The Board of Supervisors decided Wednesday that Los Angeles County cannot afford to give its poorest residents what their doctors ordered.
In an act of political triage, they let die the doctors' proposal to replace the soon-to-be-shuttered County-USC Medical Center with a new 750-bed hospital accommodating 25% fewer patients than the current facility. The majority of supervisors decided on 600 beds, or nearly 40% fewer patients, instead.
The supervisors characterized their vote as a visionary nod to a future of improved technology and managed care that would continue to make hospital stays rarer and shorter.
But their field of vision was unmistakably circumscribed by the politics of scarcity: In a county whose rapidly growing population of uninsured residents is greater than that of any industrialized nation, the only question they considered was how much to downsize the main public hospital.
"That makes no sense to me," said Dr. Brian Johnston, immediate past president of the Los Angeles County Medical Assn.
But the supervisors' caution is understandable. They are still reeling from the county's brush with bankruptcy two years ago, during which its chief administrative officer suggested staunching the flow of red ink by abandoning County-USC altogether.
That was avoided with a temporary federal bailout. But supervisors are keenly aware that they are unlikely to have forever-friendly administrations in Washington and that, thanks to Proposition 13 and its progeny, they lack the authority to bail themselves out by raising taxes if they get into another jam.
Faced with projections that the 750-bed replacement hospital favored by doctors' and hospital trade groups, the county health department and a bevy of independent consultants would run in the red, the supervisors rejected it.
Supervisor Zev Yaroslavsky led the way, asserting that a 500-bed alternative would generate a surplus with a silver lining--one that could be used to pay for perhaps hundreds of thousands more outpatient visits than the 3 million per year the county is now able to provide.
Yaroslavsky argued that increasing outpatient care is more humane than building a bigger hospital because its greater availability would allow poor people with treatable conditions to get help before they reach the point where emergency hospitalization is required.
But one of the keys to the board's consensus on the issue was Yaroslavsky's willingness to settle for a facility that will contain no more than 600 beds. At that number, studies say the hospital will only break even and therefore will not free up money for outpatient care. However, the motion passed by the supervisors left open the possibility that not all of the 600 beds would be used. If only 500 are used, more funds for outpatient treatment would be available.
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County-USC, with a licensed capacity of 1,700 beds and a budgeted capacity of 860 beds, serves all Los Angeles residents as the linchpin of the county's trauma and emergency room systems. It also cares for half the AIDS patients in the county, runs the county's largest burn unit and performs other functions for which there is no ready market, such as running a large, neonatal intensive care unit and a jail ward.
But it has special resonance as a real and symbolic safety net for the poor in the Eastside neighborhoods it towers over, from which it draws half its patients, and which Supervisor Gloria Molina, who held out to the end for a 750-bed replacement, represents. A measure of the regard in which County-USC is held in her district is one of its nicknames: Great Stone Mother.
For Molina, the controversy over how best to replace the antiquated, earthquake-damaged facility was a high-stakes political opportunity to solidify the near folk hero status she won years ago as the maverick official who derailed state plans to shove a prison down East L.A.'s throat.
She settled on the 750-bed option as the highest ground for which there was a defense. And the defense looked solid, provided as it was by the members of the medical establishment.
Dr. Ronald Kaufman, chief of staff at County-USC, for example, was passionate on the need for 750 beds. If a 500- or 600-bed facility were built, he asked: "Where are people going to go?"
Currently, he said, 70% of the hospital's 860 patients are admitted as emergencies. They stay an average of 5 1/2 days. As Kaufman did the math, construction of a 500- or 600-bed facility would mean some patients would have to be transferred to other hospitals before they were well.
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Dr. Don Thomas, a county health department official, cited forecasts that virtually all beds in a 750-bed facility could be filled with emergency room admissions and predicted that a smaller facility would lead to ambulances being diverted to carry critically ill patients on dangerous 25-minute rides to other hospitals.
As the board moved toward a decision, Molina caught what she had every reason to believe would be a break.
