The opinion of the court was delivered by: ROBINSON, JR.
FINDINGS OF FACT AND CONCLUSIONS OF LAW
Plaintiffs Renaldo and William Spivey and Iva Johnson, who sued individually and on behalf of all others similarly situated, are District of Columbia residents who live near Upshur Street Clinic, are unable to afford medical care, and received services at the Clinic prior to its closing on May 20. Mrs. Johnson received care for arthritis, hypertension, and an overweight condition. William Spivey received care for high blood pressure, migraine headaches, heat exhaustion, infections and colds. Renaldo Spivey received annual check-ups from a cardiac specialist to confirm the safety of his participation in school sports, check-ups necessitated by a heart condition.
Plaintiff-intervenor Louline Green, whose claims are also representative of those of Plaintiff class members, has been receiving regular care and treatment at the Clinic for diabetes and high blood pressure, and cannot afford to pay for care.
Plaintiff Judy Murray, a certified physician assistant and a District of Columbia resident, sued in her individual capacity. She had submitted comments opposing the Upshur Street Clinic closing in response to the April 18, 1980 D.C. Register notice.
Plaintiffs' Complaint was filed on May 23, 1980, their Amended Complaint was filed on May 28, 1980.
On May 28, 1980, the Court granted Plaintiffs' motion for class certification. The class was defined as follows:
All District of Columbia residents who need, but who are unable to pay for, clinical health services, including but not limited to the health services specified in the District of Columbia Clinical Health Services Act of 1977.
The matter was tried to the Court on July 3, 7 and 8, 1980.
Defendants are the District of Columbia, Mayor Marion Barry, DHS Director James Buford, Public Health Commissioner Rosalyn Epps, Ambulatory Health Care Administrator William Washington, and TB Control Chief Hazel Swann.
I. THE CLOSING OF THE UPSHUR STREET CLINIC AND ITS IMPACT ON THE MEDICALLY INDIGENT
1. The District of Columbia has operated public health clinics for a number of years; the Upshur Street Clinic has been open since the 1950's.
2. The District has enacted laws and developed policies expanding the scope of public health care and ensuring its availability to the medically indigent. See District of Columbia Regulations, Chapter H-7, Article H-710, §§ H-7110-7111. In 1968 the Health Department established neighborhood health centers as "the crux" of a system for furnishing clinical care throughout the District. These centers are essential components of the public health care delivery system, and primarily serve the medically indigent.
3. The medically indigent are those persons who are unable to afford adequate medical care and lack third party coverage such as Blue Cross and Blue Shield.
4. The Upshur Street Clinic was, prior to its closing on May 20, 1980, in Defendants' terms "the largest and busiest neighborhood health center in the City .... It served as an indispensable component of the City's public health delivery system (and) fulfilled the goal of the District to provide available and accessible community-based health service to District residents ... of all ages, domiciled primarily in the northwest quadrant of Washington."
"to assure equitable access by all District citizens to an effective level of comprehensive outpatient health care services."
The Upshur Street Clinic played, by the District's own admission, an "integral" role in this AHCA-administered system of outpatient health care services.
6. Prior to its closing, the Clinic was located at 1325 Upshur Street, N.W., Washington, D.C., in a large five-level brick building with approximately 25,000 square feet of useable space. The clinic had approximately four waiting rooms, ten examining rooms, six nurses' offices, and a pharmacy and laboratory under AHCA auspices; additional space and facilities at the Clinic were devoted to venereal disease and tuberculosis clinical services administered by the Preventive Health Services Administration (PHSA). Two x-ray machines and one EKG machine were available at the Clinic.
7. Prior to its closing the Upshur Street Clinic was the only public medical facility in the Northwest sector which offered general medicine, obstetrics/gynecology, and pediatrics on a full-time basis.
8. The Clinic also offered specialist services in cardiology sixteen hours a week, in podiatry twenty-four hours a week, in dermatology eight hours a week, in adolescent medicine four hours a week, and in athletic screening sixteen hours a week.
9. In addition to the general medicine and specialty services listed above, the Upshur Street Clinic also housed separate venereal disease and tuberculosis screening and treatment clinics, which further expanded the range of services available. The venereal disease and tuberculosis clinics were each available on a full-time basis. X-rays were available for the diagnosis and treatment of general medical and other problems under the auspices of the tuberculosis clinic.
10. The clinic also had a pharmacy, which dispensed approximately 80,000 prescriptions per year. Prescriptions and medications were furnished free of charge to the medically indigent.
11. A separate laboratory facility at the Clinic, staffed by health screening and laboratory technicians, collected samples pursuant to doctors' instructions and forwarded the samples to an outside laboratory where tests and analyses were performed.
12. Because it provided a complete range of primary care, commonly needed secondary care, and related ancillary services, Upshur Street was a "comprehensive" clinic.
13. Prior to its closing, Upshur Street Clinic (excluding its venereal disease and tuberculosis units) had fifteen doctors, comprised of two pediatricians, two obstetrician/gynecologists, seven physicians in general medicine, one cardiologist, two dermatologists, one athletic specialist, and one adolescent specialist.
