提醒：

字多勿入。純粹紀事，無關國家大事。

我算昰吃資本主義的奶水長大，堅信自由市場和看不見的手，主張政府越小越好，希望Taxes and Regulations越少越好。在美國，記憶中我投過三次總統選票，前兩次都投給共和黨－－慚愧的說，我就昰連續兩次支持小布希的那個笨蛋，主要的原因就昰前面那些經濟主導的理念；我相信私有化經營能產生最大效益，共和黨的小政府和自由經濟比較符合我根深地固國家功能。尤其昰經歷過台灣政治發展的洗禮，知道什麼昰白色恐怖，我對政府存有強烈的不信任，所以更不能接受民主黨主張龐大政府的構想。

大體說來，我算昰經濟上走共和黨的自由路線，但社會政策上，我傾向民主黨的開放路線。過去，為了選擇小政府，儘管我相信女人對自己的身體應該有自主權（Pro-Choice)，儘管我贊成同性戀有權結婚，享受接受法律給予的婚姻福利和保障，甚至贊成＂醫療性的合法使用大麻＂和開放胚胎幹細胞研究(Stem Cell Research)，我還昰投給反對這些議題的保守共和黨。

這次，我投Obama，並不表示我開始信任政府，也不表示我贊成保守的經濟主義或保護的經濟市場，只昰這次我除了考慮經濟和社會這兩大項議題外，還加入新任總統極有可能面對美國聯邦最高法院大法官(The U.S. Surpreme Court Justice)的任命。

美國最高法院有九位大法官，一般來說，其中四位（John Paul Stevens，Ruth Bader Ginsburg，David Souter，Stephen Breyer）傾向自由(Liberal)，四位（John G. Roberts (Chief Justice)，Antonin Scalia，Clarence Thomas，Samuel Alito）傾向保守(Conservative)，一位(Anthony Kennedy)走較中間路線，投游離票。這九位終身職的大法官，七位昰由共和黨任命－－小布希任內任命了大法官Roberts和最年輕也最保守的Alito（58歲）。據多數人觀察，最老也昰最自由派的大法官Stevens現年88歲，可能在新任總統任期內退休，另外大法官Gingsburg(75歲)在未來四年內退休的呼聲也很高。此外，中間派大法官Kennedy和非常保守的大法官Scalia現年72，也有可能在總統任職的四年裡離職。所以新任總統，在任期內，最保守的估計昰任命一位大法官(取代大法官Stevens)，最有可能昰任命兩位(取代Stevens and Ginsburg)，最＂令人不安的推測＂ （"unsettling scenario" ）昰新任總統連任後再任命屆時直趨80歲的Scalia和Kennedy的兩位大法官。

雖然聯邦大法官每年裁決的案件不多，但美國隨著社會發展而產生的＂重要＂議題，經由法律訴訟程序最後多送到聯邦最高法院大法官庭上，由大法官裁決。近年來美國對法庭裁決標準有兩種不同主張，一昰＂Strict Constructionism＂，就昰根據法律條文嚴格釋義，法官不另作闡述應用；一昰 "judicial activism"，法官以個人的觀點來解釋引申法律條文，較易推翻前例。後者，以法案立法，被嚴格釋法派批評為在法庭立法(Bench-made laws)，忽視並侵權參眾兩院的立法功能。

美國走的昰英國Case Laws路線，和歐日大陸法以法條為主的系統不同。個人蠻喜歡Case Laws的系統，因為前例可以援，可以辯論，可以推翻，隨著時代改變而有新面目。個人發現，這種Case Laws比較會激發出許多Brilliant Legal Minds－－老昰討論Codes，多無聊啊。或許有可能：儘管有法在前，但吵贏的人贏，而使得英美訴訟大興，律師人民皆好訟。話雖如此，這不表示我反對嚴格釋法的主張，我的態度一貫：立法有一定的程序，人民將意見反應給選出來的國會代表，國會代表根據人民意願立法。如果國會議員不能適當代表表達民意，下次就不要選他／她。昰的，我對民主法治的運作有很大的信心。

