O.C. Is Chasing Health Funds It Once Spurned

There was a time when Orange County’s political leaders could afford to be cavalier. Without visible ill effects, they routinely turned down federal and state funding for health care because they did not want the strings that were attached.

“It was an attitude of, ‘We’re a wealthy county. We don’t need that kind of help. We don’t want the government interference,’ ” said Chauncey Alexander, chairman of the United Way of Orange County Health Care Task Force.

Today, however, county legislators and supervisors would be only too happy to accept whatever government money they could get their hands on for the escalating costs of emergency care, community health clinics and a myriad of grossly under-funded medical programs for the poor.

As Orange County is swept up in a statewide--and even nationwide--medical care funding crisis, Orange County officials are standing in line with the state’s other 57 counties for what little money there is for health care for the needy. And the hospitals that the county has contracted with to treat indigent patients are caught in a collective financial bind that is leaving needy people without care for even serious illnesses and injuries.

While comparisons don’t tell the entire story, the county puts aside less than half the average of the state’s counties for public health and inpatient/outpatient services. In addition, the state’s own funding formulas heavily favor such urban counties as Los Angeles and San Francisco. As the formula inequities go on, Orange County gets farther and farther behind other counties in total aid for these programs.

Orange County health advocates say that the county has been slow to grasp the cumulative impact of these shortfalls.

“All I can say is we’re in trouble and the crisis is coming and somebody better wake up before it gets too bad, before it gets to a situation where it’s costing lives,” said Thomas E. Uram, director of the Orange County Health Care Agency.

All counties, of course, are designed basically to deliver the services mandated by the state and federal government and thus are mostly dependent on what is given to them to disperse. Consequently, there is little financial flexibility even for those counties that would make indigent health care a priority.

Also, counties that have their own hospitals, such as Los Angeles, San Francisco and Alameda, tend to spend more overall dollars on health care than counties, such as Orange, San Diego and Sacramento, that do not have county hospitals.

Still, Orange County’s per capita spending on health care is considered low. According to 1987-88 figures provided by the state Department of Health Services, Orange County budgeted $43.70 per capita for public health and inpatient/outpatient services (including state funds) with $18.82 as the county’s costs. The statewide averages were $104.74 per capita with $33.25 the average county’s out-of-pocket costs.

“They seem to be spending a lower proportion compared with other counties,” said Alan Oppenheim, research specialist for the state Department of Health Services.

Peter Abbott of the state Department of Health Services said that in comparison to other counties, Orange County “is putting in less of its own funds” on top of what is required by the state. He warned, however, that comparisons between counties were difficult.

There is, however, a widespread perception that Orange County has put its health-care problems on the back burner.

Despite the growing health-care needs, other growth-related problems such as highway congestion and schools have been the major concerns of the fast-growing Orange County population. At least until recently, the delivery of health services has not been a priority.

“Everybody is aware of the fact that Orange County is spending substantially less than any of the other urban counties on medical care,” said Dr. Walter Henry, UC Irvine’s new vice chancellor of health services and dean of medicine. “I think it’s a matter of what people consider as important priorities.”

Henry said the county Board of Supervisors “has not had a groundswell of public support” demanding a solution to the indigent health-care problem.”

“Until the citizens of Orange County perceive this as a serious-enough problem, I don’t believe that the supervisors are going to have the incentive to develop a solution,” Henry said.

Like other counties, Orange County is hoping--against the odds--that the state will resume some of the costs for serving the needy that were turned over to counties in the face of the tax-cutting Proposition 13, passed by voters in 1978, and other fiscal restrictions, including dwindling federal money.

Orange County’s place in line is at the back, well behind counties that, during better times, were large enough and savvy enough to lock in place a set of financial formulas for medical funding that were beneficial to their health programs.

State Sen. John Seymour (R-Anaheim) said countless efforts have been made to equalize funding so that Orange County gets its fair share. But faced with severe funding problems of their own despite funding formulas more favorable than Orange County’s, urban counties have been able to keep the current formulas in place.

“Pragmatically speaking, in political terms, you just can’t take money away from a Los Angeles County or a San Francisco County and remove it to Orange County,” Seymour said. “You’re just beaten up on the votes.”

Last May, the Board of Supervisors took a small step in trying to get the county more funding for mental health by agreeing to sue the state in an effort to restore two beds--the equivalent of $200,000--to the county’s annual allocation of 146 state-subsidized hospital beds for county mental patients. The two beds could be used by up to 60 patients a year.

All told, county officials estimate, the county is shorted more than $45 million annually in its indigent medical care, mental health, and alcohol and drug abuse programs. Total losses in mental health funds alone topped $180 million from 1978 to 1988, according to county estimates.

Orange County Health Agency director Uram blames the inequity on the county’s failure to be aggressive in getting its share in the 1960s and 1970s, when these programs came to fruition. He said the members of the Board of Supervisors at the time “were very conservative and so we didn’t pursue it, and now we are paying the price for that.”

Uram said he became so concerned about the impending medical crisis in Orange County that, for the first time in his 20 years in health-care management, he flew to Sacramento earlier this year to sound the warning to state officials.

“They’re ratcheting down those programs to the point where they can’t exist,” Uram warned.

Dr. Howard Waitzkin, a UCI professor of medicine and social sciences and chief of the division of general internal medicine and primary care, said that Orange County’s lower level of spending for indigent health care is “coupled with an extremely lackadaisical attitude about caring for indigents” on the part of the Board of Supervisors.

While there have been increases for certain health care, such as prenatal care, so far the response by the board has been “a very limited and very begrudging one,” said Waitzkin, who is a founding member of the Orange County Task Force on Indigent Health Care, which predates the current Health Task Force.

