AIDS Tops List of Many Health Crises Faced by Deukmejian Administration

During Gov. George Deukmejian’s nearly four years in office, his Administration has been tested by a series of public health crises, including one that may prove as severe as any faced by the state since its founding.

AIDS is “probably going to go down as the worst epidemic of the 20th Century and conceivably may well end up being one of the worst epidemics of all time,” said the Administration’s top health officer, Dr. Kenneth W. Kizer, who directs the state Department of Health Services.

But he noted that AIDS, which has hit California especially hard, is but one of many health issues that the state must face: “The tendency when you are talking about AIDS is to think that all our other health problems have gone away and clearly that is not the case.”

A review by The Times of Deukmejian’s performance on health issues shows that his Administration has been forced to grapple with many of the same problems that plagued his predecessors, as well as several new ones.

It has tried to deal with the abuse of elderly nursing home patients; a shattered system of care for the mentally ill; the rising cost of health care for the poor; controversies over state policy on abortion and birth control, and a series of public health emergencies in addition to the AIDS crisis.

In nearly four years in office, Deukmejian has moved with long strides in addressing several health issues, substantially increasing spending for mental health after making initial cuts, for example, and toughening enforcement of nursing homes.

But critics contend that the Administration has largely ignored the growing problem of providing health care to the working poor and the uninsured and has done little to relieve the increasing stress on overcrowded county hospitals.

In several other areas the Administration has faltered or changed direction, abandoning policies in the face of political obstacles or when confronted with an unmistakable need.

In response to the AIDS crisis, for example, Deukmejian approved dramatic budget increases for research, education and prevention efforts. In the current budget year, the state will spend $35.8 million on AIDS, up from $3.4 million three years ago. Deukmejian aides point out that the 1986-87 fiscal budget amount is almost equal to the total spent by all 49 other states and the District of Columbia combined.

“We’re clearly leading the country and we’re leading the country because of the leadership of the governor,” Deukmejian’s chief of staff, Steven A. Merksamer, said.

However, Democratic legislators have complained that the state is still not spending enough to contain an epidemic already rampant among male homosexuals and now believed to be spreading among the state’s intravenous drug abusers. These critics contend that the Legislature has dragged Deukmejian into approving the sizable funding increases needed in the war on AIDS, and they fault Deukmejian for vetoing $20 million from the budget this year for AIDS education, counseling and research.

‘Resisted by Administration’

“Not a dime of it (state spending on AIDS) originated in the governor’s office or was initiated by the Administration,” Assemblyman Art Agnos (D-San Francisco) complained. “It was initiated by the Legislature and resisted by the Administration every step of the way.”

“Nothing becomes law unless the governor supports it,” Kizer countered.

Agnos is particularly riled that Deukmejian has twice vetoed measures that would protect AIDS victims from discrimination in housing and employment. That step is important to the public at large, Agnos argues, because the fear of losing home and job can stop AIDS patients from seeking diagnosis and from learning how to prevent the spread of their disease.

And just how effective the Administration has been thus far in using AIDS money is a matter of debate. In an effort to organize an AIDS education and prevention effort quickly and bypass sometimes clumsy civil service hiring rules, the Administration chose to contract with the state-chartered, nonprofit Public Health Foundation. The contract with the foundation also helped the Administration avoid adding new state employees--one of its high-priority goals.

Hiring Plan Challenged

But after an American Federation of State, County and Municipal Employees union local challenged the hiring plan, the state Personnel Board in February declared the contract illegal, forcing the Administration to hire regular state employees through the Civil Service system.

The haggling over staff hiring meant a delay of a year and a half in setting up the AIDS office and slowed efforts to contain the fatal disease, according to one Department of Health Services official who asked that he not be identified.

Merksamer rejected the criticism as “inaccurate,” and added, “It’s because we have done such a good job generally that the critics struggle hard to find weaknesses in the armor.”

In addition to stepping up the anti-AIDS campaign, the Department of Health Services under Kizer has begun moving more aggressively to police the state’s privately operated nursing homes, partly in response to legislation, which Deukmejian signed into law after first vetoing similar measures.

Nursing Home Program

Starting 18 months ago, in a program initiated by Kizer, the health agency zeroed in on homes with a history of serious problems. Teams of investigators conducted inspections after business hours and on weekends, when least expected and when conditions were likely to be at their worst. And the department got tougher on routine inspections, following legislation that increased penalties for nursing homes that do not meet state standards.

The results have been dramatic: The number of citations rose to 1,962 in 1985--up 54% from the year before. And fines climbed by an impressive 276%, from $1.4 million in 1984 to $5.3 million in 1985.

However, complaints against nursing homes have been increasing at a faster rate than state inspectors can handle, according to health services Deputy Director Virgil J. Toney. And partly because of a large number of vacancies on his inspection staff, Toney said, many complaints against nursing homes--25% to 35% of them currently--have not been checked out in the legally required 10 days.

