Health Care.

Clinics and emergency rooms serve as the heavily strained 'safety net' for L.A.'s indigent population

PATRICIA Fuller sits in the corner of the waiting room of the Los Angeles Free Clinic, quietly reading her Bible and adjusting her glasses as she waits for her name to be called.

Fuller is "60-plus" years old, a self-proclaimed evangelist who spends her time at home writing about "the mysteries of man." She is unemployed, uninsured and doesn't have family in the area.

It takes her an hour by bus to get to the clinic, but she says it's worth it.

"The doctors here are exceptional," she says, noting that she just had a tooth extracted and there were no problems.

Before learning from a TV commercial about the array of services offered by the clinic, Fuller hadn't been to the doctor in over five years. Before that, when something went wrong, she went to a hospital emergency room.

Fuller is one of the estimated 3 million people in Los Angeles County without health insurance. For many, their contact with the health care system comes at one of two places: the handful of clinics that provide diagnostic testing with basic primary care, or at the emergency rooms of major hospitals.

These two options give the poor in Los Angeles a fragile safety net that makes it almost impossible for the destitute to receive quality preventative care -- and therefore diminishes the chances of doctors diagnosing an ailment before it becomes a dire situation.

"The unfortunate thing is that most of the preventative care doesn't happen early enough, if at all," said Dr. Cesar Aristeiguieta, an emergency room resident at County-USC Medical Center. "They don't have a regular doctor, and they wait to come and see us until their situation, in their own point of view, has become hopeless."

One in three people who make the trip to the emergency room have no insurance, according to the Healthcare Association of Southern California. But no matter what their condition or their ability to pay, every person receives care once they go to an emergency room.

"Basically, nobody goes without health care in this country because they can always go to the ER, and that's what happens all the time," said Dr. Daniel Higgins, an ER physician at St. Francis Medical Center in Lynwood. "The problem is that they get immediate care, but they don't get any kind of continuity of care."

The costs incurred by this emergency care are inevitably swallowed by the system, according to Dr. Oliver Goldsmith, medical director of the Kaiser Permanente medical group in Southern California.

"It doesn't just disappear, it goes somewhere," Goldsmith said. "The next year, John Q. Public may be paying for it in their premiums."

Back at the Free Clinic, Cesar Carrillo, 49, awkwardly eased himself around the waiting room on crutches. Unemployed and uninsured, Carrillo had surgery in October at County-USC Medical Center for a tumor that was growing in his right leg.

"It was causing pressure on my right foot, but thankfully it wasn't malignant," Carrillo said. "But this morning, in the shower, I noticed that there was pus coming out and I wondered if it was infected. I called the hospital, and they said they couldn't see me until Friday, so I came here."

Statistics kept by the Free Clinic show that 62 percent of the more than 20,000 people who visited it last year were unemployed. More than half were women, and a third were Latino.

While people who turn to the Free Clinic do so voluntarily, other clinics face the problem of dealing with patients who for whatever reason -- mental illness, fear, pride -- refuse care.

"We saw an older man walking down the street with no shoes on," said Peggy Ruppe, who works at the Joshua House Free Medical Clinic. "One of his legs was swollen to the point where his shoe had made an imprint on his foot... I mean, he was heading toward gangrene. He wouldn't go to the clinic, and he wouldn't go to the emergency room. He was just scared of any institution and resistant to getting that kind of help."

Other people, particularly those in the United States illegally, are fearful of taking advantage of government health insurance programs, according to Cathy Hoffman, who studies the uninsured for the Kaiser Family Foundation in Menlo Park.

"There is a fear of government, an attitude of, 'What if I get my name in the system, would they bring that up if I attempt to become naturalized?"' she said. "Regardless of immigration status, there is also a stigma attached to public programs. If you can possibly avoid it, you try to avoid it."'