一般來說，較保守的法官走嚴格釋法路線－－小布希總統任命的兩位大法官就昰嚴格釋法主義者。如果這次又昰共和黨當選總統，未來的最高法院就可能偏向嚴格釋法主義。拿＂同性戀結婚是否合法＂為例，目前各州法律不同，尤其昰加州這次選舉結果讓前不久還合法化的同性戀婚姻又變成不合法化，這議題很有可能會送到大法官面前請求裁決。若多數大法官以嚴格釋法來看這問題，可能的結論昰：加州人民多數決定同性戀婚姻不合法，亦當如昰裁決。可昰若有較多的自由派大法官坐庭，他們就比較願意找資料援前例，應社會需求而闡述法律，訂下新例；很多屬較＂自由＂(Liberal)的案例，就昰這樣裁定的。如墮胎名案Roe vs. Wade，就昰最高法院大法官裁議，女子墮胎昰受到美國憲法隱私權的保護；認定墮胎昰違法的州法，違反了美國憲法增修條文第14條裡根據Due Process Clause授予個人的隱私權。（... most laws against abortion in the United States violated a constitutional right to privacy under the Due Process Clause of the Fourteenth Amendment.　馬的，找中文法律專有名詞還真麻煩。)　

美國制憲和修訂增修條文時昰絕對沒有考慮到＂墮胎＂這種事的，憲法裡自然不會明文規定「墮胎屬個人隱私權，應受憲法保護。」嚴格釋法主義者因為憲法沒交代，就不會如此解釋憲法。

這任的總統可能任命一到四位大法官，可能會改變最高法院的「自由」對「保守」平衡度，因此對未來美國社會議題(Social Issues)的裁決和發展有重大影響。當然，表面上大家都會說，希望總統以持平公正的心來任命大法官；但連McCain在總統辯論中都說，我不會考慮一個和我信念不同的大法官（大約類似如此，不昰Verbatim quote.)　還好Obama昰哈佛法學博士，教了十年美國憲法，對這些議題應該有深刻的了解，也讓人相信他會作出令人信服的決定。

聯邦最高法院大法官任命很重要，但昰許多上訴法庭(Courts of Appeal)的法官也面臨汰換。這些法庭比聯邦最高法院更頻繁地面對處理人民的訴訟糾紛，產生的影響力更直接。這次的新任總統，對這些法庭法官的任命，馬上可以塑造法律新風格。詳情請看下面新聞剪貼。

個人雖然不喜歡龐大的政府機構和保護的經濟市場，但昰更不願活在拉襟制肘的保守社會裡。在這個美國最高法院可能換血的轉捩點上，我把我這一票投給民主黨。

我這種以社會議題為考量的選民不昰少數，以最高法院任命為最重要因素而投票給Obama的，57:41。（請看下面新聞剪貼。）

此外，雖然不願多繳稅，但因本戶收入沒那麼高，大概在Obama的稅制下不會失血太多，反而可能因其他激勵方案而受益。

再者，近來發現美國的醫療消費簡直昰貴到沒有人性！許多人辛苦積蓄一輩子，老來生場病就傾家蕩產申請個人破產。美國多窮人的城市，如底特律，最近連唯一的非營利性大醫院都搬離了！住在市裡的窮人若生病或受傷，根本沒有就近可就診的醫院。這昰非常失敗也昰非常可怕的現實。不過，私有化和自由競爭讓賺不到窮人銭的醫院不願再在窮人市區開門營業，新的建設也往有銭的郊區投資。能怪這些營利掛帥的醫院嗎？私有化的激勵因子就昰為達最高利益啊！可昰連接受聯邦政府財援的非營利性醫院都搬離窮人，就表示美國的醫療保險真昰有嚴重的問題。

