Pablo Benitez's health-care saga began with a small ulcer on his foot. When it broke open and started oozing pus, he guessed it was related to his diabetes so he went to a local hospital for treatment. Once there, he was refused for lack of coverage. Go to County, they told him -- meaning Los Angeles County-USC Medical Center, a 30-mile bus ride from home.
He arrived at County-USC's walk-in emergency room at about 9 p.m. Several hours passed before he saw a doctor in the minor trauma unit; he finally left at 4 a.m. Had he waited much longer for treatment, his foot might not be there.
On a Tuesday afternoon a few days later, Benitez -- a 54-year-old Mexican immigrant -- leans on his cane and walks gingerly down a hallway toward a crowded walk-in clinic. His left foot is freshly wrapped in white gauze. He has come to Los Angeles County-USC Medical Center, one of the nation's busiest hospitals, to make sure that the injury on his foot is healing properly.
Benitez shares his story more with gratitude than frustration. "The process is slow, but I felt that I got excellent treatment," he says through a translator. Unchecked diabetes often leads to amputation, and his blood sugar level had soared to five times normal. But on this follow-up visit, a check-up shows his blood sugar back in the normal range and his foot healing nicely. Benitez is also happy that he can afford this health care. Under County-USC's "ability-to-pay" program, he received hundreds of dollars worth of care for $60 up front. For some, ability-to-pay amounts to no payment at all; the shortfall is ultimately absorbed by the system and thus borne by the public.
At county, nobody gets turned away. Perhaps this is one of the reasons why it has long been a refuge for a growing class of workers, immigrants, seniors and just about anybody who doesn't have health insurance. According to a recent census report, 44.3 million people in the United States are now uninsured -- the highest number in a decade.
"It is very difficult, particularly when funding is being cut back," says Steve Moskey, spokesman for the National Association of Public Hospitals & Health Systems. "It's a time of increasing demand with uncertainty about the level of government funding for Medicare and Medicaid."
Located a few miles northeast of downtown Los Angeles, County-USC is the sprawling flagship of the nation's second largest public health system. This teaching hospital is one of America's biggest "safety net" hospitals. In 1998, it handled more than 700,000 emergency and outpatient visits, most involving uninsured patients.
On any given day, about 500 people come to County-USC's emergency units, for everything from upset stomachs to multiple gunshot wounds. The major trauma unit is so busy with urban violence that Army doctors train here to stay sharp for wartime.
The day-by-day plight of the uninsured, however, is better illustrated by the drab, utilitarian environs of the department's minor trauma and walk-in clinics. "When you're not feeling good and have no place to go," a clerk explains, "this is where you go."
Where you go -- the waiting rooms -- has linoleum floors, fluorescent lights, stale air and about 100 hard blue plastic chairs, most of them occupied from early morning until late at night. At this moment, all but a few seats are taken. Many people have been here since 8 a.m. and now it's noon.
A few patients hold crutches, some are visibly ill, most just look bored. The crowd is mostly Latino, including many immigrants from Mexico and Central America. A few faces are white, a few are black. There are a few other immigrants, too -- a man from Armenia, a family from Korea, a couple from Bangladesh. Hospital statistics suggest that only one in four in this crowd has any form of health coverage -- and only then because they're old enough for Medicare or poor enough for Medicaid (or MediCal, as its California variation is known.) The uninsured, for the most part, are the working poor.
But now they are not working, they are watching a TV that hangs from the ceiling, audible above the quiet conversations in Spanish and English. Some people chat quietly, some read, some listen to headsets with their eyes closed. Everybody waits for the loudspeaker to crackle with their name.
For the uninsured, the worst part about being treated at a place like county isn't the care itself, it's the hours and hours it takes to get the care. As one guy in the waiting room, complaining of a stomach virus, puts it: "It's got to be something real serious for them to take you in front of everybody. You've got to be cryin', half-dead."
For the most part, the atmosphere in the waiting room is calm, accepting. But there's a reason a wall fitted with bulletproof glass separates the waiting room from hospital staff.
Maybe it was the long wait, or maybe it was that the patient couldn't handle not getting the drugs he wanted. Whatever the case, in 1993 a man who had paid several visits to the walk-in clinic, complaining of various aches, returned to the hospital bent on revenge. He walked through the hospital's main lobby carrying a bag of guns, entered the walk-in clinic and shot three doctors. He took two other staff members hostage, announcing that he only wanted to kill doctors; it was simple luck that he was unaware one of his hostages was a physician. Two wounded doctors were rushed into the major trauma unit as a SWAT team descended on the emergency room. A nurse risked his life to drag the third doctor to safety. Hours passed before the gunman was apprehended, the two hostages physically unharmed. The physicians have recovered and the gunman is in prison. And that, one of the doctors here explains, is why there is now a security guard and a metal detector in the main lobby, and a wall with bulletproof glass in the clinic.
