressure on intensive care beds tends to be true almost everywhere in part because there's a vicious cycle that goes on. As we're short of nurses, the ability to get intensive nursing care on regular units gets less and less and physicians are more eager to get their patients to intensive care units which have more nurses. You then need more nurses to staff your intensive care units, meaning you steal more from the regular units, deteriorating the nursing on those regular units and creating more and more pressure to use intensive care. And that's a phenomenon that is going on in many parts of the country.

MS. WOODRUFF: Do you agree with that, Dr. Reinhardt?

DR. REINHARDT: Yes, I agree with the intensive care unit, but that's a different problem; it has to do with staffing.

MS. WOODRUFF: We heard from the doctors in the program tonight and in the program Tuesday night what various people think the causes are, but what do you think is it that lies at the core of this? Is it a mismanagement problem or is it a problem that's deeper? Is it because patients are sicker, because there's the poverty is deeper in this country for various reasons? What is it?

DR. REINHARDT: Let's look at Los Angeles. There you have a population of 25 percent of the entire population that has no health insurance at all. We the American people look to the hospitals to be insurers of last resort. That is a lunatic proposition. That could never work. Hospitals might be able to take care of 5 percent of the population being uninsured, but not 25 percent. So the real problem in Los Angeles, it seems to me, is that we do not wish to be our brother's keeper and dump this social problem into the lap of the hospitals, who couldn't solve this problem for us even if they tried.

MS. WOODRUFF: Mr. Vladeck.

MR. VLADECK: Uwe's exactly right but there's another piece to it. We've managed the remarkable feat in this country over the last decade of continuing to watch healthcare costs grow out of control while providing service to a smaller and smaller fraction of our population. We are leaving 35 or 40 million Americans who are uninsured out of the system altogether and yet, at the same time, Medicare is the fastest growing item in the federal budget other than debt service. Many states are staggering under the costs of their Medicaid programs. Businesses believe themselves uncompetitive with foreign nations because of their insurance costs going up 25 or 30 percent a year. We have a system that is profoundly out of control and is doing less and consuming more resources at the same time.

MS. WOODRUFF: And you're saying that applies to hospitals across the board.

MR. VLADECK: No. Again, situations are different. The rate of hospital cost growth in New York City, for example, is a good 50 percent than it is in the rest of the country. On average in the rest of the country hospitals are making a very modest profit or revenues slightly over cost. In New York, they're losing a significant amount of money. The specific circumstances vary from one place to another. But the general tendency everywhere is fewer and fewer people insured, more and more people having trouble getting healthcare, and at the same time a larger and larger share of our national resources going into the health system.

MS. WOODRUFF: Dr. Reinhardt, why is it worse in some places than others? I mean, obviously, big cities have more poor people who need more care, who don't have the insurance, but beyond that, what is it?

DR. REINHARDT: Well, the major driving force is the number of uninsured and the poverty level in general. If you have a city where most people have good health insurance, there really isn't a problem of healthcare and in fact, you probably there get some of the finest healthcare in the world. It is really a problem of that segment of the population that doesn't have ability to pay. And those in those same cities often who do have ability to pay are over serviced; they're getting services they don't need.

MS. WOODRUFF: And why is that?

DR. REINHARDT: Well, because you have to really blame the economics profession for it I think, my own profession. We persuaded the American consumer in the late '70s that healthcare is just like Gucci loafers, a consumption good, that patients are not sick people, they're consumers, and that doctors are not doctors, but they're providers and suppliers. When you think of Gucci loafers, you have the same problem. There's a surplus of Gucci loafers and yet some people don't have shoes. Well, that's what we've done with healthcare mainly at the behest of my profession.

MS. WOODRUFF: So we have as we saw in Los Angeles the other evening, hospitals that on the one hand have closed their door to emergency patients, but on the other end, are opening up sports medicine clinics to take care of patients who are well off?

DR. REINHARDT: That makes perfect sense to the social Darwinist leanings of the economics profession, yes.

MS. WOODRUFF: What about that, Mr. Vladeck, is that a defensible thing for hospitals to do?

MR. VLADECK: I don't know about that specific case, but people who run hospitals looking at the social Darwinists who are not only the economics profession but in many parts of government are being told that unless they can figure out new ways to get new revenue from new services they're going to go bankrupt because they're going to get paid less and less for the services they've traditionally provided well, being expected to provide an increasing volume of services to people who don't pay. I don't personally think it makes sense for a hospital that's losing money on its emergency room to open a sports medicine clinic. Hospitals have lost a lot of money on those as well. But the motives are often very, run into a set of economic realities, particularly in a place like California, where the voters keep amending the constitution to limit the amount of taxes they have to pay.

