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Diagnosis Is In: Health System Needs a Buffer From Politics : Proposal for a new medical authority in L.A. County should be fully weighed

November 05, 1995

Whatever its faults, no one can disagree that the Los Angeles County Department of Health Services provides the most essential of government services. Its hospitals and clinics are the main source of care for millions of the poor and even many in the middle class in a county where more than one in three residents has no health insurance and one in five is dependent on the Medi-Cal program for the impoverished. Even the health of the wealthy depends on the county system's control of communicable diseases like tuberculosis and AIDS, which know no ethnic, urban or economic boundaries. Furthermore, the public hospitals, in conjunction with local medical schools, have been key training grounds for generations of doctors and nurses.

For months now, the department has been teetering on the brink of fiscal and managerial collapse. Last week it began painful steps toward recovery, with the retirement of longtime director Robert C. Gates, the layoffs or demotions of more than 3,000 employees and the transfer of management of six local clinics to private hands.

The department has been buffeted by forces beyond its control: the failure of Washington to find a plan for universal health coverage, a punishing recession that has thrown thousands of Californians out of work and forced employers to scale back health benefits, and the huge wave of immigration--legal and illegal--that has swept over this region. All of this has given the department a far greater role at a time of diminishing public resources.

But, as a series in The Times last week demonstrated, the department and its bosses at the County Board of Supervisors must share responsibility. The department has been unable to put in place computers to keep track of patient records and billing and has been slow to correct the chronic problem of doctors improperly moonlighting or skimming off patients for private practices. The department has also failed to follow national trends away from costly inpatient hospital services toward cheaper local clinics and outpatient procedures and toward the managed care that has so revolutionized private competitors. In addition, the department has often been hindered by county supervisors who have treated facilities in their districts as part of their political turf and tended to micromanage.

In September, at the urging of the new health czar, former Assemblyman Burt Margolin, the county bought some valuable time when it won a waiver of federal rules from the Clinton Administration. That gave the county $364 million to keep clinics and hospitals open for now, on the condition that Los Angeles make major reforms leading toward the less costly outpatient and other preventive care systems.

It is unlikely the department can make more progress without major changes in governance, however. Margolin is working on a proposal by Supervisor Zev Yaroslavsky to create a county health authority as a buffer between the Board of Supervisors and the health bureaucracy. Margolin plans to issue his report on its feasibility by month's end.

This concept has much merit, and has proven effective in Dallas and Las Vegas. As ever, the devil is in the details. One political problem is that supervisors would have to give up coveted control, and there are key questions about the makeup of such an authority and what qualifications members should have. Clearly such an authority should be composed primarily of experts in the delivery of health care, but local governments and consumers should also be represented.

The quest for a new health department director has been hampered by a national perception among potential candidates that the job is politically too hot and that whoever gets it will be on the streets in no time, just as New York City chews up and spits out school superintendents. If the county wants to solve its health care crisis, it must start to insulate the health department from local politics--and persuade Washington and Sacramento it is not too calcified to change its ways. The opportunity is here for Los Angeles County, which has the second-largest public health system in the nation, after New York's, to provide a national model in modern public health. Let's not blow it.

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