County Fears Health Care ‘Meltdown’

Jose Gustavo Rodriguez flew to Mexico to get a liver biopsy to determine that he had hepatitis C because he couldn’t obtain timely treatment at the public hospital a few miles from his East Los Angeles home.

Christina Russi had to pull out her own infected tooth because she had no health insurance, and was trapped in her house for six weeks with scabies and no access to a doctor.

Christina Clark struggled through years of irregular treatment at a county clinic for her chronic diabetes before finding a program that got her regular care that may have saved her from having her feet amputated.

Five years ago, with a $1-billion assist from the federal government, Los Angeles County promised to reshape its notoriously bloated and baroque health care bureaucracy, thereby improving access to treatment for Rodriguez, Russi, Clark and the nearly 3 million other uninsured county residents who must rely on public hospitals and clinics.

By most statistical measures, the county--despite many massive changes--has fallen short of its ambitious goal. And now, even those incomplete gains are jeopardized, at potentially staggering human cost, by the expiration next month of the $1-billion waiver of Medicaid rules that has kept the county’s health system afloat.

A squabble involving three levels of government over who will pay for a new waiver has left talks over its extension in limbo, five weeks before the current exemption expires. Speaking of a possible “catastrophic meltdown,” the Board of Supervisors last week abruptly froze all expansion of the county’s outpatient system and it is expected to freeze staff levels in the Department of Health Services this week.

Officials fear that L.A.’s public health care revolution has ended before the first battle was won.

“We’ve had some setbacks, but we’ve also had good things happen,” Supervisor Don Knabe said last week. “If we don’t continue to follow through with reform, it’ll set us back--and worse yet, the population that needs the services won’t be getting as good services.”

That includes Rodriguez, Russi and Clark--and Rufina Juarez and her three children.

Juarez’s husband is a jewelry repairman without health insurance. Because he works, she does not have Medi-Cal but gets regular checkups with her children at the private Community Healthcare Foundation of East Los Angeles, which receives about $2 million--because of the waiver arrangement--to care for the uninsured.

If the county did not reimburse the foundation for Juarez and her children’s care, “I would only bring them in an emergency,” she said. Or take them to the emergency room of nearby County-USC Medical Center.

The waiver was granted in 1995 to keep Juarez from doing just that.

Los Angeles County was on the brink of bankruptcy. Its health care system was collapsing because it emphasized pricey hospital care over cheaper outpatient treatment.

Steering patients to hospitals rather than to outpatient care is bad in two respects, experts say. First, it means people receive medical care only in emergencies, even though their ailments could have been caught during routine checkups and treated when they were less severe. Second, it is far more expensive.

The federal waiver was intended to shift the focus of the county medical system to outpatient treatment. County officials pledged that by 2000 they would cut inpatient treatment by 33%, log 1.8 million more outpatient visits and cut their $2.4-billion annual health care budget by $294 million.

‘We Have a Lot More to Do’

They have fallen short in all three areas. Inpatient treatment has dropped by 28%, the county is 900,000 outpatient visits behind schedule and it is more than $100 million short of its savings target.

“There’s no question that it was an ambitious agenda and we have a lot more to do,” county Health Director Mark Finucane said, “but it’s pretty obvious that the county threw itself into it in a way that showed we were serious about restructuring.”

Added Supervisor Zev Yaroslavsky: “You can’t turn around a battleship on a dime. . . . [But] we’ve moved; we’ve turned that corner. . . . If we don’t get the waiver we’ll be going backwards again.”

Finucane said the county’s inpatient drop is still triple the national rate. He attributed the problems in increasing outpatient visits to the time it took the public to believe that the health system was still operating after its near-collapse in 1995. And he has acknowledged that the county’s estimates of what it could save were too optimistic.

Still, Finucane--who has been scolded by supervisors for falling short of the targets--and outside observers say that what the county has accomplished is an impressive first step.

Officials more than tripled the number of outpatient clinics that treat the uninsured through contracts like the one with the Community Healthcare Foundation. They cut the health department work force by 15.2% and reduced non-urgent emergency room visits by 27%. All this occurred as the uninsured population continued to grow and 13 local private hospitals closed.

The county acknowledged its shortfalls in its application for a waiver extension, which it filed 10 months ago, arguing that it needed more time and money to complete the transformation of the nation’s second-largest public health system.

It still has not received an answer to its request. At issue is whether the state government will fund part of the waiver. The county has already offered to chip in $60 million annually, but with no meetings among county, state and federal officials since March, supervisors last week declared that the talks had reached an impasse.

