Health Care at the Brink of Doom 

Alameda County Medical Center is one vote away from virtually ceasing to exist, and with it, eliminating the poor's safety net.

If Alameda County voters don't vote for Measure A on March 2, people will die. It's as simple as that. Tax yourselves and save lives.

This is the only thing on your ballot that matters. Forget the asinine vanity politics of Jerry Brown's "strong mayor" initiative. And the world is hardly going to end if Berkeley residents can't have instant runoff voting. But Measure A, the half-cent sales tax to save the Alameda County Medical Center -- the county's system of public hospitals and clinics -- could be the poor's last chance to save their only medical safety net.

If it fails, accident victims could die in the back of ambulances en route to a Contra Costa County trauma center. Having a heart attack, but don't have insurance? Sorry, county officials are talking about closing Highland Hospital's telemetry ward. You know the severely mentally ill people living in their own filth in downtown Oakland? Get ready to see a lot more of them, because the John George psychiatric hospital may be forced to eliminate 21 beds. Highland's outpatient cancer clinic could close as well, and uninsured cancer patients could lose their chemotherapy treatments.

Of course, the medical center, which serves 125,000 mostly uninsured patients annually, has been broke for more than a year. Officials currently put their budget deficit at $71 million, although that number tends to double every few months. You already know why: Health-care costs are skyrocketing; federal and state reimbursements are drying up; and more people are losing insurance every month. You might also know that the medical center's leaders should have seen this coming two years ago, but sat on their asses until it was far too late. Alameda County's famously liberal health-care voters, who already pay countless parcel taxes for schools and fire protection, can be forgiven for wondering why they should trust these people with their money.

Although everyone from union members to county supervisors is rallying around Measure A, a carcinogenic anger lurks beneath their united front. For years health-care advocates, medical professionals, and hospital union workers have quietly complained that county officials, who have a legal and moral responsibility to keep the medical center solvent, have conspired to enrich private hospitals at the expense of the only public provider for the indigent and uninsured.

None of them will talk about it openly for fear that such gripes will keep the public from approving the sales tax, which requires a nearly impossible two-thirds majority to pass. But critics claim that Dave Kears, the director of the Alameda County Health Care Services Agency, has set in place a complex health maintenance organization that has bled Highland dry. Passions run so high that many of these people speak of Kears with open loathing.

In 1995, in response to a state mandate, Kears created the Alameda Alliance for Health, a public HMO designed to give Medi-Cal recipients a choice of medical providers, including private hospitals such as Alta Bates, Summit, and Children's Hospital. The idea was that the poor would finally get quality care as hospitals competed for Medi-Cal reimbursements -- the only guaranteed revenue source left in the state's health-care system.

But unlike the private sector, county hospitals are required to admit indigent people who aren't eligible for Medi-Cal, and these patients drain their resources and overcrowd their facilities. As a result, these hospitals can't possibly compete with their private counterparts. Other counties have made sure a sizable percentage of Medi-Cal patients stay in their public hospitals, but Alameda County has sat and watched as the Medi-Cal money it depends on flows into the private sector.

Two years ago, medical center employees drafted a memo to the Alameda Alliance for Health spelling out this predicament. Two years after the public HMO was set up, county Medi-Cal revenue had plunged from $63 million to just under $44 million, dealing the center a crippling financial blow.

Public HMOs in Santa Clara and Contra Costa counties keep enough Medi-Cal patients in their public hospitals to keep them solvent, the memo argued, but the alliance made little if any such effort. In 2001, for example, just 9 percent of the days spent in hospitals by alliance members were provided by the medical center. Officials at Santa Clara's county HMO, meanwhile, say they funnel between 50 and 60 percent of its patients' paid hospital days into its county hospitals. "Without increased local support from both the county and the alliance," the memo stated, "some significant programs and services will have to be either eliminated or reduced."

Kears has heard this argument for almost a decade now. In fact, critics have so incessantly condemned him and his brainchild that he becomes tangibly irritated whenever the subject comes up. The problem, he claims, is that Alameda County suffers from a glut of quality care. Children comprise the largest Medi-Cal patient group by far, and while Contra Costa and Santa Clara counties provide pediatric care at their county hospitals, Alameda County is lucky enough to have Children's Hospital, perhaps the finest pediatric facility on the West Coast. Because Highland's pediatric services have become so underutilized, they have atrophied to Eastern European standards. The only way to get pediatric Medi-Cal dollars back into the system, Kears claims, would be to deny children access to Children's and send them to Highland instead -- and that would be nothing short of barbaric. "You have a facility that's excellent at what they do, Children's," he says. "They do it without any direct subsidy from the county. They're located where the need is the greatest. ... It's unimaginable for us to suggest doing anything that would put them at risk."

None of Kears' local critics went on record for this story, but Beth Capell, a Sacramento health-care lobbyist who is familiar with Alameda County's public health infrastructure, regards his reasoning with contempt. If the medical center doesn't have adequate pediatric facilities, she says, it's because guys like Kears (who used to be the center's CEO) made a conscious decision not to invest in them. The only lucrative Medi-Cal market is pediatrics, and not trying to capture this market is fiscally irresponsible. "Pediatrics and obstetrics are the two patient populations where we have damn near universal coverage," she says. "Shedding these populations by not building the capacity to care for them sheds paying customers." Capell even claims that Kears secretly wants the county hospitals to die off: "He's always been committed to killing Highland," she says.

Whenever the medical center's stakeholders aren't fighting for their lives, this is exactly the sort of vitriol you'll hear about Dave Kears. And he gives it right back if you push him too far. Such is the state of morale in Alameda County's public health infrastructure. But don't see it as a symptom of mismanagement or ineptitude. See it as what happens when people know that without your help on March 2, the county's hospitals will, for all intents and purposes, cease to exist. They know the poor will suffer, and that no one will notice.

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