Before health reform, Los Angeles County clinics served people who had no other options—sick patients with no health insurance.

But as 2014 approached, county officials realized that many of their clients would become insured and choose other health care. If they opted out, the entire system –with 19,000 employees and a $4 billion budget would face near collapse.

Thirty years ago, Colleen Hollman would have probably gone anywhere but a county clinic if she had a choice. When her kids got sick she’d spend entire days with them in an LA County clinic waiting room— a formidable challenge with healthy children and much tougher with sick ones.

“It was bad. There would be so many people waiting there was nowhere to sit,” she said.

Now after having been insured most of her life, Hollman is back in the county system. But this time, she’s not complaining.

County clinics are a lot more user-friendly now, and health care is more accessible.

The man behind the transformation is Mitchell Katz, a 55-year old family physician who rides his bike around town and still sees patients once a week at East LA’s Roybal Comprehensive Health Center. As director of the San Francisco Department of Public Health, Katz created the Healthy San Francisco program to provide health care to the city’s uninsured.

In 2011, Los Angeles County officials recruited Katz to become their director of the county Health Services Department and to make sure that its health system could survive as it implemented the Affordable Care Act. Katz has focused on improving primary care, and on cutting the year-long waits some patients endured to see specialty care physicians.

Since October, Hollman has had a chance to get an up close look the system. She was chatting with her sister-in-law when the worst pain she’d ever experienced shot through her chest.

“It felt like someone was stabbing me with a knife,” she recalled. “There was nothing you could do to ease the pain.

Hollman was having a heart attack, and doctors at Harbor UCLA opened her blocked arteries with stents and admitted her to the hospital

“They talked me through the whole process. I woke up and said I’m so happy to be alive.”

County doctors are known for their skills in handling emergencies, but Hollman said she’s been equally satisfied with the follow-up care she gets at the Bellflower Clinic.

She has Medi-Cal, and theoretically could take her business elsewhere, but she’s chosen to stick with the county.

She has her own physician at the county’s Bellflower clinic, and she’s had no trouble getting medications, blood tests, or appointments with her cardiologist. Not only is her experience at the county clinic better than it was in the past, it’s also better than that of some Medi-Cal recipients who belong to HMOs and have battled with their insurers to allow them to see specialists, or whose specialty care networks are so narrow that they’ve been forced to travel miles for care.

“It’s better than what it used to be. It’s more caring. If a doctor is behind, a nurse will come out and tell us. They try not to have so many people waiting.”

At the Insure the Uninsured Project, a Santa Monica-based think tank, Lucien Wulsin was more sweeping in his assessment.

“It’s a tectonic shift,” Wulsin said of the county’s effort to change the county health department focus from emergency to more patient-centered primary care.

Katz’ task in leading the charge was formidable, and not just because of the county’s sheer size. It’s bigger than the states of Rhode Island and Delaware combined, with 19 health centers and four hospitals.

Two previous medical insurance expansions were huge failures for the county, Katz noted. Senior citizens fled the system in the late 1960’s when they received Medicare, followed by mothers and babies who gained Medi-Cal coverage in the 1980’s, Katz said.

“History would tell you that when people get Medicaid, they choose to go elsewhere,” Katz said. This time, he said, everyone from the Board of Supervisors to front line staff understood the stakes.

“If we failed, the system would shrink, people would lose their jobs and there wouldn’t be enough dollars to care for people who remained uninsured,” Katz said. “You had motivation at every level.”

Katz counts his most important accomplishment as providing a family doctor for nearly a half million patients with chronic illnesses who need ongoing care. It’s a move that aligns the county system with health reform, which emphasizes primary care, and in doing so makes healthcare much more accessible to county patients. He adds that the system still doesn’t have the wherewithal to provide such care for each of its some 700 thousand patients.

Overall, he argues that the ACA is working for LA County, and he’s done what he was hired to do. He noted in a recent report that more Medi-Cal managed care patients – who ostensibly have health care choices—opted into the county system than opted out in 2014. But only about a third of those enrollees actually chose county facilities, or decided to stick with county healthcare after receiving coverage. Sixty-four percent were automatically assigned to county clinics when they failed to choose a healthcare provider.

Nonetheless, even former critics are giving the county fairly good reviews on its turnaround.

“I do have to give the county credit for listening to stakeholders and really taking action to improve things,” said Nina Vaccaro who heads the Southside Coalition of Community Health Centers, which represents eight South Los Angeles safety net clinics.

Those clinics depended on the county to provide specialty care for their patients, and they were anything but patient-friendly, Vaccaro said.

“I do believe they’ve changed,” Vaccaro said, “and I didn’t believe I’d say that.”

One of the main reasons South LA clinics banded together was to try to trim wait times of a year and longer to be seen by county specialists

“Our primary care providers were saying, ‘our patients are losing limbs unnecessarily.’ We have lots of patients with chronic illnesses,” Vaccaro said. “The longer they wait to access a specialist, the chances are the quality of their health will decline.”

Now, months long waits for specialty care are history, said Paul Giboney, a general care practitioner and Director of Specialty Care for the County of Los Angeles Department of Health Services. Giboney oversees a new online system called eConsult, a web portal that allows family doctors to arrange specialty care for their patients by talking directly to specialists.

Doctors no longer write referrals and wait for approvals by a third party.

“A doctor jumps on the system and is able to ask a specialist directly about the case,” he explained. “They can attach a photo of a rash or a lab result or EKG, and pose a question to the specialist…there’s a back and forth conversation.”

In 30 percent of cases, a primary care doc can treat his patients with a specialist’s online guidance, and the patient doesn’t need to see the specialty care doc at all, Giboney said. But if specialty care is essential immediately, patients get in right away.

Giboney argued that it’s impossible to compare wait times before and after eConsult because now, if someone needs to be seen right away, they are. If patients can wait, they do, but he said that waits are measured in weeks, not months.

San Francisco, Orange and San Diego counties are using some version of the system, and Giboney said he’s had recent inquiries from people in Connecticut and Chicago who are interested in something similar.

Nearly all specialties have been added to the system.

While access to county health care has improved, challenges remain, Vaccaro said. Non-English speakers still have a tough time making their way through the system, and lack of transportation is another big reason patients fall through the cracks.

Katz has ambitious plans: he’d like to open 10,000 new housing units for homeless patients in the next five years, funded by partnerships with the county. Five hundred homeless patients were placed in housing last year. Katz wants to cut wait times for elective surgeries, decrease hospital readmissions and improve poor health outcomes in South Los Angeles, where he said he’s sending health promoters into the community, rather than waiting for patients to come to clinics for preventive and other needed care.

“The obvious answer is you need to go where the people are,” Katz said.

Note. This story was edited on 4/22/15 to correct the title of Dr. Mitchell Katz. He is the Los Angeles County director of health services.

First in a series.

Next: Doctors still frustrated by denials of care and sick patients denied care.