MS. WOODRUFF: If that's not the solution, let me ask both of you what is? I mean, what do hospitals do? What direction do hospitals turn to? What direction do they turn to in the next ten, twenty years to keep this problem from getting worse?

DR. REINHARDT: In the end the problem is not the hospitals' problems, but we the people have to decide whether we want to consider healthcare a private consumption good which means some people will do without and others get too much, or whether we want to view that as a social good like elementary education. So I think we should be fair to the hospitals and say our politicians and we the taxpayers have to address this problem.

MS. WOODRUFF: But how do we do that?

DR. REINHARDT: For about an additional $20 billion expenditures on top of the 600 billion we spent, most of us agree we could get rid of this problem by issuing health insurance to the uninsured, for instance, expanding Medicaid and swallowing them up. It's a trivial problem financially, it really is.

MS. WOODRUFF: But is the political will there?

DR. REINHARDT: The political will isn't there. Recently inBoston I saw a button that says, "God bless me and to hell with you." That is the problem.

MS. WOODRUFF: Mr. Vladeck, what is the solution as far as you're concerned? I mean, is that what we're talking about? Is it as simple as Congress passing legislation to insure the uninsured and then everything going to be taken care?

MR. VLADECK: I think at the same time we expand health insurance, we have to begin to address the cost of the system, but it's clear that governmental leaders and political leaders from the President through governors and state officials and so forth have basically taken the position in the last decade that the problems of healthcare for the population as a whole are not their problem. And your emergency room, on your Los Angeles piece the other night, you had the director of health and welfare in the State of California saying, we don't have enough money to ensure that everybody in the state gets healthcare, it's not our problem. As long as we can get away with that kind of political attitude, that people dying because technology we have that can save them isn't available, as long as we take the attitude that that's not our problem, we're not going to solve the problem.

MS. WOODRUFF: Dr. Reinhardt, you've advocated, I understand, the hospitals diversifying or rather the hospitals specializing, one hospital serving heart patients, another serving obstetrics and gynecology. Talk about that for just a moment.

DR. REINHARDT: We have heard about waste. Dr. Vladeck mentioned it and others. There is mismanagement in the hospital sector. Again, we've made them each into businesses. We've told them to behave like businesses, so they all want to have a wide product line. Every hospital wants to have an open heart surgery unit. That's not only inefficient, but it also kills patients, because each unit does too few surgery to be proficient in that service. So I think in the future, either the market or planning will have to drive hospitals that some specialize in heart surgery. Others may specialize in something else, so that each of them becomes more proficient, and we don't have these duplicate of facilities which are part of the cost problem Dr. Vladeck addressed.

MS. WOODRUFF: Mr. Vladeck, does that work?

MR. VLADECK: It works for heart surgery. It works for certain other procedures. It doesn't work for fractured hips, for example, which are a major cause of admission for the elderly. I think it's the after cataracts, the procedure Medicare pays the most of is repair of fractured hips. And our data are pretty convincing that whether you do 10 hip replacements at a hospital or 200 a year doesn't make that much difference in terms of cost or in terms of how well the patients do. I think the critical issue is though that on something like the heart surgery, we know that we have too many hospitals doing heart surgery. We know that it is a lucrative procedure for most of the hospitals that do it. And we have as a matter of public policy said we are going to let the market place solve that problem when in fact the experience in the market place in the last decade has made it worse.

MS. WOODRUFF: What do we do in the meantime? You both talked about we need the Congress, the federal government to realize we need to provide insurance for those who can't afford it. You've talked about how hospitals should go off in different directions. What do we do in the meantime while we see these scenes in New York, in Los Angeles, of people who clearly are not getting the care that they require?

DR. REINHARDT: Well, we have two problems. One is the problem of access for all Americans and secondly, that our cost of healthcare is too expensive, and the issue really is one of priorities. Which do you solve first? There are many, for instance, politicians who say we have to get cost under control first. Then we worry about access. I find that inhumane. I would say let's do access first, let's give everyone access first. Then we can worry about cost without the fear of getting kicked out of the club of civilized nations.

MS. WOODRUFF: Is that realistic, Mr. Vladeck?

MR. VLADECK: Again, it's a question of political realism. I don't believe that as a nation we're too poor to ensure that people who are dying of treatable illnesses get treated. There are a lot --

MS. WOODRUFF: Right now that's what's happening.

MR. VLADECK: That's correct.

