 |  |
|
| |
|
|
|
|
Professor Emeritus of Medicine and Public Policy
Former Dean, Keck School of Medicine of USC
Twelfth Annual Borchard Lecture
Emeriti Center-Emeriti College
University of Southern California
March 21, 2007
This enormous county—4,000 square miles—contains eighty-eight cities and a population of ten million, growing at a rate of about 100,000 per year. We are the world's sixteenth largest economy, an economy that is dominated by small employers, such that, of 220,000 employers five years ago, 200,000 firms each employed less than fifty employees. The racial and ethnic makeup of our population continues to change with a numerically stable Black population, a shrinking non-Hispanic white population and substantial growth in both the Asian/Pacific Islander population and the Latino population. Persons of color are now a substantial majority in our county.
Our metropolitan region has the second largest percentage of population without health insurance in the U.S.—now estimated to be at 25 percent, or nearly one third of the entire population under the age of sixty-five. This compares with a state rate of 21 percent and a national rate of 17 percent. Less than 49 percent of our employed population has employer provided health insurance a tribute to the dominance of small employers. And yet, at least 78 percent of uninsured families have one or more fully employed family members. Our uninsured are dominated by the working poor who do not have access to employer sponsored health insurance and cannot afford the $8–$10,000 annual cost of health insurance.
So, what resources do we have to provide health care to this mix of humanity, insured and uninsured, employed and unemployed, indigent and nonindigent? California requires that counties provide health care to the indigent. Thus, at its peak in the 1960's and 70's the County operated more than 6,000 beds in eight County hospitals. With the advent of Medicare and Medicaid in 1965, the number of County hospitals and beds has decreased to its current total of five hospitals with less than 1,500 beds.
The funding of the county health system, originally dependent upon the property tax, has been the victim of a series of economic shocks. Proposition 13 severely limited the County's ability to finance the health system and made the County nearly entirely dependant upon the state and federal governments. The County, which at one time financed 40 percent of its indigent care costs from the property tax, and fell as low as 4 percent ten years ago, now provides as much as 13 percent. During two fiscal crises in 1992 and 2005, the state confiscated $1 billion of Los Angeles County property taxes, an amount which has never been restored. Federal interventions have helped significantly, but the current reality is that County health services are heading for future major deficits very soon.
Those public resources are augmented by approximately one hundred and eighty free and community clinics in the County who, together, care for about 700,000 individuals by means of 2,200,000 clinic visits per year. The number of uninsured children in the County, as high as 500,000 in 2000, has been substantially reduced by improved efforts to enroll those eligible in the MediCal and Healthy Families programs and100,000 children ineligible for those programs have been insured under the Los Angeles Children's Health Initiative from $140 million raised by a voluntary coalition. Unfortunately, that program will end this year.
Well, what about the rest of us? The County has 25,000 licensed physicians, a ratio of 243 doctors per 100,000 people. More than adequate by any standard and 50 percent more than needed if there were a totally integrated health care system. The fewer than 60,000 nurses leave a huge deficit approaching 10,000.
On the other hand, there has been a 21 percent decline in the number of private hospitals, in the past twelve years with the closure of twenty-four hospitals through 2006. Most of the closures were relatively small for-profit hospitals. Nine have closed since August of 2003. The reasons for closure are entirely economic. The decrease in County hospital capacity and the increase in the numbers of uninsured are placing increasing pressure on the private hospitals to subsidize the uninsured and indigent.
Very few new hospital beds are being built, and many hospitals that are in the process of replacing existing beds with seismically safe beds are downsizing in the process. Occupancy rates are approaching their limits. Los Angeles County has only 2.1 hospital beds per a 1,000 population, compared with a national average of 3.1. This is adequate for routine circumstances, but if we should experience a major disaster (consider a severe earthquake or flu epidemic), it would be substantially too few.
Another area of real concern is the fate of our hospital based emergency rooms. There has been a 21 percent decline in private hospital based emergency rooms since 1995, with closure of at least two more this past year. Yet, emergency room visits have continued to increase. The number of private hospital based trauma centers, which numbered twenty-three when the system was inaugurated in 1985, now number only eleven, while the County trauma centers, which provide 45 percent of all trauma care in the County have shrunk from three to two. These are enormously expensive to operate.
As our emergency resources disappear, increasingly ambulances must go long distances to find an ER which can accept them. And, with only 7 percent of the beds in the County, the County hospital based ER's are seeing 15 percent of all of the ER visits.
So what is happening to the health of our population? This is difficult to measure, but one universally recorded outcome is the leading causes of death, which can be calculated for the County and for the nation. Here, if we compare our results with the rest of the U.S., we see some encouraging results.
In Los Angeles County in the past ten years, deaths due to coronary heart disease have decreased by nearly a third, and are substantially below the national figure, as are deaths due to stroke and lung cancer. It is interesting that, even with our known severe air pollution, our death rates due to pneumonia and to emphysema are substantially below national averages. Diabetes death rates have increased. Perhaps most important is the death rate due to unintentional injury, which is a direct measure of the effectiveness of our trauma system. Here again, we beat the national average by a third—a great tribute to our severely strained system.
In this brief review, we have not highlighted the severe distortion of distribution of healthcare resources and access to healthcare geographically, which show real shortages in South Central Los Angeles and East Los Angeles.
So, bottom line, what can we conclude, and what do we need to do? In spite of our shrinking resources, our death rate data are encouraging. Nevertheless, we have to recognize that we are tempting fate. Our shrinking resources of hospital beds and emergency and trauma resources can be reversed by only one change—and that is the achievement of universal access to healthcare. Removing the barriers to access for 2.5 million people and providing adequate compensation to all providers, both the private and public sector will permit the maintenance of adequate resources while substantially diminishing administrative costs and inefficiencies. It will provide earlier and less expensive intervention in the illnesses of the currently uninsured with enormous savings and greatly improved outcomes if chronic diseases such as diabetes, high blood pressure and high cholesterol are adequately treated. It has been shown that the death rate for uninsured white males is 25 percent greater than that for the insured. Senator Sheila Kuehl's Senate Bill 840 “that establishes universal affordable and comprehensive health insurance for all Californians” would have provided that remedy, but has been vetoed by our governor.
Universal access to healthcare would also allow the geographical redistribution of healthcare resources and eliminate the access issues we confront today.
The crisis in the County Department of Health Services needs to be recognized as a crisis that involves the health of all of us. County facilities provide 45 percent of all trauma services and 15 percent of all emergency services. Without them, or with any significant decrease in them, we will all suffer.
Finally, we need to reconsider the role of for-profit hospital providers in this state and county. We need to adopt a system of public accountability and of public review of decisions to sell or close them, before they are carried out.
This lecture was supported by a grant from
The Albert and Elaine Borchard Foundation
