The county is trying to make the system more efficient, reduce wait times and ensure that those who don't need more advanced care don't overburden the system, said Mitch Katz, head of the L.A. County Department of Health Services. County officials risk losing newly insured patients, along with government funding, if they can't find ways to reduce the bottleneck.
One focus is using technology to improve communication and better screen patients. A pilot program, for example, is allowing primary care doctors at community and public clinics to quickly transmit patients' medical information via computer to a public health specialist for a consultation.
The electronic consults are streamlining referrals and helping clinic doctors make better treatment choices, said Louise McCarthy, executive director of the Community Clinic Assn. of Los Angeles County.
During an August visit to T.H.E. Clinic, Lawrence saw nurse practitioner Sandeep Lehil for the first time. He told her he was controlling his diabetes with medication and a modified diet. But his vision wasn't getting any better.
"My eyes are really bad," he told Lehil. "I can barely see."
Lawrence's medical record showed that he wouldn't be seeing an ophthalmologist for many months.
"That's a long time to live with blurry vision," Lehil said.
"By that time, I'll be blind maybe," Lawrence responded.
Lawrence, who has a soft voice, an accent and a lanky frame, arrived in the U.S. nearly 20 years ago to pick apples, and overstayed his visa. He can't work or drive, and he relies on others to cook meals to avoid burning himself. His immigration status prevents him from getting health insurance or unemployment benefits. He lives with a friend, spending most days listening to a television he can barely see. When the phone rings, he lifts it almost to his nose to see who is calling.
In mid-October, Lawrence was back at the clinic and saw a different, fill-in doctor who knew nothing about his situation, nor when his surgery would be scheduled. "You haven't received any notice?" asked physician David Hwang. "No, not yet," Lawrence answered, adding that he checks his mailbox every day.
De Leon, the referral clerk, later gave Lawrence unwelcome news: The wait to see an ophthalmologist at the county's Harbor-UCLA Medical Center was still about a year. She said she was trying to get him an appointment elsewhere sooner.
Weeks later, Lawrence took matters into his own hands. With the help of a friend, he took three buses to reach the emergency room at Los Angeles County/USC Medical Center northeast of downtown. He waited several hours but finally saw an emergency room physician, who managed to get him an appointment the next day with an eye doctor.
"You have to do what you have to do," Lawrence said.
At the medical center's specialty clinic, ophthalmologist Simon Bababeygy told Lawrence his cataracts probably were caused by his diabetes, high blood pressure and high cholesterol.
He described the surgery he would perform, on one eye at a time. And he spoke the words Lawrence had been waiting for: He should be seeing much more clearly by the end of the year.
Preparing for the surgery, doctors got an abnormal result on a heart test. Now, Lawrence has to wait to see a county cardiologist before going back to Bababeygy to schedule the eye operation. He has no idea how long that could take.
"Every time, it's something else," he said. "My eyes are getting worse. And now it's my heart."
Times staff writer Anna Gorman reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC's Annenberg School of Journalism.