L.A. health care on the edge

By Gil Hopenstandand Patrick KerkstraSummer Bruin Staff

Emilia Galan’s mother-in-law owes a great deal to County-USC
hospital. The uninsured North Hollywood resident underwent surgery
there Wednesday ­ a procedure which she could not have
afforded at another hospital.

"It’s hard to think what I would do," said Galan of where her
ill relative would receive care if the hospital closed. "It’s going
to be a big problem."

Galan’s quandary is one suddenly shared by thousands of
Angelenos.

On June 26, Sally Reed, Los Angeles county’s chief
administrative officer, released her proposal to rid the county of
its monstrous $1.2 billion debt. The announcement included one
particularly harsh prescription: the closing of County-USC
hospital, the nation’s largest health care facility west of the
Mississippi, and the abrupt elimination of 9,000 health care
jobs.

The highly anticipated decision will be made in the week of July
24, when the five person Board of Supervisors votes on the issue.
The fate of patients, county employees, surrounding hospitals and
the financial health of the county itself, are all riding on the
vote.

Los Angeles area residents may be hit hardest by the loss of
County-USC’s trauma center, one of the busiest in the nation. It
provides more than 28 percent of trauma care in the county and
receives an average of 650 emergency room visits a day.

The hospital’s reputation as one of the nation’s finest trauma
centers has added to the shock of Reed’s plan.

"County-USC runs one of the best trauma centers in the country.
If you’re seriously hurt in an accident or an act of violence,
there’s probably no better place to be taken than County-USC," said
Richard Brown, UCLA professor of public health.

"That’s an irreplaceable asset," he continued.

The hospital’s closure will put added strain on other area
medical centers ­ including UCLA ­ which together will be
forced to handle displaced emergency, government-insured and
uninsured patients. One expert described closing the facility as
"catastrophic.

"I say catastrophic because if the trauma center were closed, I
just don’t see how any other hospital around can handle the trauma
load," Brown said.

Michael Cousineau, associate director of public programs for
UCLA’s center for health policy agreed.

"I’ve heard anecdotally that people laugh at the idea of
successfully diverting the trauma cases," Cousineau said. "Thirty
percent of the trauma in the entire county is being handled by that
facility. To consider diverting that elsewhere, from my thumbnail
sketch of the situation, I just don’t think it’s possible."

Betty Robertson’s son is currently a trauma patient at
County-USC. Also uninsured, the hospital is treating his critical
condition.

"I don’t know if he could survive somewhere else," she said
quietly.

Officials at County-USC acknowledged that the burden of their
closure on other hospitals would be "tremendous.

"Should USC close, we would be rerouting trauma patients to
other centers," said Virginia Price-Hastings, director of emergency
medical service agency at County-USC. "I suspect the trauma system
would collapse. There would be too many patients for the remaining
hospitals."

Price-Hastings could not predict how many additional people UCLA
would potentially be forced to help.

"What we anticipate is that there would be a domino effect. The
closest hospital would fill up and the patients would be sent to
the next and the next. While UCLA is not in the direct line of
fire, it will be affected by the ripple effect," Price-Hastings
explained.

"We’re geographically far from them so the effect would not be
as huge as others," agreed Marshall Morgan, director of UCLA’s
emergency medical center.

Still, Morgan and others speculated that UCLA would see
increases in the trauma load and in the number of uninsured people
seeking care.

"(The workload) would increase greatly," said radiologist Albert
Gonzalez. "It would be similar to when Saint Johns closed due to
the (Northridge) quake. When Saint Johns came back up, volume went
back down."

Another cost-cutting option before the supervisors is to
maintain County-USC but close some of the county’s other five
smaller hospitals. This plan would instead call for the satellite
hospitals to push their patients onto County-USC.

Officials say significant sums could be saved by closing care
centers such as Olive View and Harbor hospitals, both operated by
UCLA. But their closure would limit patient access to the regional
hospitals, again displacing thousands.

"That maneuver would have a much greater effect on our volume,"
Morgan said. "The geography is such that Olive View services the
(San Fernando) Valley and Torrance services the harbor. We’re kind
of between them. There aren’t many big hospitals between us so more
of that volume would come to us in that scenario. Either way it
won’t be good."

Luckily, UCLA’s interests run parallel to the plans of
decision-maker Reed.

"The USC medical center would be the better choice because the
condition of the building is such that it requires replacement,
which would be a $1 billion project which we obviously can’t fund,"
Reed told The Bruin.

With more uninsured patients potentially seeking care at UCLA,
officials will be forced to decide how to treat them. UCLA’s
current policy is to move most uninsured patients to County-USC for
government-paid treatment.

"We wouldn’t be able to transfer them; the next option if USC is
closed is can we transfer to another county hospital ­ UCLA
would have to take that financial responsibility," said Morgan,
adding that the county has recently been moving "to ultimately
abdicate the responsibility of the uninsured."

That additional "financial responsibility" on area hospitals is
coming at a time of state budget woes and widespread cost-cutting
efforts. There is doubt whether they can afford to pay for all the
uninsured people in Los Angeles County.

Closing County-USC and sending its thousands of uninsured
patients elsewhere will have human, financial and political
consequences that are difficult to quantify. The topic is a sure
catalyst for community discontent and debate.

