Poor Health

Hospitals and family doctors, the mainstays of health care, are pulling out of poor city neighborhoods, where the sickest populations live.

A Pittsburgh Post-Gazette/Milwaukee Journal Sentinel analysis of data from the largest U.S. metropolitan areas shows that people in poor neighborhoods are less healthy than their more affluent neighbors but more likely to live in areas with physician shortages and closed hospitals.

At a time when research shows that being poor is highly correlated with poor health, hospitals and doctors are following privately insured patients to more affluent areas rather than remaining anchored in communities with the greatest health care needs.

The Post-Gazette/Journal Sentinel analysis shows that nearly two-thirds of the roughly 230 hospitals opened since 2000 are in wealthier, mostly suburban areas.

As health systems open those facilities, they have been closing their urban counterparts. The number of hospitals in 52 major cities in the United States has fallen from its peak of 781 in 1970 to 426 in 2010, a drop of 46 percent.

Most of the facilities closed were small to mid-size community hospitals in poor urban neighborhoods and public hospitals, leaving many low-income neighborhoods with no safety-net hospital.

• Related: An introduction to this project and how we reported it

New York City's boroughs have lost more than 20 hospitals since 1990. Detroit has gone from dozens in the 1960s to four.

Locally, in the distressed community of Braddock, residents fought a long battle against the closure of their community's hospital. UPMC shut down the Braddock facility and razed the building in 2010 as protesters gathered in the street, tolling a bell for the 104-year-old institution.

Since 1988, Milwaukee County has lost its public hospital and five city hospitals.

One of those is the former Milwaukee Hospital. A small nonprofit called City on a Hill now operates in a wing of the large complex, which overlooks one of Milwaukee's poorest neighborhoods. Once a month, when the agency hosts a free clinic on a Saturday, a line forms more than an hour early and stretches down the block.

The closures have been going on for decades.

Between 1990 and 2010 alone, 148 nonprofit hospitals closed in the largest American cities, along with 53 for-profit hospitals.

In addition, five public hospitals closed, according to Alan Sager of Boston University, who has tracked and studied hospital closures in the United States. His research shows it's not just poor-performing hospitals being closed; the ones that shut down often are rated as being more efficient than those that remain.

"In a competitive free market, efficient hospitals would be likelier to survive," he wrote in a paper summarizing some of his research results. "That hasn't happened, providing evidence that no such market is present."

When communities lose hospitals, they lose doctors, too.

The newspapers' data analysis shows that doctors are scarcer in poor neighborhoods: Fifty-eight percent of the nation's 5,800 federally designated "primary care shortage areas" fall in census tracts of highest poverty in the 52 major metropolitan areas. In the 52 metro areas, at least one in five people live in a shortage area. Those areas also tend to have higher than average populations of people with disabilities.

These are typically neighborhoods where people are isolated by poverty. They are less likely to have jobs, less likely to have vehicles and access to healthy food, and more likely to face violence in and outside their homes.

As the presence of health care providers in low-income neighborhoods decreases, a growing body of evidence shows that poor people are more likely to be in poor health – indeed, poverty itself can make people sick.

Think of a child with asthma living in a mold-filled apartment, a man with an infected foot living on the streets and sleeping in his dirty, wet shoes, or a person with diabetes without a refrigerator to store insulin.

Mary Mazul, director of population health management and integration at Wheaton Franciscan Healthcare in Milwaukee, described a conversation with a doctor she knows who works with mostly poor patients, who told her: "Mary, I'm a good doctor but my outcomes aren't so good."

"Health care can't fix poverty, homelessness, racism," Ms. Mazul said.

Early death is the simplest measure of compromised health.

A Centers for Disease Control and Prevention study of U.S. counties conducted by University of Wisconsin researchers showed that the overall rate of death before age 75 was 417 deaths per 100,000. In low-income counties, the average was 480; in higher-income counties, the average was 345. The premature death rate was 39 percent higher in the poor counties that have been losing hospitals and doctors.

