Ill Treatment

By

LOS ANGELES

The women's clinic at the Hubert Humphrey Health Center may not be
posh, but it's not unpleasant, either. The exam rooms are clean and
reasonably well- equipped; a few even feature their own computer
consoles. Attractive pink wallpaper lines the walls, except in the
children's waiting area, which beckons youngsters with primary
colors and a colorful bead and wire maze. Patients sit quietly as a
receptionist calls out names, one every few minutes, without
resorting to a loudspeaker. It is, in other words, a reasonably
civilized atmosphere for what turns out to be reasonably civilized
medical care.That might sound like faint praise, until you consider that the
clinic operates in one of the bleakest tracts of South Central Los
Angeles. From the clinic's front door, it's just 20 blocks to the
corner of Florence and Normandie, epicenter of the 1992 Los Angeles
riots. Storefront signs such as SE ACCEPTAN ESTAMPILLAS are
testimony to the enduring destitution. Wiry truants hang out on
street corners at midday, hiding their hands inside their baggy
athletic pants to conceal drugs or weapons as they approach cars
pulling up at the curb. At a sprawling, two-story housing project a
few blocks to the clinic's south, a metal picket fence surrounding
the complex has its spikes turned inward, as if to keep the
residents from getting out. The poverty rate in this section of
South Central, 40 percent, is Los Angeles County's highest; so is
the incidence of most violent crimes.

There's one other category in which this area leads the county:
illness. Asthma and hypertension have reached alarming proportions;
the age-adjusted mortality rates for diabetes and cervical cancer
here are double the rate for Californians as a whole. Although
there are many reasons for this--everything from eating too much
fatty food to breathing mold-infested air--a major factor is lack
of access to health care. One-quarter of South Central's residents
say they have no regular source of health care, which isn't
surprising given that half have no health insurance. The only place
where most of these uninsured residents can get decent medical care
is at the hospitals and clinics run by Los Angeles County. And
there aren't nearly enough of these facilities to handle the load.

The county's emergency rooms, for instance, are so overcrowded that
they turn away incoming ambulances 40 percent of the time. Even
those patients who make it into the E.R. at USC/County Hospital,
the county system's hub, typically wait eight or nine hours to be
seen, longer on weekends. The strain on other hospital wards gets
less public attention, but it's no less severe. "We have patients
routinely waiting on my own service up to twelve days to get an ECG
of their heart," says Scott Selco, a young neurologist at
USC/County. "It's not a test to satisfy our curiosity; our
treatment decisions rest on that test." Gall bladder operations,
biopsies, colonoscopies--all but the most urgent procedures have
waiting lists months long, even though it means many patients will
deteriorate and end up back in the overwhelmed E.R.s. Nobody thinks
the L.A. County system has the capacity to deal with the sort of
surge a major epidemic might produce, to say nothing of a
bioterrorist attack.

And what's true of USC/County is true of the local facilities, too.
Even at the Humphrey Center's women's clinic, it can take several
weeks to get an appointment, plus months beyond that to get routine
screenings like mammograms or colonoscopies. An energetic
gynecologist I met there said she had recently diagnosed a patient
with advanced cervical cancer. The woman hadn't gotten regular pap
smears and gynecological exams, a common situation in a
neighborhood where unpredictable work hours and unreliable day care
make it difficult to keep appointments. By the time the patient
finally came in, the doctor said, her uterus "looked like ground
beef." The doctor ordered a hysterectomy, but, with no insurance,
the patient had to go a county hospital-- and onto a two-month
waiting list.

Given that what's happening in South Central is happening in
low-income communities across Los Angeles, you might think the
county would be expanding its network of clinics and hospitals.
But, as the number of Los Angelenos without health insurance swells
past 2.5 million, a number that constitutes almost one-third of the
county's entire population, nobody is talking about expansion.
Instead, this summer the county board of supervisors voted to close
clinics, sell one of its six hospitals, and radically downsize two
more. It plans to vote on more cuts in January, perhaps shuttering
two major hospitals and several more clinics.

The problem is money: The county medical system is losing hundreds
of millions of dollars each year. In November, as a stopgap
measure, voters approved a property tax hike that will help keep
trauma centers open. And the state, despite a severe budget crunch,
is expected to chip in a little extra money as well. But the
magnitude of Los Angeles's problem has historically required help
from somebody with deeper pockets: the federal government. During
the 1990s, President Clinton spared Los Angeles severe cuts by
authorizing more than $2 billion in bailouts. But now the Clinton
money is running out. And, while the Bush administration has
authorized far larger assistance packages for the airline industry
and giant farm conglomerates, it has been decidedly less generous
toward Los Angeles's medical system. "We don't want to create a
meltdown of the L.A. County hospitals, but I have to explain to
Houston and New York and St. Louis and Nashville why L.A. County is
getting a special deal," Tom Scully, President Bush's director of
the Center for Medicare and Medicaid services, told the Los Angeles
Times late this summer. "I don't think it's our responsibility to
just write them a check and bail them out."

