County Limits on Care Sought

Uninsured patients who live outside Los Angeles County would no longer be entitled to nonemergency care in the county’s public hospitals and clinics under a proposal to be unveiled next week by health officials. The move would mark a significant shift from the current practice of treating nearly every patient who shows up.

The proposal, which must be approved by the Board of Supervisors, comes as the beleaguered health department is desperately trying to cut costs and relieve overcrowding in its waiting rooms. Other cutbacks -- including a hospital closure -- have been blocked by a federal judge.

“As we have to ration the care that we give based on the budget, it’s important that it goes to those that are most entitled,” said Dr. Thomas Garthwaite, director of the county Department of Health Services.

County officials don’t know how many uninsured people from other counties, states or even countries use their facilities, nor do they know how much money they might save by limiting their access in nonemergencies.

Their best estimate pertains to hospitals, where officials believe that nonresidents account for at least 3.7% of the care provided to uninsured people. At Rancho Los Amigos National Rehabilitation Center in Downey, the estimate is higher -- at least 8%.

Under Garthwaite’s proposal, beginning in October patients seeking care would be required to show government-issued identification or other proof of residency, such as a utility bill.

Garthwaite said the county intends to keep serving homeless people and undocumented immigrants who are living in the county and will come up with an acceptable way for them to prove their residency. Moreover, all patients who come to public emergency rooms will continue to be evaluated and treated as required by federal law.

Board of Supervisors Chairwoman Yvonne Brathwaite Burke said the residency requirement should have been enacted years ago.

Los Angeles County hospitals are so well known, she said, that they draw poor patients not just from neighboring counties but from other states and nations.

“People say, ‘You can get your operation for free in Los Angeles,’ ” Burke said. “We should never have been providing nonemergency care for people [who do not live here]. It’s just not fair to the people of L.A. County.”

Garthwaite, who has been in his job since February 2002, said he could not explain why the residency requirement had not been proposed sooner. But, he said, he began asking about it when he took office.

Health advocates said they understand the principle behind the proposed change, but fear that it will hinder residents who forget their identifications or who don’t have one from seeking care.

“Conceptually, we wouldn’t have problems with it and the purpose is a valid purpose,” said Yolanda Vera, an attorney with Neighborhood Legal Services. “The question is how are they going to actually do it.”

Others said it would set a dangerous precedent to ask for identification before providing treatment -- even if it is not an emergency.

“It’s very difficult to say you’re not going to help someone who is ill,” said Dorris Dann, executive director of Our Saviour Center in El Monte, whose Cleaver Family Wellness Clinic contracts with the county to treat indigent patients.

“We have a policy at our clinic: We see everyone who comes to our door and we try to help them. It is not a legal issue for us, it is a moral issue.”

The county is following the lead of several other areas in imposing a residency requirement.

Denver’s public health system began enforcing its strict residency requirements last year, trying to stem the flow of poor patients from surrounding counties. Its public hospital treats homeless residents -- as long as they are referred by a homeless shelter or a physician.

The area’s health-care and homeless advocates have been relatively supportive. “Until we have universal access to health care, it seems a reasonable policy to shepherd the resources,” said John Parvensky, president of the Colorado Coalition for the Homeless, based in Denver.

In Dallas County in Texas, the county’s only public hospital has enforced a similar policy for several years. Eric Wesley, a spokesman for Parkland Memorial Hospital, said patients must show they reside in the county to obtain care.

For at least a decade, Los Angeles County officials have grappled with overcrowding that they suspected was partly caused by nonresidents.

“Los Angeles County has been a dumping ground for less generous counties and private hospitals looking to minimize their expenditures,” said Miguel Santana, a deputy of Supervisor Gloria Molina. “It looks like the county is finally saying no.”

Garthwaite said the details of his department’s proposal have not been worked out yet -- for instance, how the county would ensure that a nonresident receives care elsewhere. “We have the responsibility to ensure that we’re not just putting them back on the street,” he said.

Garthwaite said that if nonresidents turn to emergency rooms for care of minor illnesses or injuries once the clinics are closed to them, the county may have to refer them elsewhere.

“At some point, you have to look at whether they’re coming in for true emergencies or not,” he said.

Denver’s public hospital screens patients before they are allowed to enter the emergency room to ensure that they have a true emergency. Those who don’t are given the phone numbers of clinics and directed to a telephone in the lobby.

Los Angeles County officials have been trying to look for ways to save money for a year, faced with a deficit once estimated to approach $800 million within three years. That task became more difficult after a federal judge blocked efforts to close Rancho Los Amigos and shut down 100 beds at the flagship County-USC Medical Center.

Another major change proposed by the health department would limit the number of patients that private hospitals could shift to county-run hospitals solely to avoid paying for their care.

Garthwaite said the proposal should help relieve emergency room overcrowding by giving priority for beds to those already waiting in the ER rather than to patients already admitted to private hospitals.

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Times staff writer Steve Hymon contributed to this report.