Just Where Will L.A.’s Sick Go?

Despite a vote by the county supervisors a year ago to replace the earthquake-damaged and utterly antiquated 1,100-bed County-USC Medical Center with a 600-bed facility, the issue of the size of the replacement remains unresolved. The county needs a hospital no smaller than 750 beds to meet vitally important health needs in the community. It is essential to look at the entire picture to understand this complex matter. Here are the facts:

* The seven formal studies that have been completed on the beds needed for the replacement have recommended a range from 684 beds to 1,060 beds. None of these detailed studies support a hospital as small as 600 beds.

* The average daily occupancy of County-USC Medical Center remains well more than 800 while the number of uninsured in Los Angeles County continues to grow, and is now in excess of 2.7 million--which doesn’t include at least another 500,000 undocumented uninsured who reside in the county.

* The total number of acute care beds in Los Angeles County will shrink by 20% to 25% by the time the current state law governing hospital seismic engineering takes its next bite by the year 2008. Many hospitals will replace seismically unsafe buildings with smaller capacity facilities that meet the new standards. Some nonconforming hospitals, whose replacement is not economically viable, will close altogether.

* Between 1993 and 1995, the amount of charity care spending by private hospitals in Los Angeles County declined by 13% while hospital expenses went up by at least 20%. In just two years the proportion of all charitable hospital care in the county provided by private hospitals declined from 33% to 25%, while that provided by county hospitals increased from 67% to 75%. To a substantial degree, this unwelcome change can be blamed on the growth of managed care companies, whose compensation policies for private hospitals have greatly diminished the resources that hospitals can provide for indigent care.

* As the total number of available hospital beds in the county declines due to seismic engineering requirements, the occupancy rate will rise. In turn, HMOs will be forced to pay higher rates because of the increasing scarcity of available beds. This, in turn, will diminish private hospitals’ willingness to admit Medi-Cal patients and there will be a predictable return of these patients to the only available resource--the county hospitals.

* The problem is not limited to the uninsured and the indigent. It is a problem for all who live in or travel through central Los Angeles. County-USC provides 30% of the trauma care in the county. There were 23 trauma centers in Los Angeles County in 1982 when the system was created. Today there are only 13 trauma centers because these centers require huge subsidies to stay open and private hospitals can no longer afford to staff and operate them without subsidies; 10 private trauma centers have closed.

* There is clearly a need for more adequate, properly coordinated and convenient outpatient clinical services for the county’s indigent and uninsured. In 1992, the County Health Access Task Force identified an unmet need of 4 million visits a year, and the number of uninsured has increased since then.

The citizens of Los Angeles County need both increased ambulatory care for the indigent and at least a 750-bed replacement for County-USC. While the eventual solution to our health care problems must be provided from state or federal sources, there are no prospects of any meaningful relief. The projected shortage of acute hospital beds in the county, the economic pressures of managed care, the ongoing needs for trauma and emergency care and the growing body of the uninsured make it foolish to predict that the private sector can absorb the burden created by replacing County-USC’s current 1,100 beds with only 600 beds. The majority on the Board of Supervisors that agreed to that were penny-wise and pound foolish. And all of us as citizens of the county, indigent and non-indigent alike, are the ones who will eventually pay for that poor judgment.