Dr. Young worked at Seattle’s Harborview hospital for a time. Harborview is Seattle’s only public hospital; all the rest are private, for profit institutions. This means that pretty much all of the indigent and uninsured emergency cases end up at Harborview, the other hospitals declining to take them in, even if they are a shorter ambulance ride for the patient. This is the story of how Harborview manages to deal with the over crowding this can cause. Harborview’s emergency department is the place where every patient, no matter how poor or drug addicted, will be treated with dignity and to the best of the hospital’s ability.

The author blends patient stories with descriptions of how the hospital works, from the traffic control center (the people who coordinate incoming ambulances and where patients end up in the hospital -sometimes bunked in the cafeteria), the doctors, the social workers to the bean counters.

What emerges is a picture of a system in a lot of trouble. Harborview itself is surviving financially, but the other six public hospitals in the Seattle area have closed. The bigger problem is *why* there are so many people using Harborview’s emergency services: it’s mostly the homeless or those barely keeping a roof over their heads. These people, who live in the cold and wet and never know when or what they’ll have to eat next, are at a much higher risk for illness than people more fortunate than them. Because they can’t afford to go to a doctor or to buy their medications, they put off dealing with their health problems until they pretty much collapse. It costs more to treat a person in this condition than it does to keep them warm and fed, but those services are scarce to nonexistent in America. The most common public perception of the poor and homeless is that they deserve to be poor and homeless; that they are lazy, drug addicted (yes, sometimes they are drug addicted), less worthy members of the human race. Because of this, measures to give them what they need to keep healthy are very unpopular.

On top of this, there is the problem that the uninsured pay MORE for their services than insurance does. Medicare says “We will pay you X amount for this service, no matter what you bill” and hospitals and doctors accept this. Insurance companies do the same thing, ending up paying sometimes a *much* smaller amount for a given service. How to make up this shortfall? Well, bill those without insurance more. The don’t have the bargaining power of Medicare or insurance companies; they can’t do anything to negotiate the cost.

As a member of the vast uninsured – and a person with several chronic illnesses- I know well the problems with the health care system. But many people remain unaware of just how large the problems with the health care system are. This book is a great place to learn about it.

The patient stories were the most interesting parts of the book to me; some patients are followed for many months. Some unexpectedly live; some unexpectedly die. The patients range from drunks to the mentally ill, to the average person, to multimillionaires. These stories are vivid and immediate, and take place embedded in the business of the hospital bits. Recommended. ( )