“All the work and progress and human benefit that has resulted from this five-year restructuring is lost because this vacuum has developed,” Finucane said. “Talking strictly about money doesn’t accurately reflect what we’ve been trying to do the past five years.”

It certainly doesn’t reflect the change in the lives of Christina and Gregory Clark.

Gregory Clark lost his health insurance in 1996 when he lost his job as an inspector of airplane parts. He struggled to find care for his 55-year-old wife, whose diabetes was getting worse, with her feet swelling and eyes aching. But despite some treatment at a county clinic, they grew disenchanted with the complex county system, which was still recovering from its brush with bankruptcy and thousands of layoffs the year before.

“You don’t really know what it’s like until you go in there to Olive View [Medical Center] and you see how many people are in line there and how many people walk away,” said Gregory Clark, who lives in Sun Valley, near the Sylmar county hospital.

Finally, the Clarks found a program at San Fernando Valley Neighborhood Legal Services that helps uninsured patients deal with the often-daunting array of paperwork and bureaucracy that accompanies the county’s health system. That program--funded by the county’s waiver--steered the Clarks to a clinic under county contract where Christina Clark is getting regular treatment. Her diabetes has stabilized.

“She would have lost her feet eventually,” Gregory Clark said. “It’s great that there is something like that [program]. I hope there’s more.”

If the waiver expires, said Beth Osthimer of Neighborhood Legal Services, “we would be back in a situation where people like [Mrs.] Clark don’t have a medical home, a place to go.”

Christina Russi thought she had found one medical home but lost it unexpectedly. Still, after years of hardship, she has found another one and hopes to be insured soon.

No Insurance for Past 5 Years

The 46-year-old Pico-Union resident said she has gone without health insurance for about five years, since her employer closed its Los Angeles office and Russi found that her lifelong profession--working as a newspaper paste-up artist--had become virtually obsolete in the computer age.

Eventually, her unemployment benefits ran out and she had to do without even the basics of health care. Though she could have taken advantage of free treatment in the county’s contracted clinics, she was not told of the possibility for months, even though she regularly dealt with county social workers while on general relief.

When one of her molars became severely infected, she pulled it out herself. When she developed highly contagious scabies in November, she had to stay in her house for six weeks and got treated only when her son, who is insured, caught the ailment and shared with her the medication his doctor prescribed.

Russi began visiting a health clinic on the edge of downtown Los Angeles for checkups this year, but when she went there earlier this month to get the results of her regular Pap smear she found that the facility had suddenly closed. The clinic is one of six in a network that officials say went bankrupt, despite its waiver funding from the county.

Russi finally found out about the Community Healthcare Foundation, two bus routes and 45 minutes from her house.

“I never in my life thought I would have to go through this,” said Russi, who is training in computer graphics and hopes to regain her health insurance in a new job.

Nor did Jose Rodriguez.

The strapping 42-year-old welder has worked without insurance for years, but last fall he began feeling exhausted. During a routine visit to the Community Healthcare Foundation a doctor noted a yellow tinge to his eyes--a telltale sign of hepatitis C. The clinic referred him to nearby County-USC Medical Center.

But once he went into the mammoth hospital, he was given form after form to fill out, he said. Finally, he had a blood test taken and was told to come back in four months.

Fearful over his worsening condition, Rodriguez borrowed money from relatives and flew to his hometown of Leon, Mexico, to be examined by his family doctor, who confirmed the hepatitis C and recommended a course of treatment.

Sitting last week at the Community Healthcare Foundation, where doctors are helping him apply for state assistance and get treatment, Rodriguez spoke in anguished tones of again being unable to get into County-USC and fill out the avalanche of paperwork needed for Medi-Cal. He lost his job because of the illness, pitching his family of four close to ruin.

“I think it’s just fair that after [I paid] 20 years of taxes the government should give me the care I need,” said Rodriguez, a legal U.S. resident, in Spanish.

A County-USC spokeswoman said late Friday that the only record the hospital has of Rodriguez’s visits is a May 15 appointment, when he was told to return for treatment three months later. She could not immediately explain the delay.

It is because the massive county health system can be so difficult for the working poor--and especially immigrants--to navigate that it is crucial they can go to clinics like the Community Healthcare Foundation’s for help and support. That is why, doctors said, it is critical that the county be able to continue to fund outpatient clinics.

“If something happens to the [clinic] program,” said Rodolfo Diaz, Community Healthcare Foundation director, “you’re just going to see a big cloud of dust outside your window on this side of town.”