Are we loosing the Health Care Battle in Los Angeles?

Unfortnately something I wrote back in 2003 appears to be coming to
pass.


HealthLeaders.com

A Local Healthcare Battle; A National Healthcare War

Robert A. Beltran, M.D., January 13, 2003



Our country faces a "Healthcare War" and one major battleground is Los
Angeles County. A fair and reasonable victory for those who seek
universal healthcare in Los Angeles will determine how the rest of the
country faces the commitment to universal healthcare. Its success in
Los Angeles will be gauged by the ability to reduce health disparities
and lower the number of uninsured in Los Angeles County. A battle cry
is starting to be heard at the county, state, and federal level that
will prove victorious.

Despite our country's focus on global issues such as terrorism,
healthcare will take center stage when Congress returns in 2003. The
number of uninsured persons is slowly increasing during our lackluster
economic recovery, while employers are facing double-digit increases in
healthcare insurance premiums. On top of these problems, a majority of
state governments are facing severe budget deficits due to the rising
cost of Medicaid health services for the poor. These are the primary
drivers which have renewed interest in universal healthcare. Recently
the President of Blue Shield of California and California State Sen.
Sheila Kuehl have called for universal healthcare coverage -- the basic
mechanism of which would be either a "one-payer" or a "pay or play"
model that would expand coverage universally.

The battleground of Los Angeles County has nearly 2 million uninsured
persons who have high employment rates in small service businesses that
do not offer health insurance coverage. L.A. County is third in line
behind Texas and New York for having greater numbers of uninsured
working persons. Unfortunately for the Los Angeles County Health
System, a major health service product line are the uninsured.

This fact has produced a consistent health department budget deficit
over the past seven years, which the federal government has chosen to
help balance. However as a condition of the last federal support
supplement in 2000, the government required that Los Angeles County's
Health Department become self sufficient over the next five years. This
means that federal financial support will incrementally decrease to
zero dollars in 2005.

Dr. Thomas Garthwaite, the recently-appointed Director of the Los
Angeles County Department of Health Services, has released his
strategies for systemwide reform to deal with this growing budget
deficit. The plan calls for severe cuts in county health services and
closures of health facilities. While thoughtful and comprehensive, this
plan is flawed because it was hastily put together. The plan causes
grave concern among community advocates, health service researchers and
health policy experts.

Of major concern is the disparity between the growing needs for
healthcare services for the uninsured and the reduction in the
availability and resources to care for this increased demand. However,
the issue extends beyond the uninsured because the county health system
serves as the major trauma system for all Los Angeles County residents.
A crumbling county healthcare system affects all residents of Los
Angeles County.

Additionally, the fear is that "value" is being sacrificed at the
expense of draconian cuts in health service availability. These cuts
will result in increased inequalities in how Los Angeles County
dispenses healthcare to all its residents.

In light of these concerns, one community-based organization, Community
Health Councils, wrote a proposal calling for a "Healthcare Safey Net
Commission." This commission would be composed of federal, state,
county, and community-based health agencies as its members as a way to
get all key stakeholders in a room and come up with a workable
long-term solution. Improving the health of communities can be measured
by many indicators. Two such indicators are racial and ethnic
disparities in health and population diversity.

In 1998, President Clinton issued his executive order on "Eliminating
Racial and Ethnic Disparities in Health." The following year, Dr. Kevin
Schulman released a study which sent shockwaves throughout the health
system. His study documented how racial and gender bias distorts
clinical decision-making. Our Los Angeles County Department of Health
Services two years ago documented similar disparities in health in a
report called," The Health of Angelenos." This report showed
disparities in health status, health risks, medical access, and other
health determinants for our multiethnic population in Los Angeles
County.

Health disparities are acknowledged as major barriers to the health of
multiethnic populations. The Institute of Medicine in March 2002
released a report entitled, " Unequal Treatment: Racial and Ethnic
Disparities in Health Care." Shortly thereafter the National Quality
Forum released a report entitled, "Improving Healthcare Quality for
Minority Patients." These reports along with the work of the
Commonwealth Fund form sufficient evidence-based information to form
strategies to eliminate health disparities.

Professional medical quality organizations are also recognizing and
supporting issues related to quality health services for underserved
communities. In the July 2000 issue of the American Journal of Medical
Quality an editorial states," The greatest challenge facing healthcare
in the 21st century is understanding the healthcare needs and
expectations of these growing multi-ethnic populations. Our prosperity
rests on our collective will and ability to address diversity through
creation of strong intergroup collaboration within an educational
environment where all can participate and thrive."

Managing, monitoring, and measuring the health of our diverse
population is not an easy task. Los Angeles County is home to 10
million residents, 33 percent of whom are foreign-born. They speak more
than 100 languages and dialects.

These two key indicators along with the concerns that the current
system is inadequate and crumbling were identified by a 2002 letter to
the county supervisors by a statewide group called, "The Ethnic
Physician Organization." The letter was signed by 47 ethnic physician
leaders representing more than 20 different ethnic physician
organizations in the state.

The L.A. County health crisis is the business of our diverse
multi-ethnic communities. The physicians, nurses, and other health
professionals from these communities carry the responsibility to
mitigate the pain and suffering that is inevitable when drastic change
occurs.

It has been said that with "great change" comes "great risk." The Los
Angeles Board of Supervisors has constructed a scenario that allows for
"great risk" and violates a primary tenet of the Hippocratic Oath
(First, do no harm.) Dr. Garthwaite as a physician and administrator
recognizes this and above all must achieve balance, equity, and justice
as he continues to work towards a coordinated, integrated, and
collaborative redesigned healthcare system.

Dr.Garthwaite's successful battle strategy needs to completely embrace
the indicators of "racial and ethnic disparities in health" and
"population diversity."

Gov. Gray Davis most recently has asked the federal government for
additional resources to stabilize Los Angeles County's financially
crumbling public health system.

It is clear that the county, state, and federal stakeholders are
preparing for a healthcare battle, the likes of which none of us has
ever experienced. The best indication that this is occurring was
demonstrated by a visit from Tom Scully, administrator for the Centers
for Medicare and Medicaid Services. During his visit with county,
state, and community stakeholders he made it clear that his agency
would not write another check to save the county health system. He
further emphasized that besides Los Angeles County, other states and
jurisdictions were experiencing similar financial challenges in dealing
with health services for the uninsured.

Since Mr. Scully's October 2002 visit, numerous letters, phone
conferences, and meetings between stakeholders have been taking place.
No solution has yet been found.

The stakeholders are concerned that if politics rather than patient
well-being becomes the aim, the battle may be won, but the war is lost,
resulting in only a short-term fix and no firm long-term strategy.

Our only salvation is the full force and leverage of a multi-ethnic
community partnership and advocacy, which will allow for wiser and more
inclusive input to the battle strategies. It is these different
perspectives that are the energy which fuels progress in such matters.

Questions remain: Can financial cost be reduced by having universal
coverage such that its opponents will see the benefits and buy in to
supporting this type of reform? Finally, will universal coverage make
healthcare a right rather than a privilege?

The answers to these troubling questions will bring the American health
system closer to the justice and equity that will improve the health
and well-being of our communities.

Robert A. Beltran, M.D. is President of Latino Med Policy Institute,
Los Alamitos, Calif. He may be reached at 626 255-7399 or emailed at
beltran@xxxxxxxxxxxxxxxxxxxx

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