因為對美國現有建保制度的不滿意，我改走社會主義路線，看看民主黨昰否能提供非以營利為目地的醫療服務。

對美國健保有興趣的，可以看看Michael Moore導演的紀錄片"Sicko"。

當然，這昰我這次投Obama的重要理由。這和Obama昰不昰黑人有沒有關係呢？如果Sarah Palin昰黑人，而且還昰黑女人，我也昰不會投她！這樣說，有種族歧視和性別歧視嗎？沒有。有愚笨歧視。

後記：

很早就想把這次美國選舉的一些想法寫出來。看了邪惡經濟帝國的「為什麼不投Obama？」，一時有感就整理出來。或許很多人以為美國人昰因種族情緒而投Obama，但昰我知道的許多人在考慮候選人時，思考的不只昰經濟議題，還有社會、健保，和宗教，以及如我持以為重的大法官任命議題。當然很多選民昰因為種族情結而投Obama，但昰美國總統的權控管理事項不計其數，每件事項都可以成為選民是否支持某位候選人的動機－－例如，保守的宗教態度昰共和黨的重要支持票源。我想說的昰，投不投某個候選人，可以很簡單的歸因於種族，但也不都昰那麼簡單的只有平板的黑白。

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Now let’s look to the Supreme Court. Right now, seven of the nine Justices were appointed by Republicans; the oldest members are the most liberal and the youngest are the most conservative. It is very likely that Justices John Paul Stevens (age 88) and Ruth Bader Ginsburg (age 75) will retire within the next four years. “Swing” vote Justice Anthony Kennedy and Antonin Scalia are both 72. So Obama should have an opportunity to appoint several new Justices.

http://www.cbsnews.com/stories/2008/11/05/opinion/courtwatch/main4574874.shtml

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Ginsburg is 75 years old, Justice John Paul Stevens is 88. Breyer and Justice Antonin Scalia are 72. Justice David Souter is 69. It is expected that Obama will get to appoint two Supreme Court Justices and Kyl said as many as four judges to the influential U.S. Court of Appeals for the District of Columbia. That federal appeals court sometimes produces future Supreme Court nominees.

http://www.bizjournals.com/phoenix/stories/2008/11/03/daily77.html

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Federal judgeship openings await Obama

By MARK SHERMAN – 8 hours ago

WASHINGTON (AP) — President-elect Obama will enter office with an immediate opportunity to begin shaping the federal courts by filling four dozen openings on trial and appeals courts.

Federal judges, with lifetime appointments, can be a president's most enduring legacy. President Bush receives uniformly high marks from Republicans, even those who criticized him on other issues, for his selection of Chief Justice John Roberts and Justice Samuel Alito.

Public attention typically is focused on the Supreme Court, where five justices are older than 70. Speculation about a possible opening centers on 88-year-old Justice John Paul Stevens, but any retirement is unlikely before the summer, if then.

By contrast, 14 seats are open on appeals courts or will be by the end of January. Democratic appointees are a majority on only one of the 13 federal appeals courts, the San Francisco-based 9th U.S. Circuit Court of Appeals.

These are the courts that as a practical matter have the final say on everyday issues that affect millions of people because the Supreme Court accepts less than 2 percent of the cases appealed to the justices.

"Most of the action is in the lower courts, from labor and employment law to civil rights to punitive damages to affirmative action and how the death penalty is administered," said Ilya Shapiro, senior fellow in constitutional studies at the libertarian Cato Institute in Washington.

The traditionally conservative 4th U.S. Circuit Court of Appeals, based in Richmond, Va., is the first court on which Obama can change the balance of power quickly. It has four openings and is divided now between five judges appointed by Republican presidents and five named by Democrat Bill Clinton.

Covering Maryland, the Carolinas and Virginia, the 4th Circuit hears a large share of national security and intelligence cases because Virginia is the home of the Pentagon and the Central Intelligence Agency.

Shapiro estimates that within four years, Obama can name enough judges to give Democrats majorities on nine of the 13 appeals courts.

