Dr. Herbert Smitherman nervously monitors the city's fluctuating unemployment rate and sinking economy.
As one of about 750 Wayne State University Medical School physicians, he looks at the deluge of job cuts in Detroit's auto, manufacturing and other industries and sees even more people lining up for health care they can't afford to pay.
Doctors at the urban medical school — working primarily through the Detroit Medical Center — are feeling the financial and academic strain of treating 70 percent of the city's estimated 200,000 uninsured residents.
The uncompensated care means less money coming into the medical school to support programs and make infrastructure improvements necessary to attract top-notch physicians and highly qualified students. The school's doctors also could be using time they are not getting paid for to educate new generations of physicians, conduct grant-sponsored research and staff other programs geared toward the city's poor.
"We're flying by the seats of our pants," said Smitherman, assistant dean of Community and Urban Health at the medical school.
He puts the total cost of uncompensated care by Wayne State medical school doctors at about $50 million each year. That includes all free care provided by its doctors and care and services for which they've billed patients and not been paid.
Smitherman estimates that 75 percent of patients treated by doctors at academic health centers are uninsured or underinsured. There are an estimated 47 million uninsured Americans.
The fortunate find free or low-cost programs run by medical school physicians. But that uncompensated care is money not being earned by the physicians or the school, according to Robert Dickler, chief health care officer for the Washington, D.C.-based Association of American Medical Colleges.
"Part of the earnings go to pay for the infrastructure so you can run the medical school," Dickler said. "If you can't break even or you can't make some margin to reinvest in the facility and your activities, you are not going to be able to care for anybody.
"This is a dilemma many of our members currently are facing."
Wayne State's partner — the eight-hospital Detroit Medical Center — also is feeling the stinging financial pinch.
The DMC gives about $200 million in uncompensated care each year in Detroit. It also handles more Medicaid patients than any other hospital or group of hospitals in the state, Smitherman said. That played a role in 2003 when the state stepped in with $50 million from taxpayers to help the DMC through a tough budget time.
For the uninsured, urban medical schools are one of the largest parts of an unraveling safety net that includes community programs, local health centers and city-run free clinics.
The city of Detroit operates three primary care facilities offering basic prenatal care, pediatric screenings, dental services and some primary care. It also runs three specialty clinics focusing on the treatment of tuberculosis, HIV/AIDS and sexually transmitted diseases.
But funding for those services also are limited, said Dr. Phyllis Meadows, director of the city's Health and Wellness Promotion department.
"We do anticipate more uninsured, but we see so many people every year, anyway," she said. "Resources don't go up."
Smitherman said Wayne State's Medical School faculty is working hard to keep up with the waves of uninsured who often go through hospital emergency rooms for treatment. That route is the most expensive for hospitals, but allows people who can't afford to pay upfront to get treatment, he said.
Payments through the federal Medicaid program help recover some of the costs of primary care for the poor and uninsured, Smitherman said, "but there is no mechanism at the federal, state, county or city level for secondary care, and that's procedures, like if you wanted to get a CAT scan or an MRI or a chest X-ray," he said.
The Rev. Richard Wilson is one of those without health insurance, but he's in a community program that pays for the treatment he gets for heart problems, high blood pressure and Type 2 diabetes.
"Unless I get into a group program, it's too expensive for me to do on my own," said the 56-year-old career pastor. His church, Tried Stone Baptist in Detroit, pays $700 each month for his medication, Wilson said.
The Voices of Detroit Initiative covers Wilson's minor lab work at a federally qualified health center run by Smitherman. But costs — such as $4,000 in preventive services, including a colonoscopy — have to be negotiated.
That starts with a call to the Detroit Medical Centers. "Then I have to call the anesthesiologist, and then I have to call the gastroenologist and ask them and negotiate with them on the price of it," Smitherman said. "Because we are faculty, what I do is call my colleagues and say, 'Would you please waive the fee on this patient who is totally uninsured and has no money, or can we get a significant discount on it?'"
What he can't get for free is paid with other federal funds, he added.
Unlike Wilson, many without insurance don't even bother to seek care because they can't afford it, said Smitherman, co-author of the book, "Taking Care of the Uninsured: A Path to Reform," published last year.
"They will do alternative medicine, over-the-counter medicine, have their friend do something," he said. "They will do anything to try to save the $200 to $300 that they would have to pay.
"It is very common for us to have people coming in and they say 'I have a rash and I treated it with Clorox,' or 'I treated it with something' and they've been doing it for a week. It's now infected. It's worse."