It was 10 a.m. on a weekday in early March, and the emergency room at Harbor-UCLA Medical Center was already full. Dr. Tom Garthwaite weaved through without pausing. He seemed unaware of the new arrivals milling around in clusters and sitting on the floor. He glanced at 20 others lined up near the front of the crowded room to sign in and breezed past the man slumped against a wall, his jacket pulled over his head.
No one recognized the 55-year-old Garthwaite, and its probably a good thing for him. As director of L.A. Countys health department, he is responsible for the long waits which can drag on for hours and even days at some county-run hospitals, delays so long that doctors complain patients are dying. Since arriving on the job 16 months ago, hes undertaken unpopular, but what he insists are vital steps to fixing L.A. Countys collapsing health-care system. Hes done away with 16 clinics, closed two hospitals and in June plans to begin laying off another 4,000 doctors, nurses and health-care workers.
Along the way, hes overcome steep political opposition on the county Board of Supervisors and silenced all but a few of the usual advocates for health care for the poor with the message that only dire moves will save the system. The chief threats to the restructuring plan are lawsuits filed by the ACLU and other public-interest groups seeking to stop Garthwaites next round of layoffs and hospital closings. They claim that patients have died at L.A. CountyUSC Medical Center because they were forced to wait up to four days in the emergency room, and that Rancho Los Amigos National Rehabilitation Center must remain open because no other county-run hospital can treat severe brain and spinal injuries. A judge this week barred the county from moving ahead with plans to close Rancho Los Amigos until she has time to make a ruling on the hospitals future, which could be as early as next week.
Even if Garthwaites plan survives the legal challenge, the question in coming months will be: Can Garthwaite, a medical doctor known for remaking health-care bureaucracies or anyone, for that matter save the massive public health system in L.A. County, where one-third of the residents, or 3.3 million people, rely on diminishing tax dollars to foot the doctors bill? Will he be remembered as the man who resuscitated health care for the poor or left it gasping for air on the operating table?
For two days, I tagged along with Garthwaite at formal and informal gatherings of doctors, administrators and politicians as he made his way around the county to sell his rescue plan. I watched him take on his critics with some of the practiced weapons of an accomplished debater. I saw him try to confront some of the disbelievers in his inner circle of top 35 health professionals. I heard him compare his current mission with his last assignment as a Clinton-administration appointee charged with overhauling veterans hospitals. Its far too early to tell whether he has the prescription for L.A. County. What is clear is that the lines in emergency rooms will not be getting shorter anytime soon, and that medical care for L.A. Countys most destitute will remain on life support for the foreseeable future.
In a federal courtroom earlier this week, Garthwaite got a dose of how hard it might be to persuade U.S. District Court Judge Florence-Marie Cooper to sign off on Ranchos closure. He sat on one side of the courtroom, and said nothing during the 75-minute hearing. On the opposite side, one of Ranchos patients, Susan Rodde, who has cerebral palsy, sat in her wheelchair. Attorneys for the patients and the county debated whether the county would be breaking federal Medicaid rules by shutting down the hospital.
Years ago the county made the decision to serve the disabled at Rancho, Melinda Bird, an attorney with Protection & Advocacy, Inc., told the judge. It cannot turn around and change this because the cost of treating disabled patients is costly. If Rancho closes, the state has an obligation before June 30 to ensure that there is something else.
Cooper said she would rule soon because so much is at stake. Outpatients are profoundly affected by this closure.
Despite how things looked in the courtroom, if you listen to Garthwaite, the prognosis is bright. He wields more than a hatchet. He has ideas for a cure that, if they solve what ails L.A. County, could change the face of public medicine. He wants every L.A. County patient to have a doctor, a Marcus Welby, as he put it. Someone they can trust, he said. Someone they can go to before they have the heart attack or the flu, someone who tracks their care from day to week to year. People love it. He believes enough money is set aside for health care; waste devours too much. He envisions a system that saves money by pushing preventive care over expensive surgeries, that electronically links hospitals and doctors to make sure all the players are serving the best interests of patients and the bottom line. It sounds like managed care for the poor. His critics dismiss his diagnosis as more the work of a medical technocrat than evidence of a compassionate doctor trying to save his patient. Especially as a doctor himself, he should know the unmet need here is great, said Annelle Grajeda, general manager of the Service Employees International Union Local 660, which represents 19,000 of the countys health department workers, many of whom face pink slips in June.