Urban health care in transition: challenges facing Los Angeles County.

The authors examine the Medicaid Section 1115 Demonstration Project currently underway in Los Angeles County. The waiver was designed as part of a response to a financial crisis the Los Angeles County Department of Health Services (LACDHS) faced in 1995. It provides financial relief to give the county time to restructure its system for serving the medically indigent population. Los Angeles County's goal is to reduce its traditional emphasis on emergency room and hospital care by building an integrated system of community-based primary, specialty, and public health care. This case study describes activities completed through the spring of 1997, approximately 1 year after the waiver was approved.     

Uncompensated care and hospital conversions in Florida.

Hospital conversions to for-profit ownership have prompted concern about continuing access to care for the poor or uninsured. This DataWatch presents an analysis of the rate of uncompensated care provided by Florida hospitals before and after converting to for-profit ownership. Uncompensated care declined greatly in the converting public hospitals, which had a significant commitment to uncompensated care before conversion. Among converting nonprofit hospitals, uncompensated care levels were low before conversion and did not change following conversion. The study suggests that policymakers should assess the risk entailed in a conversion by considering the hospital's historic mission and its current role in the community.     

Ambulatory care in the public sector: perinatal care in Los Angeles County

In planning its response to the increasing demand for perinatal services and the increasing rate of infant mortality and low-birthweight infants the Los Angeles County Department of Health Services faces a formidable set of tasks. Initiatives already in place are attempting to deal with some of the most pressing problems. However, increased services must be made available to enable the increasing number of women to access the system of care, and further outreach is necessary to encourage more women to begin prenatal care early in pregnancy. The county needs to increase the availability of perinatal care services, and these services must respond to the cultural and socioeconomic needs of pregnant women. Financial barriers to care must be eased, and the process of qualifying for Medi-Cal must be simplified. Additional private providers need to be brought into the system, and alternative care providers--such as birthing centers and delivery by midwives--should be expanded for low-risk pregnancies. The DHS has been forced to respond to staggering increases in demands for perinatal care services, and the population pressures and the widening socioeconomic gaps are unlikely to decrease in the near future. These same forces also require the DHS to respond to the increased demand for other health services. The DHS is being required to develop and maintain a complex program of health services without adequate financial resources. The solution to the perinatal care crisis in Los Angeles County and other localities with high rates of poverty cannot be found solely within local governments. It is unrealistic to expect that local taxation can support an increase of this magnitude in the need for care, and increased state and federal support is essential. Other nations, spending far less for health care, produce significantly better results: how much longer will it take this nation to recognize its responsibilities to its most vulnerable citizens?     

Providers of primary care to homeless women in Los Angeles County

Little is known about the access barriers homeless women face at the sites where they are most likely to receive primary health care. To investigate this issue, we administered a mail survey to administrators and clinicians at clinic sites that were actual or potential providers of primary health care to homeless women in Los Angeles County in 1997. The response rate was 65%. Ninety percent of the homeless women seen by responding sites were seen at only 34% of those sites (designated as "major providers"). Deficiencies were identified in several structural and process characteristics that enhance access to and quality of care for homeless women, including clinician training in care for homeless persons; formal screening for homeless status and associated risk factors; and on-site provision of comprehensive health services, including mental health, substance abuse, reproductive health, and ancillary services. Some, but not all, deficiencies were less severe at major providers. Our results suggest that, although providers of care to homeless women share challenges faced by many safety net providers, there are several policy interventions that could improve access to and quality of care for homeless women.     

Monitoring health in Los Angeles County

The University of California at Los Angeles School of Public Health, in collaboration with the Los Angeles County Department of Health Services, compiled data and developed a standardized format that displayed a comparison of mortality and morbidity data between Los Angeles County, the State of California, and the United States in 1960, 1970, and 1980 for 16 health topic areas. Findings noted both favorable and unfavorable health trends, as well as substantial data collection problems. In 1980, compared with the United States, the Los Angeles County rates for tuberculosis, gonorrhea, syphilis, and hepatitis B were as much as 45 to 128 percent higher, the homicide rate was more than double, and, for the population aged 65 years and over, the cirrhosis of the liver rate was more than 56 percent higher. The myocardial infarction rate was 58 percent lower in the population aged 18 to 64. Problems of inadequate data for many health indicators, lack of comparability in data, and conflicting information from different data sources were noted. These limitations with the data underscore the need to standardize data collection procedures and to extend the parameters on which information is collected. The approach represents a tool that could be used by many health departments to monitor their activities and set future goals.     

