The physician stares at the floor a few moments and says nothing. Then slowly, deliberately, James Lew, a doctor at Clinica de Salud in East Salinas, recounts a heart-wrenching experience.

About two years ago, a 40-year-old man walked into the privately-run clinic on Sanborn Road with a bag full of empty medicine bottles. Lew examined the man, a longtime local farmworker. “It fast became clear to me that he was very, very sick,” Lew recalled last week over lunch in a Mexican restaurant near the clinic. The patient had advanced diabetes, as well as heart and kidney diseases. After some additional exams, Lew found that the man’s kidneys were on the verge of breaking down completely. “I told him he required immediate medical attention,” Lew says. “He needed to go to the hospital.”

But there was a problem. Lew’s patient (whose name he can’t release) had no money and no health insurance. About a year earlier, he had been erased from Natividad Medical Center’s medically indigent program, which provides coverage for Monterey County’s poorest adults.

He was kicked off because he was an undocumented immigrant. Faced with a desperate fiscal crisis, the County-run hospital’s administration in late 2003 eliminated all undocumented workers from the medically indigent program as a way to save money. The decision saved the hospital millions of dollars. And it sealed the fate of Lew’s patient.

Because he knew his patient could not obtain government-sponsored health coverage, Lew told him that he should go to Natividad’s emergency room. There, doctors would be obliged to treat his acute ailments regardless of his immigration status, since federal law requires emergency rooms to screen and “stabilize” the health of every single person who shows up.

The man declined. “He said he didn’t want to be a burden on the system or on his family with another hospital bill,” Lew says. “That was the last time he came in.”

A few weeks later, Lew learned that his former patient had suffered a cardiac arrest at home and was rushed via ambulance to Natividad’s ER. There, doctors hooked him up to a life-support machine in the intensive care unit. He remained there for 10 days, and then he died.

“The irony of the situation is that his stay in the intensive care unit at the hospital undoubtedly cost more money than was needed to treat his illnesses,” Lew says bitterly.

While this tragic tale is thankfully rare, Lew says, it illustrates a widespread problem. “There’s no question that the system failed this man,” he says, his hands pressed together as he raises his head. “He had a disease that was treatable, but he was abandoned by the bureaucracy.”

~ ~ ~

For an increasing number of uninsured or underinsured patients in Monterey County, who number about 112,000, health care options are steadily dwindling. Fewer private clinics are accepting government-sponsored health plans like Medical and Medicaid. That places more strain on patients to pay for their own medications and treatments. More than 6 million California residents (or one in six) lack any sort of health insurance. And there’s little hope of that changing soon.

Gov. Arnold Schwarzenegger last week vowed to veto SB 840, a bill authored by state Sen. Sheila Kuehl that would have created a state healthcare system. The bill, which was tweaked and re-tweaked over two years in the state Legislature, would have guaranteed universal health care for all California residents—including the undocumented.

The bill is built on the idea that if everyone had access to primary care, the cost of providing care to uninsured patients facing acute illnesses—which has skyrocketed—would decrease dramatically, resulting in a break-even.

Schwarzenegger cited his no-more-taxes pledge in announcing his planned veto. Even Democratic challenger Phil Angeledis, once a firm supporter of SB 840, has backed away from openly supporting the now-doomed bill.

Meanwhile, a new federal rule requiring proof of citizenship for residents who are enrolled in Medical, who total about 65,000 locally, could result in more patients with no coverage.

The Medical rule went into effect July 1. It requires agencies like Monterey County’s Social Services department to purge (or deny access to) anyone that can’t prove they’re a US citizen from the program. Most current enrollees are children and seniors.

Bill Elliot, Monterey County’s director of Social Services, worries this policy could do more harm than good.

“My biggest fear is that this more restrictive measure and more difficult verification process will result in a falloff of those who attempt to go through all the obstacles to get health coverage,” Elliott says. In other words, enrolling residents into the program—a major goal for the staff at the County-run hospital—just became a whole lot harder.

