THE GAP IN THE SAFETY NET CANDID COMMENTS ON THE CHALLENGE OF HOW TO ENSURE HEALTH CARE FOR THE UNINSURED POOR Series: On the Table One in A Series of Periodic Discussions

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NOT SINCE 1992, when about 1,300 people congregated at the Old Courthouse to protest the Rodney King verdict, has a demonstration erupted here like last Sunday's on Delmar Boulevard in the West End.

That demonstration, a march by about 1,000 people, was fueled by the prospect of St. Louis Regional Medical Center closing. Friday, Regional stopped admitting hospital patients, a step in phasing down to about 10 hospital beds. Cuts in Regional's clinics, which provide care to many more patients, also are being considered.

But the issue is larger even than what Regional hospital's role should be. At stake is how to ensure health care for the uninsured poor. As many as about 200,000 St. Louis area residents, mostly working poor, may fall in the gap between private insurance plans and Medicaid. Regional has not been their only way to get care, but it has been a visible symbol of commitment to them. Recently, the Post-Dispatch asked a group of men and women associated with the challenge of delivering health care to the indigent to discuss this subject. The meeting was not a "summit" on the Regional hospital issue but a forum for discussing possible solutions to the larger problem here and nationally. At the On The Table meeting at Union Station were Charles A. Lowenhaupt, from Regional's board; Amy Smoucha from the Association of Community Organizations for Reform Now (ACORN); Tamarra Burnicle from General American Life Insurance Co.; Rodney M. Coe from St. Louis University School of Medicine; James Stutz from the Business Health Coalition;and Erise Williams Jr. from Blacks Assisting Blacks Against AIDS. Among the points they made: * Fragmentation reduces the effectiveness of the many resources available to help the indigent. * The working poor could be covered by expanding Medicaid if funds were available. Some participants prefer a bigger role for private programs. * Gaps in the health care safety net contribute to other problems, such as the disproportionate toll from AIDS among African-Americans. The full transcript is posted on the Web site for On The Table. This account was edited for space and clarity. More Problems To Come Coe began, saying that St. Louis' problems with health care delivery are not much different from those of other big cities. No single city or state is at fault, he said. He suggested that the federal government develop a "single payer system" - that is, a way to fund coverage through a single program like those in Canada or Britain. Coe: "A single payer system would go a long ways to alleviate the problem, won't solve it entirely, but it would certainly alleviate the problem." Speaking of Regional and the St. Louis area's problems, he continued: "There seems to be a singular lack of cooperation, because the state says they can't help; the city can't do it by itself; the private groups are talking, but there is no action." Smoucha advocates maintaining Regional hospital. She agreed that a single payer system would be the best way to ensure indigent care but doubted that it will happen because it would not make money. The condition of the poor can only worsen under current conditions here, she said. Smoucha: "We're going to inherit more problems with indigent care because of welfare reform. Nutrition is going to be less provided for by the federal and state governments. Health status is going to go down. People are going to be poorer and, as we're losing jobs in the region, there are going to be more and more uninsured. "It is estimated now that there are 200,000 to 300,000 uninsured in the metropolitan service area, at least 60,000 in St. Louis. And, interestingly, while 14.2 percent of whites are uninsured, 32.9 percent of Afro-Americans in the whole country are uninsured. "So I think that the problem is that people aren't cooperating. I've been talking to people from the state down to the aldermen. Everybody has a different notion about what has to happen and what has happened. …