Two years ago Los Angeles County officials tried to recruit Dr. Mitchell Katz to run their long-troubled health department. He turned them down.
Katz, head of San Francisco's public health department, had just launched Healthy San Francisco, one of the nation's first municipal universal healthcare programs, and wanted to see the project through.
Last week, L.A. County supervisors came full circle, voting unanimously to offer Katz the job of running their health services department, one of the nation's largest. Katz said he plans to accept. If all goes well, his hiring will mark the end to an arduous search that yielded few strong contenders.
"He's not going to change things overnight," San Francisco Mayor Gavin Newsom said, "but don't underestimate him. This was a guy on the forefront of HIV/AIDS. He understands the local delivery of healthcare."
Katz, 50, will report to a board known for meddling and face a $270-million budget deficit as well as increased demand from millions of low-income and uninsured patients.
He is moving from the state's densest county, barely 47 square miles, where no public health center is more than a 40-minute bike ride from his office, to one of its most sprawling, 4,061 square miles, where it can take 40 minutes to travel between nearby health clinics — by car.
"I think the greatest challenge is just the vastness," he said.
Some local leaders agreed.
"The scope and the mechanics are pretty similar. It's the size that no one can be ready for. It's like running Montebello and the next day running the city of L.A.," said the county's chief executive, William T Fujioka, who recruited Katz. "It's bigger, it's more challenging. Mistakes have much stronger consequences."
Los Angeles will test Katz's ability to maintain services in bad budget years without antagonizing patients, community groups, and county workers and their powerful unions.
"We have a rich provision of healthcare services here in San Francisco. I'm not sure how he will deal with the limits in Los Angeles," said Jim Lazarus, vice president of the San Francisco Chamber of Commerce.
Katz plans to relocate with his partner, Igael Gurin, a teacher at the Jewish Community High School of San Francisco, and children Maxwell, 8, and Roxie, 6, who were adopted from an orphanage in Vietnam.
An avid bicycle commuter who often attends meetings in jeans and sneakers, Katz said he will try to live within biking distance of the department's downtown office and Los Angeles County-USC Medical Center, where he plans to treat patients.
Katz, who is still negotiating his salary and benefits, is expected to start work in January. He currently earns $260,000 annually. Interim Los Angeles County Health Services Chief John Schunhoff earns $309,275.
Raised in Brooklyn, Katz graduated from Yale and from Harvard Medical School before moving west to train at the UC San Francisco Medical Center. Allies and adversaries cite his political savvy and extensive experience as a public health manager who works with community leaders.
"Mitch has done an amazing job of walking that tightrope between elected officials and the advocates," said James Illig, president of the San Francisco Health Commission. "He can transform your system."
During a recent interview at his office, Katz sat at his desk overlooking downtown San Francisco, writing a prescription for a patient as he explained moves he made to strengthen San Francisco's healthcare safety net by shifting patients from emergency rooms to primary care doctors and nurse practitioners at community clinics.
"I'm a primary care doctor; I see patients every week at our county hospital, San Francisco General Hospital, and so I know how important it is for patients to have a home, to know where to go when they're sick," Katz said. "I think working on Los Angeles and trying to create enough primary care homes so that everyone knows where to go when they're sick and can get the very best possible care would be a great way to spend the next few years."
Rather than make clinic appointments for patients months in advance, which often resulted in no-shows as frustrated patients resorted to emergency rooms instead, Katz reduced appointment wait times by expanding access to clinics.
He also expanded less expensive urgent care at community clinics and hospitals, redirecting emergency room patients — and saving money.
"People don't go to emergency rooms versus clinics because they prefer it," he said. "They go because they can be seen right away."
Last year, Healthy San Francisco partnered with Kaiser Permanente to give patients the option of seeking treatment at Kaiser facilities, something Katz said he would like to see happen in L.A. County.
He said he will also look at other successful safety-net healthcare systems for ideas, in places such as San Mateo County and Denver.