Clinics Struggle To Treat Deluge
Receptionist Maria Flores is on the front lines of health care in L.A. County.
On any given day, she fields as many as 250 calls at the Eisner Pediatric & Family Medical Center, which serves a downtown neighborhood with one of the highest rates of uninsured in the state.
New patients lucky enough to qualify for government health insurance, such as Medi-Cal, can get an appointment in two weeks. But the uninsured might face waiting periods as long as three months.
“They are like, “Wow. That long?” relates Flores. “They’re frustrated, but most of them are willing to wait.”
They have little choice, except to forage for free care at some other community clinic. Or sit for hours in a county emergency room while the critically injured or seriously ill are seen ahead of them.
The county’s $2.9 billion indigent health care system is shaky in the best of times, barely able to serve an area where one-third of the 10 million residents lack private insurance. But now, a weakening economy further threatens the system’s financial stability.
Add to that, is the scheduled expiration of a nearly $1 billion federal bailout in 2005 and a lack of other sources to replace the money.
It comes at a time when demand for services is perhaps the greatest it has ever been, with emergency rooms filling up with patients worried about anthrax or cut off from private health coverage because of layoffs.
“This is probably the most challenging period in the 29 years I have been here in terms of the revenue issues we are facing,” said Fred Leaf, acting director of the county health department.
The department has been without a permanent director since June, when former director Mark Finucane resigned, leaving Leaf and his staff to grapple with a $60 million loss in federal funds next year and a projected $500 million deficit in 2005-2006 when the bailout expires.
The bailout involves a waiver of Medicaid rules, allowing funds that normally only can be used for hospital stays to be applied for outpatient care in community clinics and the like. But Clinton Administration officials had warned the county not to expect another waiver, and little more is expected from the Bush Administration. If county officials were not counting on another wholesale bailout, they were hoping new sources of funding from other state and federal programs might help them turn the department around.
But those funding sources are in doubt.
Take, for example, the money that health care providers, including the county, receive for providing services to patients on Medi-Cal, the state’s name for the federal Medicaid program.
According to calculations by the California Healthcare Association, a hospital trade association, California ranks 48th among 50 states in its reimbursement rate on a per capita basis. Given that the funding is a combination of state and federal matching dollars, an increase in state funding would draw more federal dollars.
“We had all hoped that the Administration in Sacramento would have increased the rate,” said Los Angeles County Supervisor Yvonne Brathwaite Burke. “That impacts us on an on-going basis.”
But that was before the recession pinched revenue receipts, and the energy crisis sucked up $6 billion from this year’s state budget, and Gov. Gray Davis ordered department heads to make up plans for up to 15 percent cuts.
Even an effort to fix the state’s frayed trauma system with a $300 million infusion got whittled down to $25 million in this year’s budget. The county is expected to receive just $3.3 million of that.
“That is a clear message of the budget situation we expect to find ourselves in,” said Beth Cappell, a lobbyist for Health Access, a coalition of 200 groups that promote health coverage for all Californians.
On the federal side, county officials worry about a Bush Administration proposal to eliminate a law that allows public hospitals to make up for their uncompensated indigent care by paying them extra Medicaid funds.
The program was supposed to be phased out over seven years, starting in 2003. But now there’s talk about a not-so-gradual funding cut that could come as soon as this January.
The loss is estimated at $250 million annually statewide, and $125 million in the county, an amount equivalent to the cost of running Harbor-UCLA and Olive View-UCLA medical centers.
The Board of Supervisors was scheduled to meet over the issue with federal officials Sept. 12, but that was delayed by the attacks, and now board Chairman Mike Antonovich and Burke are headed to Washington on Oct. 29.
“It’s one of the pillars that holds up the system,” said Glen Rosselli, the state’s undersecretary for health and human services, who is involved in the negotiations. “If you knock that out you will have a tilting stool.”
Leaf said the supervisors would have no option but to cut services should the Bush Administration pursue a faster reduction in the special Medicaid funding plan.
“That will be taken into account, but that shoves it to the point where the solutions get extremely rare,” he said. “You are going to go into a mode of reduction of service, cuts in facilities. That is the only option.”
Leaf declined to specify what those reductions might be, but Mandy Johnson, executive director of the Community Clinic Association of Los Angeles County, said the county likely would look at hospital closures.
Vast county system
The county operates six hospitals, six comprehensive health centers and 20 neighborhood clinics, whose services are augmented by 100 clinics run by association’s members with county subsidies.
Under terms of the federal bailout, which seeks to move indigent care out of the costly hospital setting, the county must contract for at least 700,000 outpatient visits with association members, while providing at least 2.3 million outpatient visits on its own.
Any cuts in outpatient funding that lower those numbers could jeopardize the remaining funding in the bailout, leaving hospitals the likely target for any closures. “The outpatient services have some protection,” Johnson said.
Before he departed, Finucane proposed to close the budget gap by shuttering High Desert Hospital in Lancaster, but that was rebuffed by Supervisor Michael Antonovich. Any closures likely would send patients to the remaining clinics or the emergency rooms of private hospitals, Johnson said.
Leaf and his staff have been developing a strategic plan that will outline options for the supervisors on how the county may be able to dig its way out of the deficit hole caused by expiration of the waiver, which for planning purposes Leaf assumes will not be extended.
The plan, to be announced next month, will include some “innovative” programs along with “permanent revenue reform” that would pay the county more accurately for the services it provides. However, a loss of $125 million in special Medicaid funding will make service cuts inevitable, he said.
