Posted on Wed, Feb. 26, 2003
L.A.’s critical condition
The needs of L.A.’s uninsured are overwhelming emergency rooms. Could this be the future for all of California?
By Barbara Feder Ostrov
Mercury News
It’s a routine day at Los Angeles County’s Harbor-UCLA Medical Center’s emergency room: By 3 p.m., every bed is filled. The waiting room is packed with an additional 60 patients. An elderly man on crutches says dejectedly that he’s been waiting 17 hours to see a doctor.
More than 100,000 patients will appear at Harbor-UCLA’s ER this year. Most won’t have health insurance, or doctors of their own. They turn to Los Angeles emergency rooms like this one for basic care — to such an extent that on any given day, 40 percent of the county’s 81 emergency rooms must divert incoming patients and ambulances to less crowded hospitals.
“We are a pitcher of water that can’t be filled any more,” the ER director, Dr. Robert Hockberger, said. “It’s just overflowing.”
Look hard at emergency rooms like this one. As patients around the state see their health care options shrink, the struggle in Los Angeles hospitals could be the future for health care throughout California.
In Los Angeles, the traditional emergency-room patient — the heart attack victim, the person with a broken arm — increasingly collides with California’s newer emergency: millions of people with no health insurance.
Both groups need help quickly, often from the same place. There aren’t enough doctors or beds in the public health system to care for them all. Here, the gap between the Beverly Hills executive pulled from a fender-bender and the flu-stricken laborer from East L.A. is erased: Neither can be sure of how quickly they will see an emergency-room doctor.
The shock of that convergence, combined with a severe budget deficit in Los Angeles County, has pushed the health care system here to the edge. The financial collapse has already forced the closing of two of the county’s six public hospitals and 16 of its 40 health clinics. A move to shut down two other hospitals — including Harbor-UCLA — galvanized Los Angeles voters in November to approve a rare property tax increase. For now, the two hospitals are saved.
But the breathing room gained by that tax does nothing to address the underlying problem: that about 20 percent of Los Angeles County’s population has no health insurance, compared with just 8 percent in the Bay Area, and that the needs of the uninsured are overwhelming the entire health system.
“Everybody’s all maxed out,” said Kazue Shibata, executive director of the Asian Pacific Health Care Venture clinic in West Los Angeles, where the wait for appointments has doubled and new patients are being turned away. “It’s a very stressful time.”
Is the rest of California headed the way of Los Angeles? Some experts think so, if other parts of the state begin to mirror Los Angeles’ large numbers of poor, uninsured patients.
Rising health care costs, an increasingly sick population, and more people without insurance certainly aren’t unique to Los Angeles. As the numbers of uninsured grow throughout the state, Los Angeles’ plight — however extreme — looks more and more like California’s fate.
“We’re all on the same highway,” said Bob Sillen, who oversees Santa Clara County’s public health system. “It’s merely a question of timing.”
The following dispatches explore the travails of a health care system shaken to the core, and its implications not only for Angelenos, but the rest of us.
`Lurking danger’
Crowded emergency rooms are the most visible symbol of Los Angeles County’s health care crisis — and the one that most concerns everyone, rich and poor alike.
“I think people know there’s a lurking danger that when they clutch their chests, they’re going to have a hard time getting into an ER and a hospital bed,” said Dr. Michael Karpf, who directs UCLA Medical Center and Santa Monica Community Hospitals, both private hospitals.
“This is not just a problem for the poor,” he said. “The health care crisis in California transcends class. It covers everybody.”
The critical factor is “diversion,” when an emergency room gets so crowded it starts turning away patients. Ambulance drivers must often radio hospital after hospital looking for an ER willing to accept a patient, and then sometimes drive long distances to deliver patients to an open bed. The county’s hospitals are on diversion status 40 percent of the time.
Just after 6 p.m. on a Friday night, the emergency room at UCLA-Harbor Medical Center is already chock-full, and so is its waiting room. In the entire hospital, only two beds are open.
By 8:15 p.m., as paramedics deliver a 20-something drunk driver with a four-inch gash on his scalp, only four of the county’s 81 emergency rooms are accepting new ambulance patients. The others are on diversion.
With a click of a mouse, Harbor-UCLA joins them. “It’s time,” said nurse Russ Wright. “We’re just too full.”
Jennifer Davis, who is 30 and lives in Paramount, was one of the ones who made it in. She had come to the ER to attend to a broken arm that fractured again after a fall. At Arby’s restaurant, where Davis and her husband make sandwiches for $7 an hour, only managers are offered health insurance.
Davis waited only three hours this time. Two days earlier, trying to get her arm cared for, she waited seven hours.
“I was irritated,” she said, “but there are a lot of people that are sicker than I was.”
As Davis leaves at 12:45 a.m., Conan O’Brien, on TV, is failing to entertain dozens of sleepy, frustrated patients. An announcement comes over the ER loudspeaker.
“Will patient number 97 please go to Window 5.”
Preventive care
Los Angeles’ public health system cares for 800,000 people a year, equivalent to nearly the entire population of San Jose.
Most are uninsured. Many are poor, sick and unable or unwilling to change their lives in ways that might make them healthier.
In the 1990s, county health officials tried to save money by paying community clinics to provide preventive care to thousands of uninsured or underinsured patients who previously went to county emergency rooms and clinics.