An initial burst of fierce anger and emotion greeted the
proposal. After only one day, 1,500 protesters gathered at the
hospital to protest its potential closure.

But despite the obvious dangers and consequences of shutting the
hospital’s doors, financial reality is forcing county officials to
seriously consider taking the highly unpopular plunge.

The closure of County-USC would save about $350 million, Reed
said, and is the single largest cut in an ambitious proposal to
eliminate nearly 20 percent of the county’s public jobs.

"We have a shortfall in federal funds of $655 million," she
said. "In order to make up those kinds of reductions, we have to
close a major part of our hospital structure."

When asked what the consequences of not closing County-USC were,
Reed responded, "It would jeopardize public-safety programs, the
already strapped park system and welfare ­ all would be in
grave jeopardy."

The cutbacks are designed to help plug the $1.2 billion deficit
in this year’s county budget. The enormous deficit has its roots in
the 1970s, when Proposition 13 passed, limiting property taxes and
severely draining counties of needed resources. For years, the
state supplemented the loss, but recent statewide budget crunches
have forced Sacramento to stop that practice.

"The state has been the one who substantially got us into this
problem," said Joel Bellman, press deputy for county supervisor Zev
Yaroslavsky.

"In enacting Proposition 13, they stripped us of our most
important revenue sources and shackled us from raising those funds
in the future."

Talk is circulating in county and health care circles of
emergency help from state and federal sources. Although some are
hopeful, some seem skeptical that the politically motivated Gov.
Pete Wilson will chose to bail out Los Angeles’ health care
system.

"I think the governor is more concerned with winning votes from
the Republican right wing across the country then he is with
pleasing Los Angeles."

"Right now the prospects for any assistance from the state are
pretty bleak," Brown said.

The likely consequence of the closure is a mere shifting of the
uninsured patients and the financial burden they represent to
smaller, surrounding medical institutions.

Los Angeles has an abnormally high proportion of uninsured
individuals, Brown said. One out of every three non-elderly
Angelenos does not have health insurance, and the county built its
extensive hospital system in response to that problem.

But just as the county’s fortunes have declined, the number of
uninsured in Los Angeles has only increased. The ailments of the
uninsured will not disappear ­ but will be moved to
places less prepared to handle the costs of treating them. Those
additional costs are unlikely to be paid for by the debt-ridden
county.

"If the county is looking for ways to cut expenses, it’s not
going to do it by closing and then paying a lot of money to private
hospitals to take care of uninsured patients," Brown said.

An additional concern is that patients will wait longer before
bothering to go to a far-away hospital, worsening their condition,
and in the long run increasing the costs of their treatment.

"County-USC sees the patients that are the worst off now. They
often don’t go in until they’re damn near dead already," said UCLA
cardiothoracic surgeon Garland Hodges.

"If those patients don’t have a nearby hospital to go to,
they’re likely to wait even longer," Hodges added.

Some fear that by waiting so long, the problem will eventually
develop until it becomes critical, forcing the patient to visit the
emergency room.

"If County-USC shuts down, there is simply no way these
hospitals can absorb that volume of emergency patients and remain
financially viable," Brown warned.

Reed also acknowledged that the financial impact of closing
County-USC was likely to strain other medical centers.

"It’s going to mean that (other area hospitals) will see more
unsponsored patients, and that’s one of the things that they have
not been able to handle easily in recent years," Reed said.

UCLA is historically one of those institutions with a low rate
of uninsured patients, and thus one of the most ill-equipped to
handle a dramatic increase in treating uninsured patients.

"(UCLA) may see a real spillover or domino effect in emergency
room care, which would leave a lot of uninsured patients on our
doorstep," Brown said.

The uninsured patients who may fill UCLA’s waiting rooms present
a real quandary to the hospital ­ a paradox that’s facing the
county on a much larger scale: how to balance responsibility with
reality.

"There is some serious soul searching as to … how much of the
health care burden (UCLA) would have to pick up," said David
Hayes-Bautista, director of the Center for the Study on Latino
Health.

He said "UCLA doesn’t have that obligation legally," explaining
that the state constitution calls for each county to provide
last-resort medical services.

A vote on whether to close the hospital will be brought before
the five county board members later this month. Zev Yaroslavsky,
the newest county supervisor and a UCLA alumnus, is considered by
some to be the swing vote between the Democratic and Republican
camps.

"Gloria (Molina) and Yvonne (Brathwaite-Burke) are supporting
current service levels at all costs. Mike (Antonovich) and Deane
(Dana), the Republicans on the board, are perceived as less
supportive of those services and more willing to cut them,"
Yaroslavsky’s press deputy said.

"Zev, being new to the board and having a foot in both camps …
is perceived as someone who could go either way," Bellman
continued, describing the board members’ positions as "fluid."

The proposal before the supervisors to close County-USC is
shedding light on the human toll of budget cuts. But regardless of
how they vote this month, critical services will soon be denied to
people who need them most.

"I understand where the county is coming from," said Daniel
Cardenas, a County-USC hospital obstetrician, "but at the same time
we’re talking about people’s health and lives."

L.A. health care on the edge

Southland’s largest hospital may close to save county $350
million

Photos by Justin Warren/DB