Majority of Supervisors Seek Smaller County-USC

A majority of the Los Angeles County supervisors say they have agreed to vote today to replace the earthquake-damaged County-USC Medical Center with a new 600-bed facility, thereby reducing the number of beds in the region’s largest public hospital by more than one-third.

At the same time, the supervisors appear ready to authorize a number of new outpatient clinics, the first of which would be in the largely Latino Eastside neighborhoods around the Boyle Heights hospital.

The implications of the supervisors’ painfully patched together consensus are vast: County-USC is the keystone in a network of hospitals and trauma centers that stretches as far as the San Bernardino County line. The facility cares for half the region’s hospitalized AIDS patients, half its sickle-cell anemia sufferers and 25% of trauma cases. All told, 55,000 patients pass through County-USC each year, and an average of 860 beds are filled on any given day.

By opting for the smaller hospital, the board is moving with the statewide tide that has pushed California’s counties to scale down or close medical facilities in favor of contracting for services with private medical providers.

“A smaller facility will save limited resources and allow us to continue to develop public-private partnerships and to enhance our outpatient medical program,” said county Supervisor Mike Antonovich, who supports the plan along with colleagues Yvonne Brathwaite Burke, Zev Yaroslavsky and Don Knabe. Supervisor Gloria Molina, who represents the district around County-USC, continues to hold out for construction of a 750-bed hospital. Antonovich earlier had advocated a much smaller facility of 391 beds.

Policymakers are still debating the merits of the majority’s approach, which has led to competition and in some cases extreme animosity between private and public hospitals. If the supervisors’ bet is wrong, the results could be severe.

“If we undersize it, there’s great human damage,” said county Health Services Director Mark Finucane, who strongly backed a proposal to build the hospital large enough to handle 750 beds. “If we oversize it, there’s great financial damage.”

“I worry about the unpredictable,” said Dr. Alan Heilpern, president of the Los Angeles County Medical Assn., who supports building a 750-bed hospital.

“A little over 15 years ago, AIDS was identified here in Los Angeles,” Heilpern said at a rally organized by Molina’s allies. “Who could have predicted a new disease that has had such a profound impact on the health care system?”

The compromise number of 600 beds, said the county’s chief administrative officer, David Janssen, represents the minimum allowable for the county to continue to provide trauma care and other vital services. It also is the break-even point financially, according to health department figures.

If it goes as expected, today’s vote will be a serious defeat for Molina, who had lobbied ferociously for 750 beds.

*

As part of that effort, Eastside and Southeast county legislators including Assembly members Martin Gallegos (D-Irwindale), Antonio Villaraigosa (D-Los Angeles), Grace Napolitano (D-Norwalk) and others have met with each of the supervisors, imploring them to support the larger facility. Every major county health care organization has signed on to Molina’s proposal, which is also backed by health department chief Finucane and the Los Angeles City Council. A chaplain at the medical center has even embarked on a hunger strike.

At issue are two key elements of the shift to managed care and profit-driven health services: the related questions of who will serve the very poor and who will pay for it.

“There is a huge fight in every large county in California and the ultimate question is who gets stuck with the bill,” said author William Fulton, publisher of the California Planning and Policy Report.

According to one school of thought, county hospitals ought to take fuller advantage of Medi-Cal rules, which make it profitable to care for patients who qualify for the joint state and federal program. The money generated by the Medi-Cal patients, proponents of this approach say, could be used to treat indigent patients at the same facility.

But others, including a majority of Molina’s board colleagues, believe that private hospitals, which are aggressively seeking lucrative Medi-Cal patients, will agree to take indigents if it means more money from Medi-Cal.

So the board, in a move based as much on politics as on policy, is ready to hold the line at 600 beds.

Supervisors also appear prepared to reject a compromise proposed by Janssen, which would have authorized a hospital large enough to handle 750 beds, but initially containing only 600.

