Health policy making through operative actions: a case study of provider capacity reduction in a public safety-net...

This article describes and assesses the implications of policy decisions affecting health provider capacity in the Los Angeles County municipal safety-net health system from 1980 to 2000. Although never articulated in law or a county ordinance, the county pursued a sustained and discernable policy of cost reductions that affected capacity at King/Drew Medical Center from 1980 to 2000 without the input of beneficiaries or their advocates. Year after year, the county reduced personnel, supplies, and available beds either by reducing formal budgets or through operative actions of facility administrators that prevented the implementation of formally approved expenditures. This policy appears to have undermined the hospital system's mission of providing health services to at-risk populations with nowhere else to go. Decision making during the two decades under study revealed a decision-making pattern that challenged traditional models of policy decision making.