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The Gardener's Appendix

June 23, 2002

For the young seamstress with a high-risk pregnancy and no medical benefits, the gardener from Guatemala with acute appendicitis and the middle-aged woman whose heart condition puts insurance premiums out of reach, county-run hospitals and clinics are a lifeline. For the attorney whose Jaguar collided head-on with a sport utility vehicle, a county-run trauma center is a lifesaver.

Unless drastic change happens soon, however, many of Los Angeles County's poor and uninsured residents will lose their doctor of last resort. Fifty percent of the region's heart attack, stroke and trauma victims--rich and poor alike--who would receive lifesaving treatment in county trauma centers might find doors closed. Beginning next year, the Los Angeles County Department of Health Services faces a deficit that by 2005 will reach $800 million, one-fifth of its budget.

The best hope for the chronically ailing department is a plan that recently hired health chief Thomas Garthwaite will present to the county Board of Supervisors this week.

The first medical doctor to head the department, Garthwaite is suggesting changes that would make sense even without a looming deficit. Some have to do with internal politics and bureaucracies, such as getting rid of the various fiefdoms that keep one arm of the department from knowing what the other is doing. (Good luck.) Others aim to deliver care more efficiently by using computers to track patients and better manage chronic diseases.

Garthwaite's plan also calls for consolidations, closings and layoffs, painful cuts that would cost some employees their jobs and force poor people, many of them without cars, to travel farther for care. The supervisors will hear understandable howls of pain. (They may howl themselves about the cuts in their districts.) But unless the county comes up with a bold plan to make the department more efficient, the federal and state governments won't help out--as they must if more severe cuts are to be avoided. What the county desperately needs from them is not so much additional money, unlikely in any case, but more flexibility on where and how to spend it.

More people without medical insurance live in the Los Angeles area than anywhere else in the country, most of them working at low-paying jobs that don't provide benefits. A UCLA study released last week found the number of uninsured statewide to be lower than previously thought because more have enrolled in Medi-Cal and the Healthy Families program. The bad news is that the state budget deficit will result in fewer people in these government-paid programs.

Garthwaite has taken a cogent, systemwide look at how to deliver the best care allowed by limited resources. And in a county government that shrouds its decision-making, he presented the plan in public meetings.

The supervisors, accustomed to competing for clinics and hospitals in their districts, must give his plan a chance. They, like the Guatemalan gardener, have no alternatives.

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