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The right county diagnosis

A new authority has to take over the region's healthcare system from the supervisors.

August 18, 2007|Brian Johnston | Brian Johnston is an emergency room physician in practice in Los Angeles for more than 30 years.

With the failure of Martin Luther King Jr.-Harbor Hospital, it is time to look critically at the healthcare system operated by Los Angeles County and see if we can't do better. In doing so, it is important to look beyond the closing of a single hospital to the entire county Department of Health Services operation and ask what should be changed.

A rational analysis would lead us to remove the health system from the control of the Board of Supervisors and transfer the authority, responsibility and funds to a health authority with a governing board made up of representatives from the county and the state, as well as from the medical, dental and nursing schools and the public.

The supervisors have not just failed at King-Harbor, formerly King-Drew Medical Center. Over the last decade, they have undersized our public hospitals and health systems.

They have downsized Olive View-UCLA Medical Center, tried to close Rancho Los Amigos National Rehabilitation Center, downsized King-Drew while purporting to fix it, and rebuilt the 750-bed L.A. County-USC Medical Center at 600 beds, despite howls of protest from physicians and public interest groups and every objective analysis that 750 was the minimum number of beds needed. They also cut outpatient visits systemwide by 500,000 and elected to cut public health programs by 10%.

County hospitals also have stopped accepting transfers of stable, uninsured patients from private hospitals, imposing the financial burden on those hospitals, even as some have gone bankrupt. A 2005 study by the National Health Foundation found that, in 2000, L.A. County and private-sector hospitals each took care of 50% of uninsured hospital admissions. By 2004, the county was caring for only 30% of the uninsured, and private hospitals were caring for 70%.

All of these service reductions were taken when the system should have been expanding, as the population of L.A. grew 6.8%. Nearly 30% of the county's adult population is uninsured, according to the UCLA Center for Health Policy Research.

True, federal and state budget cuts were part of the reason for the county healthcare problems, but the county made matters worse by not acknowledging the emerging crisis, its role in creating it or its obligation to provide adequate services.

Why do the supervisors run the health system today? The county system is a legacy of the 1880s, when counties controlled the largest revenue stream: property taxes. Medical care was simpler and cheaper, so each county took care of its own. That's all changed.

Today, L.A. County contributes only about 6% to its own health budget, with the rest coming from state and federal taxes. Yet the county is still legally responsible for the healthcare of the poor and uninsured under the state Welfare and Institutions Code, even though it lacks the tax base to provide it.

So what should we do? We should ask the Legislature to establish a quasi-public health authority for L.A. County, transfer to it all current health funding -- county, state, federal -- as well as the obligation to provide healthcare to the poor and uninsured. The authority would be responsible for county hospital and clinic services, public health, mental health, emergency medical services, healthcare planning and administration.

The health authority would ultimately be accountable to the people because of the makeup of its board. The governor and legislators' would nominate some of those board members, who would be publicly vetted and would reflect directly on those who selected them. Other board members could be directly elected, and healthcare professionals could be selected for the board by schools eager to maintain their reputations.

Health authorities are neither a new nor a radical idea. Denver recently established one that is functioning well. New York and other cities have had similar systems for years.

In L.A., a health authority would have distinct advantages over Board of Supervisors' control. It would be run by people with specific healthcare expertise. It would be solely devoted to healthcare -- not to law enforcement, firefighting, libraries, courts or parks as well. It wouldn't be caught up in supervisorial politics, and it could use non-county purchasing, maintenance, legal, security, information systems or transportation services.

Los Angeles County has a healthcare system that has not met its obligations. Instead, it has adopted policies exacerbating our growing crisis and demonstrated a stubborn inability to correct its failures. The rational decision is to move to a health authority.

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