14. Described in terms of full-time equivalents (FTE), the Clinic had the following staffing pattern in calendar year 1979: 2 FTE pediatricians, 2 FTE obstetrician/gynecologists, 4.2 FTE physicians in general medicine, .8 FTE cardiologists, .2 FTE dermatologists, and .5 FTE specialists in athletic and adolescent medicine, for a total of 9.7 FTE physicians.
15. In FY 1979 Upshur Street Clinic reported 75,753 patient visits, more visits than any D.C. public health clinic facility with the exception of the D.C. General Hospital outpatient department. At a rate of 75,753 patient visits in FY 1979, Upshur Street had six times as many patient visits as Walker-Jones, the next largest Northwest clinic, and three times as many visits as Walker-Jones and the other five Northwest clinics combined. Excluding the Upshur Street Clinic patient visits for tuberculosis and venereal disease services, Upshur Street Clinic had 48,625 patient visits for FY 1979, four times as many visits as Walker-Jones and well over twice as many visited Walker-Jones as the other five Northwest clinics combined.
17. A one-week survey of users of the Upshur Street Clinic, conducted by DHS in October, 1979, confirms that most of the users of the Upshur Street Clinic are residents of Northwest Washington. Of the 643 patients surveyed, 335, or 52%, stated that the public or private health facility closest to their residence was Upshur Street Clinic. An additional 199, or 31%, of the 643 patients surveyed responded that Howard University Hospital or Upper Cardozo Clinic (operated by Community Group Health Foundation, Inc.) were the closest facilities. Since Howard University and Upper Cardozo are both in Northwest and within one and one-half miles of Upshur Street Clinic, the survey indicates that approximately 81% of the Upshur Street Clinic patients live in neighborhoods near the Clinic. It further indicates that approximately 573 of the 643, or 89% of the clinic patients surveyed live in Northwest Washington neighborhoods.
18. A 1978 DHS and Georgetown University sponsored study in which a random sample of Upshur patients were surveyed (hereinafter the Harris study) indicates that more than 75% of the patients surveyed traveled less than one-half hour to get to the Clinic. A large proportion walked or came by bus.
19. Similar findings of residential proximity were made in a 1976 DHR task force subcommittee report which found that
"An average of 92.6% of patients who attend all of these (HDR-run, neighborhood health clinics) come from the Service Area in which the clinic is located or an immediately adjacent Service Area."
20. The Court finds that a sizeable majority of Upshur Street Clinic patients live in the Northwest neighborhoods near the Clinic.
21. Several of the Northwest neighborhoods served by the Upshur Street Clinic, particularly Service Area 7, have a high percentage of persons living in poverty, and high rates of infant mortality and serious communicable diseases.
22. The Upshur Street Clinic was the principal source of health care for medically indigent residents of Northwest Washington, D.C. The District of Columbia was not able to provide the Court with an estimate of the number of medically indigent patients who were served by Upshur Street Clinic prior to its closing, because it has not systematically compiled records from which even the approximate number of medically indigent Upshur Street patients could be ascertained. At trial witnesses for both Plaintiffs and Defendants acknowledged that Upshur Street Clinic had been an important source of services for medically indigent patients.
23. The 1978 Harris study revealed that approximately 37% of Upshur Street patients were "self-pay" (i. e., did not list third-party coverage) and an additional 30% of the patients were of unknown pay status. A substantial percentage of "self-pay" patients are medically indigent. Willie Mae Watkins, for example, a former Upshur Street patient, testified that she was billed, couldn't afford to pay the bills, but was still given care and treatment.
24. The Court finds that a substantial but undetermined number of former Upshur Street patients are medically indigent. The Court further finds that as a public health clinic, Upshur Street was a major source of care for medically indigent persons.
II. IMPORTANCE OF COMPREHENSIVE CARE AND GEOGRAPHIC ACCESSIBILITY
26. The availability of a broad range of necessary and related medical services at geographically accessible locations increases the likelihood that patients will use the facility, both for preventive and remedial care.
27. The availability of this range of services at one location also increases the likelihood that patients can and will obtain follow-up tests (i. e., x-rays), examinations (i. e., by specialists), and medications.
28. Upshur Street Clinic had the highest utilization rate of all D.C. public health clinics with the exception of the D.C. General Hospital outpatient department. This high utilization rate was due in large part to the fact it offered geographically accessible comprehensive services.
29. Defendants publicly acknowledged the importance of providing comprehensive services in geographically accessible locations and reducing fragmentation in its 1976 task force report on outpatient health delivery in D.C. The members of the task force specifically recognized that the provision of more fully comprehensive health clinics would maximize both patient utilization and the effectiveness of public health care delivery.
30. This recognition of the importance of comprehensive services in providing adequate public health care has been incorporated into the Department's own definition of its public health responsibilities. Reorganization Plan No. 2, approved by the D.C. Council Human Resources Committee on February 16, 1980, requires the Ambulatory Health Care Administration to "promote a high-quality and cost effective system which emphasize(s) coordinated and comprehensive care to the patient." Organization Order No. 25 similarly states that the mission of AHCA is "to assure equitable access by all District citizens to an effective level of comprehensive outpatient health care services."
31. The availability of comprehensive health services in geographically accessible locations is particularly important in assuring adequate care for the elderly, the disabled, and those who must rely on public transportation. In this respect, the range of services ...