Scully has a point: It would be strange to single out Los Angeles
for assistance when so many other communities are suffering. To
balance its budget, Tennessee is pushing about 160,000 off the
Medicaid rolls this year; most of them will end up uninsured. In
Illinois, funding cuts that take effect January 1, 2003, will
likely force a number of Chicago clinics, serving thousands of
low-income residents, to close. Overall, 41 states are reducing
Medicaid spending for 2003, according to a survey by the Kaiser
Family Foundation. What will these cuts mean? This spring, a study
by the Institute of Medicine, an independent research organization,
suggested that as many as 18,000 adults without insurance die
prematurely each year because of their failure to get the kinds of
tests and treatments people with good insurance take for granted.
As states slash funding for their medical safety net, that number
will almost certainly rise.

But the fact that so many other communities are in the same position
as Los Angeles doesn't suggest, as Scully says, that the
administration should do nothing. On the contrary, the federal
government ought to be helping all of them. Instead, the White
House has quietly drained money from existing federal health
insurance programs while proposing to make the estate tax cut
permanent. As for pleas to help the states through extra Medicaid
money or some other direct subsidy, they've gone about as far as
the pleas to help Los Angeles County--which is to say, nowhere.

Nobody considers the Los Angeles public health system ideal. It has
evolved haphazardly, beset by corruption and inefficiency ever
since its creation in the 1960s. But, even allowing for the waste,
it has always been underfunded. Assistance from Washington has
never completely made up for the burden of handling so many
uninsured patients, and, in the '90s, the financial situation
became a crisis as the number of county residents without insurance
jumped past two million. When the prospect of universal health
insurance died in 1994, the county asked Clinton to come to its
rescue, and he did--in the form of a $1.2 billion, five-year
assistance package. "It would have been criminal to permit these
clinics to close and all of this crisis to develop," Clinton said in
1995, as he announced the bailout.

That money came with strings attached: In exchange for the cash, Los
Angeles County promised to revamp its system, gradually reducing
the use of expensive inpatient hospitals through more preventative
care at outpatient clinics. Yet by 1999, when the bailout was
nearing its end, the county wasn't even close to meeting its goals.
Critics blamed the county's board of supervisors for dragging their
heels on reform--i.e., for coddling public employee unions or
refusing to eliminate unnecessary facilities in their respective
districts--but the story was more complex than that. An independent
report by the Urban Institute suggested some key mitigating
circumstances: While inpatient care had dropped only slightly, that
was partly because the backlog of unmet need was so large; as the
county pushed people out of the hospital, more rushed in. And,
whatever its other failings, the county had followed through on one
promise: the creation of a Public/Private Partnership plan, under
which it subsidized independent, nonprofit clinics that in many
cases provided better care than the county-owned units.

Maybe it was recognition of these extenuating circumstances and
modest advances. Or maybe it was just politics --namely that
Clinton wasn't willing to abandon so many Democratic voters in the
middle of Al Gore's presidential campaign. Whatever the reason, in
the waning days of his presidency, Clinton authorized another
bailout, albeit with stricter oversight. In return, county
supervisors promised to do better, eventually giving their newly
appointed health czar--Thomas Garthwaite, formerly of the Veterans
Administration (V.A.) health system--a broad mandate to radically
restructure the county network.

At the V.A., Garthwaite had succeeded in streamlining the
bureaucratic behemoth, promoting preventative care, and
consolidating medical records. In Los Angeles, Garthwaite sketched
out plans for a similar transformation: a system under which every
county patient would get an electronic health-record card that
carried their medical records on it from visit to visit. Then,
cognizant of charges that the county was unwilling to show any
fiscal discipline, he also proposed a plan under which the county
would downsize some of its hospitals, sell off its rehabilitation
hospital altogether, and close several clinics. Despite the
opposition of activists and the public employee unions, county
supervisors backed the plan, and the cuts began taking effect in
late August.

Although Garthwaite argued that efficiency gains would soften the
blow of these cuts, one clear purpose was to sound a public alarm
and convince their would-be saviors--Scully and Bush--that they
were serious about reengineering this time around. With the public,
at least, the gambit worked. Swayed by TV ads portraying paramedics
desperately seeking open E.R.s, two weeks ago county voters
approved a referendum to raise their property taxes in order to
finance trauma care. It's expected to be about $168 million per
year for the county, enough to cover 40 percent of the expected
deficit. In addition, after months of ignoring the county's plight,
Governor Gray Davis recently hinted that he was planning to submit
a health care assistance plan to a special session of the
California legislature.