Move to Fill Jobs

Toney said he has been moving quickly to fill the jobs to bring his inspection staff up to full strength and help end the backlog.

When Republican Deukmejian was elected governor in 1982, advocates of health care programs braced for what they believed to be the inevitable sharp cuts in programs for the poor, the mentally ill and preventive health care. And faced with a gargantuan state deficit of $1.5 billion, Deukmejian did slash health programs, along with many others, as part of a successful effort to balance the state budget and create a surplus for emergencies.

He also proposed turning over a number of state-run public health programs, including the potentially explosive family planning program, to counties--part of an effort to cut the size of the state work force and shift responsibility to local governments.

In addition, his top health and welfare officials talked about adding to Medi-Cal reforms begun before he took office. They called for potentially money-saving changes such as requiring Medi-Cal recipients to choose a prepaid health plan or establishing a bidding system for prescription drugs.

Backed Away From Proposals

But in the face of political opposition, Deukmejian has, bit by bit, backed away from these and other early proposals. At the same time, the need to cope with public health calamities and the unrelenting medical needs of the poor have raised budgets rather than lowered them.

As the state treasury has been replenished, Deukmejian declared that the poor of the state would be among the first beneficiaries of the renewed prosperity. “A society’s greatness is measured not only by the triumphs of the strong,” Deukmejian said in 1985, “but also by our capacity to help those who need our help.”

As a result of the changes:

- Spending on Medi-Cal and other health care programs for the poor has climbed at a far faster rate than the Administration once advocated. By 1985, expenditures for Medi-Cal patients and for county programs for those who do not qualify for Medi-Cal totaled $4.8 billion--almost $1 billion more than Administration officials had predicted two years earlier. This year the total could climb to $5.5 billion, according to an estimate by the nonpartisan legislative analyst--a 25% increase in three years.

- Following initial cuts, Deukmejian has approved substantial budget increases for state and local mental health programs. This year the state will spend $818 million on state mental hospitals and community treatment programs, up 75% from when Deukmejian took office. The governor has pledged to make California, by the end of next year, the first state in the nation to have all of its state mental hospitals fully accredited.

- After two years of hiring freezes and staff reductions, the Department of Health Services’ employment rolls have begun growing again. The department now has more than 4,000 employees, up from 3,720 two years ago and somewhat higher than the number when Deukmejian was elected. Most of the new jobs have been in toxic cleanup and AIDS programs.

Deukmejian critics say that the Administration has fallen short in several areas, particularly in dealing with the growing problem of medically indigent adults--generally the working poor who are without health insurance, who do not qualify for Medi-Cal and who cannot afford to pay for health care on their own.

Medi-Cal ‘Reforms’

The problem is not one of Deukmejian’s making. Under the 1982 Medi-Cal “reforms,” signed into law by then-Gov. Edmund G. Brown Jr., these patients were pulled out of the Medi-Cal program, which allowed them to choose their own physicians and hospitals. Instead, they were forced to seek help from the counties, which are given a lump sum each year to pay for their care.

But counties have complained that the annual payment has not been enough to provide the patients with the services they need. And this year, as part of a battle over maintaining the state’s $1-billion surplus, Deukmejian cut $25 million from an initial $567 million appropriation.

Even before this year’s controversy, a UCLA study published in the prestigious New England Journal of Medicine showed that the health of a group of patients suffered as a result of the switch to overcrowded county facilities. Not only did the 186 patients show a marked increase in average blood pressure in the year after the change, but seven of them died. A lack of access to care under the new system “played a part in at least four of the deaths,” the UCLA researchers concluded.

County Hospitals Hurt

Other Medi-Cal “reforms,” along with federal changes intended to keep Medicare costs down, have also hurt the county hospitals while privately owned facilities have generally prospered, according to a study by the state Office of Statewide Health Planning and Development.

Health Services Director Kizer acknowledged that county hospitals in the state continue to be in trouble. “County hospitals are stressed, there is no doubt about it,” he said. “But who is responsible and where does the responsibility lie for the care of folks who can’t pay for it? Historically that has been a local responsibility.”

He agreed that “we’re going to have to address that in the future.”

But critics have harsh words for the Administration’s failure to take immediate action.

“Deukmejian has failed to take the lead in solving the health care problems of this state,” said Geraldine Dallek, a health policy analyst with the private National Health Law Program. “Over 20 states have task forces to study the needs of indigents. California is behind the other states in finding ways to care for the uninsured working poor.”

Novel Ways to Raise Funds

Some of the states have come up with novel ways of raising money without increasing general taxes, such as taxing hospital revenues or tacking on fees for each hospital bed to subsidize care for the poor, according to a George Washington University study. Kizer said similar options are being discussed within his department.

One area where the Administration has taken action is to raise Medi-Cal payments to doctors for delivering babies from $518 to $650, at an annual cost of $5 million--a move intended to encourage more physicians to provide this vital service to women who depend on the state system.