Nan Aron, president of the liberal Alliance for Justice, has complained that Bush appointees have been more likely to rule in favor of executive authority, businesses in their disputes with workers and consumers, and limiting access to the courts.

Judges appointed by Obama can be expected to side more often with "workers, consumers, homeowners, women and people of color who were discriminated against," Aron said.

With Democrats holding a solid majority in the Senate, at least for the next two years, Obama is not likely to have trouble getting his appointees confirmed. Bush and Clinton both struggled with the Senate when it was under the control of the opposition party for parts of their presidencies.

Some of the openings have existed for years, a result of Senate rules that give individual senators wide power to block nominees. In other cases, Bush has moved slowly to fill openings or Democrats have objected to the conservative backgrounds of his choices.

Among the appeals court seats to be filled are those vacated by Roberts in 2005 and Alito in 2006 when they were elevated to the Supreme Court.

Even when Clinton had a Democratic Senate majority in his first two years as president, he was slow to nominate judges, although an unexpected early retirement announcement by Supreme Court Justice Byron White partly accounted for the delay in moving other nominations.

The incoming Obama administration is unlikely to repeat that mistake, in part because of the experience of high-ranking officials beginning with Vice President-elect Joe Biden, a senator from Delaware who served 32 years on the Senate Judiciary Committee.

Biden was chairman of the committee, which reviews judicial appointments, during the explosive debates over Supreme Court nominees Robert Bork in 1987 and Clarence Thomas in 1991. He led the committee for eight years and was its top Democrat for eight more during Democratic and Republican presidencies.

"This presidential team has more experience and expertise on these issues than any in history," said Doug Kendall, president of the liberal Constitutional Accountability Center. "You'd expect this is something they will get right."

Conservatives tried to make a campaign issue of the potential for Democrats to remake the federal judiciary under Obama after Republican administrations since 1981 installed many young, right-leaning judges.

Even on the Supreme Court, where the justices often divide 5-4 on ideologically charged issues, seven justices were appointed by Republicans.

The court's two oldest justices, Stevens and Ruth Bader Ginsburg, 75, are considered the most likely to retire soonest, yet both have hired law clerks for the next court term that begins in 11 months — a signal they might be planning to stay.

Curt Levey, executive director of the conservative Committee for Justice, is worried about the prospect of two Obama terms. He has said that there is a 75 percent chance that Obama eventually will have the chance to replace not only several liberal justices, but also the older conservative justices as well and create a liberal majority.

He pointed out that in this "unsettling scenario" Justices Antonin Scalia and Anthony Kennedy both would turn 80 in the final year of a hypothetical second Obama term and one or the other is likely to retire by then.

http://ap.google.com/article/ALeqM5jMU8pZTTBJh7FF0jgF3WNjxztQAgD94AR6JG0

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Exit Polls Say Supreme Court Was a Winning Issue for Obama

Exit polls from CNN provided more evidence that the Supreme Court was a winning issue for Senator Barack Obama. Data from the nationwide survey of voters shows that those who called the Supreme Court a factor in their vote broke for Obama 53 to 45. Voters who called future Supreme Court appointments the most important factor went for Obama even more strongly -- 57 to 41.

People For the American Way President Kathryn Kolbert issued the following statement:

http://site.pfaw.org/site/PageServer?pagename=media_2008_11_exit_polls_say

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High Court: Obama Chance To Appoint Supremes

[Election 2008]

President-elect Barack Obama may have the rare chance to appoint two judges to the Supreme Court, giving the former law professor an opportunity to make a further lasting mark on American society.

Already observers are weighing in on what Obama could do in the key decision on replacements for the highest court in the land.

"It is quite likely he would choose a woman or a minority," said Nathaniel Persily, a law professor at Columbia University in New York.
"If he could find a Hispanic woman, that would be ideal, the best choice," he added.