Alexander of United Way said the Orange County Health Task Force, a coalition of 45 organizations, “is coming to the conclusion that the county has got to take a different tack . . . on the whole question of their responsibility for primary health care, for actually putting money into providing services for people. They (the supervisors) have tended to dismiss that.”

Alexander, who was at various times executive director of the National Assn. of Social Workers and the Los Angeles Heart Assn. before he retired, conducted a study of the county’s health-care budget over the last two years and found that it had received the lowest proportionate increase of any of the county’s functions.

The study, presented to the Board of Supervisors in July, was used to pressure the board to deal with rising crises in two areas of health care: the closing of trauma centers, which are money-losing operations for many hospitals, and diverting mothers in labor away from UCI Medical Center because their care is not fully reimbursed by the government.

“The obstetrical service problem at UCI Medical Center is the 3.5 Richter scale precursor to a 9.5 health-care earthquake . . . (and) the forerunner of other service failures,” the Health Care Task Force warned the Board of Supervisors.

The task force is also trying to get additional help from Orange County’s legislative delegation.

“I think we’re making some small strides in that direction,” Alexander said.

A month ago, the Legislature approved a measure that would pump $1.5 billion into health care--$17.5 million of it to Orange County--from the 25-cents-per-pack cigarette tax approved by voters under Proposition 99. Orange County’s money will go mostly to help pay hospitals and doctors for emergency care services given to the poor without reimbursement.

Alexander said the Health Care Task Force will urge that any discretionary money that comes to the county under Proposition 99 be used for preventive health care, including prenatal care.

But these are small steps in an overall health-care situation that is moving, Alexander warned, “from crisis to catastrophe.”

Many in the health-care system maintain that while it would be easy to dismiss the current problems in the medical system as affecting only the poor, the scope of the problems are soon going to be affecting everyone in the county.

“In terms of health care, it’s coming home to roost. The system is now starting to literally fall apart,” said Jon Gilwee, regional director of the Hospital Council of Southern California. “If they close a service, like an emergency room, that service is closed to everyone no matter how much money you have. So it now is affecting everyone, regardless of your financial status.”

Supervisor Harriett M. Wieder added that the problems in health-services funding ought to be a “red flag” for all citizens.

“If it’s a problem for government to meet the responsibilities of health care for indigents, it’s the bellwether of the problem for every private citizen,” Wieder said. “As more emergency centers close and trauma centers are in jeopardy, that’s when John Q. Public is going to realize there’s a problem.”

Twenty or 30 years ago, the Board of Supervisors was dominated by a majority that wanted to avoid state or federal money because it brought controls with it, said William E. Erickson, a member of the Health Task Force and executive director of Casa Teresa in Orange, a home for single mothers.

“It was the resistance to the controls that caused the we-don’t-want-it-because-they’ll-tell-us-what-to-do attitude. . . . It was just (the idea that) tax money is bad money,” Erickson said.

As the county’s needs grew, so did the county’s willingness to deal with them. But then there was a change of attitude at higher levels of government about funding local programs, Erickson said. “So just about the time Orange County is really anxious and eager to get their full funding, the trends from the source of those fundings was going in the opposite direction,” he added.

Dennis Carpenter, Orange County’s lobbyist in Sacramento, said that after Proposition 13, the county was “standing down there like a plucked chicken holding the sack.”

“It’s easy to pick on the ‘supes’ because they’re very visible,” Carpenter said of his employers. “They’re right where rubber hits the road.” But he said he did not see any lack of effort on the part of the supervisors to deal with the health system’s problems.

“There’s just not a hell of a lot of leeway they have, a lot of stretch, that would permit them to do more at the county level,” Carpenter said.

Sen. Seymour said he is fighting a long-held attitude in Sacramento that Orange County is so affluent that it does not need any help. While that attitude is changing, he said, now there are “too many voices chasing too few dollars.”

TRAVAILS: A back injury forced a Santa Ana woman with no insurance to the economic edge. A28

Does Orange County Care?

Does Orange County, one of the wealthiest areas of California, turn a cold shoulder to the poor?

Some people say the county’s indigent have a tougher time than in other areas. The Times Orange County Edition today continues a four-part examination of the county’s commitment to the needs of its poorest citizens.

Sunday: Some advocates for the poor say the county scares away people who are truly in need with a unique program in which deputy district attorneys are stationed in welfare offices to do criminal background checks on certain welfare applicants. And the county also has one of the most rigorous workfare programs in the state.

Monday: Providing new, lower-cost housing has not been a priority for most local governments in Orange County. Despite state laws requiring that communities set aside 20% of redevelopment funds for affordable housing, some are just beginning to spend them for that.

Today: In the face of a serious crisis in health care, the county is locked into state-funding formulas for health services that were put in place 20 years ago--at a time when the county was run by politicians who spurned money from outside as “governmental interference.”

Wednesday: Wrestling foryears with one of the nation’s lowest charitable giving rates, Orange County now is gaining a reputation for selfish attitudes towards social welfare programs.

COMPARING HEALTH SERVICE LEVELS 1987-88 TOTAL HEALTH SERVICES

NET COUNTY PER CAPITA COST COUNTY APPROPRIATIONS PER CAPITA San Franisco $373.38 $158.53 Santa Clara 140.90 27.99 Alameda 129.14 46.82 Los Angeles 121.09 41.29 Riverside 101.19 26.04 Contra Costa 93.77 35.17 San Bernardino 63.83 20.42 Sacramento 46.13 18.78 San Diego 45.02 17.08 Orange 43.70 18.82

Comparison between counties is difficult because there is substantial variability in the reported data. Also, some counties, including Orange, San Diego and Sacramento, do not have county hospitals.

Source: The California Department of Health Services

MEDICAL TREVAILS: A back injury forced a Santa Ana woman with no insurance to the economic edge. A28