Patients Nobody Wants

Millions of Americans can not afford a doctor or the insurance to pay for one. The crisis of health care for the poor and uninsured has dramatically worsened in Texas, where an oil-based economy suffers a depression. For three months, reporters Rita Rubin and Olive Talley researched the growing crisis and its victims. Their five-part series in the April 25-30, 1987, Dallas Morning News focused on the people, institutions, legislative reforms, economics, and legal framework that shape the answer to the question of whether health care is a right or a privilege. 

 

Houston — Sheiks from the Middle East, businessmen from South America and some of America's wealthiest routinely fly to Texas for its state-of-the-art diagnostic and medical treatment facilities. But for more than three million Texans, there is little hope of reaping any benefit from the state's internationally recognized health-care achievements. 

These Texans are the poor or uninsured, or — worst of all — both. These are the patients nobody wants. Their numbers always have included the traditional health-care needy: the laborer in the Rio Grande Valley, the pregnant teen-ager in rural East Texas, and the urban single mother. 

And increasingly — experts say alarmingly — the group also is embracing the "New Poor," the erstwhile oil field roughneck in West Texas and the one-time office worker in Houston, neither of whom now has a job. Because insurance frequently is tied to employment, the plummeting Texas economy has slammed the door to basic health care on many who once took it for granted. 

"Statewide, you're seeing people who never ever needed the public system, and they need the public system now, and they don't know how to use it," said Dr. Ron Anderson, a member of the Texas Board of Health and president of Parkland Memorial Hospital in Dallas. 

"Right now, we have a change in ethnic mix at Parkland, because we have a lot of white, blue-collar workers out of work," Anderson said. "I think it's a direct reflection of the economy." 

In 1985, the most recent year for which information is available, only Oklahoma and Arkansas had a higher proportion than Texas of residents without health insurance, according to the Employee Benefit Research Institute in Washington. 

An Urban Institute analysis indicates that those three states and Louisiana account for the greatest regional proportion of uninsured residents in the nation. Both institutes estimate that more than one in five Texans in 1985 did not have public or private health insurance; nationally, only one in six didn't have health insurance. 

While Texas' new poor, or unemployed, may be the most recent phenomenon to stretch the limits of the state's indigent health care system, there are at least two other factors: Texas' largest industries, such as oil, construction and agriculture, are among the least likely to offer health insurance, and the state's eligibility criteria for Medicaid, a public health insurance program, are among the most restrictive in the nation. 

Meanwhile, experts say, the spread of AIDS, the aging of the population, and technological advances that save lives that once would have been lost all contribute to the number of people unable to pay for health care. 

Without changes in the way health care is financed, said Arthur Caplan of New York's Hastings Center, a medical ethics think tank, "It's a recipe for disaster." 

 

The Hospital of Last Resort 

By Olive Talley 

 

Galveston — John Sealy Hospital is the mecca of medicine for the sick and poor in Texas. They arrive hourly for the help that no one else is willing to provide. So many patients are rejected by other hospitals across the state that the nearly 100-year-old University of Texas Medical Branch institution is a maze of humanity. 

In the pediatrics clinic, runny-nosed, giggling children climb over their mothers' laps, chairs, and anything else that gets in their way of play. Parents take turns pacing the floor with crying infants. 

Chatter fills the hallways. Nurses in green surgical pantsuits maneuver wheelchairs and hospital beds through the green-and-beige hallways like big-city taxi drivers, artfully dodging elderly patients who slowly shuffle through the narrow halls. 

In the cancer clinic, 27-year-old Kris Humphries and his wife squeeze their small frames into a brown vinyl recliner where he must sit for the next hour while a machine pumps cancer-fighting chemicals into his veins. 

A dizzy, aching Charles Martin stretches out on a chest-high table as a machine shoots into his neck X-ray particles that he hopes will shrink a hard lump there. 

Dozens of others wait their turn behind Martin. 

Patients — needy from all over Texas — sit and stand jammed together at the pharmacy. They wait hours to get prescriptions filled for free. 