Only two women have served on the Supreme Court, and two African-Americans have succeeded one another in the same seat, but never has an judge with a Latino background been appointed.

Hispanics are an ever-growing demographic in the United States, making up 15 percent of the population. But beyond the race or sex of the candidate, observers are gearing up for appointments of politically progressive judges to the bench to replace the older liberals sitting on it today.

John Paul Stevens, appointed by president Gerald Ford, is 88 years old, and is expected to resign soon. The nine justices are appointed for life.
Widely considered to be on the liberal side of the court, Stevens' replacement with another liberal would maintain the bench's fragile balance.

Currently four conservatives, four liberals, with the moderate Anthony Kennedy holding the middle ground, compose a balance Obama is expected to sustain.
Ruth Bader Ginsburg, 75, appointed by president Bill Clinton, is another liberal lifer also expected to resign within Obama's first term in office.

During Obama's campaign the Democrat hinted at what he expected of his appointees, and certainly could surprise conservative commentators expecting him to name someone more radical to the post.

"His pick might be radical, not in the ideology but in the background," noted Persily. Obama could pick someone who has not made a career in the judicial system, for example a politician or law professor, he added.

The president-elect has said he would take his own experience into account in making the decision. "I taught constitutional law for 10 years and when you look what makes a great Supreme Court justice, it's not just the particular issue and how they rule but it's their conception of the court," said Obama in a interview during his campaign.

Traditionally the two major parties, Democrats and Republicans, have split firmly on their judgment of what the Supreme Court can and can't do for the evolution of American society.

Republicans have forcibly lobbied for judges who strictly adhere to the constitution, and criticized Democrat appointees who attempt to advance societal norms in a way they call "legislating from the bench."

A slew of controversial issues such as gay marriage, abortion rights, gun ownership, the death penalty, privacy and the Internet are all likely to resurface in coming years.
Many in the weakened Republican party fear the more liberal judges could make sweeping changes in law that could serve as precedent throughout the nation. But in the hubbub surrounding Obama's projected appointments, his friend Cass Sunstein, a preeminent American legal scholar at Harvard University, Massachusetts -- where Obama himself studied -- noted a fact often overlooked.

"The first thing to know about Obama, which hasn't gotten sufficient attention, is that he is himself appointable to the Supreme Court," Sunstein said. "He is a constitutional specialist who has taught for many years. There's a guarantee that we'd get someone of the first intellectual rank."

"Not Harriet Miers," he added, referring to the ultra-conservative lawyer nominated by President George W. Bush, and who was withdrawn when criticized across the political spectrum for never having served as a judge and being ill-prepared and uninformed.

Copyright © 2008 Agence France Presse.

http://blackstarnews.com/print.php?a=5084

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Nonprofit Hospitals Leave The City for Greener Pastures

OCTOBER 14, 2008

DETROIT -- Ascension Health, the country's largest nonprofit hospital system, says its mission is to serve all, "with special attention to those who are poor and vulnerable." But in this city, where one in four people don't have health insurance, it's become harder for the poor and vulnerable to find Ascension.

Last year, Ascension's local subsidiary closed Riverview Hospital, the third hospital it has shut down in Detroit in the past 10 years and the only hospital that remained on the city's blighted east side. Meanwhile, 30 miles away, in a suburb of multimillion-dollar homes, Ascension is opening a new $224 million hospital.

View Interactive

Dwindling Options in Detroit

Of the 42 hospitals in the city in 1960, fewer than 10 are left. See a demographic breakdown of Detroit, a map of the city's open and shuttered hospitals, and a look at Ascension's system.

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Ascension's approach to the Detroit market is an increasingly common strategy among nonprofit hospital systems: Close money-losing facilities in poor areas where a large share of patients are uninsured, and build or refurbish hospitals in affluent places where people have private insurance coverage.

Nonprofit hospital systems have shuttered facilities from Los Angeles to Chicago to Newark, N.J., while spending billions on suburban expansions. This all comes as large nonprofit chains have been enjoying some of their most prosperous times ever.

