With 4,500 nurses among the last holdouts to a comprehensive labor settlement between L.A. County and its workers last week, the county finds itself in a bind.

The nurses want more money and greater levels of staffing, but the county insists it can't afford either, at least not at the levels that the Service Employees International Union Local 660 is demanding.

"The SEIU has spent the last year convincing employees that everyone in local government has lots of money," said David Janssen, the county's chief administrative officer. "But the surpluses are in Sacramento and Washington, not here."

The county health department just received a $1.2 billion five-year bailout from the federal government for indigent services, and it must find ways to cut costs by nearly $1 billion when the bailout ends. Even if it could come up with the money, an acute nationwide nursing shortage is making it nearly impossible to find nurses.

"We face an $884 million shortfall over the next five years in the Department of Health Services," said Gail Anderson, acting associate director for clinical and medical affairs for the county DHS and medical director of Harbor-UCLA Medical Center. "That underscores the problem we have as we try to be competitive with salaries. Meanwhile, the nationwide shortage means there is a much smaller pool of nurses to draw from. That's the dynamic tension we have here."

Anderson said DHS has mounted an aggressive recruiting campaign to reverse a 14 percent decline in county nursing staff over the last five years. But he said that bringing the current staffing level of 4,325 nurses up to anywhere near what the nurses are demanding would take several years.

County nurses acknowledge that there is a nursing shortage, which makes it more difficult to attract nurses. But the solution, they say, is for the county to staff up and offer higher salaries and benefits so that nurses will want to work for the county.

A registered nurse employed by the county makes an annual salary slightly above $30,000.

"The county is finding it difficult to recruit and retain nurses because the working conditions are so poor, the staffing levels are so poor and the pay is so low," said Grace Corse, a critical care nurse at Los Angeles County-USC Medical Center and head bargainer for county nurses. "If nurses were offered decent staffing levels and decent pay, then they wouldn't be so frustrated in their inability to provide quality care and they would want to stay."

Corse said that the nurse-to-patient staffing levels at the six county hospitals range from one nurse for every 10 patients to one nurse for every 30 patients. (These figures exclude intensive-care units, which must be staffed at a level of at least one nurse for every two patients.)

"There's no way you can provide quality care when you are one person having to tend to the needs of 20 or 30 patients. That's why nurses leave the profession," she said.

The nurses are seeking a ratio of one nurse for every four patients. They are also seeking a pay raise greater than the 11 percent hike spread over three years that the county has put on the table.

But county CAO Janssen said there simply isn't enough money available to meet the nurses' demands.

"It's not the fault of nurses and other health care providers that the health care system is such a disaster," Janssen said. "The fact is, under terms of the most recent federal government waiver, we have to make some dramatic cuts in the health department over the next five years."

The only way to minimize those cuts, Janssen said, is to lobby the state and federal government for more funds.

Lobbying for funds

"We have a lobbying team trying to bring in more funds, but it's like spitting in the wind," he said. "Look at what happened this year in Sacramento. They have been taking away $400 million a year every single year from our budget. (That diversion began in 1992 as the state used local property tax dollars to help balance a budget that was $14 billion in the red.) They had a huge $14 billion surplus this year, and what did we get? $31 million. If we had gotten more of those dollars, we could have used them to help plug the hole in our health department."

Janssen said the situation with the federal government is little better, despite the $1.2 billion bailout agreement last June.

"The money will help in the short run, but until the federal government changes the way it reimburses us for indigent services, we're looking at this problem continuing."

The county was able to come up with enough funds to grant the vast majority of its workers who went on strike this month a double-digit raise, spread over the next three years.

The SEIU has reached agreements with the county covering 80 percent of the 47,000 county workers, with raises ranging from the 9 percent the county initially offered all the way up to 21 percent. But county nurses, along with some other health care workers and county librarians, had not reached agreements as of late last week.

SEIU officials say that the offered 11 percent hike over three years that is currently on the table for nurses is insufficient and they fully expect the county to up its offer.

But the staffing issue seems more intractable, according to Healthcare Association of Southern California spokesman Jim Lott.

"This is truly a nationwide problem," Lott said. "If we're seeing it among our private-sector hospital members, then I've got to believe that it is at least as difficult, if not more so, to recruit nurses for the county hospitals, given the demographics of the patients that use those hospitals."

Complicating the situation is a new state law that requires all hospitals to maintain certain minimum staffing levels. The law was initially supposed to take effect this coming January, but that has been postponed at least six months, since the state Department of Health Services has yet to come up with its recommended staffing levels.

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