Disability rates also are higher among low-income residents. The Post-Gazette/Journal Sentinel analysis of U.S. Census data shows that in the lowest-income areas, an average of 12 percent of the population has disabilities. In the highest-income areas, the average is 5 percent.

It is those higher-income areas, where people are healthier and mobile, that are most likely to get new hospitals. At the same time that UPMC was closing its hospital in Braddock, it was constructing a $250 million hospital in Monroeville, where the average household income is more than twice as high.

"To me it's like free-market fire departments," said Robert Connolly of Common Ground, a Milwaukee community organization that started a health care cooperative last year. "Would anyone advocate building one on a corner across from another one to compete for fire business?"

Or closing down a fire station in a neighborhood with a higher rate of fires?

The past few decades of closures completed a chapter in which the founding principle of hospitals in the United States was stood on its head.

Most hospitals began as charitable institutions dedicated to the poor, often started by religious groups or social reformers.

In Milwaukee, Lutheran deaconesses converted a hilltop farmhouse into a hospital for the poor in August 1863. It is the ancestor of the complex on Kilbourn Avenue that is now home to the nonprofit City on a Hill.

Originally named Milwaukee Hospital, it was often called "The Passavant" after William A. Passavant, a Pennsylvania-born Lutheran minister who founded hospitals, orphanages, seminaries and colleges across the country, including what is now UPMC Passavant in McCandless. Passavant brought German deaconesses to the United States to replicate the medical training and hospital model established in Dusseldorf, spreading the best care practices of the day.

He traveled to Milwaukee to work with local leaders who wanted to establish a hospital for the poor. Four Milwaukee doctors volunteered their services for the new hospital.

• Related: See the history of a Milwaukee hospital through images
• Related: A timeline tracking the transformation of health care in the United States

"At that point, there was nothing here," said Diane De La Santos, executive director of City on a Hill. "It was all volunteer. The director was a pastor."

Individuals and congregations contributed to the effort, sponsoring beds or making donations of livestock or ice for the icehouse.

Around the country, dozens of similar institutions were founded. Look on the website of a typical health care giant and you'll find a version of the humble beginnings story:

In Buffalo, N.Y., Sister Ursula Mattingly – "one of God's trouble shooters" – was the first president of the Sisters of Charity Hospital established in 1848. It is now part of the Catholic Health system, a network of hospitals and clinics that serves western New York.

In Washington Territory in 1856, Mother Joseph of the Sacred Heart arrived to find "a new world of physical hardships" where there were no hospitals "and little in the way of charitable services for those suffering the misfortunes of life on the frontier." She established the hospital that eventually expanded into today's Providence Health & Services, an $8.7 billion health care system with facilities in Washington, Oregon, Alaska, California and Montana.

In the 19th and early 20th centuries, local governments – often counties – began to open public hospitals, designed to serve the poor.

Most hospitals remained charitable institutions, but many began to accept paying patients as well. At Milwaukee Hospital, the first non-charity patients were admitted in 1873, at the rate of $5 per week. By the 1920s, hospitals served affluent as well as poor patients; medical schools became well established; and the American medical profession grew more powerful and prestigious.

The advent of private and public insurance reshaped the economics of health care.

During the Great Depression, administrators at Baylor Hospital in Dallas created the "Baylor Plan" – the first prepaid hospital insurance plan in the United States and predecessor of Blue Cross. Insurance for physicians' services was also developed in the 1930s.

The success of these programs encouraged more insurers to enter the health care market, and a labor shortage during World War II led to health insurance becoming part of many benefits packages, spurred by government tax incentives. Employers found that offering a health insurance package was a way to attract workers, and the federal tax write-off companies got for providing the benefit gave an incentive to make it a regular practice.

The entry of the government in the health insurance market with Medicare and Medicaid in the 1960s put many more Americans on an insurance plan, and more and more employees had private insurance through their employers.

By 1968, 80.8 percent of Americans had health insurance coverage, according to a statistical report published by the U.S. Centers for Disease Control and Prevention.