But as in other areas, critics contend that the increase was long overdue and too small to have much of an effect. As a result, too many low-income pregnant women will first see a doctor only when they show up at county hospitals for delivery.

Deukmejian vetoed an additional $10.6 million that would have allowed an increase in payments to $925 for obstetrical care--an amount that might have brought substantial numbers of physicians back into the Medi-Cal system, according to a survey of county health officers conducted by Dr. Curtiss E. Weidmer, health officer for El Dorado County.

As the cost of malpractice insurance for doctors who deliver babies has skyrocketed, fewer and fewer physicians, who typically receive close to $1,200 for private patients, are accepting those on Medi-Cal, Weidmer said.

“The increase (to $650 per delivery) will help keep physicians in, but it won’t bring them back,” Weidmer said.

Infant Mortality Rates

Without proper predelivery care the number of miscarriages, premature deliveries and infant deaths is almost certain to increase, said Wendy Lazarus, director of the Southern California Child Health Network.

Infant mortality has continued to fall in California, from 11.1 deaths for every 1,000 live births in 1980 to 9.4 in 1984, the last year for which statistics are available.

But Lazarus contends that the overall improvement “masks what is happening to the poorest kids.” Black infant mortality has been falling, but continues to be 75% higher than for all youngsters. And Lazarus is troubled by recent increases in infant mortality and low birth-weight babies among certain ethnic groups in Los Angeles County.

“There is a notable increase for the last 10 years straight in the number of babies born in this state,” Lazarus said, “and (government programs) have just not kept pace so that pregnant women can get early health care, which can prevent low birth-weight babies and death.”

Under Constant Pressure

Kizer, speaking in general terms, noted that his department is under constant pressure to serve many health care needs. “One of the truths you have to come to grips with in health care in general is that there will always be a greater demand than you can satisfy. There is always going to be more that you can do.”

Another health issue that has continued to smolder during the Deukmejian years is the state’s role in birth control and abortion.

In his first year, the governor appeared to be taking direct aim against birth control clinics when he slashed $9.5 million from the family planning budget. The following year he promised to restore half of that amount if the Legislature agreed to transfer the program to county governments.

Planned Parenthood and other advocates for family planning argued that the controversial programs would be damaged if conservative county supervisors were given control. The Legislature refused to go along with the Deukmejian proposal.

Point of Contention

But under Deukmejian’s conservative health and welfare secretary, David B. Swoap, who left office a year ago, family planning continued to be a point of contention.

Under Swoap’s direction, the state Office of Family Planning considered blocking all payments to birth control clinics that also provided abortion services. Apparently aimed at Planned Parenthood clinics, which are often the target of anti-abortion groups, the proposal was never carried out. But last year, Deukmejian signed into law a similar restriction, banning family planning grants to any group that “performs, promotes or advertises abortions”--language that was inadvertently included in the annual budget bill through a clerical error.

Eventually the courts declared the provision unconstitutional.

Two years ago, Swoap replaced the state’s family planning advisory board with a new panel that included outspoken leaders of the anti-abortion movement, including the Rev. Royal Blue, state chairman for the Moral Majority.

Statutory Rape Law

For more than a year, the advisory board has been discussing the state’s rarely enforced statutory rape law, which makes intercourse with a female under 18 a crime. Conservative groups have called for enforcement of the law as an alternative to providing teen-agers with birth control prescriptions and information. But family planning advocates have called such an approach unrealistic. A board meeting scheduled for last month, which would have included a discussion of the issue, has been postponed until after the Nov. 4 election, according to a Department of Health Services official, who asked not to be identified.

Despite what she regards as the Administration’s anti-family planning posture, Hellan Dowden, executive director of Planned Parenthood Affiliates of California, praises Kizer, who has clearly taken command of public health issues since Swoap’s departure a year ago. “He is a public health person,” she said. “He cares about the public health and has taken much less of an ideological stance than Swoap did.”

“Frankly, I think that the governor has taken more heat (on the family planning issue) than he deserves,” Kizer said. “He is pretty moderate in his views.”

Open to Proposals

And Kizer himself has proved to be open to proposals that make anti-abortion groups bristle. He said, for example, that he has met with school officials from Los Angeles and San Francisco who are seeking financial help for school-based health clinics. The in-school programs have been attacked by anti-abortion groups because they give teen-agers ready access to contraceptives and birth-control information.

“Unfortunately, the clinics have gotten a rap that is not justified,” Kizer said. He estimated that 80% of what the clinics do have no connection to birth control or pregnancy, but deal instead with other problems of adolescent health. “I think it is a program that warrants further investigation,” he said.

But last month, Deukmejian vetoed a measure that would have provided $310,000 to help launch such programs. The governor argued simply that he was obliged to a veto a number of proposals to protect a $1-billion “rainy day” state surplus in the budget.