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County's Dilemma: Cost vs. Care

Health: L.A. supervisors weigh clinic closures against the commitment to serve the poor and uninsured--a thankless balancing act.


One night a few years ago, a man crashed his car into the side of Los Angeles County-USC Medical Center. In his hand, doctors recall, was a crumpled piece of paper from a local physician's office. On it was a map showing how to get to the Boyle Heights hospital and the words: "You are having a heart attack. Go to County-USC."

County-USC doctors recount this story to illustrate a dynamic that makes them both proud and frustrated: People who are turned away from other medical facilities for lack of funds come from across the region and the state, even from abroad, to L.A. County's public hospitals for a wide range of essentially free medical care.

But the strain of caring for the poor and uninsured is forcing local officials to reconsider the amount of care they offer. The health department is asking the Board of Supervisors this week to adopt a strategy that would reduce the number of places patients can receive general medical care but, for the time being, preserve high-end hospital care and emergency rooms.

By doing that, the county will be attempting what critics say is an impossible balancing act--maintaining its commitment to take all comers, even while making it more difficult for patients to find medical help. It may also run the risk of flooding already overburdened emergency rooms with patients who have been unable to get basic medical care.

"We have been providing a higher level of services to the uninsured than any other county in this state," Supervisor Gloria Molina said. "We're going to have to downsize the number of services we provide. They're just going to have to drive farther, wait longer."

The supervisors will debate what would be the deepest cuts ever made to the $2.4-billion health department--closing nearly a dozen clinics, reducing beds at County-USC by more than 10%, and ending inpatient services at High Desert Hospital in the Antelope Valley.

More cuts, including the possible closure of emergency rooms, could come this fall, unless the federal government sends more funds to Los Angeles.

Though it has enough cash on hand to limp through another year, officials argue that the county cannot continue to provide the array of medical services it offers. The county faces an $800-million deficit by 2005 because of declining federal aid.

The county's new health director, Dr. Thomas Garthwaite, said planners are trying to close clinics that offer predominantly nonspecialized services such as regular checkups and immunizations, while preserving sites that have more specialized treatments.

The thinking, Garthwaite said, is that the working poor who rely on the county may be able to pay for normal doctor's appointments but not for pricier specialty care. "In this case, we're caught between a rock and a hard place," he said.

In addition, health officials are considering eliminating services that might not be included in a normal health plan, such as cosmetic surgery.

"I think the citizens and the government of L.A. County can be proud that they've had an open-door policy in regards to their health-care system," Garthwaite said. "I'm not sure that is sustainable over the long run unless additional revenues can be generated. In a way, it becomes a magnet for patients that are uninsured."

Health advocates say the proposed cuts will effectively end its open-door practice. "At a certain point you can say everyone has access to health care," said Anthony Wright of the advocacy group Health Access, "but when you scale it down past a certain point, it's a fraud."

Wright gave the example of an uninsured person with diabetes who goes to county clinics for insulin shots. With fewer clinics and longer lines at those that remain, the diabetic may miss several needed treatments.

"It's not just a matter of convenience," Wright said. "It means people with diabetes get limbs amputated because they did not get their insulin."


'Care Rationing'

Mark Tarnawsky, a spokesman for the union that represents most of the health department's 22,000 employees, said that closing clinics is akin to barring certain groups of people from hospitals.

"It's a Darwinian kind of care rationing," Tarnawsky said. "Let's cram more people into small places and see who can get in first."

Ana Mendoza of Compton wonders whether her family will be able to get in. For 10 years, they have gone to the Compton Health Center for regular medical care--checkups, TB shots, family planning and more. Mendoza's 65-year-old mother goes there every month to get medicine for her dangerously high blood pressure.

That clinic is closing next week--it was cut by supervisors in February--and the family is being sent to another clinic, which supervisors are expected to vote to close this week.

"I don't know what they are thinking," Mendoza said. Eventually, she said, the only place for treatment will be the emergency room of Martin Luther King Jr.-Drew Medical Center in Watts, where waits can top five hours.

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