Care, Not Hospital Size

In 1997, after a tough and sometimes nasty political battle, the Los Angeles County Board of Supervisors voted to rebuild aging and quake-damaged County-USC hospital with 600 beds. That was 150 beds fewer than wanted by Supervisor Gloria Molina and some other advocates, and the bitterness over the vote has lingered.

The budget bill the state Legislature sent Gov. Gray Davis last week contains a measure backed by more than a dozen legislators, many of whom represent County-USC’s Eastside area, as Molina does. The measure essentially withholds $6 million in federal health care funds unless Los Angeles County agrees to rebuild County-USC with 750 beds. It was a hardball maneuver that might be good politics but it’s poor health care policy.

The legislators say they merely want to ensure that the county discharges its obligation under state law to provide hospital care to indigents. What they are fixated on is a number. What would be best to focus on is finding a way, or a variety of ways, to ensure that the people who need health care--emergency, acute and preventive--get it, in a way that is most convenient for the patients.

Simply put, giant public hospitals are the health care paradigm of the past. Medical technology has made possible many same-day surgeries, and health policymakers across the country have come to agree that the best health care is provided not on an emergency basis in big hospitals but on a regular basis in community health clinics.

This is not to say that political calculations alone are driving legislators’ opposition to a smaller County-USC hospital. Molina, along with state Sen. Richard Polanco, Assemblyman Gil Cedillo, Rep. Xavier Becerra and some other L.A.-area lawmakers, has raised legitimate concerns about the failure of the existing community clinics to provide health care to the county’s 1.8 million uninsured and to help bring more poor people into underused public insurance programs.

While some of the state legislators’ criticisms are on target, their solution is off. Instead of hammering county supervisors for their sensible reluctance to erect a larger hospital, state legislators should wield a powerful tool--the public Medi-Cal and Medicare funding that private and nonprofit hospitals receive--to compel these institutions to accept more indigent patients. Currently, many nonprofit hospitals in the county that receive substantial tax breaks for operating in the public interest do not in fact accept many indigent patients.

The county is now seeking $90 million in new federal health care money to provide care for uninsured schoolchildren; part of it would go for newly built county-staffed clinics in Los Angeles schools and in mobile vans. The plan, modeled on similar programs in Florida, Texas, Kansas and Arizona, would provide community-based preventive and diagnostic care, taking pressure off hospitals.

The hard truth is that there is nothing magical about 750 beds. At 600 beds, County-USC would remain the major hospital of a large region. The answer is not to tack on 150 more beds in one place but to take health care, particularly preventive care, closer to the people through community clinics that treat minor illnesses before they become emergencies.