Trends in Air Pollution Outside Los Angeles County

Polyvinyl chloride polymers and formulations were pyrolyzed in a stream of air by gradually raising the temperature from ambient to approximately 600 C. The pyrolysis air stream was diluted with twice its volume of room air, and rats were exposed to it. Exposure to an air stream containing the pyrolyzed products of 1 to 2 gm of polyvinyl chloride polymer resulted in the death of 50% of the animals. Most deaths were due to carbon monoxide (CO), and carboxyhemoglobin (COHb) levels correlated well with the amount of plastic pyrolyzed. Little histological evidence of lung damage was evident. When oxygen (O₂) was added to the air stream to prevent deaths from CO, pulmonary edema and interstitial hemorrhage developed. The lungs of some animals exposed to high levels of pyrolysis products of vinyl chloride-vinyl acetate copolymer also showed focal edema and intra-alveolar hemorrhage. Polyvinyl chloride formulations, containing additives and inert materials, were in general less toxic per gram of sample pyrolyzed.     

Uncompensated care provided by emergency physicians in Florida emergency departments

Uncompensated emergency department (ED) visits can negatively affect patients, clinicians, and hospitals, particularly as overcrowding occurs. Florida provides a unique market to analyze uncompensated ED care due to the high percent of for-profit hospitals, which typically provide significantly less uncompensated care, coupled with the older population that is more likely to be insured through Medicare. A survey of 188 Florida hospital emergency physician groups was conducted to estimate the level of uncompensated care provided by each ED physician group in 1998. The response rate was 44 percent (eighty-three ED physician groups). All ED physician groups provided substantial uncompensated care regardless of hospital ownership type. Uncompensated care averaged 46.8 percent and ranged from 25.8 to 79.4 percent. A model was developed to predict the amount of uncompensated care using ED volume and payer mix. A rise in the percent of self-pay patients causes a disproportionate increase in uncompensated care, such that EDs with high levels of self-pay visits have markedly higher uncompensated care rates. The results suggest the need for a uniform reporting method of ED physician uncompensated care cost.     

Uncompensated hospital care for pregnancy and childbirth cases.

BACKGROUND: The large number of medically indigent patients in the United States is a major concern to policymakers and may be due to recent increases in the number of uninsured people. The purpose of this study was to identify the factors that affect the amount of unpaid hospital charges for services provided to pregnant women. METHODS: Individual and hospital data were collected on a representative set of 235 pregnancy and childbirth patients with unpaid hospital charges from 28 hospitals in the state of Indiana. RESULTS: Most of these patients did not have insurance coverage (63.8%), yet the majority were employed in the public or private sector (72.3%). Over half (55.5%) of the total uncompensated care amount for this group was from the $1000 to 2499 debt category. The median charge for these patients was $1468, of which the typical hospital was able to collect only 25.5%. CONCLUSIONS: The findings support the belief that any national effort to expand the availability of health insurance coverage to women through increased employment will not totally eliminate the uncompensated care problem. The findings also indicate that rural hospitals face the uncompensated care problem mainly because a significant portion of rural patients are without adequate health insurance coverage.     

Health insurance coverage among Chinese Americans in Los Angeles County.

OBJECTIVES: This paper examines the factors associated with health insurance coverage among Chinese Americans in Los Angeles County. METHODS: Data were obtained through interviews conducted in 1993 and 1994 with Chinese Americans (aged 18 through 65 years) residing in Los Angeles County. A multistage probability sample was used to select respondents. RESULTS: The final sample consisted of 1747 respondents, which represented an 82% response rate. Thirty-nine percent of the respondents in the survey were without health insurance at the time of the survey. CONCLUSIONS: Logistic regression analysis showed that marital status, length of residence in the United States, education, employment, and household income were associated with health insurance coverage among Chinese Americans.     

Lung cancer and air pollution in southcentral Los Angeles County.

An increased rate of lung cancer has been consistently observed from 1968-1972 among males in southcentral Los Angeles. This excess risk occurs across several social classes and occupational categories. No differential excess of oral cavity, pancreatic, laryngeal and bladder cancer was observed in the same area, lessening the possibility that regional variations in smoking habits accounted for the excess lung cancer. Air sampling has indicated an excess of certain polynuclear aromatic hydrocarbons (PAH) in southcentral Los Angeles. There was a correlation between the geographic distribution of lung cancer cases and the general location of industries which have emitted these PAH. A case-controlled study of smoking, occupational and residential history in the southcentral area is underway.