Net income at Ascension, which owns 67 hospitals located mostly in the Midwest, South and Northeast, nearly tripled to $1.2 billion between 2004 and 2007 thanks largely to investment gains. With financial markets struggling over the past year, Ascension reported net income of $351 million for the year ended June 30.

Shutting down unprofitable operations and expanding profitable ones is a common business maneuver, but nonprofit hospital systems aren't ordinary businesses. They're required to provide benefits to their communities, such as free care for the indigent, in exchange for the billions of dollars in annual tax exemptions they receive.

Ascension, which is affiliated with the Roman Catholic Church, says its more profitable subsidiaries can't be used to subsidize those that are struggling. "Such an approach would mean that needs in other communities may not be met," says Ascension spokeswoman Trudy Barthels. The 38 subsidiaries, which Ascension calls "health ministries," operate with a large degree of independence and have to be "self-sustaining," she says. Ascension adds that it ties how much capital it allocates each subsidiary, in part, to its profitability.

St. John Health System, Ascension's Michigan subsidiary, says Riverview lost $16 million in 2006, just before it announced the closing. Uninsured patients were using Riverview's emergency room for non-emergencies -- an expensive and inefficient way to deliver routine care, says Robert Hoban, St. John's chief strategy officer. The neighborhood's real need, he says, is not for a hospital but for more primary-care doctors. He says St. John is studying ways to provide more of that kind of care there.

 

Abandoned Patients Search for Care

3:39

Catering mostly to the poor and elderly, Detroit Riverview was the only hospital open on the downtrodden eastside of the city, but shuttered its doors recently. Now the hospital's former patients search for a new hospital to call their own. This, despite the former owners of the hospital opening a new facility in affluent Novi, Mich. WSJ's Barbara Martinez reports. (Oct. 14)

But critics of the closure, including neighborhood residents and former employees, say shutting down Riverview had the effect of driving doctors away. Of the 50 doctors who worked in office buildings on the Riverview campus, at least a third have left or cut back their office hours since the hospital closed, including all but one of the pediatricians and the sole oncologist.

Malaz Alatassi, an internal-medicine doctor who had office hours once a week at Riverview, has since cut down to twice a month and is considering leaving the area for good. "The message patients got was that all doctors have left," said Dr. Alatassi. "It was a bad thing for the community. I feel bad giving up my patients."

St. John officials say that there hasn't been a large-scale exodus and that they are finalizing negotiations to add another primary-care doctor to the campus.

Ascension traces its roots to 17th-century France, where a group of nuns known as the Daughters of Charity traveled from city to city to care for the poor. In the early 1800s, the order found its way to the U.S., creating one of its first hospitals in a three-room log cabin in St. Louis.

In 1999, the Daughters of Charity National Health System and the Sisters of St. Joseph Health System merged to create Ascension, a nonprofit giant with facilities in 20 states and the District of Columbia.

Many Ascension meetings still begin with a prayer and nuns hold some management roles. Ascension is also a well-oiled money machine with sterling credit ratings. Its cash and investments totaled $7.3 billion for the year ended June 30, including about $1 billion restricted to self-insurance trust funds or limited by donors for specific uses or to be maintained in perpetuity. Ascension's chief executive, Anthony Tersigni, earned $2.4 million in total compensation in 2006, according to the hospital system's latest filing with the Internal Revenue Service. Ascension declined to provide more recent compensation figures.

Ascension spent $320 million on charity care in its hospitals in the year ended June 30, or 2.5% of its patient revenue -- the highest percentage among the nation's five largest nonprofit hospital systems. But its St. John subsidiary devotes a much smaller percentage to traditional charity care, with 0.8% going to it in the 2008 fiscal year.

Ascension and St. John say their traditional charity care numbers don't take into account all the other money they spend on helping the poor in the community, such as health education, writing off bad debts and their losses on Medicaid, the government health-insurance program for the poor.