"Our whole pricing system is illogical and unnecessarily complex," said George Brown, CEO of Legacy Health Care in Portland, Ore. "It's a system created by the bright idea during World War II of giving employers tax breaks."

That created new incentives and erased others.

Because a third party was paying, patients weren't deterred by the normal market mechanism – cost. And because health care providers were being reimbursed on a fee-for-service basis, they had little incentive to keep those costs down. Health care got more and more expensive. It also became lucrative for many providers and insurers, spawning a booming – and competitive – new industry. In the 1960s, the number of hospitals climbed, reaching its peak in 1970.

Those structural economic changes meant hospitals got most of their revenue from selling specific services to private and government insurers rather than seeking donations and endowments to finance general care for whoever needed it, said Martin Gaynor, E.J. Barone Professor of Economics and Health Policy at Carnegie Mellon University.

"If the way you survive is by selling stuff, why are you going to behave differently from other big businesses?" Mr. Gaynor said.

Business boomed and hospitals expanded as insurance reimbursement rewarded tests, treatments and hospitalization.

The Milwaukee Hospital complex, which changed its name to Lutheran Hospital in 1966, continued to expand, with additions in 1970 and 1974.

Hospitals competed with one another to get patients and began to acquire or merge with other hospitals and to buy physician practices to get their patients.

But even as hospitals added beds, technology and changes in Medicare were reducing the need for them. In the 1980s, Medicare switched to paying a fixed amount for specific services. This gave hospitals an incentive to send patients home as quickly as possible, since they got paid the same whether a patient stayed three days or seven days, for example, after a given procedure.

Advances in technology made it possible for outpatient care to replace inpatient care for many procedures. The demand for health care services continued to grow, but many hospitals struggled to fill their beds. That led to chaotic patterns of growth and retraction.

Health care experts recognized that competing hospitals were overbuilding and duplicating services and expensive equipment, which increased the costs of care. Nevertheless, expansion continued across the nation. When the supply exceeded demand, mergers, acquisitions and closures resulted.

Mergers continued as struggling systems sought to survive by joining forces, and powerful systems absorbed hospitals to gain market share. Weaker hospitals in poor neighborhoods often merged and then were shut down as "campuses" of bigger systems.

In Milwaukee, that played out in the 1980 merger of Lutheran and Evangelical Deaconess hospitals; the new institution was called Good Samaritan.

In 1984, Good Samaritan merged with St. Luke's; the Deaconess campus was closed and its buildings razed the following year.

Good Samaritan continued to buy properties and renovate its Kilbourn Avenue location. It merged with Mount Sinai in 1987 to create the Sinai Samaritan Medical Center based on North 12th Street. The Kilbourn Avenue complex – 10 blocks away – become the "west campus."

After three mergers in seven years, the system, which had been renamed Aurora Health Care, announced a three-year consolidation plan in 1988. It called for a reduction in beds from 913 to 581.

Within a decade, the west campus was shut down and the buildings were boarded up.

Health care providers and public officials often argue that the closure of a hospital in a dense urban area with other health care facilities doesn't have an impact on access to care for patients.

Aurora officials said at the time of the west campus closure that with another Aurora facility so close, residents in the neighborhood of the Kilbourn campus still had a local hospital.

"Many rich white people seem remarkably stoic in the face of hospitals closing in African-American neighborhoods," said Mr. Sager, professor of health policy and management at the Boston University School of Public Health.

But the fact that urban dwellers have hospitals within reach doesn't mean they get what they need to be healthy or that closures don't affect their neighborhoods.

With the closure of the facility on Kilbourn Avenue, a community in which most residents live below the poverty line lost an institution that provided jobs and customers for area businesses. And crucially, it lost doctors.

"If you looked back even a 100 years you would see doctors everywhere – following the population," Mr. Sager said. "But doctors have become much more geographically concentrated. They are no longer in rural areas, in urban areas. They are in suburban areas. When you lose the building you lose the doctors. That makes it hard to have legitimate medical care."