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As advocates for the poor pointedly ask: Why is it that a country as prosperous and powerful as the United States -- now basking in an era of increased personal wealth, historically low unemployment and reduced poverty -- seems incapable of providing the sort of comprehensive health coverage that has long been provided in many industrialized capitalist democracies?
Even now, with health care the subject of intense debate in Congress and on the campaign trail, the uninsured find themselves waiting again. Politicians are focusing first on the rights of the insured, pushing to give patients the right to sue HMOs, seek extra medical opinions and have emergency services fully covered. The plight of the uninsured, meanwhile, simmers on a back burner. "The Patients' Bill of Rights doesn't even include a right to health care," says Dr. Ida Hellander, executive director of Physicians for a National Health Program, a Chicago-based group that advocates a comprehensive, government-regulated system on the order of Canada's or those found in Scandinavia. "We make it very difficult in this country for people to get care ... The politicians are way, way behind the public on this issue."
The Republican presidential front-runner, Texas Gov. George W. Bush, wants to make it easier to sue HMOs and promotes medical savings accounts. Democrat hopefuls have addressed the issue of the uninsured more directly. Vice President Al Gore, placing the emphasis on coverage for children, would expand and modify existing plans. Former Sen. Bill Bradley would scrap Medicaid, use tax subsidies to cover the uninsured and require parents to have health insurance for children -- a plan Hellander blasts as "a giveaway" to insurers. But no serious candidate (unless you consider Warren Beatty serious) is promoting universal health care as an social objective equivalent to, say, public education or police and fire protection.
It is somewhat ironic that the Health Insurance Association of America -- arch villains in Hellander's eyes -- also would like to focus more on the uninsured, albeit for very different reasons. "The uninsured is basically our No. 1 issue," says Richard Coorsh, a spokesman for the industry that would rather not be No. 1 on Congress' hit list. "We think Congress has it backwards. Their work will add to the cost of premiums and correspondingly add to the number of uninsured."
If that happens, it would only continue a trend in which the ranks of uninsured have swelled by 10 million people in the past decade. In the years since President Clinton took office vowing to bring health care to all -- an initiative crushed in Congress amid heavy lobbying from insurers and doctors -- the number of uninsured has increased by 4.5 million. One reason was a cruel irony of welfare reforms: By taking jobs, many of the poor lost Medicaid benefits.
A study released last summer by the nonpartisan Henry J. Kaiser Family Foundation showed that 84 percent of the uninsured are from families that have a member working full-time or part-time, leaving only 16 percent with "no attachment to the work force." Moreover, most new jobs in America's evolving economy are in small firms less likely to offer health plans. Finally, there's the immigration factor: 34 percent of the foreign-born lack insurance, compared to 14.4 percent of the native-born.
In Los Angeles County, where an estimated one in every four persons lacks health insurance, the cost of caring for this population triggered a financial crisis in 1995 that threatened the closure of several public health facilities. The system's collapse was averted after the Clinton administration authorized a Medicaid bailout that, to date, amounts to $1.1 billion. As part of the recovery plan, County-USC opened three satellite comprehensive care clinics. One of the goals is to reach patients with chronic conditions, like Pablo Benitez, before their health worsens -- and before care becomes more expensive. The clinics are busy, but County-USC's non-acute waiting rooms stay crowded.
For a lucky few in the crowd, the wait is short. After signing in, each person's blood pressure and temperature is checked. lf those symptoms are troubling, the patient may see a doctor within minutes. If not, the tedium commences. In the front room, Maria de Jesus Garcia offers the accepted wisdom to first-time patients: Expect a four-hour wait at minimum -- and don't be surprised if it takes longer. Once, she says, she saw a doctor fairly quickly -- and then had a three-hour wait in the pharmacy. If you really must to be somewhere in the afternoon, she advises, you better get here by 6 a.m.
All these people, all that waiting, yet few obvious signs of frustration. "I think it's that, when they come in here, they see the level of acuity -- both the volume and acuity," says Dr. Michael Orlinsky, director of the minor trauma unit. "Virtually everybody is understanding. They see people working hard ... And most people realize they're getting a damn good deal."
Jason Funk, a 20-year-old man wearing baggy shorts and a backward baseball cap, is almost cheerful. He says he arrived at 9 a.m. because of an ear infection and clogged sinuses. Based on one previous visit, "I'll probably be here til 9 tonight," he says. Doesn't the delay bother him? "Yes and no. I mean, sure, but I know I've got to get it taken care of." In the back row, Boris Khodaverdi surveys the crowded room and shrugs: "They are way too busy," he says. "There's just too many patients. You can't blame them for having too many patients."
A closer check reveals some fraying nerves. Irene Sevilla, suffering back pain, looks up from her romance novel with alarm when she overhears that, at the finance window, she will be asked to pay $60. "I can't pay! Even the $60! ... My daughter supports me. We're here because we can't pay." A hospital administrator tries to calm her; finance clerks will question her to assess the matter of no-cost versus low-cost.