But things haven't gone nearly so well in Washington. During the
spring and summer, Scully said repeatedly that he had no interest
in writing more checks to L.A. County. At most, he said, the
federal government could provide a one- time-only infusion of about
$150 million in "bridge money"--enough to pay off about one-third
of the county deficit for a single year. After some not-so-
delicate prodding by Los Angeles Representative Jane Harman, Scully
agreed to visit Los Angeles shortly after the election. But, even
during that visit, his message remained the same: "I have no plans
to be a knight in shining armor."

A few months ago, that hard-nosed position might have been
defensible. Why should the federal government help L.A. when the
county and the state are unwilling to help themselves? But now the
voters have done their part. So have Garthwaite and the county
supervisors. Even Governor Davis seems ready to do his. Suddenly,
it's the Bush administration alone that's walking away from the
problem.

And not only walking away. The administration is actually making the
problem worse through its other actions. One of the underreported
stories of the last two years is the administration's gradual
reduction of Medicaid money for the uninsured. Over the last decade
or so, states have exploited Upper Payment Limits--a Medicaid
provision designed to help subsidize care for the uninsured-- in
order to collect extra money from the federal government and then
channel it for things like roads, schools, or debt repayment. The
Clinton administration started cracking down on this in the late
'90s. But at least a few states really were using that money for
health care--and California was one of them. Now the Bush
administration has drastically reduced that money, costing Los
Angeles an estimated $125 million per year.

Which would be fine if the Bush administration were doing something
else to help cover the cost of serving the low-income uninsured.
But, while the Democratic Senate this year approved a bill that
would increase the federal matching rate for Medicaid, thereby
giving the states (and, indirectly, places like Los Angeles) money
to get through the next few years, Bush has opposed it. Similarly,
funding for the State Children's Health Insurance Program will
start tapering off next year. Created under Clinton, that program
played a key role in keeping the number of people without insurance
nationwide from climbing in the late '90s. Yet the White House has
not proposed even maintaining current funding. On the contrary,
according to a recent report by the Center on Budget and Policy
Priorities, the latest Bush S-CHIP budget would force over half a
million children out of the program over the next five years.

Tellingly, the administration's primary effort to reduce the ranks
of the uninsured consists of a proposed tax credit for people who
buy insurance themselves. It's worth just $1,000: According to a
survey of health insurance plans by the advocacy group Families
USA, on average, that's barely one-fifth of what it would cost a
healthy middle-aged woman to get a decent policy--i.e., one that
covers basics such as prescription drugs. Plus, there's no
mechanism to make sure insurance companies don't simply refuse
policies to those people with serious medical conditions. That's
why most studies suggest the primary beneficiaries of such a break
will be people who already buy health insurance-- not the people on
waiting lists to see doctors in L.A. County.

So what happens to Los Angeles if the rest of the cuts go through?
It will mean even longer waits, more delayed treatments, and
ultimately more people suffering medical problems--something
already happening, thanks to the first round of downsizing. "We
used to get about ten new patients a day showing up at our doors,"
says Roland Polencia, the director of the Clinica Oscar Romero, in
the heavily immigrant, heavily Latino Pico Union neighborhood just
west of downtown. "Now it's forty to fifty, and that's happened
literally in the past few weeks." Back in South Central, the
closure of the Compton Clinic has sent patients trudging across
town to the Humphrey Center, although not everybody makes the trip,
given that it's 20 minutes by car but as much as two hours by bus.
"I have clients with gall bladder problems," says Loretta Jones,
director of Healthy African-American Families. "They have
discomfort. They have pain. They can't sit on the bus for two
hours. They just end up staying home." That's just one reason the
closures are bound to press county E.R.s even more, even with the
new trauma tax in place. The cuts will "make this winter a scary
time of year," says veteran pediatrician Irma Gonzalez, who
moonlights at the USC/ County pediatric E.R.

Alas, political pressure for more assistance may not build until the
diseases of the inner city spread into the suburbs. "Look, I live in
a community that's affluent. A lot of people don't have health
insurance at McDonald's, where I take my kids. If [they're] not
screened for T.B., hepatitis, and so on, guess who's vulnerable? We
are, the people who live in these communities," says Carl Coan,
president of the Eisner Pediatric and Family Medical Center,
located near downtown.

Coan is right about the suburbs' vulnerability, and, sadly, he may
also be right that it will take an epidemic to jolt Washington into
action. After all, the public health situation in the United States
is already critical. Nationally, the uninsured now number 43
million and are growing fast. Yet the White House still has "no
plans to be a knight in shining armor." Let's hope it gets some
before it's too late.

Correction: The twelve-day wait at USC/County is for an ECG
(echocardiogram), not an EKG (electrocardiogram). We regret the
error.

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