A St. John spokeswoman said it's unfair to compare St. John's figures to Ascension's because more patients in Michigan qualify for Medicaid than some of the other states where Ascension operates. In those states, more people receive charity care because fewer people are eligible for Medicaid.

Before its closing, Riverview was one of the few remaining hospitals in the Detroit city limits. Of the 42 hospitals that dotted this 139-square-mile city in 1960, only four are now left. At the same time Detroit's hospitals have dwindled, its number of uninsured has grown. An estimated 200,000 of the city's 800,000 residents have no health insurance.

Located in one of Detroit's poorest wards, Riverview sits among empty buildings on East Jefferson Avenue, a thoroughfare sprinkled with subsidized senior housing, empty and overgrown lots, partially burned homes, and graffiti-stained shops.

Even in a struggling city, Riverview's neighborhood stands out for its abysmal statistics: Thirty-four percent of the population lives below the poverty line, infant mortality is more than double the national average and the rate of AIDS deaths is five times higher, according to Richard Lichtenstein, an associate professor at the University of Michigan's School of Public Health. Its poor patient base made Riverview a perennial money-loser.

In 2003, St. John executives campaigned to persuade local regulators to let it build a new hospital in the wealthy suburb of Novi (pronounced no-vie), 30 miles to the northwest. The new facility's profits, they said, would help ensure the survival of St. John's operations in Detroit by subsidizing their losses.

"We are very, very committed to staying in Detroit," St. John's Mr. Hoban said at a public hearing on the new hospital plan, according to a transcript. "We wouldn't be here today if we weren't committed to staying in Detroit."

Approval for the Novi hospital was granted. That year, St. John shut down its hospital in northeast Detroit, reducing its presence in the city proper to Riverview and St. John Hospital and Medical Center. St. John had already closed another Detroit hospital, Saratoga Hospital, in 1998.

Mr. Hoban says today that even with the closure of those hospitals and Riverview, "we still have the same number of beds per population" in the city after a recent expansion of St. John Hospital and Medical Center.

Riverview continued to be a drag on St. John's financial performance. Nearly 50% of its patients were uninsured or on Medicaid and another 42% were on Medicare, the federal program for the elderly. Unlike Medicare, Medicaid reimburses hospitals at much lower rates than private insurance plans and often not enough to cover costs.

In 2006, Dr. Cheryl Gibson-Fountain, Riverview's former chief of staff, says she was told by St. John that the hospital could not afford the less than $5,000 Riverview was planning to spend on its annual health-and-immunization fair. The point of the fair was to screen area residents for early signs of disease. A spokeswoman for St. John said the hospital participated in other health fairs.

Even as it eliminated the fair, St. John spent $9 million in design and architecture fees for its new construction projects in the year ended June 30, 2006, according to its IRS filings.

In February 2007, a potential lifeline materialized for Riverview. St. John officials were in talks with Michigan State University about making it one of the university's teaching hospitals, Riverview's president told employees in a letter. Under the proposed deal, the state would have taken ownership of the hospital with St. John receiving a fee to manage it. But the deal fell through when Michigan State chose to link up with another hospital.

"We were looking for teaching space for our students," said Randy Hillard, the university's associate provost for human health. "They wanted to give us the whole hospital, and we needed to pay them a $10 million management fee on a hospital that was losing millions of dollars."

St. John closed Riverview in June 2007. That year, St. John paid then-Chief Executive Elliot Joseph $1 million. Mr. Joseph defends the closing of the hospital, pointing out that the population of the metro areas had shifted from the shrinking city to the growing suburbs.

"At the time we closed Riverview, the state of Michigan said that there were an excess of 1,200 hospital beds in the city of Detroit," Mr. Joseph said through a spokesman. "We believed, accurately, that the best way to improve the health of the community in the Riverview area was by helping people establish relationships with primary-care physicians."

