Robert A. Beltran, M.D., M.B.A.
Vice-Chair, Governing Board
California Latino Medical Association
reprinted from California Physician, California
Medical Association On-line Magazine
Our country faces a War on Health Care and a major battleground is
Los Angeles County. What happens here will foreshadow how our country
faces the commitment to provide health care for all.
On June 26, 2002, Los Angeles County’s new health director, Dr.
Thomas Garthwaite, released
his strategies for systemwide reform "
This is a thoughtful and comprehensive document, but it is flawed,
perhaps because it was put together do quickly. Dr. Garthwaite took
office just five months ago. And while, he and his staff have spent many
long and sleepless nights crafting it, the plan causes grave concern for
community advocates, health service researchers, and health policy
experts. They find flaws in the methodology, in the process, as well as
in its conclusions.
Some critics of the Garthwaite plan have said that he has used a
"chainsaw" instead of scalpel to make cuts and consolidations,
leaving many jagged edges. One of these jagged edges exposes sometimes
hidden inequalities in how our nation dispenses health care. In 1999,
Dr. Kevin Schulman, then of Georgetown University Medical Center,
documented how racial and gender bias distorts clinical decision-making.
This sent shock waves throughout the health system, reminding us of how
pervasive discrimination is in health. One-year prior, then-President
Clinton issued his Executive Order on "Eliminating Racial and
Ethnic Disparities in Health."
Our own Los Angeles County Department of Health Services documented
the same disparities two years ago in a report called, " The Health
of Angelenos." This report showed disparities in health status,
health risks, medical access, and other health determinants for our
multiethnic population in Los Angeles County.
And there is more evidence from private foundations and federal
agencies. The Institute of Medicine report on "Unequal Care",
released in March, discusses strategies on how to eliminate ethnic and
racial disparities in health. The work of the Commonwealth Fund
concentrates on two major areas related to improving health insurance
coverage and access, and improving the quality of health care services.
Many in the healthcare arena find it incongruous that Los Angeles
County can propose a major redesign of its health care system, yet
downplay strategies and programs to reduce bias in the delivery of
This is a major short fall in the proposed redesign and it must be
corrected if the Garthwaite plan is to be credible, successful, and
Furthermore, many stakeholders in our county healthcare system hope
politics as usual will not prevail; that Garthwaite will rethink his
plan and in doing so provide a more inclusive process that utilizes the
resources and intellectual capital of our multiethnic physicians and
their medical associations.
After all, it is this group of healthcare providers who have the
cultural/ linguistic and relationship expertise to communicate with the
impacted populations. They are the physicians, nurses, and other
professionals whose task it will be to mitigate the pain and suffering
that is inevitable when drastic change occurs.
Let there be no doubt. The scenario, which our Board of Supervisors
has constructed, will cause the crippling and collapse of our countywide
healthcare delivery system. The Hippocratic Oath has a primary tenet:
"First do no harm." It should be embraced by the supervisors.
Surely, combining the county crisis with the existing nurse shortage,
increased delays in emergency room care, physician group failures, and
the instability of healthcare finances is a recipe for terminal failure.
What can be done to avert this disaster and the consequences that
Our only salvation is the full force and leverage of community
participation and advocacy, which will allow for wiser and more
inclusive input. This, in combination with more flexible, efficient use
of state and federal monies, will avoid full system collapse.
Short of this, no medicine, no bureaucratic magic, no surgical
procedure can restore life to an already ailing healthcare system so
badly in need of coordination, integration, and collaboration of
services and healthcare providers both public and private.