Many county officials statewide at first threatened to defy the federal government and not implement the policy, but they have since relented, Elliott says.

Maria Giuriato, a Salinas city councilwoman and county social services official, stresses that while the County will implement the rule, it probably won’t result in many illegal immigrants losing their coverage because the undocumented haven’t been eligible for Medical since the 1990s.

Those who stand to lose out the most, she says, are residents who are eligible for the program but are scared away by its more burdensome bureaucracy. As for undocumented immigrants, the government trend to marginalize them from healthcare services continues.

Many public health officials and medical professionals interviewed for this story believe that the undocumented in this population are in the most danger of experiencing a healthcare crisis.

~ ~ ~

For the County’s uninsured population, there remain only two viable options to access medial care. Monterey County Health Department’s system of clinics is one, as are the privately run clinics of Clinica de Salud. Both offer sliding-fee payment options.

For the uninsured who can’t afford to pay anything, each entity offers access to a program that covers some of the most basic healthcare needs, like lab tests and medications. But the County’s program doesn’t accept undocumented residents, who form a large segment of the population in places like East Salinas. And Clinica’s program, which only provides care to patients for three months, is severely underfunded by the State.

“We have less than $400,000 a year to fund this program for all seven of our clinics,” says Medical Director Dr. John Silva. “So we’re finding that eight months into the fiscal year, we’ve used up all our money for this particular program. And we need it, because about 15 to 20 percent of our patients rely on it to pay for their care.”

There is a third option for uninsured patients, however, especially those who live close to Salinas, home to one of the highest concentrations of low-income families in California. It’s an expensive option, and not very effective at treating long-term illnesses that need to be managed over time. But for some, the emergency room at Natividad Medical Center is a last medical refuge.

~ ~ ~

In the cool night air, an ambulance’s rear doors fling open and a bloodied Asian man, who minutes earlier was pistol-whipped in the head by a street thug, is carried into Natividad’s emergency room on a gurney. Moments later, a woman who’s just given birth is rushed in with bleeding so severe that her life is in danger. A little after that, a handcuffed and burly looking prisoner in an orange jumpsuit is escorted in by three armed prison guards.

Dr. Jeffrey Arnold, the ER doctor on duty this night and the hospital’s new chief medical officer, rushes to attend to each patient with the assistance of nearly a dozen nurses. Aided by a steady stream of coffee, they work fast and make decisions on the run. People’s lives are hanging in the balance and they know it. All the while, the incessant beeps and clicks of medical equipment permeate the air as new patients keep flowing in.

The scene is just as most people might imagine a graveyard shift at an emergency room, with plenty of blood and agony and high drama. But in the last couple of years, a change has been taking place inside this particular ER.

While doctors and nurses at Natividad still see their fair share of patients brought in due to car crashes, heart attacks and other sudden trauma, they’re also seeing a larger number of patients who simply have no place else to go. These are patients who, because they have no insurance and can’t afford to pay for their own care, have put off treating their chronic illnesses until they’ve become acute. They know doctors will have to treat them at the ER.

“We are seeing a larger percentage of patients without access to primary care,” says Arnold, a fast-talking man in his early 50s who sports a goatee and reading glasses slung low over his nose. “About 75 percent of the people we see here [out of 30,000 annual visits] have no healthcare at all or only have insurance plans like Medical or Medicaid.”

While Arnold has 15 years experience working in emergency departments at big-city hospitals like Cedars Sinai and UCLA/Harbor Medical Center in Southern California, he’s still impressed by some of the patients he sees at Natividad.

“Here you see the kinds of cases that you just won’t see in suburban hospitals,” he tells me as he multitasks between filling out a patient’s form and peering at someone else’s cardiogram chart. “We see chronic diseases that are more spun out of control and that could have been treated earlier, but weren’t. We kind of interface with the Third World.”