• Related: Seven reasons health care in the United States is costly and irrational
• Related: Nonprofit health systems increase market share in affluent suburban markets

The federal government designates areas with fewer than one physician per 3,500 residents as "health professional shortage areas." The Post-Gazette/Journal Sentinel data analysis shows that the majority of those are in urban poverty corridors (most of the rest are in rural areas). It also shows that those "health care deserts" expand when hospitals close.

The residents – less likely to have cars – often lack access to family doctors, as well as dentists, psychologists and psychiatrists.

The physicians who remain in poor neighborhoods face added challenges.

Patients have lower incomes so are less able to pay for services out of pocket, said Darrell Gaskin, deputy director of the Hopkins Center for Health Disparities Solutions at Johns Hopkins Bloomberg School of Public Health. Doctors must deal with reimbursements under Medicaid that are lower than those from private insurers or Medicare.

"The supply of physicians and other health care providers in minority neighborhoods may be affected by lower quality of community amenities," Mr. Gaskin said. Lack of medical laboratories, medical supply companies, financing and credit for small business all act as barriers, he said, and drive up the cost of operating a practice.

Meanwhile, medical students facing education debt, which has soared in recent decades, are more likely to choose to enter higher-paid specialties, such as an anesthesiology or oncology.

Two-thirds of U.S. physicians are now specialists, well above the level in other rich democracies, where roughly half fall into that category. The United States has only about half as many family doctors per thousand people as other developed countries.

The number of medical students entering family practice training dropped by 50 percent between 1997 and 2005, according to American Academy of Family Physicians data. Most now become specialists, who are more likely to be affiliated with large hospitals where most patients are privately insured.

• Related: A project on diabetes in low-income neighborhoods produced by Milwaukee Neighborhood News Service in conjunction with Marquette University students and partially supported by the O'Brien Fellowship

Smaller clinics that serve low-income neighborhoods often struggle financially.

"I've worked at six different Milwaukee clinics that closed, including a clinic for the homeless and several low-income neighborhood facilities," said Bonnie Tesch, an Aurora physician who is the volunteer medical director of the clinic run by City on a Hill. "Usually it was because of political things, funding.

"The last one, honestly, no one told me it was closed. I arrived one day and there was a sign on the door, and that's how I found out, like the patients."

Jeff Smith, chief clinical officer at Aurora, said that operating in low-income neighborhoods is a major challenge for health care systems. Under the current system, he said, "it's a burden that the health systems alone cannot meet. It's really going to require the community coming together to meet those needs. Certainly the health systems are part of that, but this is really a problem that's big enough that the health systems themselves can't fix it."

Aurora Sinai is the only hospital left in the downtown area, he said, and bears a huge burden in caring for the large numbers of poor patients there.

Aurora officials said its network of clinics that serve low-income neighborhoods, including Walker's Point Clinic, a large free clinic south of downtown, help fill in the gaps in care. Programs such as parish nurses, hospital-based and free-standing clinics, school initiatives and community outreach are part of the mix at Milwaukee's other major health care systems, including Wheaton Franciscan Healthcare, Columbia St. Mary's and Froedtert Health.

Dr. Smith said large health care systems like Aurora have to use their profitable hospitals to subsidize remaining city hospitals like Sinai, which operates at a loss every year.

Officials from Milwaukee's big health care systems all said they worry every time they hear that a city hospital might close, because it would mean the load of uninsured or Medicaid patients would increase for the remaining urban hospitals.

The shifting economics of health care pulled hospitals from what had once been their primary purpose: serving the needy. As hospitals saw poor patients as toxic to their financial health, the percentage of charitable care given by U.S. hospitals dropped.

A 2013 New England Journal of Medicine study found that nonprofit hospitals provide, on average, 7.5 percent of their operating expenses for IRS-defined community benefits. Such community benefits include education and other activities not related to the free or reduced-cost service many associate with the idea of charitable care. The average spent on free or reduced-cost care is around 2 percent.