"Business is booming — we've still got wall-to-wall poor people," said Edward T. Wimberley, director of the department of social work at the University of Texas Medical Branch at Galveston, which operates John Sealy. 

Some come out of tradition: This is where their relatives have come for decades. Others arrive after hospitals or counties closer to home have rejected them because they don't have money. 

Despite passage two years ago of legislation designed to help poor Texans in medical need, "a lot of people who fall through the cracks still come to Galveston," Wimberley said. "I can't say for sure, but they [other health care providers] must do a billfold biopsy on the spot and send them down here." 

Wimberley ought to know. His staff of 50 social workers is called whenever a patient has no money to pay for food, lodging or transportation. The calls are frequent. 

Blanca Sanchez, 37, and her husband, Andres, 39, rode for 12 hours on a bus from Crystal City to Galveston the night of Feb. 3. On arrival, they did not have enough money to pay for meals. They would have to stay two weeks. 

While doctors at John Sealy operated to remove a tumor at the base of the cannery worker's skull, social workers rounded up food coupons for the hospital's cafeteria and nearby fast-food restaurants for Mrs. Sanchez. 

Mrs. Sanchez, a soft-spoken mother of three, considers the help that she and her husband got from John Sealy a godsend. 

"I know God is with us," Mrs. Sanchez said one day in February as the couple prepared for the 12-hour bus ride home. "I thought I was going to lose him [her husband], but he gave us a miracle." 

 

Last year, Wimberley's social workers helped 31,000 people such as the Sanchez family. At times, the social workers finagle money — often less than $20 per person — from the patient's home county to help pay for food and transportation during the Galveston visit. 

Finding housing for outpatients and their families, Wimberley said, is a bigger problem. Many are offered housing in the Salvation Army shelter or at cheap, run-down boarding houses that show the lashing of the Gulf Coast's storms and years of disregard. 

But sometimes there just isn't enough help to go around, said Wimberley. "These people have enough knockdown, drag-out, big-time troubles to keep 125 social workers real busy," Wimberley said. "We do the best we can." 

The influx of the poor, abandoned by local governments and hospital districts throughout Texas, has swamped the Galveston hospital. Hospital administrators say they are forced to take action against counties to make them comply with new laws that define their responsibility for the medically needy. 

"We're just overwhelmed," said Dr. James Guckian, vice president for medical professional affairs at the University of Texas Medical Branch at Galveston. 

More than 192,000 patients were treated in the hospital, its emergency room and its outpatient clinics during fiscal year 1986, according to figures from John Sealy. 

The statistics reveal little of the suffering and hardship — financial and emotional — that forcing patients to travel hundreds of miles for treatment can bring, administrators say. 

John Sealy's patients last year came from 210 of the state's 254 counties. And two-thirds of them never paid a dime. 

Helen Farabee, who was chairwoman of a state task force on indigent health care, said John Sealy must assume a higher responsibility for the poor than other hospitals and counties because it is the only state-financed, full-service hospital in Texas. 

"But you have to modify that and see how much responsibility is realistic," she said. 

The hospital spent $93.2 million last year to treat patients who could not pay — $5.2 million more than the state appropriated to fund hospital operations in 1986, according to hospital records. 

An analysis by the Washington-based Urban Institute and commissioned by the Dallas Morning News shows that nearly 1.4 million Texans without medical insurance meet the federal definition of "poor." In 1985, by that definition, a family of four was considered poor if it earned $10,989 a year or less. 

"Although there is a general perception out there that we're the state hospital dedicated to indigent care, one hospital — no matter its size — could not take care of all the indigents in Texas," said Dr. Alvin LeBlanc, vice president for hospital affairs at UT Medical Branch. 

"We're trying to retool the system," LeBlanc said. "We're saying it's dumb for a person to come here from Jefferson County with the flu when they don't have a place to go because they can't pay." 