MS. WOODRUFF: I guess what I'm asking again is what do we do during this period? I mean, it sounds like Dr. Reinhardt is saying these people need to be taken care of until we figure out how to pay for it.

MR. VLADECK: I think specifically the taxpayers in New York City where we are especially where we are affected by the AIDS epidemic in particular are going to bear a disproportionate cost for treatment of a variety of national epidemics because I think my fellow citizens in this city are probably unprepared to have patients dying of AIDS in the street. But we are going to be, we are going to be paying that out of local taxation. Long-term it's going to harm the economy of this community. I think this community, however, will make the choice to expand service. I don't think that's necessarily going to be true in every community across the country and I think the inequities are only going to increase until we decide that this is a problem for all of us as a nation.

MS. WOODRUFF: Gentlemen, it is a tough problem and we thank both of you for being with us. Dr. Reinhardt, Mr. Vladeck, thank you both. ESSAY - TRUE COLORS

MR. MacNeil: Finally tonight, our regular Essayist Roger Rosenblatt thinks leaves aren't the only things revealing their true colors this fall.

ROGER ROSENBLATT: Hard to know what to call a leaf's true colors. Easiest enough to say green and be done with it, a leaf being that for most of its life. But how can one be certain that the essential, the soul deep colors of leaves, are not what they become in autumn? Right now, even though the blood red, rust, bronze and gold only erupt for the shortest time. After all, other things in nature show their true colors briefly at the moment they are about to disappear. People do that. At moments of extreme fatigue and desperation when there is no retreat from cliff, one reaches into one's innards to produce the real McCoy, the creature who has shed all manners, self-deception, politics. For a statement or two, an action or two, you glow as the leaf you always were. Recently the Communist regime in East Germany showed its true colors by clubbing citizens demonstrating for political change. In Leipzig and Dresden, police with riot sticks gave it all they had until their energy flagged and peaceful protest prevailed. Nearing its end, sensing its end, Communism in Eastern Europe showed what it really is, an idea and an authority that work only by the exertion of force. In the Soviet Union proper, a report revealed that the Kremlin, not local party leaders, called out the troops to smash a democratic protest in Georgia in April. Against its own people, mainly women and children, 19 dead, hundreds hospitalized, a government used sharpened shovels and poisoned gas to assert its viability. In the end, a moment of truth, even in baseball. At bat in the top of the 9th, down 3 to 1 with two outs and Candlestick Park deep in rapacious roaring, anticipating a Giants victory in the playoffs, the Chicago Cubs came up with three singles and one more run before calling it a season. The run and the singles were meaningless as far as the final score went, but not meaningless for a club that was picked last spring to finish 3rd at best. Interesting, you are who you are. No matter how anyone tries to deny the fact, yourself, included. The Cubs would not be denied their 9th inning hits because deep down, they were scrappers, not losers. The queen of the scrappers died recently, Bette Davis, the brilliant banshee of such scenes as that in Dark Victory when she begins to go blind from a brain tumor as she plants hyacinth bulbs, and of such lines as --

MS. DAVIS: [Movie Segment] Fasten your seatbelts. It's going to be a bumpy night.

MR. ROSENBLATT: -- surrendered reluctantly to a cancer that had been detected in 1983. In recent years she also suffered a stroke but no affliction could diminish the power with which she filled a room, a theater, a camera lens. Devoured inside, she continued to make films to the end, showing exactly who she was by repeating her self conceived epitaph. She did it the hard way. Everything she said she shouted the way only confident New Englanders shout, as if to state publicly that they are definitely here until they are definitely not. New Englanders know how brief the high color season is, one week at most, more often two or three days. Then come the stiff winds, and the quick descent into winter. Still tourists pile into cars, exploding upon the region, and filling bed and breakfast inns just to spend those few days staring at the dazzle. A distant hill bulges with color, but the individual leaf seizes one's attention even more forcefully, having achieved its singular effect by arriving at a point of self-realization. At the moment one is about to leave what one has known and proceed into darkness the colors are true. RECAP

MR. MacNeil: Again, the main stories in today's news, there were strong aftershocks but no serious damage or casualties in the earthquake area of Northern California. House Speaker Thomas Foley said he'd propose as much as $2 1/2 billion in disaster relief. The Senate rejected a constitutional amendment against flag burning. The Senate also approved a bill Pres. Bush says he'll veto, funding Medicaid abortions for victims of rape or incest. Some 39 million Social Security recipients will get an average cost of living increase of $25 a month starting in January. Good night, Judy.

MS. WOODRUFF: Good night, Robin. That's our Newshour for tonight. We'll be back tomorrow night. I'm Judy Woodruff. Thank you and good night.