My name is Andy Leeka.  I am President and CEO of Good Samaritan Hospital in downtown Los Angeles.  And I think I have a bird’s-eye view of what is taking place in the inner city and the challenges we face through three issues.

Number one, the underfunding.  There are six and a half million people that don’t have insurance in the state of California.  It’s an over $12 billion problem.  Because of that underfunding, of getting reimbursed less than your cost with some payers or getting reimbursed nothing at all, it puts excessive strain on the hospital to try to do any type of cost-shifting to insurance companies which ultimately comes down to citizens or payers to pay for that unfunded care.  And it is, in fact, an unfunded mandate because it isn’t an option whether we treat people—ethically, much less legally—as they come through our emergency department. 

Secondly, in terms of an inequitable distribution of funding, over the years, what has taken place basically since 1991 is there is a system that was developed at that point in time in terms of getting funding to hospitals.  Over time, that system is out of date.  I mean, it really is out of date.  There is really no more cost shifting that hospitals can do to other payers.  Because of that, there is an inequitable reimbursement that may take place with the provider community between one hospital and another. 

And the third aspect, I’d say, is in terms of everybody stepping up and doing their share.  And that’s in terms of hospitals as providers.  It’s in terms of physicians, in terms of insurance companies, in terms of employers, and ultimately in terms of individual citizens paying their fair share.  I know that’s being worked on right now, but from a hospital’s perspective, you know, that’s the given-and-take behind this to make the system as a whole work rather than one particular component being penalized.  Ultimately, it’s starting to tip out of balance and may be going out of business.  And that’s what we’ve seen with the closure of emergency departments, with the closure of hospitals over the past decade or so, that that imbalance in fact can have a domino effect on the remaining provider community.