Hospitals are starving for dollars as well. Largely because of shrunken payments from government programs and managed care plans, more than 60% of California hospitals are losing money on patient care.
"I think the industry is very close to a precipice," said Arnold R. Schaffer, president of Glendale Memorial Hospital and Health Center.
Schaffer compares his job to that of an "Ed Sullivan Show" performer, struggling to keep a dozen plates spinning on sticks all at once. Among his worries: the rising costs of labor and uninsured patients, the shortage of nurses and critical care beds, the dearth of doctors willing to take emergency calls and upcoming state deadlines for highly expensive earthquake retrofitting.
Los Angeles County, of course, cannot be considered in isolation. It is part of a state where the government and employers have shown an exceptional reluctance to pour more money into the health system.
Health plan premiums in California--though recently on the rise--are about 10% below the national average, according to the Kaiser Family Foundation.
In the public sector, the state's spending on impoverished residents who receive Medi-Cal benefits--though recently raised for physician visits--is among the lowest nationally. And the state has failed to make use of hundreds of millions in federal dollars to expand insurance coverage to children of the working poor.
In addition, California grapples, like every other state, with nationwide clampdowns on health care costs--perhaps most dramatically illustrated by the federal Balanced Budget Act of 1997, which cut Medicare payments to hospitals and doctors by billions of dollars.
"It all comes down to no money flowing in," said Dr. Marie Kuffner, president of the California Medical Assn. "It's as though the water is so low, all the rocks are sticking out. There's nothing to float on."
Los Angeles County might be considered among the rockiest ground.
The county's staggering 32% uninsured rate--representing 2.7 million people--may signal where the rest of the country is headed, says Kaiser's Levitt. The number of uninsured people nationally has dipped recently to about 43 million--or 15.5%--but could climb rapidly again in a recession.
Nowhere perhaps are the pressures more obvious than within Los Angeles County's public health system--the network of hospitals and clinics that serve the poorest residents.
The emergency room at the county's largest medical center, County-USC, is regularly overwhelmed by a mixture of urgently ill or injured patients and those who might have been easily treated earlier in doctors' offices--if only they could afford doctors.
Patients at the Boyle Heights hospital can wait 24 hours, even 36 hours, for beds, doctors said. The emergency room becomes a makeshift intensive care unit, without the requisite staffing, because there frequently aren't enough beds or nurses upstairs.
Doctors find the situation particularly galling in a state with a $10-billion budget surplus.
"I just don't understand it," said Dr. Ed Newton, a soft-spoken attending physician. "I keep expecting it to improve with the economy. When the economy is flush . . . how come we can't have nurses here? That makes me angry."
On a recent Friday night, described as "quiet" by staff, a dozen untreated patients lay on gurneys outside the trauma booth where surgeons and nurses struggled to treat a wave of patients wounded in gunfights, stabbings or car accidents.
At 2:40 a.m., the son of one elderly man suffering complications from prostate surgery the previous day began screaming at nurses for attention.
"He's been here six hours! That's not right!" the son yelled as the attending surgeon, Dr. Stuart Swadron, rushed to calm him.
"That's what happens sometimes," Swadron said later, under his breath, striding briskly to attend to other patients. He passed an alcoholic man on a gurney who begged--"Please Doctor!" for some Librium to help him stop shaking.
"This is so difficult!" the doctor said. "[This man is] a human being. He deserves to be seen like anyone else. It's the ultimate juggling act here."
Swadron's next case was a 34-year-old woman--uninsured, with life-threatening complications from diabetes. She was barely conscious.
"This lady here has been suffering symptoms for months and months," he said. "This shouldn't have gotten this far. If she had [insurance] it wouldn't have. . . . Poor thing."
The county, of course, does not deliberately funnel impoverished patients into its emergency rooms in the middle of the night. But critics say officials have repeatedly missed opportunities to reform the system so it is more efficient and humane.
The county health department is afloat only because of two bailouts from the federal government totaling more $2 billion--money that will dry up by 2005. That will leave a gaping deficit similar to the one that nearly dragged the county into bankruptcy in 1995.