10 Years, 12 Reports Later, County Health Still in a Fix

Ten years ago last week, Los Angeles County supervisors received a stern warning. The public healthcare system, pushed to the brink of collapse that summer by a $655-million budget shortfall, was still in jeopardy, the county’s specially appointed health czar reported. And the supervisors were advised to relinquish some control to a board of experts.

The supervisors asked for a report.

The next year, they asked for another.

They asked for reports in 1999, 2000 and 2001.

Then in January, they asked for another, after a consultant said an independent health authority might prevent dangerous lapses in care like those that killed patients at Martin Luther King Jr./Drew Medical Center.

Yet today, after at least 12 reports, most of the five supervisors, who have each been in office for at least nine years, still say they don’t have enough information to decide if they should change the way the county’s troubled $3.7-billion health system is run.

“It hasn’t been studied,” Supervisor Gloria Molina said, calling the reports inadequate.

The restructuring of the nation’s second-largest public health system -- a move repeatedly endorsed by healthcare experts -- has never been promised as a solution to all of Los Angeles County’s healthcare woes.

But an analysis of reports, meeting minutes and board transcripts shows the idea has languished for a decade as the five supervisors cycled through reports and task forces, instead of tackling a reform that might require them to surrender power.

“They haven’t done the heavy lifting,” said Michael Cousineau, an associate professor at USC’s Keck School of Medicine who co-authored a comprehensive 2003 study that recommended a health authority.

Now, some worry that the board’s decade of inaction may seriously handicap the search for a new health director to oversee the network of hospitals and clinics charged with serving the poorest residents. Dr. Thomas Garthwaite, who endured nearly weekly browbeatings from supervisors, announced his resignation from the job late last month.

“I’ve had people say, ‘Are you nuts? I’m not going to go there,’ ” said Dr. Ron Anderson, a former chairman of the National Assn. of Public Hospitals and longtime head of the independently run public hospital system in Dallas. “They have to do something to clean up before they are going to attract top talent.”

But changing the structure of a huge public health system means “the politicians have to be willing to relinquish control,” said Dr. Patricia A. Gabow, chief executive of the 8-year-old public health authority in Denver, considered a national model.

In Denver, then-Mayor Wellington Webb agreed to cede control of his second-largest department and even led the reform effort, Gabow said. “If you’re going to do it,” she said, “it takes a political champion with tremendous courage and perseverance.”

All five Los Angeles County supervisors defend their management of the public health system. And they say they take seriously their duty to ensure that the county provides good healthcare for its poorest residents.

“It’s a heavy responsibility,” Supervisor Don Knabe said.

Los Angeles County’s healthcare system was in crisis when the idea for a healthcare authority was brought to the Board of Supervisors in 1995.

Squeezed by cuts in funding and paralyzed by an inefficient bureaucracy, the system had run up a deficit that threatened to bankrupt the county.

Through the summer of 1995, the supervisors talked about closing four of the six public hospitals. More than 3,000 healthcare workers were either laid off or demoted. There were protests, lawsuits and employee walkouts.

Only President Clinton’s last-minute personal intervention -- with a $364-million federal bailout -- kept the system from crumbling.

Medical experts and policy-makers agreed that fall that the county had to change the way it ran its public hospitals and clinics.

Within hours of posing for photos with Clinton at Santa Monica Airport, Westside Supervisor Zev Yaroslavsky, then in his first year on the board, told a health department official: “There has to be a clear, unmistakable message that we are not going to go back to the way things were.”

Burt Margolin, a former chairman of the state Assembly Health Committee whom the supervisors tapped as their health czar to guide them through the crisis, suggested a new model for running the health system: a health authority.

The idea was not revolutionary. Dozens of cities and counties rely on independent authorities to operate their public hospitals or healthcare systems.

These authorities are not a magic bullet, their champions concede. But in the best cases, advocates say, the independent structure insulates the health system from political influence by putting control in the hands of experts rather than politicians who are sometimes pulled by the demands of their constituents.

Independence also gives a healthcare system greater flexibility to cut costs, deal with problem employees and search for increasingly scarce healthcare dollars, supporters say.

Skeptics say health authorities muddy responsibility for the public health system and add a costly layer of bureaucracy, as they have done in some places.

In his Dec. 12, 1995, report, Margolin suggested a “semi-autonomous” authority that would shift much of the management responsibility to a new board of experts. Earlier that year, he led a task force that recommended the same thing.

The idea was embraced by advocates for the poor, the head of the Los Angeles County Medical Assn. and the Healthcare Assn. of Southern California, a group of mostly private hospitals.

But it stalled.

Supervisor Mike Antonovich, a Republican from the San Gabriel Valley who was in his 15th year on the board, and Deane Dana, a South Bay Republican who was nearing the end of his 16-year tenure, immediately rejected the idea.

Democrats Molina, who was elected in 1991, and Yvonne Brathwaite Burke, who was elected in 1992, said the idea deserved more study.

Only Yaroslavsky, another Democrat, embraced it.

The supervisors asked the county’s newly appointed health director to look into the idea.

But no report was ever made. And the supervisors let it lie dormant.

In the late 1990s, the idea resurfaced as another financial crisis threatened to capsize the health system.

