Departing from a plan touted seven years ago as the cure for Los Angeles County's ailing health-care system, county officials on Tuesday approved a 25% cut in the government's $60-million "public-private partnership" program that subsidizes the county's private clinics.
For a county that has already substantially reduced services to address a budget deficit expected to reach $800 million within three years, the cuts represent a further fraying of a "safety net" health system that is supposed to serve the poor and uninsured.
In recent weeks, public attention has been focused on the closure of 11 clinics run directly by the county. Those closures were described by county officials as sensible, if unpopular, reductions to a bloated and inefficient health-care delivery system.
But they were only part of a $150-million cost-reduction plan, and now $12.5 million in cuts to public-private partnerships are taking effect.
Effectively made in June through budget reductions and formalized Tuesday, these latest cuts are doubly painful because they appear to undermine the health-care model adopted by the county in 1996 after its last health-care crisis. The five-year trial program adopted that year cut some services but relied heavily on public-private partnerships to provide quality ambulatory care for the poor and uninsured.
Responding to the complaints of a member of the public who criticized the cuts during Tuesday's Board of Supervisors meeting, Supervisor Zev Yaroslavsky acknowledged the change in approach. But, Yaroslavsky added: "There's nowhere else for us to turn."
Even before Tuesday's vote, the private clinics were feeling the domino effect of the broader crisis.
At Clinica Para Las Americas in the Pico-Union section of Los Angeles, Executive Director Linda Dacon handed out pink slips to seven employees earlier this week because her agency's county contract wasn't renewed.
More than 150 private clinic sites--a third of which had been funded--have been eliminated from the program. And of the 98 sites that will still receive public-private partnership funds, about half got less than last year, and the other half were awarded the same level.
The clinics eliminated or cut are scrambling to make up for the shortfall. Some are trying to apply for foundation grants; others are debating whether to charge indigent patients.
Of the facilities that remain open, some private clinics are reducing hours, seeing fewer new patients and in some cases laying off workers.
The loss of services at the private clinics will, some fear, create a new problem further down the road, such as new stress on emergency rooms.
Take, for instance, Para Las Americas. Last year, the organization received $525,000 to see about 67,000 indigent patients. The agency had operated six days a week for a total of 57 hours. With the cuts, it is contemplating staying open just three days a week for a total of 24 hours.
"We expected to get cut but not eliminated," Dacon said. "How do I pick and choose who gets an appointment? That's what wakes me up at 3 in the morning."
As they look for a more effective master plan to provide health care to the county's 3 million uninsured, county officials are negotiating with state and federal health officials for a $350-million bailout.
If no relief comes, the health services department could close more county facilities in October. At that point, officials say, public money for private clinics could disappear altogether.
"These cuts are already making it more difficult for children to get immunizations, go to school and be productive workers," said Mandy Johnson, chief executive of Community Clinic Assn. of Los Angeles, which represents the private clinics.
County health department officials decided which clinics to fund using criteria that included federal accreditation, diversified sources of funding, comprehensiveness of services and location.
The clinics that fared better were those designated "strategic partners." Also funded were "traditional partners"--those that showed, among other things, stability and met other criteria, such as providing linguistic services and operating in areas where the county needs them.
Still, clinics that lost their contracts, such as Para Las Americas--whose public-private partnership funds made up 61% of its budget--were not bad operations, county officials said.
"At this time, when we have to leverage every dollar we have, we needed to get to the agencies that had a more diversified funding base," said Ingrid Lamirault, acting director of the office of ambulatory care.
The private clinics are operating in a health-care system struggling to provide service to many uninsured and poor patients. Private clinics increasingly have been called on to help as the county curtails public services.