Clinic’s Grim Prospect: Turning Away the Desperate

On South Grand Avenue, 10 minutes from the skyscrapers of the financial district, an ugly concrete building with slits for windows squats like a bunker among factories and warehouses.

And a bunker it is. This county health clinic is where 250,000 people a year come for refuge from the diseases and injuries that well up outside its walls.

This is the place that tries to make sure the guy serving your Caesar salad doesn’t spread tuberculosis. The place that keeps a diabetic construction worker on the job instead of lying in bed with gangrenous feet. The place where prenatal care helps prevent four-pound babies whose treatment costs $1,500 a day.

You could look at the C. Claude Hudson Comprehensive Health Center as an upstream dam, one of dozens of little dams holding back scattered, swelling creeks of sick people. The dams prevent a flood of patients from roaring through the already crowded halls of County-USC Medical Center--and through private emergency rooms.

But the little dams may be about to let loose. County workers will soon begin measuring the Hudson clinic’s perimeter for chain-link fencing in order to close the place down and shut the sick out.

The government is short on money and the Hudson center is just one of 34 clinics and health centers scheduled to close Oct. 1, wiping out 1.8 million doctor visits a year for people who often have nowhere else to go.

Hudson takes in tens of thousands of working poor and indigents who can’t go to private doctors because they don’t qualify for Medi-Cal, the state’s medical insurance program for the poor. Most of those excluded either don’t fit the bureaucratic categories (families on welfare are eligible, but non-disabled childless adults under 64 generally are not), or they are illegal immigrants.

The cuts are also expected to wipe out more than 6,000 county jobs. The linoleum-floored halls of Hudson are thick with emotion as clerks and technicians try to comfort worried sick people, fearing that they themselves may end up as indigent as the patients.

There is talk of having this center taken over by a private hospital that would aim to actually make money, or at least break even. There is talk of some kind of public-private partnership. But that kind of policy debate seems far removed from the daily tasks here.

‘I’m Terrified’

For now, the doctors and nurses at Hudson are still giving shots and stitching gashes. In between, they are strategizing about how to stop doing what they do, struggling to figure out where to tell these patients to turn.

So far, they don’t know what to tell them.

“I’m terrified for them,” said Dr. Marc Weigensberg, who treats diabetic children. The medication and education these children get through the county prevent blindness, kidney failure and death. Now some of them may be on their own until they end up in an emergency room.

Although the doctors and nurses here are on the front lines against death and disease, the care they give inside this dowdy building rarely offers the high drama of “ER.” There are more pus-filled infections than gushing gunshot wounds, more prescribing of cholesterol medicine than high-tech heart operations; there are Pap smears, mammograms, lead tests for toddlers.

The premise is simple. Immunize kids, and there won’t be the deadly outbreak of measles that killed dozens of people in Los Angeles five years ago. Get a man to take his blood pressure medicine and he won’t come back in an ambulance.

It isn’t only the needy who will be hit by the cutbacks, doctors here warn: An outbreak of whooping cough won’t distinguish between wealthy and poor babies. And when a Lexus gets smashed up on the freeway, its driver is going to be carted through an emergency room that will be more crowded than usual--jammed with people who used to come to Hudson and places like it.

There are no Lexuses, or many cars of any kind in the Hudson parking lot. Most people come here by bus, if they can afford it, or on foot.

Only 25% of Hudson’s patients are lucky enough to have Medi-Cal, according to Dr. Mary Abbott, the clinic’s medical director. She’s a tidy blond woman--Donna Reed cast as the Gen. Norman Schwarzkopf of this embattled fortress--trying to figure a way of shuffling her patients into the hands of private doctors while maintaining smooth operations within Hudson’s doors.

She frets that the great majority of Hudson’s clients, with no insurance and little money, will probably be adrift once the clinic shuts its doors.

They are people like the man who got a splinter of wood in his eye doing carpentry. All it takes is some flushing with saline solution. Now it won’t get infected and cause him (and other taxpayers) great distress.

There’s the uninsured little boy with a serious cut whose mother had taken him to a private hospital emergency room but gave up when it demanded $600 up front to sew him up, according to nurse Yvonne Flemming. The mother brought him across town to get it done here for $45.

There’s the guy who came in the other day with a nasty-looking three-day-old burn on his foot. It turns out, recalls physician’s assistant Donald Pierre, that he had untreated diabetes and a blood-sugar level so high he was on the verge of losing consciousness. While he was getting an intravenous feed and insulin, he started vomiting blood; something was wrong with his stomach, too.

“A lot of times they come for one problem and we find they have others,” Pierre said.

Pierre patched the man up and sent him over to County-USC in one of the vans that circle the county, connecting its facilities like a network of veins and arteries.

