Executive Director, Bruce Iwasaki

County Health Cuts

February 6, 2003

The Los Angeles County Board of Supervisors held its mandated Beilenson Hearings Tuesday, receiving public comment on proposed cuts in the County health care system. Advocates from LAFLA and Neighborhood Legal Services were present, and Elena Ackel testified, in an effort to forestall or delay literally life threatening reductions in services.

Last fall the county closed eleven community based health clinics thus eliminating a half million patient visits a year. This week the Board voted to close Rancho Los Amigos National Rehabilitation Center, a highly regarded and unique rehabilitation facility. It also plans to close one hundred hospital beds at the flagship L.A. County-University of Southern California Medical Center, although even at the hearing, the county's health services director offered no specifics on which beds, for instance, surgical or intensive care, pediatric or general ward, would be phased out. The public notice announcing the hearing states that the County expects to save over $15 million per month from these reductions. The County faces a $210 million health budget shortfall, with even greater deficits projected in future years.

A System on the Brink

For the first several hours of testimony, the Board heard from witnesses who required wheel chairs, many of them patients or former patients, some of them staff and other supporters. It would be hard to conceive of a more powerful and poignant image of the human pain the proposed cuts will inflict as the witnesses implored the board to reconsider its planned cuts.

Our government benefits unit lawyers have been working for months on gathering declarations from medical personnel and patients and developing legal theories. The case is a difficult one and the stakes are immense. The patients treated by the County health care system are our clients: low-income, uninsured working families, who face pneumonia or diabetes, knife wounds or strokes, and have nowhere else to go to be healed.

L.A. County currently operates six hospitals, six comprehensive health centers, seventeen health centers and ninety-six public-private partnership clinics. It has over 2.5 million people without health insurance * one-fourth of the population, which is twice the national average. The County's trauma centers provide half of the areas's trauma services. The system sees 800,000 patients annually, three-fourths of whom lack health insurance, and has over 2.3 million patient visits a year. The County's hospitals have a 96% occupancy rate, compared to 65% in private hospitals.

LAFLA has long been involved in protecting the County health system. Twenty-two years ago then executive director Kathy Krause led a successful effort to save health care for undocumented immigrants. In my salad days I helped negotiate the Ability to Pay Plan that is still used by the County; my last major case at LAFLA stopped cuts in services planned in 1987.

Challenges of Reform Litigation

But the scope of the currently planned reductions dwarfs previous cuts. And that has made it extremely difficult to develop a winning strategy. Elena Ackel, Silvia Argueta, Yolanda Arias and Sandra Robinson have obtained statements from doctors and patients demonstrating that the existing system is already stretched so far that people are dying because of insufficient capacity in the system. And with colleagues from Neighborhood Legal Services and other public interest firms, they have developed creative theories for attacking the problem. Yet ultimately, the solution will involve other players, including the state and federal governments, contributing financial resources. And that is a very hard sell.

This Board of Supervisors is different from the one in the 1980s, which was dominated by elements hostile to our clients. This board majority clearly wishes to avoid these service reductions, but is up against the wall. They can credibly argue that some cuts are needed now to avoid a total collapse next year. So while in typical adversarial litigation one tries to depict one's opponent as wrong, incompetent, or craven, in my view, the only way to forge a compromise to this complex problem is if the various political forces can find enough common ground to be regarded as heroes. There needs to be some payoff for them to do what is otherwise against their financial or political interests.

In some respects, this case is an advanced example of the challenges that legal service firms have encountered in recent years: litigation, while an essential tool, is becoming ever more difficult as an instrument for reform. Systemic cases are harder to win now.

Why Impact Litigation is Harder Now

Part of this stems from past success, and part from the nature of litigation. In ancient times -- until the mid-1980s -- the main struggle for poverty law advocates was to establish certain rights: a fair hearing for welfare cutoffs, explicit consumer protections, the warranty of habitability, to name a few. Litigation is suited for clear-cut issues, black and white in the several meanings of the phrase, right and wrong, lawful or not. But when the issue is one of degree, courts have a difficult time. [The more nuanced line drawing is supposed to reflect the legislative process, with all of its irrationalities and especially, moneyed interests.] Gray issues -- at least for broader, impact cases -- are hard to win in court where the judge must decide that someone loses and someone wins.

While the success of legal aid advocates had been to establish certain fundamental rights, today the battle involves the details that give meaning to those rights. For example, making bureaucracies act more promptly, treat our clients' cases with more regard for individual circumstance, obtain child support, provide job training opportunities, or relieve and support all incompetent, poor, indigent persons. While individual cases can be viewed in a win/lose dimension, efforts to reform an entire system are not so easily judged: Can one say an entire system -- especially one run by the largest state or largest county in the nation -- either succeeds or fails entirely?

Does this mean we give up on litigation? Absolutely not. It does mean we have to be good at even more things. Not only outstanding at research, writing, discovery, and oral advocacy, but excellent at exploiting legislative opportunities, developing smart media strategies, and using service cases to create systemic impact.

I believe we improve the odds at having greater impact by effectively telling client stories and creatively capturing and publicizing our successful outcomes. Our focus must not be the process of what we do. The focus must be external: on the changes in clients' lives. For example: aggregate dollars in back rent waived, new employment salary earned, or child support orders enforced. Not only will these measures accrue to the benefit of LAFLA, they will influence the policy debates involving programs for our clients.

In the meantime, we are struggling for the most potent message in the health care cuts case. We must convey that the County health care system affects everyone, not only the poor, and that a weakness in one element causes problems elsewhere. And we need to offer a credible alternative model that addresses extremely complex financial and medical care policies. And we have to act fast.

BGI