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Are we losing the Health Care Battle in Los Angeles?

Unfortunately something I wrote back in 2003 appears to be coming to pass.
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From 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@latinomedjournal.com

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