Health Director Stays Immune to Criticism : Bureaucracy: The county’s public health system is in deep trouble, and many hold Bob Gates responsible. But he says he tries not to take it personally.

County health Director Bob Gates, the man steering the public health system through its funding crisis, is no stranger to either tension or criticism. He attracts both in heavy doses.

Gates, a battle-hardened administrator some consider “the consummate bureaucrat,” has developed the nerves of a world-class poker player and could write a book on crisis management.

But now, in a time of more impoverished patients and fewer dollars, the criticism is piling up. And Gates tries to take it in stride.

“I judge the source. Are they in a position to really know about me or the department, or not?” the 53-year-old Gates said. “You can’t make people happy all of the time. You have to make choices people are not going to be happy with, and some of them are going to personalize it.”

These days, people are personalizing it perhaps more than at any other time in Gates’ nine-year tenure as director of one of the nation’s largest health systems.

The agency he heads employs enough doctors, nurses, administrators and others to populate Gates’ hometown, San Juan Capistrano, in Orange County. There are enough annual hospital admissions, patient visits and walk-in traffic at the county’s 66 clinics and hospitals to match the population of Oregon.

Even some of Gates’ critics concede that he has managed as well as could be expected as he jumps from one crisis to another. He has had to expand services to meet a huge influx of immigrants, negotiate contracts with private hospitals to hold the shaky trauma network together, work through a nurses strike, find money to expand prenatal services, and deal with the early retirements of top executives and an ongoing hiring freeze.

But in many respects, the wheels seem to be coming off the health system, and much of the blame is falling on Gates. Critics say he has been unable to come up with a satisfactory plan to ease overcrowding in emergency rooms, eliminate the months-long waits that indigent patients have to endure to see a specialist, or develop a consistent model and philosophy of health care that would lead to uniform care throughout county health facilities. And, they say, a revolving door policy in the executive suite has created a morale problem.

They are even going after Gates’ quiet style as a public administrator, a field where dullness is considered a character strength and flamboyance a weakness.

Gates, on the one hand, must be the hard-nosed head of a 27,000-employee health agency and, at the same time, be a professionally shy, soft-spoken public administrator who takes pains not to steal the limelight of the five elected members of the County Board of Supervisors who have the power to fire him without notice.

“He is generally well thought of in the industry . . . (the) consummate bureaucrat,” said David Langness, a spokesman for the Hospital Council of Southern California.

“He is in a very tough spot. Some say he is too meek, that he doesn’t stand up for his rights. Others say if he spoke any louder, he wouldn’t have his job,” Langness said.

The most recent tempest is the recent Board of Supervisors decision to close 24 county health centers, a decision based on a budget plan that Gates drafted.

There is a good chance that the clinics will stay open because local officials believe that the state Legislature will temporarily suspend matching fund requirements that have been holding up $72.8 million in tobacco tax revenues earmarked for the county.

But many in Gates’ constituency of hospital administrators, poverty lawyers and health care workers believe that it was outrageous to even suggest closing the health care centers. These facilities, they say, serve as the first defense against tuberculosis, provide tens of thousands of poor women with prenatal services, and are a cost-effective way of providing primary care and preventive health services to the poor and indigent population.

Critics have been making their points for months in a series of budget hearings. Through it all, Gates--tall, gray-haired, bankerly conservative--has remained unruffled, speaking barely above a whisper at hearings.

His style reflects decades of tutoring by past and present county executives that began when he joined the county in 1963. At the time, he was a hotshot honors student with a master’s in public administration from Syracuse University. Acting Chief Administrative Officer Harry Hufford, one of Gates’ early mentors, called him “quite a catch.”

Gates left the county in 1968 to take an administrative job at what now is the UC Irvine Medical Center. He returned in 1978 as a deputy director of the Department of Health Services. It is not in Gates’ nature to bang on tables, make desperate pleas or take an action even close to what some health advocates seem to want, which is for him to appear ready to fall on his sword to save the county’s health system.

His quiet, unemotional presentation of what would happen if the 24 health centers were shut down had Marjorie Sa’adah, director of Homeless Health Care Los Angeles, ready to scream at a recent budget hearing.

“We want to know why we don’t have an advocate as our leader,” she said. “Why doesn’t he tell the board about the people and jobs that are going to be lost? These aren’t people sitting on their butts--these are nurses, physicians, physicians assistants, health educators and community health workers. . . . They are the solution, not the problem.”

After grilling the health director sharply at another hearing, hoping for a response, Supervisor Gloria Molina, one of Gates’ most vocal critics, said in frustration: “It’s sort of like he just takes a whole lot of punches and does not defend himself . . . so I’m never sure that he cares.”

Gates’ latest--and perhaps most serious--problems began in February, when three emergency room physicians were wounded at the county’s flagship County-USC Medical Center. The shootings resurrected chronic complaints about lax hospital security, illustrated the plight of patients pushed to the limit of endurance by long waits at county medical facilities, and established that key reports had not been read and that warnings were ignored.

Then Gates admitted that administrative foul-ups had jeopardized more than $1 million in badly needed federal grants to fight the tuberculosis epidemic.

A mess, and subsequent lawsuit, developed when Gates removed the head of the County-USC Medical Center, Jerry Buckingham. Critics said the move reflected Gates’ tendency to deflect criticism from himself to his managers, in this case the criticism over the emergency room shootings.

An effort to transfer a popular, nationally known public health expert, Dr. Shirley Fannin, from her job as director of infectious diseases was rebuffed after Fannin protested and the Board of Supervisors stepped in, demanding an explanation. Neither Gates nor anyone else in his department seemed to have a good reason for moving Fannin.

Even one of the positive announcements, that the County-USC Medical Center had been removed from probation by a hospital rating service and had been restored to full accreditation, only served as a reminder that the facility had almost lost its accreditation.

Molina calls his agency “the most mismanaged department the county has.”

“I think there is very little or no oversight. It is not patient-friendly. It isn’t people-friendly. I think there is a lot of bureaucracy, a lot of passing of the buck,” Molina said during an interview.

Supervisor Ed Edelman, chairman of the five-member board, said he has “a number of questions about (Gates’) strength as a manager.”

“His strengths are, I think, in finding revenue. He is very good at that. . . . His weaknesses are in management,” Edelman said.

Despite the criticism, both board members say there are no efforts under way to fire Gates.

Gates, the county’s health director since 1984, expresses surprise over the criticism.

In his mind, he has been performing heroic duty over the last 10 years.

Twelve years ago, health care spending represented 16.83% of the county’s then $1.4-billion budget; today, it has dropped to an 8.35% share.

Despite the county’s shrinking commitment, the health services budget has more than doubled, jumping from $917 million annually to $2.3 billion.

That rise is because of many factors, including increasing populations of the poor who qualify for state and federal assistance programs, but many attribute a share of the big budget jump to the aggressiveness of Gates and his staff in pursuing state and federal health dollars.

Still, even with the budget growth, there clearly is not enough money.

“Go back to 1980, and the county was putting in the same amount of money it is now. Each and every year we have had to figure out what’s the shortfall, how are we going to deal with it, develop contingency plans, develop new strategies to bring in more state and federal revenue and pursue those,” Gates said. Simply put, he added, “we are in a survival mode.”

Hufford said: “These jobs (running big government agencies) are like sitting on a volcano--a volcano that can explode at anytime underneath you. . . . In an era of dwindling resources, you have to take more risks, and anytime you take a risk, it can backfire on you.” Gates said he has no regrets, and he plans to be around for the next couple of years to help guide the county into a managed care system based on private health maintenance organizations.

As for his critics, he said he tries not to take their comments personally.