Health care.

Los Angeles County faces the irony of having one of the nation's most financially strapped public health are systems, and one of its most flourishing private managed care industries.

The county is home to both the largest population, and largest per capita percentage of uninsured residents of any metropolitan area in the United States. Care for these people, many of whom are the working poor, pushed the system to the verge of collapse two years ago.

It was then, with thousands of hospital worker layoffs imminent, and even the closure of mainstay Los Angeles County-USC Medical Center envisioned, that a federal bailout forced L.A. to make some fundamental changes.

Thanks to the bailout, and under the direction of Department of Health Services Director Mark Finucane, the county is knee-deep in a five-year effort to shift manpower and financial resources from in-patient hospital care to outpatient services. Following the lead of managed care, the county is placing increased emphasis on illness prevention, and on getting patients who are sick into the right kind of facility.

The grand experiment, coupled with a state effort to shift Medi-Cal patients into managed care programs, hold perhaps the best hope for L.A.'s public health. The state effort, known as the Two Plan Model, established a nonprofit HMO called L.A. Care to compete with a private HMO - Foundation Health - for Medi-Cal patients. L.A. Care began enrolling members in April, while Foundation is expected to begin enrollments sometime in July.

Meanwhile, managed care in L.A. generally is riding high: Health Systems International and Foundation Health recently merged to create HMO behemoth Foundation Health Systems in Woodland Hills; Prudential HealthCare is locating a 1,400-employee regional customer service center in downtown L.A., the biggest influx of new jobs in the city in a decade; and all L.A. City HMOs will benefit from a change in the business license tax now being negotiated that will place managed care companies in a lower tax bracket.

As one of L.A.'s biggest lobbyists, the private health care industry is emerging as one of the best-organized industries in town. Indeed, the coordination among the five largest L.A.-based HMOs was evident in staring down the city over the tax issue could serve them well on future issues, perhaps on contracting for indigent patient care, or lobbying for future incentives to remain L.A.based.

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