Systemwide, Aurora spends 2.2 percent of its net revenues on community benefits, 1.1 percent on charitable care. Aurora Sinai – which lost $15.3 million in 2012 – spends 2 percent of revenues on charitable care.

Most U.S. hospitals are nonprofit and retain tax exemptions based in large part on the premise that they provide services to the community. But free or reduced-cost care for the poor is now a very small part of what hospitals do.

In a little over a century, poor people have gone from hospitals' reason for being to the patients hospitals most want to avoid.

Two years after the former hospital on Kilbourn Avenue closed, the Urban Ministry Center, a small nonprofit affiliated with Parklawn Assembly of God Church, joined with a national group called Convoy of Hope to organize a community event that included a jobs fair, health screenings and activities for children.

Diane De La Santos, then a vice president of public affairs at Aurora Health Care, learned the group was searching for a place to hold the August 2000 event and helped it get use of the parking lot of the vacant hospital complex.

Eight thousand people showed up.

The big turnout made it clear that the community had many unmet needs and that the empty hospital could have another life, Ms. De La Santos said. Four months later, Aurora transferred its four remaining buildings – 321,000 square feet – to the nonprofit now called City on a Hill.

• Video: City on a Hill volunteers warm up for a monthly free clinic
• Video: How City on a Hill found its mission
• Video: Convoy of Hope rolls into Milwaukee

Ms. De La Santos said she and others saw "the inevitable deterioration of a neighborhood when you pull out a large institution like that."

She started as a board member in 2001, then became a loaned executive two years later after the group had difficulties and went into debt.

By that time, "I was at a place in my life where I was more concerned with the significance of my life than with my career." She left Aurora and now heads City on a Hill.

City on a Hill runs on less than $900,000 a year; with 14 full-time employees and one part-timer, it relies heavily on volunteers. Ms. De La Santos does the grant writing and fundraising herself.

City on a Hill has chosen to focus on youth programs because that is where it sees the best chance of having an impact, Ms. De La Santos said. But the health needs of the community are great, and the monthly clinic has limited capacity. It serves an average of 306 patients a month in a neighborhood where 64 percent live below the poverty line.

In the city's far northern and far western suburbs, Aurora expanded into areas where patients make more and have insurance that pays more.

In early 2010, Aurora opened a $250 million medical center in Summit, where 1 percent of the families are in poverty. Officials at ProHealth Care fought the new hospital, arguing the beds weren't needed because of its nearby facility. Later that year, Aurora opened a $254 million facility in Grafton, where it touts "home-like patient rooms with private baths" and "extensive landscaping with the area's native plantings."

The facilities were built in the heart of the state's two wealthiest counties.

And both were built within five miles of existing hospitals.

MILWAUKEE – Hundreds of plastic bins are stacked like jumbo shoeboxes, nearly scraping the ceiling of a bare-bones room in a former hospital. People sit nearby in rows of chairs, waiting to be matched with a pair of donated eyeglasses from the carefully labeled containers.

It's a slow process at City on a Hill, a nonprofit that runs a monthly free clinic in a poor neighborhood on Milwaukee's north side. Many in the chairs look tired or anxious as they wait for their number to be called.

Then John Patton Jr. shows up.

He sprawls comfortably in his seat, throws his arms on the backs of the chairs next to him, and chats with those nearby. Then he focuses on the volunteer calling out numbers and waits a beat after she calls number 27 before booming out, Bob Barker style, "Number 27, come on down!"

"You know I'm a comedian to the highest degree," he confides as the room loosens and smiles.

Mr. Patton is a tall man with a broken-toothed smile; he uses his showman's voice to good effect in his annual gig as a Salvation Army bell ringer.

He's also an example of the complex interplay between poverty and health. Like many of the country's 46.5 million people living at or below the poverty line, he faces chronic health problems, doesn't get regular health care and lives in circumstances that make him sicker.

