摘要：The Los Angeles County University of Southern California Medical Center will open soon, replacing the county’s current 74-year-old facility with a modern, although smaller, facility. Los Angeles County has provided hospital care to the indigent since 1858, during which time, the operation of public hospitals has shifted from a state-mandated welfare responsibility to a preeminent part of the county’s public health mission. As this shift occurred, the financing of Los Angeles County hospitals changed from primarily county support to state and federal government sources, particularly Medicaid. The success of the new hospital will depend on whether government leaders at all levels provide the reforms needed to help the county and its partners stabilize its funding base. LOS ANGELES COUNTY hospitals are among the nation’s notable public health achievements. More than 150 years after it first provided hospital care for the indigent, Los Angeles County is about to open a new hospital, replacing its 74-year-old and earthquake-damaged Los Angeles County University of Southern California Medical Center (LAC–USCMC) with a modern, although smaller, facility. The current LAC–USCMC hospital is among the largest in the state and the centerpiece for health care in Southern California. It operates a busy trauma center and an array of primary and specialty clinics and is affiliated with the University of Southern California, which has operated a medical school there since 1885. 1 Annually, the hospital receives nearly 800000 emergency and outpatient visits and more than 46000 inpatient admissions. LAC–USCMC patients, like other Los Angeles County Department of Health Services (DHS) patients, are primarily poor and uninsured. More than three quarters are living below the federal poverty level, more than 70% are Latino, two thirds are uninsured, and almost two thirds were born outside of the United States. 2 The hospital’s public role goes beyond serving as a safety net for the poor. It has trained thousands of physicians, nurses, and other health professionals. It provides one third of all trauma care in the county and has been the site of many significant scientific contributions in clinical medicine and surgery. 3 The hospital has even been used as a visual backdrop for a popular daytime television drama. Yet, from its earliest days, it has been in the forefront of real-life controversy and political drama, as the County of Los Angeles has struggled to keep its health care system afloat. 4 The Los Angeles County story is more than the history of a single hospital; it is indeed a chronicle of a community’s complex and contentious struggle to shoulder the burden of health care for its indigent and uninsured population. Other communities have similarly struggled to protect their public health and hospital systems, which reflect the historical role of public hospitals in confronting local problems associated with poverty, immigration, and lack of access to health care. 5 The Los Angeles County hospital system was built under changing and sometimes conflicting social policies governing both public health and welfare for the poor. Although public health laws contributed to the evolution of the DHS, the Los Angeles County hospital emerged largely from the county’s responsibility to provide for the health and welfare of its indigent population. The Pauper Act of 1855, adopted shortly after California achieved statehood, evolved to become Section 17000 of the state Welfare and Institutions Code. Passed in 1935, Section 17000 delegated the health and welfare responsibilities of the indigent to the counties. 6 Counties appropriated a portion of their tax base to health care, and by 1966, 66 public hospitals were distributed across all but 9 of the 58 counties. 7 Los Angeles County’s health care system began in 1856, when 6 Daughters of Charity of St Vincent DePaul traveled to Los Angeles from Emmitsburg, Md, to open a hospital. 8 Their 8-bed facility later became St Vincent’s Hospital, from which the county purchased medical services for indigent patients at a cost of $1.22 a day. It was not long before the cost of caring for the indigent became an issue in Los Angeles, and in 1878, the county opened its own 100-bed Los Angeles County Hospital and Poor Farm as a way of lowering costs to the county. 9
