FORUM

Healthcare Safety Net Frays in Budget Fight

Graham Ramsay Ellen Rothman

Earlier this month, when I arrived at the free health clinic in South Los Angeles where I work, reporters from the L.A. Times were already there. Our lines had gotten longer, they had heard, and they wanted to be there early in the morning to see it. Sure enough, the line for appointments already stretched down the block 30 minutes before the clinic was set to open.

The reporters were doing a story on the California budget impasse. The staggering $15 billion budget deficit, the largest in California history, had stymied the legislature in its efforts to come to some consensus as to how to rein in the costs. Last spring, Governor Schwarzenegger signed into effect a 10 percent cut in Medicaid reimbursements in an effort to balance the budget. California already has one of the lowest reimbursement rates in the country, and providers railed against the cut. Finally, a federal district court ruled against it. But without a budget in place, we had not been reimbursed at all—neither at the original nor at the discounted rate.

Initially, the lack of budget met with some institutional resignation at my clinic—a common occurrence in the yearly ebb and flow of funding. The L.A. Times has reported that some clinics and service providers have been forced to draw on personal resources to continue providing services while others have closed their doors already or will in the next few weeks. At our last all-staff meeting, our CEO said that Medicaid owes us more than half a million dollars. “I couldn’t sleep last night,” he said, “but by 4 a.m., I figured out that we have enough savings and lines of credit available to make payroll until November. We’ll definitely have a budget by November. It’s never gone on that long.”

While Medicaid providers all over California are suffering from the budget impasse, South L.A. has been particularly affected, since it follows on the heels of the closure of Martin Luther King–Drew Medical Center last year. MLK was the local mainstay of healthcare for the uninsured and underinsured. All that remains is a skeleton operation of specialty outpatient services and basic primary care.

Even before the MLK closed its doors, South L.A. contended with sparse inpatient beds, insufficient primary care clinics, and grossly inadequate specialty services. Since the closure of MLK, the strain on the remaining healthcare providers has been dramatic. Our patients can wait six months or more for specialty appointments, MRIs, and mental health. In a community with fewer healthcare opportunities than average, our patients are sicker than average with among the highest rates of diabetes, obesity, and asthma in the country.

The spiraling economy has generated tremendous need for free services. People have lost their jobs, their homes, and their health insurance. In South L.A., the economy, the budget impasse, and the closure of Martin Luther King–Drew Medical Center have converged into the perfect storm for the healthcare safety net.
In my clinic, we feel the impact. Demand for services has soared over the past two months, and our waiting room is regularly filled to bursting. For weeks, we have been working as hard as we can, as fast as we can, and as long as we can, not to improve revenue or boost the productivity numbers that our administration was so focused on last spring, but to satisfy the intense need for basic medical services. We are in a race just to keep up with the front door.

All the local clinics are balancing the bills to protect payroll, and ours is no exception. Our medication dispensary is looking bare, and we are missing some of even the most basic antibiotics and blood pressure medications. Work on a new clinical building that was supposed to have opened last month is stalled indefinitely.

I assume that the California budget stalemate will be resolved shortly. Just this evening as I drove home, NPR reported that a deal could be reached in as soon as 10 days. As an eternal optimist, I trust that most of the clinics will weather this storm undeterred. But this financial threat unmasks a hidden crisis. Healthcare opportunities at all levels—primary, specialty, and inpatient care—have been dramatically compromised at the same time that patient demand is skyrocketing.

Last week, I saw a woman with a terrible kidney infection. She was febrile, dehydrated, and she told me that she had spent the whole night shaking and sweating in bed. By the time I saw her in clinic, she was on the verge of hospitalization. Next time, I told her, please don’t wait so long to come in. These infections can be dangerous. “But I did come earlier. They couldn’t see me because there were already too many patients,” she said.

—Ellen Rothman, HMS ’98,
practices at a community health center in Los Angeles.

Editor’s Note: Governor Schwarzenegger and the California legislature reached a budget agreement on Sept. 19, after this story was filed.

top