The Hudson center is part of an intricate system of linkages that are about to be severed. Hudson acts something like a traffic cop, directing serious cases up to County-USC and tuberculosis treatments down to smaller county clinics, trying to prevent logjams.

Doctors at the big hospital can call up lab results ordered by someone at a clinic on a centralized computer. Physicians like Weigensberg go back and forth between clinics and the hospital to follow up on patients. These connections will be weakened even if the patients are able to find private doctors or clinics.

The county’s major hospitals, which are scheduled to stay open, aren’t going to be able to take all these patients on. Three-quarters of the hospitals’ outpatient clinics may be closed, even as demand for them is going to expand exponentially with the closure of neighborhood clinics.

One Hudson patient, a mother named Natasha, said she doesn’t know where she’ll go then. She has no Medi-Cal.

Natasha has brought her 2-month-old daughter, Ariel, in for immunizations. The baby is still crying from the shots as her mother takes her over to the counter to make an appointment for her next checkup in two months, in October.

The clerk makes the appointment, even though she knows the clinic is scheduled to be closed by then. The clerks at Hudson--unlike some other centers--haven’t gotten official word to stop making appointments. The clerk makes sure, however, to update Natasha’s home phone number. She will need to reach her to cancel the appointment for Ariel, who will most likely be without a doctor by the time she reaches 4 months.

Workers Shaken Too

The doctors at this clinic look at patients like this and see a looming public health crisis. The nurses, receptionists and lab technicians look at the patients and see themselves.

The workers--mostly minority, mostly women, sometimes barely hanging on to middle-class status with two jobs per family--know that they, too, could end up poor and without health insurance.

Brenda Bravatti, an administrative assistant at the clinic, gradually loses her composure as she translates for Teresa Aguilar, a tiny 57-year-old diabetic who speaks only Spanish.

Aguilar used to clean houses for a living until her illness made her nearly blind. Now, her 27-year-old son supports her, her invalid husband and her two teen-age daughters on $1,000 a month he scrapes together as a construction worker. None of the family has Medi-Cal. She can’t afford to pay for the insulin she gets here for free. Maybe she will use herbal remedies instead, she said. With Bravatti translating, Aguilar describes the clinic as a haven where nurses and doctors know her and her family. “There is trust,” she said. Sometimes clinic staff give her daughters clothing so they’ll have something to wear.

Then Aguilar must stop talking. Bravatti has broken into tears.

“We’ve never been as scared as we are now,” sighed Bravatti, a single 35-year-old mother of three. “We’re just like the patients. We don’t know what’s going to happen to us.” If she gets laid off, she said, “I’ll become one of my patients. Who knows if I’ll qualify for Medi-Cal or food stamps?”

The fate of Bravatti and her co-workers is held in a thick book of computer printouts that ranks them by seniority. A steady stream of staffers pores over it. Like the old draft lottery, a low seniority number is bad luck. Bravatti’s is seven.

“I’m a goner,” she said.

Hudson acting CEO Nancy Delgado and top doctors and nurses have been holding daily meetings on shutting down the clinic’s various services. Adult care, pediatrics, urgent care . . . one by one the services map their own demise.

On a recent Monday it was prenatal care. In a windowless war room, medical director Abbott wrote down the services to be shut down on a giant pad of paper on an easel as grim-faced staff--12 women and one man--stared into their plastic foam coffee cups and took notes on legal pads.

High-risk pregnancies, HIV-positive mothers, Pap smears, ultrasounds, battered women--each issue demanded that this clinic find somewhere else to send patients. The paper gets filled with red arrows snaking here and there, but each ends up with a big “MTF” (more to follow)--meaning they just don’t have the answers.

There are the logistics of storing records. Even after the patients have nowhere to go, their paperwork has to have a home. And patients will have to be given copies of their records before they are sent on their way.

Delgado said not to charge the patients for the copying costs.

“It’ll be our gift to them,” she said, her voice heavy with irony.

One doctor explains that it is possible County-USC Medical Center’s prenatal clinic will be shut down. Heads shake in disbelief.

Abbott instructs the pharmacy to give extra bottles of medicine to patients on their last visit to tide them over--to what, she’s not sure.

She explains that a list of private doctors willing to take Medi-Cal patients is being compiled, and the discussion hones in on the cruel economics of trading bodies. Private doctors, explains a community worker, will be happy to see a pregnant woman--one time. “The initial patient visit, that’s where the revenue comes from,” she said. But if the woman has diabetes or some expensive complication, many doctors won’t see her again, the woman said.

Abbott comes to “social services”--a euphemism, in this case, for help for battered women. This clinic tries to catch abuse early and connect women to shelters and legal assistance to help prevent further injury. One staffer said when she called various agencies to see if they could take over this work, “They just laughed.”

Abbott takes a deep breath.

“Now it will be the emergency room,” she said.