Ruth Terry`s painful odyssey through Chicago`s public health system began about 2 a.m. one night last October when labor contractions awakened her in her South Side home.
Her previous child had been born after just 40 minutes of contractions. Fearful that this baby, too, would come quickly, Terry, 33, rushed to call a city ambulance, which set off with her for the nearest hospital. That was Holy Cross, a 17-block drive.
But there were complications. Holy Cross physicians discovered that the unborn baby had passed stool in the uterus, raising the possibility that it might choke. Terry was overweight, she had already given birth to seven children and her prenatal care had consisted only of one ultrasound exam.
When hospital officials learned that Terry`s ultrasound had been done at St. Frances Cabrini Hospital on the Near West Side, they shipped her there, 75 blocks away.
Rather than admit her, officials at Cabrini contacted Northwestern Memorial Hospital, but officials there wouldn`t take her either. Finally, she was sent to Cook County Hospital, another ambulance trip, another mile away.
At last, after a 17-hour ordeal, baby Victoria was born at 9:30 p.m., a healthy child.
Transferring women in labor for economic reasons, called ”dumping,” is against federal law. Whether Terry was dumped isn`t clear; hospital officials deny it. But they all knew that her insurance was the government`s Medicaid plan.
And under Medicaid, a hospital that carries out a normal infant delivery is reimbursed $776, although the average actual cost is more than twice that much-$1,500. The hospital has to make up the difference.
Ruth Terry`s journey was not unique. From the lack of care during her pregnancy to her shuttle nightmare through private hospital emergency rooms to County Hospital, her experience was all too common in the expensive, fragmented and often indifferent health care system that is supposed to care for the poor in Cook County.
It is a public health care system that is critically ill.
The costs are enormous: $1.5 billion in tax money was poured into public health care in Chicago and Cook County last year alone. Yet the poorest people, those who most rely on the system, die earlier and more often from preventable and curable diseases than people who can pay for their own care.
The system is understaffed and hamstrung by inadequate facilities as, increasingly, money drives medical decisions. The 12 Chicago-area hospitals that have closed since 1985 did so largely because they were overwhelmed by the costs of caring for the poor and uninsured, believed to number 1.5 million in the Chicago area.
It is a health care system gone so awry that those working within it call it a non-system. They cite these sorts of examples to back their claims:
– Nearly 100 patients were admitted every day last year to Cook County Hospital, which consumed $284 million in taxpayer funds last year. Yet the hospital is so poorly staffed that trauma doctors and nurses personally carry blood samples to the lab, fearful of a repeat of the mismatches that have caused two transfusion deaths in the last two years. Nursing shortages, botched records and unsanitary conditions again last year pushed County Hospital to the brink of losing its accreditation, where it has teetered for more than two decades.
– Pregnant women waited an average of two months for their first prenatal visit at Chicago public health clinics in 1989. That was double the average wait of just two years earlier. Meanwhile, the city`s infant mortality rate ranked among the worst in the nation.
– Half of the women transferred to County by private hospitals were too far along in labor to be safely and legally transferred, according to a 1988 study. Last year, 5,900 babies were born at County and 175 of them died, a rate higher than that for infant deaths in Malaysia, Belize, Romania or Trinidad.
– An average of 200 patients a day crammed into each city and county health clinic, often waiting up to half a day to see a doctor. Others have waited as long as eight hours to get a prescription filled at County Hospital. Patients bring their lunch, and some sleep in a maze of waiting rooms.
Cook County`s public health system is a sprawling network of 57 Department of Health clinics; Cook County Hospital; the county`s Fantus Clinic and five outlying clinics; and about a dozen non-profit health centers.
The private sector includes more than three dozen hospitals that treat the poor. Five health maintenance organizations and more than 8,000 private doctors treat Medicaid patients.
Each component of the system is, in its own way, both part of the solution and part of the problem.
Duplication and waste squander resources. Little emphasis is placed on prevention and the routine doctor`s visits that can keep people healthy. This underemphasis on prevention contributes to rising health costs.
Bankrupt facilities such as the Mile Square Health Center on the city`s West Side and Provident Hospital on the South Side remain closed while neighborhood activists squabble and politicians shudder at the cost of reopening them.
Entrenched political forces fight for the status quo. Government bureaucrats protect their fiefdoms. Organized medicine and the hospital lobby guard their incomes and independence.
Said Dr. Berry Lewis of Bethany Hospital in Chicago`s Garfield Park neighborhood: ”We have here a permanent underclass who are medically unserved and go anywhere they can get through the turnstiles. This is the most disenfranchised community I have ever served.”
”A moral twilight zone has come into being,” warns Leonard Fleck, associate professor at Michigan State University`s Center for Ethics and Humanities. ”Neither physicians nor hospital administrators want to take responsibility for the health of those who can`t pay.”
For every Ruth Terry, there are many others who travel through the public health system without humiliation or needless pain. But the system has been ignored until demands far outstrip facilities, staff or available money.
