The Place Where They Have To Take You In

Days and nights on the front line at Minnesota's busiest emergency room.

"And my job," Debbie says, "is to tell them, 'We have to think about what's best for John right now. We'll get him up there and we'll have someone else call in the morning, and hopefully get this resolved.' But the truth is, I don't know if they'll get it resolved. And even if they do, if it's MinnesotaCare, that's not retroactive. So it's quite possible that they'll get billed for this admission. And the thing is, she's got five kids, she works full time, her husband works. What is she supposed to do?

"Plus, the kid knows all of this. We try not to discuss it in front of him. But he knows." She shrugs, then starts to fill out the admission paperwork--fast, before the parents change their minds. The bill could run them upwards of $1700. "Call me cynical," she says to the doc when he comes to check back, "but I get the job done." He's still shaking his head as he leaves, mumbling something about "national health care."

There are about 24 million Americans in the same boat as the boy's parents now, including some 400,000 in Minnesota. At one time they might have been treated in a lot of hospitals and doctors' offices under the rubrics of "charity care" and "bad debt"--balance-sheet notations for patients who couldn't pay and weren't really expected to. But that practice is fast falling out of favor in a health business where the new buzz-words are "demarketing of services" and "management of patient mix."

What's left is the county hospital, charged by statute and history with providing care for the indigent--or, as they like to say at HCMC, treating "regardless of ability to pay." That doesn't mean patients won't be billed: Statements are duly printed, sent out, even turned over to collection agencies. The eventual collection rate from the uninsured is around 10 percent.

Frank knows all this. He was waiting in the Peds corridor one night for his daughter to get an athletic injury sewn up. Normally, he said, the family stayed away from doctors. But the school said Jeanie could be left with a permanent scar, and they didn't want to take the chance.

Frank graduated from college in '76, with a degree in electrical engineering. Back then, he remembers, "They pretty much fell all over themselves to get us. Offered us benefit packages, profit-sharing, retirement plans, the works. Health insurance was just a given.

"Then the bottom fell out of the industry, and my company sold the engineering department to the Japanese. Eventually they closed the whole thing. By the early '80s, even the engineers were taking jobs as senior techs--if they could get them. Some of my friends ended up making $6 or $7 an hour; I've been doing more like $10 or $11, which isn't really that bad." Frank had his own home remodeling business in Chicago before he moved his family to Minneapolis. He hasn't had health insurance in years. "We've been lucky," he says. "We have seven kids, but other than athletic injuries here and there we really haven't had anything. When we do--well, they send you the bill, you scratch your head and try to figure out a way to pay it off over time. We're pretty much done with the last one."

Does he ever worry about what might happen if someone in the family got really sick? "I told you, we're programmed not to. Seriously. We can't worry about that."

Unlike some of its big-city counterparts, HCMC has been lucky so far, not yet overwhelmed by the growing stream of people for whom it is the last resort. It's clean, bright, well-equipped and ranked in the top 100 in the nation for some of its specialties. It was also just recertified by the American College of Surgeons as a Level 1 trauma center, which means it's qualified to treat any injury; the only other Level 1s in the state are St. Paul-Ramsey Medical Center and the Mayo Clinic in Rochester.

Partly as a result of its credentials, HCMC has maintained a pretty diverse revenue base. A good number of its patients have private insurance; many more are on Medicare or Medical Assistance. The fact that most bills are thus covered by "third-party payors" allowed the hospital to write off almost $30 million last year in charity care and bad debt (three times higher than the highest figure for a private hospital), and to still serve all who need it. "We've had millionaires here," says hospital administrator John Bluford, "literally millionaires. They got into a catastrophic accident, and they got exactly the same care as the person in the bed next to them who was penniless."

But the squeeze is on. While Bluford touts the surplus HCMC managed to turn in 1994, he acknowledges that the system was barely in the black in 1995. For 1996, HCMC faces a potential deficit of up to $5 million. And the federal government is preparing to cut (or "slow the rate of growth") in programs that make up as much as 60 percent of the hospital's revenue. Medicaid losses alone could come to between $650 million and $850 million for Hennepin County over seven years. If you add cuts in Medicare, and potential matching reductions in state funds, the total could reach $2 billion.

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