Los Angeles County's embattled health chief resigned Wednesday, leaving the nation's second-largest public health care system rudderless as it faces the prospect of a gaping $884-million deficit in five years.
Mark Finucane, who took the helm of the $2.4-billion agency five years ago with the charge of rebuilding the system after a near collapse, said the county needed someone with "a different perspective and fresh legs" to handle the system's latest troubles.
Finucane's resignation--effective in June--was a mutual decision made by him and the county Board of Supervisors, said Supervisor Yvonne Brathwaite Burke, who, like her colleagues, clashed frequently with the 53-year-old department head.
"We had been having discussions back and forth," Burke said. "It was worked out over a period of weeks and finalized [Tuesday]."
Finucane, who is regarded as a survivor for having remained at the head of such a pressure-cooker department for half a decade, said the resignation was his idea.
"There's a natural cycle to these jobs," he said. "After five years, it's time for me to step off this track."
Finucane came on board with great promise in 1995, an energetic administrator who had seen much smaller Contra Costa County in Northern California through financial trouble of its own.
Since coming to the county in 1996, Finucane, who makes $241,062 a year, has been the highest-paid county department head.
When he arrived, Finucane vowed to turn around the health department, which at that time was losing so much money that it threatened to drive the entire county government into bankruptcy.
His charge was to use a $1-billion bailout of the health system by the Clinton administration to move county health care away from expensive hospital services and toward cheaper treatment at outpatient clinics and doctors' offices.
Fighting a system where the culture and bureaucracy were deeply entrenched, Finucane was able to make some changes. He began partnerships between public and private clinics and made it easier for many uninsured county residents to receive care.
In a county with a huge immigrant population and among the highest rate of uninsured residents in the nation, he is widely regarded as having enlarged and improved the county's public health services, such as disease control and epidemiology. He also set up a system to rate restaurants based on their attention to sanitation and health concerns.
"Access to health care has improved on Mark's watch," said health care advocate Beth Osthimer, a frequent critic of the county and its health chief.
But five years later, the structure of the system as a whole remains largely unchanged. The county received another bailout of $1.2 billion last year from the Clinton administration but that lapses in 2005, when the department will face an estimated deficit of $884 million.
During public meetings over the years, supervisors have repeatedly blamed Finucane for this fix, saying that he missed opportunities to reform his department.
In seeking renewal of the bailout last year, Finucane acknowledged that the county fell short of the reduction of inpatient treatment, increase in outpatient visits and the level of budget savings promised the federal government in 1995.
However, officials took credit for more than tripling the number of outpatient clinics under contract to treat the uninsured. They said the health department's work force was 15.2% smaller and the number of non-urgent emergency room visits had declined by 27%.
But the bottom line was clear: The county needed more time and money to make the transition to a different kind of health care system a reality.
The entire process--painful because the stakes are high and the solutions involve cutting clinics and hospitals--has been unusually rancorous, even for the personality laden politics of Los Angeles County government.
The supervisors' discontent with Finucane has been so long-running and so public that it is a regular source of gallows humor at board meetings. Other department heads have quipped that they are glad Finucane absorbs much of the board's ire because that way they are not called on the carpet.
"It's been no secret that the Board of Supervisors is not respectful of him," said Dr. Brian Johnston, former head of the Los Angeles County Medical Assn. and a board member of the California Medical Assn.
"It's been a shocking display," said Johnston, who blames the health chief and the supervisors for the health department's troubles. "They're very skeptical of everything he says and disrespectful to him in public."
Finucane said his tense relationship with the supervisors did not precipitate his resignation. That, he said, is to be expected in a high-pressure public health position, where money is scarce and the community's need is enormous.
He said he was proud of several accomplishments while at the county, and has promised to stay on to help the board look for a replacement. The health chief, who only recently moved his family here from Contra Costa County, said he plans to stay in Los Angeles, and will probably work in a private sector health job. Already, he said, headhunters have contacted him about new positions.
Supervisor Gloria Molina, at times Finucane's harshest critic on the board, said she admired Finucane's strength and determination--even when it meant standing up to her and other supervisors.