That approach, Janssen said, would allow the county to increase capacity if the 600 figure proved unrealistic.

Under a plan hammered out in a flurry of behind-the-scenes activity over the last several days, the new hospital may start with even fewer than 600 beds, but be large enough to handle that many if necessary, said Antonovich and other sources.

Any additional cases would be sent to private hospitals, assuming that the county is able to strike deals with them.

According to sources, Burke and Yaroslavsky emerged as the key players in the compromise. Antonovich said the board was hoping for a unanimous vote, but Molina said she could not support a small facility.

“This [750 beds] is not a negotiable number,” said Molina, who is expected to bring a number of Latino legislators, as well as hospital employees and local residents, to the board meeting today. “We’re not betting on a horse here.”

Molina, backed by a consultant’s report, said it would be difficult to persuade private hospitals to agree to take indigent patients. And, indeed, far from gratefully accepting indigents in order to get Medi-Cal patients, some of the state’s private hospitals already are going directly after the Medi-Cal funds.

In Ventura County, for example, the private Community Memorial Hospital has lobbied intensely against any expansion plans for the public Ventura County Medical Center. The private hospital even sued the public one (and lost), saying it amounted to unfair competition for the county hospital to have the right to accept Medi-Cal patients.

The political elements at play in the L.A. County decision, sources said, were the board majority’s distaste for Molina’s hardball tactics and its collective anxiety over whether a larger hospital would be affordable.

*

Molina has “handled this all wrong,” said another supervisor, who spoke on condition of anonymity. “She’s saying, ‘Do it my way or I’ll make your life miserable.’ And this time the board has said, ‘Make our life miserable. How miserable could it be?’ ”

The argument over the size of County-USC has been raging for more than three decades, ever since local officials began to discuss replacing the Depression-era building.

The number of beds used at the facility has been steadily shrinking, down to 960, even though the building is licensed to house 1,700. More than five years ago, the supervisors approved the concept of a new hospital with 960 beds, but backed off when they realized they couldn’t afford it.

To find the right size, the board commissioned several studies. But in the end, much of the discussion came down to disputes over numbers. Antonovich proposed scaling the facility all the way back to 391 beds, which would cost $694 million, and contracting out for the rest of the patients’ care. Yaroslavsky at one point advocated 500 beds, and board colleagues Burke and Knabe vacillated between 500 and 600.

At the top of the scale was Molina’s proposal, which would cost about $1 billion in federal, state and local funds.

The discussion became intensely political. Just as Molina was mustering her troops for another assault last month, the Federal Emergency Management Agency stepped in, forcing the board’s hand with a letter that said continued delays might threaten the $480 million in post-earthquake aid that Washington had approved more than a year ago toward building the new facility.

“Some of us,” confided one of Molina’s board colleagues, “knew that letter was coming.”

Other supervisors simply may not have wanted Molina to succeed, said Democratic political consultant Harvey Englander.

“You’ve got policy issues, and then you’ve got the politics,” Englander said. “Within the concept of politics you also have personalities. And some people might say that perhaps if Supervisor Molina had been less confrontational on other issues she might have been able to make more headway on this issue.”

*

The Eastside supervisor is the first to admit that she doesn’t compromise easily, and that has strained relations with other members of the board.

Some of her colleagues’ reluctance to work with her, she said, “could be characterized as” personal.

“All public policy in the end is a political decision,” Molina said. “But it shouldn’t be an issue of just horse-trading.”

In refusing to support either Molina’s proposal or Janssen’s compromise, the board also is rebuffing a significant bloc of influential Latino elected officials, including Los Angeles City Councilman Richard Alatorre, Rep. Lucille Roybal-Allard (D-East Los Angeles) and at least six members of the state Legislature’s powerful Latino Caucus.

Molina’s allies have stopped short of threatening the supervisors with legislative reprisal. But, Assemblyman Gallegos said, “We would like to have some of our needs addressed. We’ve helped them. Now we need them to help us.”