Hard Choices in Health

Public health officials of Alameda County, weary of the deceptive ways that health care for the poor is rationed, are developing a program of health- care priorities to make sure that the best use is made of the limited dollars. It is a project of national significance.

Oregon already has established priorities for spending its public health-care dollars, guaranteeing prenatal care, for example, but denying organ transplants. That concept has inspired the reform effort in Alameda County. Neither Oregon nor Alameda public health officers favor the denial of services, but they have been given no choice by those who control the money, including the taxpayers.

“We have undertaken the study, not because I don’t think more money can be spent on health care, but because I don’t think we are going to get it,” David J. Kears, director of the Alameda Health Care Services Agency, explained to us. The county includes Oakland and Berkeley but extends east and south to fast-developing and more affluent areas as well. The agency’s responsibilities include public-health services, mental-health, alcohol and drug-abuse programs, and the operation of two hospitals.

At the heart of the funding crisis affecting all California counties is declining state and federal money and constitutional limits on other revenue. The problem will be gravely worsened in the next budget year if Gov. George Deukmejian succeeds in his plans to reduce funding for medically indigent adults and to use new tobacco tax revenues to supplant rather than supplement health-care tax funds.

But, as Kears and other public health officials frankly acknowledge, rationing of health care for the poor already is in effect. “We never say no, we just say get in line at a hospital or clinic,” he commented. “That is deceptive. We know that after 10 hours of waiting, some will never get the service they need. It is like a lottery. You can’t make everyone a winner.”

So Kears has set up task forces of professionals to look at the major health-care areas served by the county. They will develop priorities of care and the cost of delivering that care. Their conclusions are scheduled to go to the Alameda County Board of Supervisors at the end of June. Then the board, through hearings, will have an opportunity to implement a plan that makes clear what care the county can now provide,

“Whatever we do, we need to define what is adequate care and what we are willing to fund,” Kears said. “If this process gets through to the state and federal level--the real solution can’t be done by Alameda County--it must be done in Sacramento and Washington--perhaps we can embarrass them into providing leadership.”

That, in itself, is a welcome contribution. And, if nothing else, the report will expose to the bright light of day the realities of the tattered safety net of public health in the richest state of the richest nation in the world.