Shortly after Riverview closed, St. John's critics seized on renovations at the system's lone remaining city hospital as a symbol of their anger. St. John moved the lobby of St. John Hospital and Medical Center to overlook the wealthy, almost exclusively white suburb of Grosse Pointe Woods rather than Detroit, which it had faced for more than 50 years.

William Anderson, who was director of medical education at Riverview, says he believes St. John was saying, "We do not want to be in Detroit where there are so many poor, black people."

St. John denies that race and wealth had anything to do with it; the change was dictated by simple geography. The lobby-moving project was part of a $163 million upgrade to the hospital that added 144 private-room beds and more parking. Maureen Petrella, a St. John spokeswoman, says the expansion was added "to the north part of the property because that is the only space that was available on this landlocked site." Patients can still enter the Detroit side of the hospital.

To ease the impact of Riverview's closure, St. John maintained a bare-bones emergency room there for 12 months. The hospital's ER had always been bustling, handling 30,000 patient visits a year.

In February, a 60-year-old barber named Alfred Gaut was on his routine exercise walk in nearby Belle Isle Park when he was shot in the leg by teenagers playing with a gun. The police took Mr. Gaut to the shrunken Riverview ER, his daughter and two of his sisters say. Mr. Gaut, who was on Medicaid, was told he had flesh wounds and sent home with crutches and painkillers, the family says.

Mr. Gaut had been training to become a barber instructor. When he didn't show up for a ceremony at which he was to receive his instructor's license two weeks later, his family and friends went looking for him. They discovered his badly decomposed body in his apartment. The medical examiner's office listed the cause of death as "indeterminate."

Tia Gaut, Mr. Gaut's 38-year-old daughter, wonders if things might have turned out differently if there had been a hospital to admit him. "I want to know, why did they release him?" she asks.

Ascension and St. John declined to comment about Mr. Gaut, citing patient-privacy laws. But Ascension notes that every 52 seconds one of its hospitals nationwide treats an uninsured patient, and it provides care for many Medicaid patients.

St. John shut Riverview's ER for good on June 30. It's now an "urgent care" center only equipped to handle small emergencies such as cuts or burns. Unlike full-fledged emergency departments, urgent-care clinics aren't required to treat all patients regardless of their ability to pay.

A sign at the reception desk reads: "Attention all Riverview urgent care patients: There is a $50 charge if you do not have insurance." Ms. Petrella says patients who say they can't pay can "request free care or installment payments." St. John wouldn't say how many people request such accommodations nor how many get them.

Sister Mary Ellen Howard, the executive director of the Cabrini Clinic, a free clinic located just a few miles away that treats about 1,600 uninsured patients, says the health-care situation in Detroit is desperate. Even before Riverview closed, her clinic periodically limited the number of new patients it accepts. Another nearby free clinic for the uninsured says it continues to turn away about 30 callers a day looking for help.

A few months ago, Sister Howard met with Cynthia Taueg, vice president of community health for St. John, to ask if she could send a few of her uninsured patients to a St. John hospital for minor procedures or surgery. The Cabrini Clinic operates only with volunteer family-medicine doctors. The nun says she was turned down. "We're doing enough already," she says Ms. Taueg told her. St. John and Ascension donated $43,000 to the Cabrini Clinic last year.

In an email, Ms. Taueg said Sister Howard's account of the meeting "is not entirely accurate," but she didn't respond to subsequent emails and phone messages asking her to elaborate. Ms. Petrella says St. John only makes its specialists available to uninsured patients within its own network of affiliated hospitals and clinics "due to limited resources."

While East Detroit adjusts to the reality of not having a hospital, Ascension's state-of-the-art Providence Park Hospital opened last month in Novi with private rooms that feature flat-screen televisions and large windows for viewing what the St. John Web site describes as "green space, wetlands, foliage and wildlife habitat" on a campus "rich in natural beauty."

Write to Barbara Martinez at Barbara.Martinez@wsj.com