By BRIAN D. JOHNSTON

Under a law adopted in 1922, the counties of California are obligated to provide medical care to those who can’t pay for it. That made sense then, when local county taxes were the principal revenue stream. It makes little sense in 1998, when 94 percent of the L.A. County health care budget comes from state and federal taxes.

It makes even less sense considering one-third of the L.A. County population 2.8 million people has no health insurance, and thus depends on county government. The law approaches absurdity considering that the counties are hamstrung by Proposition 13.

L.A. County had a brush with bankruptcy in 1995. Orange County actually went bankrupt, yet we continue to obligate the counties to care for the uninsured. It’s time to move the obligation from the counties to the state.

Under Welfare and Institutions Code Section 17000, Chapter 5, the counties are providers of last resort for the poor and needy, but the counties are overwhelmed by growing numbers of patients unforeseen in 1922. The L.A. County system is neither designed nor funded for 2.8 million people, and in the face of growing demand, L.A. County is actually downsizing its health care system.

The Board of Supervisors cited financial considerations last November when it voted to replace the current L.A. County-USC Medical Center, which now typically holds 890 patients, with a 600-bed facility, despite forecasts of population growth of 6.7 million people by 2020, a large percentage of whom will probably be uninsured. Common sense and simple arithmetic require a larger, not a smaller facility.

Jammed waiting rooms, closed clinics, talk of selling or closing hospitals, and newspaper reports of medical misadventure tell us the county system is failing and can’t legally raise revenues to meet its statutory obligation to the uninsured. In 1994, half the uninsured patients needing hospitalization in L.A. County were admitted to private hospitals, because the county couldn’t accept them. The private sector is also threatened, and the threat is growing.

The state has actually made the situation worse. For the last 10 years, Sacramento has not effectively dealt with the growing numbers of uninsured. Today more than 7.5 million people, nearly a quarter of the state’s population, is uninsured, the highest percentage in the nation. We have failed to enroll over 1 million eligible children in the Medi-Cal program. While setting up Medi-Cal managed care, the state has cut the lowest Medicaid payments in the country by an additional 25 percent.

Sacramento has only availed itself of $500 million of the $855 million in federal funds available for the Healthy Families Program. Only 450,000 of a possible 585,000 children will be covered. If this were not enough, since 1992 the state has transferred approximately $2 billion in local revenues annually to the state, and has refused to return more than a small fraction of that money.

Sacramento has gotten away with this in part because the health care of the poor and the uninsured is a “county problem,” which the state can ignore or even exacerbate.

Transferring the obligation to care for the uninsured from the counties to the state would be risky, because of the state’s history of callousness and ineptitude in health care. It is a risk we must take, however, because the state, at least, has the revenues to do the job.

Perhaps transferring responsibility will make the state more effective in reducing the numbers of uninsured more than 70 percent of whom are employed, or dependents of workers. If the state were in charge of all health care for the poor and uninsured, the Medi-Cal program might be adequately funded to meet the actual needs of its beneficiaries. County-to-county variances in services and quality could be reduced, and scarce resources used regionally.

Transferring the responsibilities to the state won’t automatically solve the problem, but it will move it to a level of government capable of dealing with it, if we insist that it do so. The recent history of health care in L.A. County demonstrates that the Board of Supervisors can’t solve the problem. Its origins and solutions lie outside their jurisdiction.

To continue the status quo is to invite gradual degradation of the county health care system, and the people it serves. Inaction poses a grave threat to the private health care system as well.

Brian D. Johnston is president of Janzen, Johnston & Rockwell, a Marina del Rey-based emergency medical group that contracts with hospitals to administer their emergency departments.