Medi-cal man: as head of L.A. Care Health Plan, Los Angeles' largest public HMO, Howard Kahn has an insider's view of the county's increasingly dire health care crisis. (People).

As chief executive of L.A. Care Health Plan, Howard Kahn plays a critical role in the delivery of health care in Los Angeles County. The plan is the largest publicly funded health maintenance organization in the United States, serving 800,000 county Medi-Cal recipients. The plan largely provides care through subcontracts with Blue Cross of California and four other HMOs. It also competes with Health Net Inc. to serve this population, dominating with a 60 percent market share. Now Kahn is navigating his agency amid one of LA. County's worst financial crises, which has prompted a cutback of county health services. In response, the agency has issued millions of dollars in grants to safety net medical care providers.

Question: Is the county health department's financial position as dire as the supervisors say it is?

Answer: The county is honestly being squeezed by the failure of this country to come to grips with the issue of uninsured. The feds don't fund this massive number of people who don't have insurance. The state has its budget crisis. And it's worse here in Los Angeles because of the immigration issue and the heavy service-industry reliance.

Q: But didn't the feds and state just come through with a $250 million bailout?

A: By the time they got done negotiating, the county got another 18-month extension (of its bailout). So you go to sleep at night having temporarily solved the problem, but it's coming up again.

Q: What do you think will happen?

A: A couple of things. We have to admit to ourselves that we are just patching things up. You can continue to patch for a while. You can maybe get another waiver. But you have to change the whole picture of how the county gets paid by the feds. Right now the county is between a rock and a hard place. They get paid by the number of inpatient hospital days while they are being told to increase their outpatient visits. You have to change the fundamental rules and mechanisms so maybe they would get payments on a population basis or on the number of outpatient visits. But it is very complicated.

Q: In the meantime, what level of care are the poor in Los Angeles getting?

A: I am not sure that we can make very definitive statement about the quality of care. We are just starting to measure that. Clearly, though, they have none of the niceties. They have long waits. I am sure the physicians feel pressured to deliver care in a rapid-fire manner, and the nurses too.

Q: Do you agree with Supervisor Michael Antonovich that illegal immigration is a problem?

A: I don't like to say it's illegal immigration. I think of it as employment of undocumented people. People wouldn't come here if they couldn't get jobs. And they are supporting the economy. Eight-five percent of the families who are uninsured have people who are working in them.

Q: You serve a membership with a large percentage of non-English speakers.

A: We have right now 10 or 12 what we call threshold languages, meaning there are enough people speaking those languages that we have to be able to serve them. That includes Chinese, Romanian, Armenian, Tagalog, Vietnamese, Khmer and others.

Q: How do you assist these people?

A: If you walk into our member services area we have (bi-lingual) staff. All of our materials are translated into our threshold languages. We go out and train (medical) provider offices. We also provide formal translator training. And we also make telephonic translator service available.

Q: Many of these immigrants are not used to taking advantage of preventative care. How do you keep them out of emergency rooms?

A. It really depends on the culture. A lot of the people do come from where there is not a tradition of formal preventive services, so we encourage them. For example, we send out flyers reminding them to get checkups. They also are not accustomed to having access to those services just because of financial issues (which is not a problem within L.A. Care.)

Q: Are you concerned, as others are, about the level of profits among the private health care plans that serve Medi-Cal recipients?

A: Is there too much easy money to be made on these programs? It's a very tough question for me and it's a fair question and it's one we are looking into right now.

Q: How is that?

A: Our board has very specifically said to us, "We want you to look at the amount of money that is going to medical care, the amount of money that is going to administration and the amount of money that is going to profit." We are just in the process of looking at that.

Q: So what exactly is your relationship to your members and the plans?

A: We are a broker for them. We help people make a choice between the plans. We help them choose their physicians. We regulate the plans. We make sure the services are being provided on a timely basis. We hopefully add value.

Q: When you came on board the agency was rocked by troubles, including a critical audit of loose management practices that could have exposed the agency to fraud. How did you deal with that?

A: After I got here about three months we reorganized. We reduced the number of staff by about 10 out of 60, and reorganized some departments to make them more effective and efficient I think we are on solid footing right now.

Q: Aren't there simpler arrangements where a single plan in a county provides all the Medi-Cal managed care with state oversight?

A: L.A. is too complex and too large. Roughly a third of the Medi-Cal recipients in California are in L.A. County, so it's a very large plan to manage from a distance. The other side of it is that we are supportive of the (private community clinic) safety net providers who are out there. We require the plans to make a serious effort to contract with them. And when a member has not chosen a health care provider we can help steer them to the safety net providers.

Q: Is there a better approach for taking care of the poor, such as establishing a universal care system?

A: I believe very strongly in universal care, but sadly, I don't think most people feel the crunch enough yet to really get behind the more dramatic changes. It will take one of two things. The continuing escalation of cost so more people feel directly threatened, or an increasing number of people lacking coverage.

Q: There are several universal care bills in the Legislature, with Sen. Sheila Kuehl's bill calling for a single-payer state directed system. Do you support that approach?

A: I don't think that a centralized bureaucracy is necessarily the most efficient system. And the public gets nervous about government operating things, but is equally nervous with anybody but the government regulating things.

Q: What about pay or play, requiring businesses to either provide health coverage or pay into a state fund that would provide it?

A: It depends on how it is implemented. The fear behind it is it will hurt employment. We are talking about $140 per month per employee to buy insurance these days. If you add that onto a low-wage workers' cost the employer might revisit that employment deci-

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Howard Kahn

Title: Chief executive

Organization: L.A. Care Health Plan

Born: 1956, Los Angeles

Education: A.B., development studies, U.C. Berkeley; M.A., public policy, University of Minnesota 

Career Turning Point: Working as an emergency medical technician in college and seeing how badly Oakland's public health care was delivered.

Most Admired Person: His partially sighted father, who got family off welfare by running a hospital vending stand.

Hobbies: Snowboarding, bicycling, camping and backpacking 

Personal: Married, three boys