Last August, officials moved to overhaul this system by convening the Chicago and Cook County Health Care Summit. It was a joint effort among Gov. James Thompson, Mayor Richard Daley and Cook County Board President George Dunne.
The summit issued a package of proposals earlier this year that carry an estimated first-year price tag of $45 million in federal, state, county and city funds.
But Thompson and Dunne have refused to support the recommendations, and an unwillingness among state and local politicians to allocate more tax dollars or offend health-interest groups has sidetracked the effort to improve the process of healing the poor and keeping them healthy.
Legislative hearings on the summit, called by Sen. Margaret Smith (D-Chicago), are scheduled to begin Monday, but most politicians and officials say little will change. Neither the funding nor the political overhaul that is needed seems likely to materialize.
Bringing change of any kind to such an entrenched system will not be easy. Treating the poor is a difficult task that becomes almost impossible because doctors and nurses fight the environment as well as the disease.
Those who treat the poor say they become angry at parents who do not see the early signs of illness in their children, and they become frustrated at the amount of illness directly related to habits such as drug abuse and alcoholism.
Statistics from Chicago`s poorest neighborhoods show a link between poverty and illness, whether induced by behavior, lack of access to good medical care or, most likely, a combination of these and other factors.
It is Chicago`s poorest communities-which also include most of the city`s black population-that rely most heavily upon public clinics. The need is acute: In these neighborhoods, people are as much as twice as likely to die before age 64 as people living in middle-class or wealthy areas.
Many early deaths are from diseases such as pneumonia, influenza and diabetes that, properly treated, do not have to be fatal so early or at all, according to Illinois Department of Public Health statistics.
”The poor are under a great deal of pressure for just general survival, keeping a roof over their heads and food in their stomachs,” said Isiaah Crawford, a psychologist at Loyola University. ”So their own personal health care, or preventive care, takes a back seat.”
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Cook County Hospital, the perennial villain and hero of Chicago`s health scene, by most accounts provides top-notch medical care in many areas.
But health professionals there are constantly hampered by the poor management of the Cook County Board and by buildings that have fallen into disrepair, the result of inadequate maintenance and the apathy of generations of patronage workers.
In a scene several decades removed from modern health care, two critical- care nurses recently spent two hours mopping the trauma unit`s floor because they could no longer stand the dirt, dried blood and discarded rubber gloves. Last month, druggists in the hospital pharmacy stopped accepting overtime assignments to protest overwork, forcing patients to wait up to eight hours for prescriptions. Asthmatic children wheezed in the grimy waiting room as mothers begged hospital workers to move faster.
Professional staff at County, Cook County`s only general public hospital, have lost their patience with summits and studies.
”Nothing will change at Cook County Hospital as long as the politicians are running it,” said Dr. Aubrey Masilela, an emergency medicine physician.
”They should just get things done. We need no more meetings.”
Harsh working conditions and a nationwide nursing shortage contribute to the lack of full-time nurses. Last year, $15 million was paid for nurses`
overtime and to hire part-time nurses.
The nursing shortage means that patients do not get medication as often as they should. At night, a ward nurse may be responsible for up to 25 patients even though the American Nurses Association recommends one nurse for every 8 to 10 patients.
Night nurses are so strapped for time that they have been known to fill in the same measurements of pulse rate, blood pressure and other vital signs on several patients` charts.
Part-time nurses plug gaps in the trauma unit, where a nurse is needed for each patient, even though some part-timers have no experience in trauma care.
On a recent Saturday night, head trauma nurse Cindy Buczko had only three full-time nurses. The other six were part-timers hired for the night. Buczko put them in the ”back room,” where patients are monitored after their initial injuries are treated, and hoped for a slow shift.
”There is not one of them that I could trust to help with the patients when they first come in and it`s a life-or-death situation,” Buczko said.
Making the situation worse, patients who have no insurance or who are on Medicaid but who do not need trauma care-some are merely drunk-are ”dumped” at County by other hospitals, further overloading physicians and nurses.
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Illinois spends $1,780 for each of its 1.1 million Medicaid recipients. That places the state 39th in the nation. New York, by comparison, ranks second and spends $4,163.
Hospitals that treat large numbers of poor patients received a boost in their reimbursements last year. But those payments still do not cover costs for the first line of defense against illness, primary care in a doctor`s office.
With reimbursement rates set so low, private physicians have little financial incentive to treat the poor unless they do a volume business, jamming in as many visits and procedures as possible to generate enough money to make it worthwhile.
These volume businesses, known as ”Medicaid mills,” proliferate in poor neighborhoods, sometimes just down the street from city clinics or non-profit centers. They often are used by drug addicts or others seeking easily-obtainable prescriptions and a no-questions-asked routine.
Among those squeezed the hardest are those who have no health insurance, not even Medicaid, and the facilities stretched the thinnest are those that care for them.
Jamie Lawrence, a nurse`s aide, and her 6-year-old daughter, Alicia, are patients at the Erie Family Health Center, a private, non-profit agency with clinics in West Town and Humboldt Park.
