Should Los Angeles County act as a broker of health care services rather than a provider? Should it contract out some of these services but maintain critical trauma and burn units? And if it did so, would the change substantially ease its fiscal crisis?

These are among the formidable questions confronting the new Health Crisis Task Force. The County Board of Supervisors created the panel to find alternatives to closing the County-USC Medical Center and making other horrific cuts in medical services. A huge demand for health care for the working poor and indigent, coming at the same time that Sacramento has been cutting funding, has plunged the budget into the red. More than half of the county's projected deficit of $1.2 billion is due to a shortfall in health services--$655 million.

In addition to closing the medical center, Sally Reed, the county's chief administrative officer, proposes eliminating four comprehensive health centers and 25 neighborhood centers. Only two comprehensive centers and 14 community clinics would remain open. Reed hopes that private hospitals will fill the need.

HORSE-AND-BUGGY: There is no doubt that the county now has an expensive, antiquated system that relies on hospitals providing in-patient care. In contrast, private insurers and health maintenance organizations have shifted to less costly outpatient systems. Can county hospital services be decentralized and made more cost-effective if some care is shifted to clinics or contracted out? Might mobile clinics provide cheaper basic care in this sprawling county?

For the last year, county health administrators and a coalition of 13 Downtown-area private hospitals have been informally discussing a public-private partnership. In Los Angeles County there are six county hospitals and 79 private hospitals. Most of the private hospitals have emergency rooms, and on any given day more than half of all private hospital rooms are vacant. But capacity is one thing and economics is another. Private hospitals are willing to consider a contractual agreement but they insist on reasonable compensation. Last year, private hospitals in all of California lost $2.7 billion in indigent charity care, provided almost entirely through emergency rooms and trauma centers.