A Gigantic Public Health Job

Not to put any pressure on Dr. Thomas L. Garthwaite, who on Friday started as director of Los Angeles County’s beleaguered health department, but here is what his immediate job description looks like:

* Find $100 million in savings.

* Overcome union opposition, since finding those savings is going to mean consolidating or even closing underused facilities, which in turn will mean eliminating some jobs.

* Don’t cut services to the people whose lives depend on the county--doctor of last resort for 2.5 million people without any insurance and provider of half of all trauma care for rich and poor alike.

That’s just the first nine months. After that, Garthwaite, the former undersecretary of health for the U.S. Department of Veterans Affairs, will have to persuade the federal government to change the way it reimburses Los Angeles County for caring for the poor. Without help, the county is going to have to make even more drastic cuts, severely limiting the types of care it delivers and the number of people it serves. One worst-case scenario would be to close county hospitals altogether, potentially overwhelming private hospitals and undermining the already fragile trauma care system. Everyone in the county, with or without insurance, would feel the effects.

Garthwaite takes over a county health department about to go broke--again. A Clinton administration bailout in 1995 kept the county on life support. But the plug gets pulled next year as the federal funds start tapering off, leaving the county with a $344-million shortfall in the 2004 fiscal year and a $688-million deficit the year after that.

The problem goes beyond what can be blamed on bungling bureaucrats and turf-defending county supervisors, no matter how much either has contributed to problems in the past. Los Angeles County has more people without health insurance than any other county in the nation. The vast majority work or are dependents of workers; about half of the jobs in the county are in small companies that often don’t provide health insurance. These people make too much to qualify for government programs like Medi-Cal or Healthy Families but not enough to afford private insurance. When they get sick or injured, the county picks up the tab. And between Proposition 13’s restrictions on raising taxes and the state Legislature’s takeover of local revenues beginning during the last recession, county government cannot by itself keep up with the costs of caring for this ever-rising population. What it needs from the state and federal governments, if not more aid, is at least fewer strings and more flexibility.

Garthwaite is no stranger to seemingly impossible causes. For example, he got the labyrinthine veterans’ network operating on the same computer system. Accomplishing that in the L.A. County health department, where patient records are for the most part still kept by hand, would save millions of dollars now lost because of duplicated services and missed reimbursements--and would improve patient care too.

Proving that the county is serious about doing its share is the only way to convince the federal and state governments to do theirs. Unlike at the Veterans Affairs Department, Garthwaite will not have powerful lobbyists behind him. He will have only the poor--unless every other county resident realizes that fixing this problem is not just the right thing to do but the only way to keep the health care system intact for everyone.