Waiting room

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."

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