Ill Treatment

by Jonathan Cohn | December 2, 2002

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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