An elderly woman he’s treating at the moment is a case in point. In her 60s, she is lying on her back in a corner bed, meekly uttering a few phrases in Spanish. (Arnold cannot release her name or allow me to talk to her because of the hospital’s strict confidentiality rules.) A relative, probably her granddaughter, hangs near the foot of the bed nervously.

Arnold checks in on the woman for a few minutes. “She has one of the largest goiters I’ve seen in years,” he says when he returns to the desk. He picks up a phone and calls an internal medicine physician at the hospital who will treat the woman overnight.

“She came in with chest pains, shortness of breath, heart racing,” Arnold says. “She’s a great case, medically speaking. It’s something dramatic that you don’t see other places.”

Arnold describes another patient whom he treated in the ER not long ago who had no access to health care. “We had this woman from Mexico with a breast tumor that was so large it was bleeding through her shirt,” he says matter-of-factly before moving on to another patient. “Very dramatic.”

Jeff Brody, another ER doctor at Natividad, says he’s seen cases where the emergency room turned out to be a patient’s best shot at getting care.

“Not long ago a woman came in with rectal bleeding,” says Brody as he sips from a large coffee cup. “She had no insurance, so at the clinic they were requiring her to pay $1,000 up front to get a colonoscopy. She didn’t have the money.”

When the woman learned she could make monthly payments for the same procedure if she came through the ER, she checked herself in.

“They finally did the procedure,” he says. “She was able to make the monthly payments, and learned that she had a precancerous condition.”

While some patients treat the ER like a clinic, asking for the same doctor who treated them previously to fill their prescriptions or to get a needed shot, it’s not the correct way to treat chronic illnesses.

For one, it’s very expensive—either to the patient or to the hospital, if the patient doesn’t pay their bill, which can easily run up into the tens of thousands of dollars.

More importantly, says Dr. John Silva of Clinica de Salud, the ER is not designed for people who need to manage their illnesses.

“In Monterey County, diabetes is becoming an epidemic,” he says. “Those patients need long-term care, and an ER doesn’t help those people in the long term.”

Dr. Laura Osorio, the medical director for Monterey County Health Department’s clinic system, agrees. But she goes a step further. The people who need help the most are those who aren’t going to the clinics or even the hospital’s ER.

“I think the largest uninsured population is the one we don’t know about,” Osorio says. “And that’s very problematic. Because Type II diabetes, for example, is usually diagnosed five years after its onset. So people without insurance will go to a doctor only after they’ve already developed severe complications from diabetes and it’s a lot harder and more expensive to treat.”

~ ~ ~

On a map, the busy urban corridors of Williams Avenue and North Sanborn Road in East Salinas lie only a few miles from the tourist playgrounds of Monterey and Carmel. But they look and feel a world away.

The people who live here are almost exclusively Mexican immigrants, or the children of immigrants. Spanish is the dominant language on the streets and in the shops. Many here live below the poverty line. Countless are undocumented. At the end of the workday, a long line of cars rush in from all sides as men and women who have labored in the farm fields all day return to their crowded homes, apartments and trailer parks.

It is in these neighborhoods where many of the most medically vulnerable people in the County live, according to the doctors and hospital administrators who regularly treat patients here. Here, according to those medical professionals, a health crisis is brewing.

One reason is the lack of access to adequate health care programs. But another is the propensity of poorer ethnic communities to develop illnesses like diabetes and hypertension.

According to a study released this year, Paradox in Paradise: Hidden Health Inequities on California’s Central Coast, nearly one-quarter of adolescents who live below the federal poverty level are overweight, far above the state average. Latinos and African-Americans, the study says, are almost twice as likely to develop diabetes than White residents.

But there is yet another reason for the vulnerability of communities like East Salinas. That has more to do with outlook and attitude than anything else.

Standing on a street corner just south of Alisal High School last week, one person after another came to the fruit and vegetable truck stand operated by Jesus and Rocio Delgado. And one after another, each and every one of the people I spoke to told me that they didn’t have health insurance. The reasons varied.