Doctors tried to do the right thing. At free clinics like the one in South Central operated by the University Muslim Medical Association, primary-care physicians identify problems they are not equipped to treat. They send those patients to specialists at the county’s King-Drew Medical Center.
“The treatment we get at the UMMA clinic is fantastic,” said Kathy Windley, a longtime patient there.
But that “fantastic” care is a key part of the reason the public health system is facing a crippling $710 million deficit over the next four years. The patients’ needs are so great that many are referred to hospitals for expensive specialists — treatment the county can’t afford.
That high level of care has kept Windley, 52, alive. She has survived three heart attacks and five cases of congestive heart failure, the last occurring when her best friend was shot on Windley’s porch.
Unable to exercise because of her weakened heart, she suffers from obesity as well as arthritis, pre-diabetes, hypertension, sinus infections and a persistent depression she doesn’t like to talk about.
Her husband, Sam, also battles pre-diabetes, as well as high cholesterol, sleep apnea and a mysterious infection in his large intestine. Neither can work because of their health. They take 14 medications between them.
“As we emphasized more outpatient care, we picked up more disease that required specialty care or hospitalization,” said Dr. Gail Anderson, medical director of the county-run Harbor UCLA Medical Center, which gets many clinic referrals. “That’s the irony here.”
Rush of patients
The strain on the county’s public health clinics shows in the long lines at the Hubert H. Humphrey Comprehensive Health Center in South Central, a forbidding high-rise that is the most advanced and specialized of the county-run health centers.
When mounting costs forced county supervisors to close 11 public clinics last year, the nearby Imperial Heights clinic was among them. Twenty-thousand patients needed a new medical home, and all were sent to Humphrey.
Clinic officials insist that the quality of care has not changed, that it is merely more inconvenient. But the clinic is bursting at the seams, and experts say quality can’t help but suffer when harried doctors can spend only a few minutes with each patient.
In handling such a huge pool of patients, the clinic is one of the county’s guards against making problems worse at emergency rooms — but crowding is forcing cracks in that wall.
Some patients, who can’t or won’t brave the long waits and leave the clinic before being seen, later wind up in emergency rooms when their illnesses worsen. Some people whose regular clinic closed now have no idea where else to go, and also head for the hospital.
Inside the clinic, interim director Joe Keys sifts through a mountain of 5,000 letters telling such patients where they could now find help. All these letters came back — stamped “Return to sender” because of moves or the false addresses many undocumented patients give their doctors.
Clinic staffers have no time to track these patients down. Last year, doctors treated upward of 130 patients a day in the urgent care center, which stays open until midnight. “Now,” Keys said, “we’re hitting that number before noon.”
Outside, slumped in a plastic chair in a bleak concrete courtyard, Tyrone Jose Ayon had the resigned air of a man whose fate it is to wait.
When he arrived at the clinic’s urgent care center on a weekday morning, Ayon was told it would take 10 hours to see a doctor about the silver-dollar-size abscess on his arm.
Four hours later, he had yet to embark on the first stage of his visit: having a nurse take his vital signs.
“I’m not paying for it,” said Ayon, 43, who is studying to become a medical assistant before his welfare payments run out. “So I guess I can’t really complain. I just sit here. I bring my lunch — and my dinner.”
On the day Ayon visited, the urgent care center had 60 patients waiting when it opened at 7:30 a.m. It had processed 98 patients by 11 a.m.
“We’ll be up to 200 by 5 p.m.,” said Dr. Casper Glenn, who directs urgent care. “There’s just such a big rush of patients now. I just don’t know what’s going to happen.”
Temporary fix
Capri Maddox has health insurance and a good job as a paralegal. She has never set foot in any of Los Angeles County’s public clinics; she’s never needed to.
But she did need emergency-room care for a severe asthma attack in 1999. That experience, she says, gave her new respect for the region’s hospitals and hammered home the need to support them, even if it meant something close to unthinkable in Los Angeles — new taxes.
“We all watch the news and you see every day that someone ordinary all of a sudden has something tragic happen to them,” said Maddox, 31. “You know that everyone is pretty vulnerable.”
For Los Angeles residents who are middle class or richer, the county’s public health crisis isn’t generally a major concern despite intense media coverage. County-run clinics and hospitals typically are in neighborhoods they avoid.
But in November an overwhelming proportion of county voters — 73 percent — approved Measure B, a property tax increase to shore up the county’s public hospitals and trauma centers. They were spurred, many believe, by a last-minute barrage of television ads portraying paramedics desperate to find an open emergency room.
The passage of Measure B, showing public support for the health care system, also proved pivotal in the county’s negotiations with state and federal authorities for a recent $250 million bailout that will help ease some of Los Angeles’ problems. The tax — three cents on each square foot of a building (the annual tax on a 2,000-square-foot house would be $60) is expected to raise $168 million a year.
But even with the passage of Measure B and a temporary bailout, Dr. Jane Spiegel, a West Los Angeles internist, worries that her patients won’t be able to get the care they need, when they need it.
At St. John’s Hospital in Santa Monica, where Spiegel is affiliated, “a lot of the time our ER is completely filled and my patients can’t get a bed in the hospital itself.” Recently, one of her patients had to wait 36 hours for emergency abdominal surgery.
“No one cares if you have insurance if the doors are closed,” said Maddox, the paralegal. “It’s not about insurance; it’s about accessibility.”