 

The system LeBlanc wants to change was set up in 1985 to provide medical care for the poorest of the poor in Texas. The legislature ordered counties without hospital districts to set aside 10 percent of their general tax revenues to pay medical and hospital bills of their indigent. At a minimum, counties are required to pay up to 30 days' hospitalization or $30,000 — whichever comes first — for any single, unemployed person who made $75 month or less. A family of four, for example, could earn up to $221 a month, based on the eligibility criteria. 

But many still aren't being treated in their own counties. The burden, refused by some counties, has fallen on John Sealy and other big public hospitals. 

At the same time, state funds for John Sealy Hospital were cut $20 million last year. And LeBlanc anticipates further reduction because of the state's financial problems. 

"We'd like to see primary care better developed at the county level," LeBlanc said, leaving the more difficult, more specialized cases — including trauma cases — to the Galveston teaching hospital. 

To that end, John Sealy administrators are asking counties and hospital districts to sign patient care contracts. Under those agreements, the hospital treats the counties' patients for a fee, which is calculated on a percentage of John Sealy's costs for treating the counties' residents during the previous year. 

Galveston County Judge Ray Holbrook saw the changes in John Sealy's policies coming. "They're in a tight squeeze financially, so they're trying to squeeze as much from the counties as they can," said Holbrook. 

Galveston County has referred its poor to John Sealy for nearly 17 years, but Holbrook said the county has never paid more than $300,000 for their care. 

Last year, more than 17,000 Galveston County indigents were treated at John Sealy at a cost of $16.5 million, UT Medical Branch's figures show. 

The hospital has proposed a $1.7 million contract with Galveston County. Although it is more than three times the annual amount paid in the past, Holbrook said his county and dozens of others in the southeast Texas region that relied heavily on John Sealy in the past have little choice but to pay. 

The disagreement, Holbrook and other county judges say, is that the counties' responsibility extends only to those who live at, or below, one-quarter of the federally established poverty line. John Sealy is pushing them to assume responsibility for a "vast wasteland of people out there" who have slightly higher incomes who can't pay, he said. 

Holbrook and others say the counties simply can't afford to do that. They fear if they don't sign such contracts, though, John Sealy will limit the number of patients from their counties and start turning people away. 

If that happens, "there's going to be a revolution," Holbrook said. 

"I think people will be out on the streets, knocking on the doors of the county courthouse and city hall, and they're going to be turned away by many places." LeBlanc denies that John Sealy Hospital boycotts patients, but he admits that admissions are tighter. LeBlanc said he has told his staff to accept patients if there are beds available, if the patient would be valuable to the educational program and if the transferring facility is incapable of handling the problem from a medical point of view. 

Jefferson County commissioners signed a three-year contract to pay up to $1.7 million a year for indigent patients from that county. The fee was based on the $6.5 million in unpaid bills for more than 7,300 patients from Jefferson County, John Sealy's figures showed. 

If John Sealy is getting tougher, hardened admission policies will not apply to individuals who walk in off the streets or show up unexpectedly at the emergency room, LeBlanc said. If the patient has no resources, though, John Sealy will be looking to the counties and hospital districts when it comes time to pay the bill. 

Helen Farabee, of the state task force, said she supports John Sealy's innovations, provided patient care is not sacrificed. In addition, she said, John Sealy should remain flexible with those counties that do not consistently "dump" on the hospital and that have limited finances. 

"I think it's acting appropriately to explore what role it can play, as Parkland must explore with counties around it," Farabee said, referring to efforts by Dallas County's Parkland Memorial Hospital to sign obstetrics contracts with outlying counties that "dump" patients on Dallas County. 

"John Sealy cannot go on absorbing the . . . population explosion," she said. 

As of April 10, John Sealy had signed contracts with 24 counties, mostly in southeast Texas, for care of poor, uninsured patients. Nine counties agreed to qualify anyone who meets the federal definition of "poor." Eighteen contracted for obstetrics services in which circuit-riding doctors from John Sealy visit patients at clinics in their home county and deliver their babies in Galveston. 

Said LeBlanc: "I can assure you . . . the patient is not going to lose out of this."