Waving the Waiver

Photo by Virginia Lee Hunter

The Times columnist (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 Times columnist 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.

In 1995, however, the state didn’t have a $13 billion surplus. And since the Clinton administration is finally coming under heavy Republican fire (according to the March 26 New York Times) for its role in the 1995 health-services deal, it sure would help everyone out if the governor were to kick a few tens of millions of that surplus the county’s way. If only to show an inquisitive Republican Congress that this waiver isn’t what some GOP wights have begun calling “a sweetheart deal” with Washington. Or perhaps just to tell the world that Davis cares about the nearly 30 percent of the state’s population that lives in L.A. County. And which overwhelmingly voted for him two years ago.

“It used to be easier to deal with Pete Wilson,” said one disgruntled county official. Which is perhaps unfair, since Wilson didn’t contribute a dime to the original waiver deal.

And the county must also share fault. It took nearly two years after the 1995 waiver before most of its stipulations were actually brought into practice. Before the older, county-owned clinics were updated to work better, and before our local government was able to win the trust of local, nonprofit medical facilities.

Now, even before the waiver decision, that trust is battered. As one nonprofit-clinic administrator angrily noted last week, the county’s cooperation remains flawed. “We’re only getting paid now for cases we treated in December,” she noted, “yet we are audited every month. And the county sends us the patients with the worst diseases and the least insurance.”

In fear of the waiver’s being waived, she said, the county has canceled all clinical contracts after July 1: “Imagine that you have a chronic condition, or are awaiting the results of a cancer test.” And imagine the bureaucratic disaster awaiting such patients if the waiver is denied and the county has to try to transfer its care responsibilities back to its old health centers and hospitals.

Some say that if the county hadn’t ignored a recommendation that accompanied the original waiver proposal, things would be better. The recommendation proposed an independent board of health-department supervisors, to track every aspect of the huge Department of Health and Human Services instead of leaving that responsibility to the overextended five-person Board of Supervisors. San Luis Obispo County, for instance, has such a board, with 15 members. I understand it sorts out the public-health bureaucracy very well. Perhaps our own board was reluctant to delegate this authority. A smaller step in that direction, however, was introduced last week by Supervisor Don Knabe, who recommended that the county’s risk-management inspector general start investigating repeated hospital mishaps — in particular, a recent one, the careless death of patient Blanca Maldonado at King-Drew Medical Center. Knabe noted that Maldonado’s death, which cost nearly $200,000 in settlements, resulted from a staff blunder identical to one cited in a 1995 DHHS fatality.

Having I.G. Mike Kranther monitor any DHHS operation is a long-overdue step toward DHHS oversight. Had someone thought of this idea five years ago, it might even have helped tilt this month’s waiver decision in the county’s favor.

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