“As long as I wake up with an appetite, I’m fine,” jokes Delgado, a mustached and portly man who doesn’t remember the last time he went to see a doctor. “I just put my health in God’s hands and hope for the best.”

Later, he admits that he’s a little afraid of what a doctor might tell him. “I know this one lettuce picker who was told by a doctor that he couldn’t eat this, couldn’t eat that,” Delgado says as he turns to his wife, who is handing out change to customers who are filling up on fruits and snacks. “But he looks fine, really, he looks perfectly healthy.”

Later a man shows up on a bicycle. His name is Juan Marquez. He’s in his 30s and says about two years ago he came down with strong pains in his stomach every time he’d eat spicy or greasy foods.

“I went to the Clinica de Salud down the street and paid $260 to get myself checked out,” he says. When asked if he was eligible to be covered by some sort of program that would pay for his costs, he says he is. “But I didn’t take it,” he says, as he half-shrugs his shoulders and looks upward. “I didn’t want to go through the paperwork and do that hassle. I just wanted to get in and get out.”

A little bit later, a 29-year-old mother comes by pushing her 2-year-old daughter in a stroller. While her daughter is insured by Medical, the mother isn’t. “I don’t know why not,” says the woman, who is probably 50 pounds overweight, and admits not having been to the doctor since her daughter was born. When asked if she’s eligible, she says she doesn’t know.

“I feel fine,” she says. “If I feel sick I guess I’ll go to the doctor and find out.”

An 18-year-old man walking by says essentially the same thing. He’s not insured. He hasn’t been to the doctor since he was a kid. And he’s not sure if he’s eligible for health insurance.

To Julie Edgecomb, director of outpatient service at the Monterey County Health Department’s clinics, this attitude is proof that immigrants don’t come to this country to access services like healthcare. If anything, they avoid them as long as possible.

But the responses by these Salinas residents speak to another issue. And that’s that a large number of people are willing to take big risks with their health, usually in order to save time or money or both.

I know this because I’m one of them.

While I earn too much to qualify for most government-sponsored healthcare programs, my wife and I figure we don’t make enough to afford the health insurance coverage available through my company for a family of four. We’ve decided that we’re willing to risk our health for a while until we figure something out. In the meantime, we try to minimize our risks by eating right and exercising as much as we can. And hoping that nothing bad happens.

Dr. John Silva at Clinica says mine is an increasingly common case in the US. He hands me a report called “Gaps in Health Insurance: An All-American Problem.” It says that 46 million people in 2004 (about 11 percent of the country’s population) didn’t have health insurance. More than 80 percent of these were either working Americans or dependents of working people.

What’s more, while low-income families were the most likely to go without insurance, 41 percent of working-age Americans with incomes between $20,000 and $40,000 were uninsured for at least part of the last year, a huge jump from the rate just five years ago.

And yet, even as more middle-income Americans begin to the feel the pinch of having no healthcare coverage, there seems to be little political pressure being put on political officials to do anything about it.

Only 4 percent of voters surveyed by the Public Policy Institute of California said health insurance was a topic they’d most like to see the state’s gubernatorial candidates discuss. That’s far behind topics like immigration, education and the economy.

Meanwhile, people like Gerardo Galban are finding their own way of dealing with the problem.

Standing outside Natividad Medical Center last week waiting to visit a friend in the ER, Galban admits that he is suffering from diabetes and has had no health insurance for the last year.

“I was on disability because of a back problem but then it ran out,” he says. “Basically, I haven’t had any money to buy my medications, so I’m not taking them.”

He says he knows it’s risky. But to compensate, he’s changed his lifestyle.

“I stopped drinking soda, I stopped eating greasy and fatty foods,” says Galban, who is 44 years. “And I’ve been doing whatever exercises I can to keep in shape.”

He says he’s never felt better and that he expects to have health coverage kick in again in a month or so if he lands a construction job he’s been courting for some time.

“There’s not much you can do in these cases,” Galban says as he throws down the cigarette he was smoking—one of his few remaining vices. “But you have to at least try.”