He has no regular job, until recently had no health insurance, and has health problems that include high blood pressure, a congenital heart defect, an injured back, gout, depression and the broken tooth. Mr. Patton, 51, dropped out of high school in his sophomore year. He says he has been told that he tested at third- or fourth-grade reading and math levels.

He has worked at a foundry, at restaurants, cleaning sports facilities, making commercial frozen pizzas and sorting clothes for a uniform service. In recent years, it's mostly been down to the bell-ringing and odd jobs for neighbors. He loves to read – celebrity bios, comic books, stories about UFOs – but struggles to write. He's lost at a computer keyboard.

He patches together his life making a circuit of neighborhoods near his home, mostly on foot. He knows people at clinics, social service agencies and emergency rooms.

For years he's been stuck in a cycle that is played out all over the country: without a full-time job, he couldn't get health insurance. Without health insurance, he couldn't get regular care or the therapy that might make him employable. Without income, he faced shortfalls and stresses that contribute to his health problems.

During the past several months, he's been trying to work his way out of the cycle by seeking insurance and income.

City on a Hill has been a regular stop for him for two years. He can get a medical check, groceries, clothing, toiletries, a hot meal and prayers offered for him by volunteers. But the once-a-month clinic offers only very basic health care – screenings, prescription medication refills and checkups.

Housed in what was once a large hospital campus, it operates with a small staff and volunteers and serves just over 300 people each month. The old hospital, which began 151 years ago as a charity, is once again a small facility focused on the poor. It once had hundreds of beds and was one of five hospitals serving poor residents in the downtown area. Now only one – Aurora Sinai – is left, and its emergency room is often a first stop for residents.

A 2012 National Health Interview Survey found that nearly 80 percent of adults who visited emergency departments over a 12-month period said they did so because of a lack of access to other health care providers. Emergency rooms, which can't refuse patients, and clinics in poor neighborhoods, which usually don't refuse patients, serve the large urban populations that once had many more local doctors and hospitals.

Before he started going to City on a Hill regularly, Mr. Patton usually only sought care when he was sick or injured, and it was frequently at Aurora Sinai's ER. Sometimes he gets care at the hospital's clinic across the street.

Mr. Patton is one of nine children. He lives with his parents, a brother and sister in a small house on a well-maintained stretch of Cherry Street, in a neighborhood where more than 40 percent of the residents live below the poverty line. He hasn't been able to afford his own place for several years.

It's a tightknit neighborhood along the half-circle street. Gladys Tatum, 72, lives a couple of houses away and has known Mr. Patton since he was a boy.

"He was a skinny, boney thing, but I remember he could draw like a whip," she says. "He was always waving and hollering, 'Hey!' Always drawing out on the circle."

He does chores for her.

"I called him a son," she says. "I can ask him whatever – whatever I ask him to do and he'll do it. He's very respectful."

Mr. Patton's mother was recently diagnosed with breast cancer. One of his sisters was murdered several years ago. Another died in a hospital after being treated for cancer. He says he struggled with drinking when he was younger and sometimes went to the emergency room after being hurt in fights. He has a scarred ear from being hit in the head with a bottle, he says. Another time he crashed while bicycling.

"I was riding on a bike, on an icy day – drunk!" he says. "I hit a fence. I got up and got back on the bike and rode 20 more blocks. The doctor couldn't believe I got back on the bike. I broke my leg in three places. That shows that alcohol is something else."

His back problems come from a 1998 injury at Grede Foundry, where a chain suspended from a crane moving a dumpster-size container broke loose and struck him in the back.

Asked how he pays his medical bills, he responds, "I don't!" then muses, "I probably got bad credit. They send me bills."

A 2014 Henry J. Kaiser Family Foundation report found one of every three Americans have difficulty paying their medical bills – either they have problems affording bills, or are still trying to pay back bills over time or simply can't pay them at all.

The Kaiser study researchers analyzed 2012 National Health Interview Survey data and interviewed individuals who had problems. They found that many people ended up in debt collections. Hospitals typically refer bills not paid within 90 days to collection agencies.

