By Hillel Aron
By Joseph Tsidulko
By Patrick Range McDonald
By David Futch
By Hillel Aron
By Dennis Romero
By Jill Stewart
By Dennis Romero
|Photo by Virginia Lee Hunter|
The Timescolumnist (this was more than a year ago) was trying to prove how much East Los Angeles needed the largest possible new County USC Medical Center. So he went down to a clinic adjoining the old hospital and spoke to some people standing in line to get inside. They said: If only the county would expand the medical center — a.k.a. General Hospital — to its maximum 750 beds, there wouldn’t be a long wait.
The columnist, needless to say, agreed. He thus got it all wrong, just as many others have, before and since. For a century, big hospitals symbolized urban public health care, just the way battleships symbolized national strength. They were monuments: One protected our health and the other guarded our shores. It often seems that simple even now, when most public health care comes from clinics. This false assumption has had a dramatic effect on our health services.
Which brings us to the infamous Los Angeles County Medicaid-waiver issue, which is currently threatening the level of health care offered by this county’s Department of Health and Human Services (DHHS).
Nowadays, health officials resist the costly option of putting people in hospital bed care. They prefer treating patients in clinics and then sending them home. The Timescolumnist missed the basic truth: If General Hospital were expanded at huge cost (the proposal still backed by Supervisor Gloria Molina, plus the entire Latino legislative delegation), that clinic line might be a mile long, because one category of health care now comes at the expense of the other. And the more clinical care you have, the more patients you help before they need to get “hospitalized”: that is, put in pricey bed care. A cost that is borne either by insurance providers or, for about 3 million poor county residents, by the county itself. Not to mention us, its taxpayers.
This treatment-category issue lies behind the county’s ongoing fight for a renewed federal Medicaid rules waiver. The future of this waiver — which would patch a $250 million hole in the county budget — is getting more dubious by the moment. In its original, 1995 form, it was granted under the condition that the county do the kind of care shift we’ve just described. But minus the waiver, the county will have to reverse its new arrangement, dismantle a newly extended 170-clinic public-private system and once more divert routine patients to costly acute care.
Under the old, hospital-based system, the usual public-health “clinic” was the emergency room. It’s where you went with your bronchitis, your broken ankle, your crushed thumb. Where you waited while the ER staff trundled by the auto-accident survivors, the shooting victims, the heart-attack cases that were their proper stock-in-trade.
It’s not just an agony awaiting someone to tend an injured thumb in an emergency room; considering what the involuntary ER patients you see are there for, it’s also an embarrassment.
This is the human face of the key issue in county health care today. For the five years since the county last found itself nearly a billion bucks in the hole, the Department of Health and Human Services has been promising the federal government it would move from one category of care to another. This was a radical step, because that same federal government was also stuck with the battleship-hospital standard, which it promoted by making most Medicaid reimbursements for bed, not clinical, care. So the waiver became not just a matter of fiscal convenience to L.A. County. It also represented a revolution in federal public-health policy.
The start-up of the care revolution was impossibly slow. But since then, the county has formed an unusual and successful pact with over 100 private, mostly nonprofit clinics that has extended its health care far beyond the hospital bastions into the community itself. This new way of doing things has pushed 28 percent of potential bed patients into cheaper, clinical care. At least 27 percent of those minor ER cases mentioned above have also been diverted to clinics, according to Supervisor Zev Yaroslavsky. These are good numbers, but the county promised a 33 percent change five years ago. That’s why the waiver’s renewal is in trouble.
President Clinton justly took credit for setting up the original waiver. And previous columns also have described the contribution of Bert Margolin, the former legislator who brokered the arrangement. But the Service Employees International Union’s Local 660 also helped swing the deal. The AFL-CIO’s (formerly the SEIU’s national) president, John Sweeney, is now trying to get it renewed. And the county local itself came out last week in what was the most important demonstration in favor of the waiver so far. Local 660 official Kathy Ochoa said, “We’re really concerned about getting all three governmental agencies together to share their responsibility for putting this back together.” So is the entire local congressional delegation — Democrat and Republican alike.
But where should this SEIU demonstration really have been held? It was staged in downtown Los Angeles. Should it perhaps have been in Sacramento? Our governor is garnering much blame for the waiver problem — even though the state, at first glance, seems completely out of the county-federal loop. As I recall, back in ’95, the only state legal involvement in the project was the necessary approval of the deal by an obscure executive committee.