Health, Political Realities Clashed in Hospital Vote

The Board of Supervisors decided Wednesday that Los Angeles County cannot afford to give its poorest residents what their doctors ordered.

In an act of political triage, they let die the doctors’ proposal to replace the soon-to-be-shuttered County-USC Medical Center with a new 750-bed hospital accommodating 25% fewer patients than the current facility. The majority of supervisors decided on 600 beds, or nearly 40% fewer patients, instead.

The supervisors characterized their vote as a visionary nod to a future of improved technology and managed care that would continue to make hospital stays rarer and shorter.

But their field of vision was unmistakably circumscribed by the politics of scarcity: In a county whose rapidly growing population of uninsured residents is greater than that of any industrialized nation, the only question they considered was how much to downsize the main public hospital.

“That makes no sense to me,” said Dr. Brian Johnston, immediate past president of the Los Angeles County Medical Assn.

But the supervisors’ caution is understandable. They are still reeling from the county’s brush with bankruptcy two years ago, during which its chief administrative officer suggested staunching the flow of red ink by abandoning County-USC altogether.

That was avoided with a temporary federal bailout. But supervisors are keenly aware that they are unlikely to have forever-friendly administrations in Washington and that, thanks to Proposition 13 and its progeny, they lack the authority to bail themselves out by raising taxes if they get into another jam.

Faced with projections that the 750-bed replacement hospital favored by doctors’ and hospital trade groups, the county health department and a bevy of independent consultants would run in the red, the supervisors rejected it.

Supervisor Zev Yaroslavsky led the way, asserting that a 500-bed alternative would generate a surplus with a silver lining--one that could be used to pay for perhaps hundreds of thousands more outpatient visits than the 3 million per year the county is now able to provide.

Yaroslavsky argued that increasing outpatient care is more humane than building a bigger hospital because its greater availability would allow poor people with treatable conditions to get help before they reach the point where emergency hospitalization is required.

But one of the keys to the board’s consensus on the issue was Yaroslavsky’s willingness to settle for a facility that will contain no more than 600 beds. At that number, studies say the hospital will only break even and therefore will not free up money for outpatient care. However, the motion passed by the supervisors left open the possibility that not all of the 600 beds would be used. If only 500 are used, more funds for outpatient treatment would be available.

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County-USC, with a licensed capacity of 1,700 beds and a budgeted capacity of 860 beds, serves all Los Angeles residents as the linchpin of the county’s trauma and emergency room systems. It also cares for half the AIDS patients in the county, runs the county’s largest burn unit and performs other functions for which there is no ready market, such as running a large, neonatal intensive care unit and a jail ward.

But it has special resonance as a real and symbolic safety net for the poor in the Eastside neighborhoods it towers over, from which it draws half its patients, and which Supervisor Gloria Molina, who held out to the end for a 750-bed replacement, represents. A measure of the regard in which County-USC is held in her district is one of its nicknames: Great Stone Mother.

For Molina, the controversy over how best to replace the antiquated, earthquake-damaged facility was a high-stakes political opportunity to solidify the near folk hero status she won years ago as the maverick official who derailed state plans to shove a prison down East L.A.’s throat.

She settled on the 750-bed option as the highest ground for which there was a defense. And the defense looked solid, provided as it was by the members of the medical establishment.

Dr. Ronald Kaufman, chief of staff at County-USC, for example, was passionate on the need for 750 beds. If a 500- or 600-bed facility were built, he asked: “Where are people going to go?”

Currently, he said, 70% of the hospital’s 860 patients are admitted as emergencies. They stay an average of 5 1/2 days. As Kaufman did the math, construction of a 500- or 600-bed facility would mean some patients would have to be transferred to other hospitals before they were well.

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Dr. Don Thomas, a county health department official, cited forecasts that virtually all beds in a 750-bed facility could be filled with emergency room admissions and predicted that a smaller facility would lead to ambulances being diverted to carry critically ill patients on dangerous 25-minute rides to other hospitals.

As the board moved toward a decision, Molina caught what she had every reason to believe would be a break.

The latest in a long line of county health department consultants asserted last month that, financially, it did not much matter whether the county built a 500-, 600- or 750-bed facility.

After taking into account the cost of renting additional bed space from private hospitals to care for 750 patients, as doctors said the county would have to do, the results would be a wash.

Molina and the medical establishment were joined by virtually every major Latino elected official from Los Angeles County, bridging, at least temporarily, her long-standing feud with Los Angeles City Councilman Richard Alatorre and giving her position a decidedly ethnic tilt.

But even implied and, in some cases actual, threats by state and federal Latino legislators to be less cooperative with supervisors in securing funding unless supervisors came through with a 750-bed project were shrugged off.

Yaroslavsky, who co-authored the successful motion with Supervisor Yvonne Brathwaite Burke, included a doomsday provision tht would be triggered if legislators make good on their threats to block certain expected funds: A facility with a cap of 600 beds will turn into one with a cap of 500.

Molina found herself as alone on the issue as Supervisor Mike Antonovich, who found no support for his proposed 391-bed option and, in the end, supported the 600-bed solution.

Part of Molina’s isolation may have been due to her poor personal relations with colleagues. Her fellow supervisors tend to be put off by an uncompromising manner.

Alatorre, her long-standing political adversary, credited this possibility, which he said he found “sickening” under the circumstances but apparent.

“It just seems . . . that this is payback time,” he told the board.

As defeat for her position loomed, Molina showed an uncharacteristic willingness to compromise, putting forth a motion that would have meant a 600-bed facility in a building big enough to house 750 beds.

Molina said she had been advised to try it by two state legislators, and by Alatorre to try to find a “middle ground” where her colleagues could meet her.

Her voice cracked slightly as she mentioned Alatorre’s name. He later came to the dais and squatted by her chair to have a private conversation.

Her motion died for lack of a second.