Often that debt dogs patients and drags down their finances. Medical bills account for the majority of all debt that is referred to third-party collection agents and for 17 percent of debt that is re-sold in the debt-buying industry, the study reported.

Mr. Patton was sued by Sinai Samaritan Medical Center for $1,730 in 1995 and by Aurora Health Care for $5,450.39 in 2005.

In the 2005 case record, his response is written on lined paper torn from a spiral notebook. It reads:

Dear Hon Dennis P. Moroney.

I John E Patton Jr. is on able to pay the money due to the fact i've lost my job and have no way to pay Aurora Health plus I own the IRS $5,000. I have no studry income at this moment.

Although he did not have regular employment at the time and might have qualified for charity care at a hospital, he didn't realize that was an option. Eventually the collections workers stopped contacting him, he says. "They realized I have no money to pay."

He later found out about an Aurora program that provides free and reduced-cost care for patients who have no insurance or financial problems.

"We'd rather be proactive and have someone who qualifies get help" paying hospital bills, says Mark Huber, vice president of social responsibility at Aurora. He says Aurora works to identify a patient's ability to pay up front and let those who need assistance know about programs available.

Jeff Smith, chief clinical officer, says it's cheaper in the long run to work with patients who have problems paying than pursuing them or turning them over to collection agencies.

After Mr. Patton went to the Sinai emergency room with chest pains in February, he wound up in the hospital for four days and left with a diagnosis of atrial septum defect – a hole in his heart. It's a congenital condition that poses no immediate threat, but doctors told him it could make him more vulnerable to stroke should he develop a blood clot.

Though he was enrolled in the hospital’s charitable care program, Patton got a bill in March informing him that current and past charges amounted to $23,817.40. Hospital officials told him it was a mixup and the charges have since been eliminated.

Mr. Patton gets free medications at City on a Hill, so in March he arrived at the clinic with a sheaf of prescriptions – one set he got when he was discharged from the hospital and another from a follow-up visit at the Aurora clinic. The volunteer doctor at City on a Hill sorted through the two sets of prescriptions and instructions, trying to decide whether Mr. Patton should or shouldn't get antidepressants, whether he should go on a regimen of baby aspirin for his heart, as one doctor had ordered.

Such lapses in communication within and between medical care providers make it difficult for physicians working with patients who don't have a single source of regular care, such as a primary care doctor.

Mr. Patton is trying to get Social Security disability benefits for the old work injury. He took a settlement payment of a few hundred dollars instead of pursuing disability at the time – something he now sees as a mistake because his back pain keeps him from being able to stand for long periods or do the physical work he is qualified to do. Disability payments would give him a steady income he's lacked for years.

He applied on his own in November and was turned down. He is getting help on his appeal from Lisa Woodall, a benefits specialist with Milwaukee County Disabilities Services. She says there are hurdles that Mr. Patton, and many others, face in seeking disability payments.

"Social Security's definition of disability is a condition that persists for 12 months or more that prevents you from working," Ms. Woodall says.

Since Mr. Patton worked after the injury, he did not qualify. They are trying to show he qualifies based on his current medical condition.

The lack of continual medical care can weaken the cases of people like Mr. Patton, says Ms. Woodall.

"A big thing with back injuries," she says, "is that without insurance the person can't get an MRI, and without an MRI you often can't prove the severity of the injury."

In addition, she says, many of those she sees can't get treatment, such as surgery or physical therapy, that might make them well enough to work.

"But even if you can show you can't do a certain kind of work, Social Security will look at the work you've done and say, 'OK you can't do that but what about other kinds of work?' "

Mr. Patton's spelling and writing are child-like. He wasn't sure how to spell the name of one of his sisters and could not subtract $45.72 from $100. So Ms. Woodall found it would be very difficult for him to do office work or any job that involved reading, writing or computer work.

Ms. Woodall had him fill out the form himself and then wrote in summaries of what he was trying to convey to show the evaluators the extent of his deficits. The initial application for disability benefits takes around six months. The first level of appeal usually takes three to four months, longer if there is a lot of new information being added.

