Raise Taxes or Shut
Down
Washington Post
By Rene Sanchez/Washington Post Staff
Writer
December 31, 2002
LOS ANGELES -- David Altman, the chief medical officer of the
largest trauma center in this sprawling county, scoffed when he
first heard the idea. Raise property taxes to stave off the
financial collapse of local public health care? Fat chance that
will ever pass.
Or so he thought.
In their desperation to keep hospitals
open, voters herelast month did just that, approving new
property taxes for the first time in a generation. The county
hasn't had a property tax referendum on the ballot since the
statewide, landmark anti-tax Proposition 13 in 1978, but this
year's passed overwhelmingly, with 73 percent
of the vote.
At the time, the $170 million the new tax is projected to
raise annually was hailed as a godsend for the county's ailing
health care system. And it still might be. But already, there is
more bad news.
To close a budget deficit expected to reach $35 billion, Gov.
Gray Davis (D) is proposing to restrict benefits and eligibility
in the state's Medicaid program. That move could affect more than
300,000 people and inundate hospitals like the one Altman
supervises near downtown Los Angeles with many more patients too
poor to pay for treatment they badly need.
"The system keeps getting tremendously strained," he said. "It
is extraordinarily fragile right now."
Some officials are calling the last-resort decision Los
Angeles County made to rush a property tax increase onto its
ballot a harbinger of the predicament soon to confront states and
counties nationwide.
The measure's success, they add, may tell another important
story: that health care is returning to the top of voter
concerns.
The struggles of Los Angeles County, where more than 2.5
million residents have no medical insurance, are one sign among
many across the country of how growing economic hardships in
states are creating new crises in health care.
Last month, the nation's governors said that states are facing
their worst financial problems since World War II. Many have been
able to delay difficult budget choices over the past year either
by freezing spending or raiding reserve funds. But now, with
those options exhausted, they face an unwelcome reckoning: raise
taxes or curtail aid to millions of indigent patients.
Many states say health care costs are their fastest-rising
expense, but fear that cutting medical services when demand for
aid is increasing and public health care networks are under
growing financial pressure will only make matters worse. A
national group of public hospitals says that half of its members
are now operating in debt, up from one-third a year ago.
That voters are worried is evident in Arizona, where a ballot
measure to double the state tax on cigarettes to $1.18 a pack and
to use the $150 million that step is projected to raise strictly
for local trauma centers in dire financial straits passed 2 to 1
last month.
"The situation has changed in the last year or so," said Chris
Burch, executive director of the National Association of Public
Hospitals and Health Systems. "States are in very precarious
financial situations. People are beginning to feel a lot more
vulnerability about health care."
With public health care consuming so much of state budgets,
officials around the country are looking for cuts as they try to
balance their books.
In Washington state, Gov. Gary Locke (D), who is trying to
close a budget deficit of nearly $2 billion without raising
taxes, has proposed suspending a voter initiative passed last
year that requires tobacco tax revenue to be spent on expanding
health insurance for low-income residents. Locke's proposal could
eliminate coverage for tens of thousands of people.
Massachusetts is confronting its budget deficit by limiting
medical benefits for thousands of poor residents and ending all
of the coverage others have. As many as 50,000 people will lose
eligibility for the state's Medicaid program early next year.
Thomas Finneran, the speaker of the Massachusetts House, warned
recently that soaring Medicaid costs could soon "bankrupt" the
state.
In Michigan, officials say some clinics and hospitals that
serve the poor are being forced to limit hours and offer only
core services because of the state's financial troubles.
Michigan's newly elected governor, Jennifer Granholm (D), who
faces a deficit in excess of $1.5 billion when she takes office
in January, just convened a summit on Medicaid funding
problems.
"The economic realities of health care are as bad as ever,"
said Sherry Mirasola, a spokeswoman for the Michigan Health and
Hospital Association. "Many of our members are trying to hang on,
but things are tenuous at best."
The sluggish economy is continuing to hit many states with a
double whammy. With tax revenue dwindling, they are having a
harder time funding health care programs. And with unemployment
rising, the ranks of the uninsured are growing -- and that is
putting even more burdens on Medicaid budgets, which are financed
by the federal government and states.
Governors are pleading for federal help, and here and
elsewhere Bush administration officials are in complex
negotiations to try to increase or better organize Medicaid
funding. But the administration is also warning states that it
does not have much money to spare because of the federal budget
deficit and new spending demands for homeland security.
"States are just beginning to face this issue, and there's no
telling yet how it's going to play out next year," said Richard
Cauchi, a health care analyst for the National Conference of
State Legislatures. "But we are certainly seeing real crises that
will have to be dealt with."
The scope of the problems facing Los Angeles is in some ways
unique because of the sheer size of the county's far-flung public
health care network and its huge, growing population of poor
immigrants. Its percentage of uninsured residents is twice the
national average. About three-fourths of the 800,000 patients the
county serves each year lack insurance. But the roots of its
fiscal problems are the same as those in public health systems
nationwide.
The county is saddled with budget deficits in health care that
could soon top $500 million. Earlier this year, it closed 11
medical clinics, converted one of its hospitals to an outpatient
facility and reduced beds and services at another.
But even those painful cuts were not enough. Two other large
public hospitals began bracing for closure because of money
shortages. So county officials decided to take a political gamble
and ask residents to raise property taxes, a step that has been
taboo ever since the anti-tax rebellion known as Proposition 13
caught fire here in the 1970s.
"We would have avoided this like the plague if we had any
other choice," said Los Angeles County Supervisor Zev
Yaroslavsky.
The measure proposed raising taxes by about $43 a year on an
average-sized residential lot in Los Angeles County. It needed a
two-thirds majority to pass, and anti-tax groups were so
confident that it was doomed they barely lifted a finger to
campaign against it.
But county leaders waged a frantic campaign to persuade voters
that the looming demise of the health care system would harm the
rich as much as the poor. One television ad promoting the tax
increase featured a paramedic in an ambulance with a critically
injured child receiving word from an emergency dispatcher that
the nearest trauma center was no longer open and that the victim
had to be taken to a distant hospital. "It's too far," the
paramedic said.
The tax increase received landslide support even in
conservative enclaves around Los Angeles County. It will keep the
two hospitals that had been targeted for closure open -- for now.
But county leaders may have only bought more time. They said they
still need federal help. And they are worried about the massive
cuts California may soon make in its health care budget.
Still, Yaroslavksy said he has reason to hope.
"I never thought I'd live to see the day when voters here
would increase their property taxes for anything," he said. "This
should be a wake-up call for political figures and policymakers
around the country. Health care is back on the public's radar
screen, and anxiety about it is definitely rising."
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