Prodded by harsh fiscal reality, the Los Angeles County Board of Supervisors voted 4-1 Wednesday evening to dramatically downsize County-USC Medical Center, the nation's busiest public hospital.
In approving a new, 600-bed facility, the board majority turned aside the objections of health care experts, community activists and an unusually united coalition of Latino elected officials from all levels of government who packed the meeting and offered a rare public display of bare-knuckled political clout.
But apparently uppermost in the supervisors' minds was the memory of how the public health system's costs nearly drove the county to the brink of bankruptcy two years ago. The votes to be cast by a majority of the board's members were clear from the moment the daylong hearing began.
Supervisors Yvonne Brathwaite Burke and Zev Yaroslavsky made the motion to build a new hospital with no more than 600 beds.
"We recognize our legal and moral responsibility to provide a health-care safety net for the indigent," Burke said. "We also have a responsibility to ensure that the safety net is not jeopardized by undertaking a capital project of such unrealistic magnitude that we cannot sustain it. . . . "
Only Supervisor Gloria Molina, who had fought hard for a larger hospital, voted against the board majority's move to rebuild earthquake-damaged County-USC with just two-thirds of its current 960-bed capacity.
Throughout the day, scores of speakers in blunt political exchanges, calm professional voices and impassioned pleas spoke in favor of a 750-bed facility. Not a single voice was heard in support of the smaller hospital.
Even Los Angeles City Councilman Richard Alatorre, long a political foe of Molina, joined with Latino members of Congress and the Legislature in imploring the supervisors to build no less than a 750-bed hospital.
"You have an opportunity to do the right thing for the people of Los Angeles County," Alatorre said. "This is not just a Latino issue. This is a health care issue. This is about the life and death of people."
Alatorre decried as "disgusting" suggestions that the board majority resisted the larger hospital in part to deny a victory to Molina, the sometimes contentious Eastside representative.
"This is not about Gloria Molina," he said.
"I'd pay heed," Alatorre told the supervisors, referring to threats by Latino legislators to hold up state funds for the county if the larger hospital is not built.
The board majority's preference for 600 beds was opposed by every major health care organization in the county. Spokesmen for some of them warned that the new hospital--the cornerstone of the county's public health system and emergency trauma network--would not be big enough to meet the needs of a growing population of poor and uninsured residents.
Fully aware that the odds were stacked against the 750-bed hospital, which he had strongly advocated, county health services director Mark Finucane spoke quietly before the board, methodically laying out his arguments for the larger complex.
"It is a very small hospital compared to what you have today," Finucane said. "You're talking about the biggest public hospital in the United States right now, in the midst of the biggest uninsured population." At 750 beds, he said, the hospital would still be significantly smaller than it is now, with 960 beds. "This is a very, very tough call."
Dr. Brian Johnston, past president of the Los Angeles County Medical Assn. and an emergency room physician at nearby White Memorial Hospital, bluntly told the supervisors that it was "extremely unwise to downsize the linchpin of our county health system."
Johnston warned of dire consequences to patients if the 600-bed hospital is too small. "They are going to be dying in the hallways," he said. "Dying waiting to get into the operating room."
Ulysses S. Griggs Jr. of Community Rehabilitation Services in San Gabriel invoked the name of the late supervisor Kenneth Hahn in urging the board to select the 750-bed hospital option. "If Kenny Hahn were here he'd be camping on your doorsteps until he persuaded all of you to vote for 750 beds."
But with Washington and Sacramento backing away from their own commitments to the poor, Los Angeles County is left as the health care provider of last resort to a huge and growing population of 2.8 million people who have no health insurance.
Four of the supervisors were not willing to commit the county to taking the financial risk of building a $1-billion hospital with 750 beds that the county could not afford to run. A 600-bed hospital would cost between $788 million and $907 million depending on the design, and would be less expensive to finance and operate.
Supervisor Yaroslavsky, one of the architects of the 600-bed proposal, argued that Finucane and the health department had not made a sincere enough effort to negotiate contracts with private hospitals that have empty beds to which any excess patients could be sent.