Lawrence has no health insurance. She earns too much money to qualify for Medicaid but not enough, she says, to buy private insurance. Alicia has severe asthma requiring expensive medication, frequent doctor`s visits and costly sessions on breathing machines.
Lawrence sticks with Erie because ”the doctors here take their time with Alicia. They explain things to me. I would not want to go anywhere else. Alicia loves her doctors here.”
But allowing Lawrence to continue there, rather than sending her to County Hospital`s free asthma clinic, is costing Erie money. She pays only $20 of the usual $60 cost.
Other patients who can`t pay line up at the 60 city and county health clinics, which logged 1.5 million patient visits last year.
At County Hospital`s Fantus Clinic, an average of 1,200 patients came in each day last year.
”If I tried to get an appointment for a patient to be seen by one of the residents I teach, I would be told that they are all booked for three months,” said Dr. Isaiah Perry, who teaches at County and treats patients at the Bethel Holistic Health Center in West Garfield Park.
”And I would say, `Then overbook them,` ” Perry said. ”If you have someone with leg ulcers, they can`t wait three months to be seen.”
The financial burden on taxpayers climbs even higher because swamped record-keepers in city clinics fail to process thousands of dollars in paperwork, and state reimbursements are lost.
The situation is compounded when clinic patients sent to private hospitals are forced to start all over with new doctors and new batteries of tests, duplicating procedures already done at public expense. There is no organized system to consistently forward records of patient histories and diagnoses.
Skimpy resources are a fact of daily life for those who work in public clinics.
At the West Town Neighborhood Health Center, 2418 W. Division St., chief administrator Georgia Hairston often doubles as appointment clerk and receptionist. The X-ray equipment is ”antiquated and breaks down
constantly,” technician Marjorie MacNamara says.
It costs an average of $70 in staff time, materials and general overhead to provide the services given during each patient visit at a Chicago clinic such as West Town. The state reimburses at a flat rate of only $26.
Still, the clinic provides essential medical care and many social services. It has a laboratory; a pharmacy; hearing and vision screening;
dental services; a tuberculosis clinic; AIDS virus testing; and a nutrition program for women and children.
Pregnant women are seen until the 34th week of their pregnancy and then continue their care and deliver their babies at the center`s ”partner hospital,” Norwegian American, 1044 N. Francisco Ave. Medical records are forwarded by fax machine.
The demand for prenatal care is so great that most pregnant women must wait one to two months for their first visit-much too long, says Hairston. The backlog is due to a critical shortage of workers and the funds to hire them.
”I can`t use another doctor if I don`t have a clerk to pull the patient`s records, a pharmacist to fill the prescription or a lab technician to do the tests,” Hairston said. ”When you lose those kinds of people, there is no replacement from the city.”
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The public health system cannot keep up with the pace now, let alone spend more time on preventive care, without an infusion of money and staff. But money alone isn`t the answer.
Improvement of housing and prevention of disease can ease many problems. There are individuals and organizations that are taking steps they hope will pay off in the future.
Mt. Sinai Hospital, in the heart of Chicago`s West Side, is making an effort with the Ogden Courts public housing complex across the street from the hospital. The hospital helped the Ogden Courts Women`s Organization get $25,000 in grants and a hospital board member donated $7,500 to build fences, improve security and make basic repairs.
The hospital`s philosophy is simple: Instead of waiting for a leaky roof to cause sickness, ”you fix the roof to keep the people well,” says Diann Smith, a Mt. Sinai vice president.
Elsewhere on the West Side, Dr. Jorge Prieto emphasized treating patients with respect and dignity to encourage them to come back, not just for serious problems but for treatment of the small ailments that can deteriorate into serious, and more costly, illnesses.
A Mexican immigrant who once practiced in the desert villages of his native land, Prieto charged just $3 a visit for most of the 20 years he worked in Chicago`s Pilsen neighborhood.
He helped start the South Lawndale Health Center, 2611 S. Lawndale Ave., a County Hospital satellite that is manned by a bilingual staff and which emphasizes sensitivity to patients.
The clinic offers bilingual counseling for women who have lost their babies. This program was an outgrowth of a tragic series of events that befell a woman named Dora Ruiz, who was 17 weeks` pregnant when she went to County Hospital for an ultrasound exam.
As Ruiz waited for her test results that day, a doctor asked her to translate for his Spanish-speaking patients. Then he asked Ruiz to tell another woman that her fetus was dead.
”I said, `You want me to tell her, just like that?` ” Ruiz said. ”I looked at her and her sad face and said, `Your baby`s dead.` She started crying. I was crying, too. I told her more words than the doctor said, trying to soften his coldness. I said, `Mother Nature didn`t want your baby to be born.` ”
Ruiz translated for another woman who was devastated because her premature baby had died at birth. ”When I talked to her, I was crying and crying,” Ruiz said. ”I was so sad.”
It became her turn to weep when she was called into the doctor`s office.
”I sat in the same chair and the doctor said, `Well, Mrs. Ruiz, your baby`s dead.` No feelings, no nothing. It was like an animal died.”
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Monday: The health summit-a lost opportunity?