Now it's Choudhury Mustafa, the man from Bangladesh, who corners the administrator. "I am waiting from 9 -- almost three hours," he says. His wife needs treatment for ear troubles. Why, he wonders, isn't there a separate clinic for eyes, ears, nose and throat? "In our country you go to a separate counter."
All emergency rooms have their war stories, but County-USC's are better than most. Inside the minor trauma unit's "stretcher" hall, Dr. Gail V. Anderson, chief of emergency medicine, points to the spot where a suicidal man who had leapt from the 12th-story roof crashed through the ceiling, landing on a gurney. He suffered remarkably few injuries, and was treated on the scene. Six months later, Anderson says, the man jumped from the opposite side of the roof, avoiding the emergency room, and completing his objective.
After 41 years at County-USC, Anderson has witnessed more than his share -- and aside from the odd suicide mission or hostage stand-off, he has also seen two generations of social change in health care. Before becoming founding chairman of the Department of Emergency Medicine in 1971, he oversaw the obstetrics and gynecology department for many years. He remembers the frustration of being unable to save women who came in suffering infections from illegal abortions -- horrors that helped fuel a movement that reversed society's attitude toward abortion. Now he wonders if rising anger over managed care and the increasing numbers of the uninsured will prompt more dramatic change.
To be uninsured and face huge hospital bills is to risk financial ruin. But what if American health care has changed so much that the uninsured, after all that waiting, receive superior care?
The medical culture of a public teaching hospital such as County-USC, trauma unit doc Orlinsky suggests, is more conducive to proper treatment than the business culture of the HMO. "I've got a tremendous amount of pride that we will do what's right for the patient," he says. "When medicine becomes a business, there's a real problem. At a hospital like this, patient care is patient care ... Nobody says to me, Orlinsky, you can only spend this amount of money on a patient."
Even if the phrase "socialized medicine" sends the American Medical Association into toxic shock, the managed-care mess is making many doctors reconsider a national health program. "I feel we have our priorities wrong," Anderson says. "I think the money we spend going to the moon is not that important -- not when we have people on the streets and people in need of care. We need a plan where everyone has access to care. But I'd like to see it run efficiently. I guess that's an idealistic world."
Today, incremental approaches to expand Medicaid and Medicare are the focus of most initiatives addressing the uninsured. A recent study by the Kaiser Family Foundation's Commission on Medicaid and the Uninsured last summer found that of 11 million uninsured children, 43 percent were believed to be eligible for Medicaid but not enrolled, and another 27 percent may be eligible under the Child Health Insurance Program (launched in 1997); that adds up to 7.7 million children. "Finding improved ways to make families aware of these benefits, to simplify the enrollment process and to reduce barriers and stigma, are critical to reducing the number of uninsured children," the report concluded.
To some, however, such stats are only proof that incremental approaches don't work. For health care to be regarded as a right, Physicians for a National Health Program's Hellander says, it may require a social movement akin to women's suffrage or the civil rights movement of the 1960s. The uninsured, she says, are "stoic" when they should be angry. After all, public money underwrote the training of every doctor and the construction of most hospitals. A wisely administered national plan would make for a healthier population at lower public cost.
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Inside the walk-in clinic at County-USC, it's hard to tell the stoic from the glum. Now it's nighttime and the TV is tuned to "Buffy the Vampire Slayer." It is just as crowded as it was at noon, though a few seats have opened up around a disheveled, sad-looking soul who looks as though he hasn't bathed in weeks. There's something oddly beautiful about this, just to know that, here, even bums don't get the bum's rush.
As before, the mood appears calm. But sitting in the front row, Donald Feagin admits that his patience is wearing thin. This is his sixth hour of waiting. His head hurts, his allergies are a nightmare and he has a stomach virus. He isn't grumbling about the state of American health care, but the quality of the room's speaker system. When Feagin complained to a clerk about the delay, he was told that his name had been called a half-hour earlier -- he just didn't hear it. Now Feagin worries that he wouldn't be seen before midnight -- and he has to get up at 4 a.m. for work.
In this waiting room, most of the faces are unfamiliar. But Jason Funk is still here in his backward baseball cap, his visit approaching 12 hours, just as he had predicted. It might have been shorter, he says, but the first doctor sent him upstairs to a specialist. Now he's waiting for his prescription to be filled.
Funk says he is a recovering drug addict who is now in a church "discipleship program" that provides him lodging and meals. Even now, after the long wait, Funk's mood seems buoyant beyond reason. But then he explains why.
"I talk to people," he says. "I get to share Jesus with them."
After decades at County-USC, Anderson doesn't see any change happening until there are more doctors. In the meantime, he empathizes with those in the waiting room. "I'm amazed by their patience," he says.