The Ailing Patient 

Thursday, May 29 2003

The usual glee that accompanies major court victories was clearly missing Tuesday after lawyers for uninsured Los Angeles County patients won yet another order blocking a huge contraction of the massive county health-service system.

Attorney Yolanda Vera of Neighborhood Legal Services said the county was being less than candid about how large its budget shortfall really is and how much could be saved by shutting Rancho Los Amigos National Rehabilitation Center in Downey and shrinking County-USC Medical Center by 100 beds. But she said she and her clients took no pleasure in forcing the county back to the drawing board to deal with a deficit that county health officials insist could reach $1 billion by 2007.

“Litigation is the worst possible way to do health-care reform,” Vera said after U.S. District Judge Florence-Marie Cooper rejected the county’s bid to proceed with its austerity program. “This problem can be solved only when you have federal and state and local governments getting together and fixing what really is a crisis of the uninsured.”

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Cooper’s ruling brought relief, but little surprise, to health-care workers and patients at the center known simply as Rancho. The judge already had blocked the closure in an earlier suit brought by Medi-Cal recipients. That ruling is now on appeal, and the county almost certainly will appeal Tuesday’s decision as well. But getting rulings on the two cases from the 9th U.S. Circuit Court of Appeals will take months, ensuring that the county will have no chance of closing Rancho by June 30 as called for in its strategic plan for dealing with the deficit.

Health Department spokesman John Wallace said closures could be ordered later in the year and would take about two months to put in place. But county officials said privately that keeping Rancho open into the fiscal year that starts July 1, with a 9th Circuit ruling still months off, virtually promises a full year’s budget for the hospital, meaning it will stay open for another year.

That’s good news to the plaintiffs in the two suits — and very bad news at the same time, because county officials say it substantially moves up the time when the money runs out and requires even more massive closures and cutbacks.

California law requires counties to provide medical care to residents who cannot be treated at private hospitals. In Los Angeles, the mandate translates into an obligation to care for the one-quarter of the county’s population that has no health insurance of any kind, plus the thousands of others in the Medi-Cal program for low-income Californians who are sometimes turned away (unlawfully) from private health centers.

The county’s health system was saved in 1995 by a Clinton administration bailout, which required a drastic shift in health resources from hospital care to supposedly less expensive outpatient services. It was not enough, and the Bush administration — facing tougher economic times and a less cozy relationship with the Democratic majority on the Board of Supervisors — kicked in another $250 million this year but made it clear there would be no more money coming. Meanwhile, the size of the county’s uninsured-patient load, now 600,000 a year, continues to grow as insurance costs skyrocket and employers shirk the burden of providing coverage. That left the county with the prospect of a $265.1 million shortfall by 2006.

State law, while mandating indigent health care, also forbids counties from ending their fiscal year in the red. Los Angeles County health chief Dr. Thomas Garthwaite sought to drastically slash the size of the department with painful cuts like Rancho, a world-class center for rehabilitation after major injury — and the only such center available to county residents with insufficient insurance coverage.

Patients sued the county to block the closures earlier this year, and their arguments were bolstered by reports of patients waiting for days to see doctors at county hospitals and several deaths due to delayed care in the already overburdened system.

Senior Deputy County Counsel Sharon Reichmann told Cooper that the reports were later discredited and that the county could continue to provide care — greatly diminished but still within its legal mandate — if it is permitted to shut Rancho and pare service at County-USC. Otherwise, she insisted, the county would be faced with the almost unthinkable prospect of slashing emergency-room service and public-health programs like tracking communicable diseases. Such cutbacks would reach far beyond the uninsured and affect every Southern California resident, regardless of their insurance status or the size of their pocketbook.

“It’s very difficult not to stand before this court and not sound callous and indifferent,” Reichmann told Cooper. But she added that the county could no longer provide the “Cadillac” service that she said was far more comprehensive than other counties provide.

“We don’t have a luxury model,” Reichmann said. “We have a Hyundai now. It’s different.”

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