This time, Knabe, Dana’s former chief of staff who succeeded him in 1996, asked for a report, saying the health department “needs to have a restructured system that will enable it to have a balanced budget.”

The supervisors responded in 1999 by creating a Blue Ribbon Health Task Force.

When that task force -- noting the county’s “propensity toward the implementation of short-term, crisis-based solutions” -- suggested the supervisors look at other ways to govern the health system, the supervisors asked for another report.

The county’s chief administrative officer sent the supervisors 30 pages outlining models used by other cities and counties.

The supervisors responded by creating another task force, this one called the Ad Hoc Hearing Body on Governance.

In 2002, that task force suggested further study of a health authority, should the supervisors fail to improve the health system.

The supervisors did not revisit the issue for three more years.

But in January, amid intense publicity about the troubles at King/Drew, a new group of experts -- the national turnaround firm hired to rescue the Willowbrook hospital -- recommended the supervisors consider an authority to run the county hospitals.

The board voted 4 to 1 to support a motion by Knabe asking the chief administrative officer for “a workable plan.” Antonovich dissented.

At the meeting, the supervisors reiterated positions that have remained largely unchanged after a decade of reports and task forces.

“It’s something we need to do, and the time is now,” said Yaroslavsky, who has supported an authority since 1995 but never put together a majority to back him.

Antonovich, who always opposed the idea, ridiculed it as “a lot of fluff,” saying, “To paper over a problem with a new commission that’s going to cost dollars we don’t have is not the way of getting the job resolved.”

And the other three once again said they needed more information.

“The timing is perfect to look at everything, to put it out there and to ask the questions,” Knabe said.

The supervisors should “put forth a meaningful attempt to look at alternatives,” Burke said, adding, “We have never had the level of information that we should have had in order to make any kind of decisions here.”

Molina said: “It would be worthwhile to know how it operates in other areas so that we could have probably a good model that will work for us.”

In April and June, the chief administrative officer sent the supervisors reports detailing how health authorities in seven other communities operate and outlining the steps needed to implement one in Los Angeles County.

Meanwhile, in June the county’s civil grand jury recommended a health authority after commissioning a 186-page report on the issue from an independent consultant.

Garthwaite added his endorsement. “It’s not a bad public health system,” Garthwaite said recently. But, he added, “It’s structured to fail.”

Today, however, there are no champions for wholesale reform on the Board of Supervisors.

All five supervisors say they need to focus on King/Drew and another fiscal crisis that is expected to leave the county health department $127 million in the red next year -- much as it was in 1995 when the health authority idea was brought to the board.

The supervisors give various explanations for why, after a decade of reports and task forces, they haven’t resolved the issue.

Burke and Knabe, who both supported studies of the idea in the 1990s, now say they only really became interested in it after the troubles at King/Drew.

Molina said she has always been open to a health authority, but blamed the chief administrative officer and the health director for not providing the board more information. “I don’t know how you get answers,” she said.

Yaroslavsky said he has done all he can. “It got nowhere,” he said. “I’m not into symbolic, Don Quixote-type exercises.”

Longtime observers say they are not optimistic anything will change soon.

“What you are asking people to do is give up power,” said Jim Lott, executive vice president of the Hospital Assn. of Southern California and a longtime advocate of independent oversight for Los Angeles County’s public hospitals. “Those hospitals are in their districts, and they employ thousands of people. I think the supervisors like that.”

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(BEGIN TEXT OF INFOBOX)

Reports and more reports

Los Angeles County supervisors have received at least a dozen reports over the last decade about how to overhaul the way the county’s massive public health system is governed.

County Health Crisis Task Force - July 24, 1995 - Recommends creation of a semi-autonomous authority of health policy experts to run the health system

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County Health Crisis Manager - Dec. 12 - Recommends creation of a semi-autonomous authority of health experts to run the county health system.

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County Blue Ribbon Health Task Force - Sept. 15, 2000 - Recommends an independent study of alternative options for running the public health system.

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County Chief Administrative Officer - Aug. 29, 2001 - Outlines four possible governance changes for the health system and reviews models being used by eight other jurisdictions.

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County Chief Administrative Officer - Sept. 21 - Reviews how other California counties run their public hospitals.

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County Chief Administrative Officer - Feb. 1, 2002 - Lays out possible timetables for changing governance structure of the county’s health system.

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County Ad Hoc Hearing Body on Governance - Feb. 5 - Recommends creating a health authority if county fails to take steps to improve the health department in the following 12 months.

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USC Keck School of Medicine team - May 2003 - Reviews new governance models for public health care system and prior studies and recommends creation of a health authority.

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Navigant Consulting - Jan. 31, 2005 - As part of assessment of problems at Martin Luther King Jr./Drew Medical Center, recommends that county look into creating a health authority.

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County Chief Administrative Officer - April 18 - Outlines health authority legislation, history of prior reports, experiences of seven other jurisdictions and possible timelines for changing governance.

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County Chief Administrative Officer - June 28 - Provides short answers to 23 questions from supervisors about creating a health authority.

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County Civil Grand Jury - June 30 - Recommends creation of health authority based on a 186-page report assessing shortcomings of county health system and outlining solutions.

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Source: Los Angeles County