WASHINGTON STATE has a great law that mandates free health care for poor people. However, according to a report released on December 21 by the Northwest Federation of Community Organizations (NFCO), Seattle hospitals are ignoring their legal obligations.

The Charity Care Law (RCW 70.170), which was passed in 1989, requires all hospitals to waive or lower fees for anyone who makes up to twice the federal poverty level if they can't otherwise afford necessary care -- things like emergency room visits and child births. According to estimates from the State's office of Financial Management, 1.5 million people could qualify. But when local health care advocates did an undercover investigation of the seven nonprofit hospitals in Seattle as part of a regional study, they found that charity care is largely inaccessible and that hospital staffers often don't even know the program exists. As a result, people are ushered through hospital services -- never being told their health care can and should be subsidized -- quickly racking up bills they can't afford.

"A lot of people who ended up getting charity care have had to bang their fists to get it," says Washington Citizen Action organizer Chris Hanssmann. (WCA is the local affiliate of NFCO, a nonprofit social justice group.) "If such a great program exists it should be offered up [to people], because nobody should have to go without care."

Hanssmann says while Washington may have some of the strongest guidelines for free health care in the country, getting coverage remains difficult. The problem is compounded by the fact that insurance companies recently stopped selling plans to individuals, limiting coverage to group plans. So low-income Washingtonians, often in work situations that don't offer group plans, need the state safety net.

NFCO Policy Director Lissa Bell started investigating charity care in October, after the organization had collected stories from people who couldn't pay their bills. Advocates suspected there was a widespread problem. They were right. A mix of NFCO advocates and community members posed as patients with severe asthma, calling and visiting hospitals to check up on the charity care program. The Stranger received the dismal results in an early version of the report: "Not Making the Grade: Nonprofit Hospitals Fail in their Charity Care Mission." The report grades hospitals from "A" through "F" on how accessible they made charity care.

Bell says they found a number of problems with hospitals' operation of their charity programs, including an overwhelming failure to post information. The state wants hospitals to inform people of their rights as soon as possible. However, hospitals don't have to verbally tell people about the program until after they are admitted. As a result, patients often receive care while charges start to add up, before payment is guaranteed. But NFCO discovered that patients often weren't told about the program at all.

None of the Seattle hospitals got an "A," and two -- Children's Hospital and Group Health -- flunked the test. Both hospitals, however, say they have programs to cover costs for poor patients. Children's Hospital has "uncompensated care" and Group Health has "sponsored care." "I don't like to use the term charity care. The words are demeaning, really," says Group Health spokesperson Elizabeth Barefield. But she says, "We do have a program and it is supposed to help people." Either way, NFCO's study found that the hospitals failed to carry out the state's mandate for helping the poor.

"If I'd known then what I know now, I wouldn't have gone to the hospital. I would have stayed sick," says Kellie Silvey. Two years ago, Silvey's roommate took her to the emergency room at Providence Medical Center, after she became severely disoriented due to a neurological disorder that causes her to have seizures. Silvey, 29, is unemployed and makes $512 a month from Social Security for her permanent disability (well below the $687-per-month poverty level).

She told hospital staff right away that she didn't have insurance. They admitted her anyway, saying her health came first. But shortly after she was released, the bills started coming. They never offered her charity care. When Silvey didn't pay, they sent her to collections. "I owe a few thousand dollars, but it might as well be millions, because to a person with no income it's all the same," she says.

The study also showed that while anyone is likely to have a hard time accessing charity care, getting information or an application is particularly difficult for Spanish speakers. Hospital staff hung up on Spanish-speaking inspectors 13 of the 20 times they called during the investigation.

Ultimately, the biggest problem is that the law governing the accessibility of free care isn't enforced. The State Department of Health is supposed to enforce it, but according to spokesperson Larry Hettick, "You can't really call it enforcement." He says the health department never inspects hospitals to make sure they comply with charity care requirements. It took grassroots watchdog group NFCO to discover this huge embarrassment to the state. If the health department determines that hospitals are violating the law, it can fine them up to $1,000 a day, and ultimately can turn them over to the attorney general for prosecution.

While the state hasn't seen the study yet, activists like local attorney Janet Varron are already getting involved in community education, because they're concerned that low-income patients don't know the state requires hospitals to help pay their bills. "I think charity care is one of the best-kept secrets," she says. She works with nonprofit agencies like NFCO and is collaborating with other attorneys to post information on the web about access to charity care.

NFCO hopes that hospitals take their cue. "We're not asking that they throw charity care at anyone who walks in the door," says Hanssmann. "But they need to let people know that it is an option, because some people don't have other options."

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