A Second Opinion

The Los Angeles County Board of Supervisors urgently needs a second opinion before it plunges ahead with a much-needed program to replace the crumbling County-USC Medical Center and expand other county hospitals and trauma centers. That second opinion can best come from a broad-based county commission of professionals with a mandate to review the master plan now in its final stages, and to consider other options.

As matters now stand, the county is going to budget in the next fiscal year planning funds for expansion to meet some, but by no means all, of the critical requirements at Martin Luther King Hospital while awaiting a master plan being developed by Medical Planning Associates and expected in October or November. In all likelihood, the master plan will propose a comprehensive billion-dollar bond issue to replace the existing 1,450-bed main hospital at the County-USC Medical Center with a smaller facility at the same location, supplemented by a new hospital and trauma center in the San Gabriel Valley. It would call, too, for further expansion of Martin Luther King, Harbor and Olive View county hospitals.

That may be the best way to go. There seems to be no debate about the importance of replacing the main building of County-USC. The 60-year-old structure is deteriorating rapidly and the cost of rehabilitation would be exorbitant. Furthermore, this is a good time for capital programs because the county can cover about half of its replacement and expansion costs with state funds under a 5-year program enacted last year.

But there are some serious questions that may not be adequately addressed unless the discussion is broadened to include the entire hospital community, not just the county Department of Health Services and the system of county-run institutions. The best way to broaden the discussion is to create an independent commission. Indeed, the commission could become a model for other counties in the state, many faced with similar building crises. Only one county in the state has in place anything like an independent hospital planning commission, and there is a paucity of master plans statewide.

The first task of a commission, it seems to us, would be to draft a master plan embracing all hospitals in the county, public and private, so that anticipated needs can be judged against available facilities, and there is a clear understanding of total available capacity. It would be troubling if a new facility were to be constructed when existing facilities nearby are operating marginally because of high vacancy rates.

Implicit in a broad review of that sort would be a review of basic policy for financing the care of the medically indigent. Is it best to continue the trend of recent years, diverting most of that care to the county hospitals? Or would it be better to return to the policy that was part of the original plan for Medicaid--Medi-Cal in this state--to provide public funds to pay for that care in whatever hospital, public or private, was most convenient for the patient? California may have moved too far along the path to two-tier health care to return to that more equitable policy, but that can be determined only by careful study. There is evidence that the care could be provided at less cost and with greater sensitivity to the needs of the poor if the broad-based program of the past, using all hospitals, were revived.

Any move to decentralize services now provided at County-USC raises complex questions related to medical education and staffing. The center’s high quality medical education program could be weakened if as many as one-third of its patients were transferred to the proposed new San Gabriel Valley hospital. Could the same staff-quality standards be assured at such a new medical center?

Clearly, a county commission cannot answer one of the key questions: How to pay for uncompensated care? An expanded Medicaid, as proposed in a recent study led by the American Medical Assn., would mobilize the combined federal-state Medi-Cal to provide the basic funding essential to supplement the now under-funded medically indigent program. But the already difficult financial situation has been reduced to chaos with a move this year by Gov. George Deukmejian to divert some of the new tobacco tax funds to replace general fund financing for the medically indigent, a plan that would worsen an already desperate situation.

Even as the state funding situation is being sorted out in Sacramento, however, a new county commission could take a giant step toward finding the best way to deal with the future of hospitals in Los Angeles County. And, whatever the outcome, the process very likely would serve to encourage a closer coordination of all hospitals, public and private, nonprofit and for-profit.