Sickness and Subways

One thing was made perfectly clear from the Shock Corridor reductions of Los Angeles County health care last week: providing health care for this region’s needy is not a problem that can be handled, ultimately, on either the state or local level.

The Board of Supervisors last week tentatively voted to knock $57 million and 5,000 positions out of the foundering system that gives care to around 800,000 indigent people, the rough equivalent of the population of Detroit. What wasn‘t made clear was just how many of these people will now be out of the system. And what the fatal consequences to some of them could be.

There was strong protest from an audience of a thousand people. But what I did not hear were specific new solutions on how to solve this grievous lack of funding for health care in the largest local system in the nation. It was easier to call the board members names. But that didn’t solve the basic problems of sudden revenue losses in a catastrophic budget year combined with long-term faulty Department of Health Services (DHS) management.

I didn‘t agree with all of the department’s cutbacks. The worst mistake is that DHS didn‘t create $100 million of in savings by simply and immediately padlocking King-Drew Medical Center. This action would not only have taken out the worst hospital in the system. It would have set a terrific example among the surviving establishments that there would be dire consequences for having low-rated clinical departments and a decadeslong high ratio of patient deaths. Making K-D the survivor among the non-USC county hospitals can’t help but send the opposite message at a time when maximum system performance is most needed.

The board had no real choices. It can‘t print its own money for health care. The money that is there comes almost entirely from the state and from Washington. Except, as we just saw, when it doesn’t.

The county‘s own accountability in this matter is clear. Knowing that the 1995 federal fiscal support of its services was temporary, it promised Washington to restructure, to cut beds and increase clinical, outpatient care. (Federal and local health mandates, stuck in the Dr. Kildare era, gave fiscal preference to bed care, while most of the patient demand now is elsewhere.)

But DHS didn’t deliver what it promised. More importantly, it didn‘t rebuild itself to focus on this key objective. Blame here accrues to both the board’s bad oversight and the previous DHS director, Mark Finucane, a well-meaning in-house performance artist who seemed to assume that, when it came to changing the department, if you waved enough carrots, you could skip the stick.

So new DHS Director Thomas Garthwaite has been handed a huge backlog of overdue hard decisions. Mostly, apart from K-D, he seems to be making the right ones to save the system, if not all the patients. We‘ll know more in eight months or so, when the hearings are finally over and the Mean Times DHS takes its final shape.

The major lesson here is the conceptual failure of state and local health care to meet the need for health care for that least articulate and most needy of constituencies, the working poor. Since most of DHS’s indigent clients can‘t vote -- being either noncitizens or children or both -- whenever the budget gets tight, they are, like the steerage passengers down below on the Titanic, the first to go. But in last week’s hearings the patient population that takes the biggest hit from the cuts was direly unrepresented before the board.

For instance, on the one hand, the staff chief of Antelope Valley‘s local congressman, Buck McKeon (R-Valencia), spoke out against downsizing High Desert, which, according to Garthwaite’s reports, last year served only 50 local indigent patients.

Yet on the other hand, Supervisors Gloria Molina and Yvonne Brathwaite Burke, who represent the lion‘s share of the county’s hundreds of thousands of indigents, signed off on cuts in care to the poor.

Now here is a project for socially aware activists looking for an impossibly difficult but worthy task. How about building a Los Angeles County Patients Association, perhaps modeled on Justice for Janitors or the Bus Riders Union, that could represent what you might fairly call the victims of health-care injustice? And, perhaps, to file legal actions to protect their services in the same fashion that the Bus Riders Union sued to get more buses for the working poor? Kathy Ochoa, an official of Service Employees International Local 660, which represents many county health workers, last week proposed an organization that would combine the interests of county caregivers and recipients. That‘s a start. But these parties’ interests are often by no means identical.

The final answer, however, is a national health-care system for everyone. The economy is a national issue, and so is the population that this economy‘s missteps produces. It’s 10 years since Bill Clinton had his national health-care proposal shot out from under him by the Republicans and the corporate health-care and pharmaceutical cartel. Has public -- and for that matter, private -- health care improved a lot since? Certainly not in this particular county.