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Clinton Health Plan Mixed Bag for County : Insurance: Proposal would pay for treatment of 2.7 million people who lack coverage. But officials are concerned about the end of subsidies to urban hospitals.


For Los Angeles County, with a health system in crisis and one of the heaviest concentrations of low-income, medically needy people in the nation, President Clinton's health plan promises mixed blessings.

It would provide health insurance to most of the estimated 2.7 million county residents who lack coverage. The plan would pump a stream of money to patients whose care has contributed heavily to a financial crisis that has public and private hospitals on the critical list.

But it would also end the federal disbursement of millions of dollars to urban hospitals that receive a disproportionate share of these non-paying patients. That money allowed the county to keep public health centers open this year during a budget crisis and provided badly needed money to nonprofit hospitals for support of financially shaky trauma centers.

Another drawback for Los Angeles County is that the Clinton proposal would not include illegal immigrants in its plan to guarantee health insurance to all Americans, although if undocumented immigrants are employed, the plan would require their employers to cover them in company-sponsored plans.

In another major change, the plan would end the federal Medicaid program, called Medi-Cal in California, as it is known today. Most of the county's 1.5 million Medi-Cal patients would lose their ability to choose their doctors under the fee-for-service system and would be shifted into managed care plans. Only disabled Medi-Cal patients would remain under the fee-for-service system, and then only temporarily.

This troubles some health care workers because even though many believe that managed care plans have much to offer low-income people, these plans have a bad track record in California. In the past, health maintenance organizations have fought mandatory controls that would have required them to take Medi-Cal patients on the grounds that state and federal reimbursements fell far short of covering the cost of such patients.

At this point, local health experts are cautious in their assessments of the Clinton plan, which is said to be undergoing revision.

The general reaction to the plan is that it is strong on philosophy and guiding principles, but short on the hard numbers that local health officials want to see. Dr. Jonathan B. Weisbuch, medical director of the county Department of Health Services, said the county has enough medical resources to make the Clinton plan work, but it would not be easy. "We are in for a hell of a journey," he said.

State and local health administrators have in some cases been working for years to get the type of plan Clinton is proposing.

California last year embarked on a project to shift all Medi-Cal patients into a managed care system, and counties are setting up local health alliances that will be able to fit into the revamped health system proposed by Clinton. The Clinton plan envisions a system of regional and corporate alliances of consumers and employers that would purchase care from collectives of doctors, hospitals and insurance companies.

The problem is that as in many parts of the United States, the county's health care system is divided starkly between the haves, who with extensive insurance coverage get the pick of top hospitals and physicians, and the have-nots, who either have no insurance or rely on public insurance programs such as Medi-Cal. This group, which the Clinton plan seeks to help, faces long lines in emergency rooms, months-long delays in getting appointments with specialists, spotty care, bureaucratic red tape and a host of other problems in order to get medical care many Americans take for granted.

Robert C. Gates, director of the Los Angeles County Health Department, said he believes one of the fundamental premises of the Clinton plan--that managed care programs can result in better and more inclusive care to needy Americans--is on target. But, like other local health administrators, he said he was concerned that the plan will not extend its universal coverage to undocumented residents.

Estimates on the number of undocumented immigrants in the county range from 250,000 to 700,000. Even though a copy of the Clinton plan being circulated in the county envisions that federal funds will finance the care of the undocumented immigrants using emergency rooms, Gates is worried.

"You cannot just ignore undocumenteds. There has to be some recognition, some funding for undocumented aliens. Without it, the rest of the plan is not going to work in this county," Gates said.

He said he was also concerned that the Clinton plan anticipates phasing out reimbursements to urban hospitals for the care of the indigent. The county received $450 million in such payments this year, and they were credited with allowing the county to keep open all its hospitals and regional health centers.

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