"It's all based on pieces of paper," she says. "That's why it's so important to create an accurate portrayal of a person's life on those pieces of paper."

In addition to illiteracy, many poor patients lack the skills to navigate the health care bureaucracy, including access to a computer or the ability to handle online applications and forms.

Until this year, it was very difficult for childless adults in Wisconsin to enroll in Medicaid. Under provisions of the Affordable Care Act, it became easier and social service workers had told Mr. Patton he was eligible. He called numbers he was given and told people he thought he had already applied. He kept saying he was waiting for a call back on it. He was vague on what he had done, what he needed to do, and what was involved.

In February, Ms. Woodall finally sat him down at a computer in her office and helped him fill out an application form.

It was a slow process. Mr. Patton sat leaning forward, peering through glasses sitting crooked on his head, typing with one finger, long pauses between pecks. He read the sections softly aloud, trying to parse them, struggling to maneuver the mouse.

"OK, so that's it – you need to click 'next,' " Ms. Woodall said. "Whoops, let's get out of that – you don't want to click 'Vietnamese.' "

Mr. Patton laughed self-consciously and repeated over and over, "Oh, Lord!" as he looked up at the screen and back down at the keyboard.

"Where did I miss the train?" he asked under his breath.

"It's asking if you've ever had TB."

"What the heck is TB? OK, no."

"You're doing it. You're on the train," Ms. Woodall said.

Although Mr. Patton knows the people and routines of the clinics he visits, he struggles to understand his health conditions. He wonders what the hole in his heart means, why he feels so tired, what the dark marks that have appeared on his skin mean.

Though the medical services at City on a Hill are limited, Mr. Patton feels at home there. He likes the fact that its executive director, Diane De La Santos, is always at the door to greet every arrival. There is a woman who comes in regularly on clinic days and is often confused.

"She won't eat!" he says. "She'll sit there and want to talk and talk. But they always make sure she gets a meal. Diane, she so sweet, she'll say, 'Ernestine, eat dear, we'll talk later.' "

Bonnie Tesch, an Aurora internist who has volunteered at the clinic since it started and is its medical director, has seen Mr. Patton regularly there for more than a year.

She loves his upbeat spirit, but knows that he faces darker periods, and would like to have him get a psychiatric evaluation.

"If he had regular health care, he might not be so disabled, he might be able to work," she says. "He can't do what he used to do, he would have to go back to school, but he's very smart actually."

The years of unemployment and events in Mr. Patton's life have taken their toll. He's spent a lot of time waiting in offices, waiting for phone calls, waiting for a mailed response to a form he's filled out. Although he finally was notified he had been enrolled in Medicaid in April, he was disheartened to learn shortly after that he might have to wait 18 months for a hearing in his disability case.

"I don't know what I'm supposed to do," he says. "Guess I'll just keep doing little odd jobs."

He had a longtime girlfriend until last year. "We never got married. Men – we are chicken. Fear of marriage kept me from doing it." She left him.

"I was crying about her. I used to draw a lot. I used to make my own comic books." He got lessons at the Milwaukee Art Museum when he was in high school, he says, but never found a way to pursue his love of drawing. He used to spend time in the library, or in comic book stores, but lately he hasn't been motivated to leave the house as much.

"There's down spirals – when you're without money trying to get here, get there," he says.

A 2012 Gallup poll found about 31 percent of Americans in poverty reported they had at some point been diagnosed with depression; 15.8 percent of those not in poverty said they had been diagnosed. The poll also found that impoverished Americans are more likely to report asthma, diabetes, high blood pressure and heart attacks than those not in poverty.

"If you or I had a crisis, we would probably have someone to call," says Ms. De La Santos. "But if all your relationships are broken, or with people who are in a more precarious situation than you, you don't have that."

In one section on the application for disability benefits, Mr. Patton wrote: "Mind dirp [drifts] all the time fell sad some dedin [during] the day mous of time."