The worst blot on the United States' healthcare system is the 44 million people - one in six of the population - who are without health insurance. The number is growing, up one million between 1997 and 1998.

The worst blot on the United States' healthcare system is the 44 million people - one in six of the population - who are without health insurance. The number is growing, up one million between 1997 and 1998.

Care is available to the uninsured, but as charity not as of right. Stories are common of patients undergoing "wallet biopsies" to determine their worth before they are admitted and of ambulance staff deciding where to take an unconscious patient - to a public or private hospital - by the state of his or her shoes.

Although there are heavy penalties for any hospital that turns away a critically ill patient, the law requires only that their condition be made stable, before negotiation begins over how the bills are to be paid.

The uninsured are the nearly poor - those above the income cut-off for Medicaid, which varies from state to state. Many are self-employed or in part-time jobs and cannot afford the high health insurance premiums.

Naz, a freelance photographer, was quoted $250 (£166) a month for a policy that was, he said, beyond his reach. Last year, aged 38, he needed a gall bladder operation costing $15,000. He got it for $4,000, but only because his uncle was head of surgery at a hospital in Philadelphia.

"He fixed me up. But he keeps asking me now if I have got health insurance. At my age I have to do something," Naz said.

The mix of private and state insurance in America leaves big gaps - which means that the uninsured have to rely on safety net providers. They get poorer care, less prevention, and tend to turn up for treatment at a later stage in their illness, when it is harder to treat. Their only resource is the public hospitals and clinics, which in many cities fight an unequal battle for resources.

Christine Burch is executive director of the National Association of Public Hospitals. "Since we all continue to rely on these providers as a society, we must finance them rationally," she said.

At the DC General, the public hospital in the Capitol Hill district of Washington, one of the city's poorest, they operate a sliding scale of charges related to income, and bad debts tend not to be chased. The hospital qualifies for certain federal payments for "uncompensated care" but has faced severe financial difficulties in recent years and the numer of beds has fallen from 470 to 250. There are calls for it to be closed, but that would leave other hospitals in the city to care for the uninsured, a prospect about which they are unenthusiastic.

In the emergency room, which treats 900 major traumas a year - mainly gunshot and knife wounds - a convict shackled hand and foot and clad in an orange suit shuffled by. Don Marshall, a specialist in emergency care at the DC General, said: "The public hospitals need proper funding. They need tobe a state of the art safety valve for society. I don't think that concept has ever been proposed by the people who make the decisions."

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