At the edge of a cliff: Crisis in Los Angeles
Crunch-time for county after years of red ink
With TB control programs across the country caught between flat federal funding, declining state and local revenues, and increasing numbers of foreign-born patients, many TB controllers sound as if they are pointed straight down on the slope of the so-called "U-shaped curve of concern" — the part of the cycle when funding for TB falls off, provoking rising case loads, which, in turn, inspire renewed attention and funding.
Even though Los Angeles County has its own situation-specific set of problems, it’s tempting to call TB controllers’ troubles there emblematic of trials besetting programs elsewhere in the country.
One cruel irony in Los Angeles is that the TB control program, though having to bear deficits along with the rest of the county health system, is innocent of having contributed to the crisis, TB experts say. "If anything, TB control has probably done better than other parts of the system in shifting to outpatient services," says Annette Nitta, MD, TB controller for the county. "Public health in general is not responsible for racking up the debt. The part of the system that’s bleeding money is the hospital side."
For years, the county’s health care system was heavily weighted toward inpatient care, causing it to hemorrhage rivers of red ink. Adding to the fiscal woes were strong public employee unions, plus huge numbers of indigent patients without insurance, many of whom are foreign-born workers. Since 1995, the county has struggled to eliminate costly redundancies in its hospital system, shifting more services to outpatient care.
Indeed, if $54 million from a 1995 federal bailout weren’t about to run out, the county still would be plodding along, painstakingly implementing the necessary structural reforms, adds John Schunhoff, PhD, chief of operations for county public health.
Unfortunately, time has run out. In the face of a health department deficit projected to run as high as $800 million by 2005-2006, the county Board of Supervisors recently approved cuts of $57 million, including a 10% cut to public health spending amounting to $8.9 million.1 Eleven of 18 county health clinics are destined for closure. Though none of those is directly involved in TB case management, some of the clinics do TB screening and treatment for latent infection; and that, in turn, stands to adversely effect the rest of the program, Nitta contends. "Those people will have to go somewhere else, and that conceivably will interfere with case management," she points out.
In addition, High Desert Hospital (located in Lancaster), the state’s only civil detention facility for noncompliant TB patients, also is scheduled to close. One plan to bring in revenue and keep High Desert open calls for the facility open a skilled-nursing wing whose patients would come from the state Department of Corrections.
Alternatively, one of the public hospitals still standing after the cuts might be able to open a civil detention facility, says Schunhoff. "But that’s touchy, too, since the future of those facilities is also up in the air," he adds.
Despite redundancies and other expenses linked to inpatient care, a big chunk of the trouble is not of the county’s making. "Indigent care is a huge factor driving the crisis," says Nitta. Even though TB patients are eligible for Medicaid reimbursement — in theory, at least, though the state has had only slight success in getting them enrolled in the program — neither private nor public insurance or reimbursement are available to indigent patients seeking care other than for communicable diseases from the county health system.
Too, the state is disproportionately burdened with medically indigent patients, Nitta points out. "Of all states in the union, California has the highest proportion of medically indigent people," she says. The number of medically indigent patients in Los Angeles County alone equals 2 million people.2 Plus, the medically indigent make up the whopping portion, 80%, of the county health system’s caseload.
Clearly, it is the medically indigent who will bear the brunt of the cuts. "There’s no argument from the county that this is where the burden will fall," says Schunhoff. Yet public health may also wind up paying a heavy price. According to Nitta, TB cases in the state are up, from 3,297 in 2000 to 3,332 in 2001; and in LA County, instead of continuing the recent trend of fairly robust dips each year, cases fell only slightly last year, from 1,065 cases in 2000 to 1,046 in 2001.
1. Health threats strain staffs. Los Angeles Times, July 8, 2002.
2. Give health chief options. Los Angeles Times, July 7, 2002.
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