More than a quarter of the people in the Southland lack health insurance, poor people and ethnic minorities often face more severe health problems than wealthier whites, and emergency and reproductive health services are spread increasingly thin.
Such is the mixed diagnosis offered in a comprehensive report on health care in eight counties, including Orange and Los Angeles, released by the Southern California Study Center at USC.
However "well endowed" the region's overall system, the Health Atlas of Southern California says its resources are "unevenly distributed across the region and its populations." Access to care remains elusive for many people in the eight-county region.
"If I had to pick one [problem], it's access in its many dimensions--physical access, access to the emergency medical system, financial access and cultural access for all the different ethnic groups," said Michael Dear, the study center's director and atlas co-editor.
One of the biggest hurdles is a lack of insurance coverage. According to the research, Los Angeles County alone has 2.7 million uninsured people, including nearly 700,000 children. Half of the uninsured are foreign born, many Latino and from working families.
Even in Orange County, which had the lowest percentage of residents without health insurance among the eight counties, more than 500,000 fend for themselves when paying for medical care. The 20% of county residents who are uninsured include more than 90,000 children. The majority of the uninsured are Latino or Asian.
The result is that many people delay seeking health care and preventive screenings or do not obtain them at all. In Los Angeles County, uninsured people with diabetes or hypertension are three times more likely to be without a doctor's care than are those who have insurance or Medi-Cal.
"Until we make significant moves to reduce the number of uninsured . . . the 'good part' of the [health-care] system will remain very limited," said Michael Cousineau, the USC researcher who wrote the atlas chapter on insurance coverage. "This is a serious problem we haven't dealt with. Government has yet to adequately address it."
Even people who have insurance often face choices limited by managed care. The atlas notes that here, in this "bellwether region for managed care," many people have become disenchanted with restrictions in choice of providers and access to services. At the same time, managed care entities are seeing a drop in earnings.
Obtaining reproductive care represents an access problem of a different kind. The atlas notes that mergers and acquisitions have led to a substantial increase in the percentage of hospitals affiliated with religious groups. Twenty-two of Los Angeles County's 113 general acute-care hospitals are religiously affiliated, mostly with the Roman Catholic Church.
In Orange County, six of the 35 acute-care hospitals are affiliated with religious groups, all but one the Catholic Church.
"Though that is 17% of hospitals, these hospitals are larger than other hospitals and make up 24% of the acute-care beds," said Elizabeth Grady, a professor at the USC School of Policy, Planning and Development.
Religious affiliation is a good thing in one sense because faith-based institutions tend to be committed to the poor and uninsured and continue to serve communities even when profits dip, the researchers noted. However, religious affiliations have slowly chipped away women's access to abortions, contraception and fertility treatments, the atlas notes.
"That in some ways is like a small time bomb hidden away in this report . . . a time bomb ticking away at the heart of the system," Dear says.
Emergency services are slowly eroding as well. According to the report, as of December 1997 there were 95 hospitals in Los Angeles County capable of tending to emergency illnesses and injuries, 15% fewer than seven years earlier. The most obviously underserved areas, researchers said, are the Antelope Valley and South Los Angeles.
Moreover, Los Angeles County has only 13 trauma centers, down from 23 in 1984. Many centers are treating people outside their immediate area.
The same is true in Orange County, which has lost 25% of its trauma centers this decade. Fountain Valley Regional Hospital and Medical Center shut its trauma center in the early 1990s. That leaves active trauma centers at UCI Medical Center in Orange, Western Medical Center-Santa Ana and Mission Hospital Regional Medical Center in Mission Viejo. The northern and western parts of the county have no nearby trauma center; as a result, Long Beach Memorial Medical Center is included in the Orange County network to serve that end of the county, said Sam Roth of the Orange County Medical Assn.
The report raises a controversial issue in emergency medicine: whether time spent stabilizing critically injured patients in the field might be better spent transporting them to the nearest trauma center as soon as possible--the so-called scoop and run approach.
The atlas highlights many of the region's gains as well. The area ranks better than the national average on many health indicators, with lower mortality rates from coronary artery disease and cancer in every county. Most counties also have achieved federal objectives for 2000 in reducing adolescent pregnancy, gonorrhea and AIDS. The region also has made progress reducing air pollution from particulates and ozone.