"There were a lot of complaints and a lot of concerns and a lot of issues, but for the most part I'm one who felt he had been doing an unbelievable job considering the kind of challenges the department had," Molina said.
In leaving now, Finucane said, he was giving a possible successor time to develop a survival plan before 2003, when the first of the county's oncoming deficits, for $184 million, is projected to hit.
Finucane had developed a restructuring plan aimed at offsetting those deficits, but supervisors have complained it does not itemize specific reductions.
He was due to unveil a more specific list of possible cuts this month.
The fate of his last proposal, to close High Desert Hospital in the Antelope Valley, was perhaps representative of the obstacles he faced.
Hospital administrators there had not heard of the proposal until contacted by a reporter, and the idea drew a stinging rebuke from the supervisor who represents that area, Mike Antonovich.
Indeed, one thing clearly hampering Finucane has been the supervisors' opposition to cutting health services in their districts. Drawing on tobacco settlement money, supervisors approved $86 million in new programs in October that Finucane had initially not recommended, even as they berated him for not cutting enough.
"What we're also saddled with is a Board of Supervisors who talk tough . . . but [if the proposal is to] cut our clinics, cut our hospitals, we go out screaming in the streets," said Molina, who supported those cuts. Molina, however, had fought cuts to the county hospital in her own district.
One county employee, who spoke on condition of anonymity for fear of retaliation, on Wednesday observed that with more politically touchy decisions on the horizon, now may have been the best time for the director to leave.
"It wasn't going to get any better," the official said. "If he stayed here for another year he was going to get tarred and feathered."
(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)
Health Department Chronology Key developments at the Los Angeles County Department of Health Services during and immediately preceding the tenure of Mark Finucane:
* June 1995--A financial crisis in the county health system threatens to push nation's largest county government to brink of bankruptcy. Chief Administrative Officer Sally Reed suggests closing County-USC Medical Center to deal with the crisis.
* September 1995--President Bill Clinton averts closure of hospitals and clinics by announcing an initial $364-million bailout of the health system and granting a waiver of federal Medicaid regulations. County promises to move the health system from expensive hospital treatment to less costly outpatient care. The bailout later grows to $1 billion over five years.
* November 1995--County supervisors hire Mark Finucane, director of Contra Costa County's health department, to take over the nation's second-largest public health system.
* January 1996--Finucane starts work, vows to push forward with reorganizing health care system. "I realize that is my No. 1 assignment," he said. "I've got to get to it fast." But progress proves slow.
* September 1997--UCLA experts say the county health care program is a hamstrung bureaucracy, underfunded and understaffed. Study calls for more reorganization.
* November 1997--County supervisors, over Gloria Molina's vehement objections, approve a downsized County-USC Medical Center, igniting a political fight that continues for years. Finucane becomes one object of Molina's displeasure.
* May 2000--County acknowledges it fell short of achieving the reduction of inpatient treatment, increase in outpatient visits and budget savings promised in 1995.
* June 2000--County wins extension of waiver from Clinton administration. Supervisors promise again to continue the shift from inpatient hospital care to less costly outpatient treatment. But the five-year waiver dramatically reduces federal assistance beginning in 2002.
* September 2000--Supervisors end battle over County-USC Medical Center with promise to build a 600-bed hospital in Boyle Heights and a small hospital in Baldwin Park.
* October 2000--Finucane warns again that mounting deficits will force cuts in operations and facilities. While complaining about the need for reductions, a majority of supervisors approve new health programs using tobacco tax money.
* December 2000--George W. Bush is elected president, leaving the Board of Supervisors without a sympathetic Democrat in White House.
* February 2001--Finucane issues memo to supervisors warning that deficit may force closure of facilities, possibly including High Desert Hospital in the Antelope Valley, angering Supervisor Mike Antonovich.
* March 2001--Finucane announces his resignation, with plans to remain until at least June 30 to assist in transition to his replacement.
Researched by JEFFREY L. RABIN / Los Angeles Times