THERE’S A THEORY MAKING THE ROUNDS in the emergency department at Children’s Medical Center Dallas: “I’m not sure why it is,” Dr. Thomas Abramo told me one morning last April as he headed toward one of the ER’s cramped treatment rooms, “but it just seems like the cutest kids with the nicest parents always turn out to be the sickest.”

Inside, Valeria Galarza, a seven-year-old girl with cinnamon-colored skin and giant eyes lay quietly on a gurney. Abramo gently probed her abdomen, while her father, Luis, described how she’d been complaining of pain in that region for a few months. They hadn’t sought help, he explained, because the family had no health insurance, but the pain had become more acute the night before. Abramo nodded, then asked Valeria if she’d been coughing a lot, and she shook her head. “I was thinking it might be pneumonia with referred pain to the lower abdomen,” he said, turning to the resident taking care of Valeria. “But we need blood tests to see what else it could be. It could be worse than that.”

Abramo left the examining room and headed out to an L-shaped counter that is the hub of this sprawling trauma center just northwest of downtown Dallas. The six corridors that extend out from the hub were filled with doctors and nurses striding briskly to and from the ER’s eighteen treatment rooms, their blue surgical togs color-coordinated with the unit’s walls. Abramo, 48, has helped run this department since it opened, back in 1991, watching it go through multiple expansions and become one of the busiest and most respected pediatric emergency facilities in the country. But while there is never a shortage of patients at Children’s (the waiting room was full that morning), Abramo and his staff see more upset tummies and runny noses these days than true emergencies. The Children’s Medical Center emergency room has always been the hospital of last resort for the indigent and uninsured in North Texas. But since last year’s cutbacks in the Children’s Health Insurance Program (CHIP), the federal- and state-funded health-care program for families of the working poor, nonemergency traffic has only increased, and Abramo and his ER colleagues have occasionally found themselves overwhelmed.

After checking in with a few residents at the hub, Abramo headed for the “wheezer room,” a long, drab rectangular space where children with breathing problems are treated. That morning a dozen or so kids who’d suffered asthma attacks sat with their mothers and fathers, sucking on nebulizers to open their inflamed bronchial tubes. Two of them belonged to Sonia Yguerabide, an attractive and talkative young mother. As Yguerabide described her children’s symptoms, Abramo used his stethoscope to listen to them breathe. “She has asthma,” he said, addressing Yguerabide’s seven-year-old daughter first. “Has she been taking medication?” Her mother told him that it had run out; when she lost her job, she’d been dropped from CHIP. Then Abramo turned to her son, a frail four-year-old who had a deep, braying cough. “He may or may not have asthma,” said Abramo. “But he definitely has croup.” While he wrote a prescription, Abramo explained to Yguerabide that in the future, her children would be better off with regular doctor’s visits than trips to the ER. She said she understood, but with no insurance to cover those visits, it was hard to imagine that her children wouldn’t one day be treated again by the emergency pediatricians at Children’s.

Abramo made his way through the rest of the patients in the wheezer room and was walking down another corridor when his cell phone rang. It was the hematology department with word on the blood tests for Valeria. “It looks like she has leukemia,” Abramo told me as he hung up. The hospital would try to qualify the Galarzas for public assistance, he explained, but if that failed, Children’s would wind up eating the cost of her treatment. Fighting the disease could take months to years and tens—maybe hundreds—of thousands of dollars. “What did I tell you about the cutest kids?” he said.

IF YOU WANTED TO WITNESS firsthand how the rising number of Texas’s uninsured families has affected the health-care industry on the ground, you couldn’t find a better place to start than Children’s Medical Center. The story, of course, has been all over the state’s newspapers: Last year, faced with a projected $10 billion shortfall in the state budget, the Legislature ordered cuts in social services to make up the difference. One of the hardest-hit programs was CHIP. By instituting more-restrictive eligibility requirements and raising premiums, the Legislature forced nearly 130,000 kids—25 percent of CHIP’s enrollment—out of the program. A year later, one in five Texas children—more than in any state in the country—are uninsured.

What you may not know is where those kids are going. Increasingly, their parents have turned to emergency facilities like the one at Children’s instead of doctors’ offices. For every vehicle-wreck victim or leukemia patient Abramo and his staff see, there are at least three minor wheezers or kids with a winter flu bug. Their parents bring them here because they know that the law mandates that the ER, as an emergency facility with federal funding, treat them. As such, the patient load at the Children’s ER has increased by 17 percent since 2000, from about 90,000 patients a year to 105,000. “There are times when we’re overwhelmed,” nurse Richard Escobedo, a ten-year veteran of the Children’s ER, told me during one visit. “We’ve had to go on a minor divert status, where we get patients sent elsewhere.” Bobbie Minns, another veteran nurse, agreed. “I’ve seen the waits in winter go as long as twelve hours,” she said. “I come in for my shift and see this family in the waiting room, and they’re still there when I leave.”

Meanwhile, the amount that the hospital spends out of its own pocket on patients who have no insurance has more than doubled over the past decade. And it’s not just the administrators at Children’s who are feeling those costs. The shift from preventative care to emergency care is driving up the cost of health-care premiums statewide. A visit to the emergency room, after all, where a patient’s life is always assumed to be at risk, demands a much more expensive treatment protocol than a trip to the neighborhood clinic. Take, for example, the treatment of asthma attacks, one of the emergencies Children’s has found itself increasingly inundated with. The ailment could be brought under control for a few hundred dollars a month by a private physician. But if a child is not insured and not getting regular treatment, his asthma is more likely to flare up, and the cost of an ER visit and resultant hospitalization might be as much as $7,000. Meanwhile, minor asthma attacks are just one of many such nonemergencies being treated in the Children’s ER. On one visit, I found Abramo treating a young boy with an infection on his scalp. “He has a fungus,” Abramo patiently told the child’s mother. “Use Selsun Blue if you can.”

Cases like these have created a sort of negative feedback loop: More and more uninsured children show up at the ER with minor problems, which drives up the cost of everybody else’s health care, which drives more children out of the health-care system. “We’re just headed in this direction where a smaller and smaller group of people is paying for the health care of more and more,” said Abramo.

The shift is beginning to affect the hospital’s bottom line. Though Children’s operated in the black for the first half of 2004, there were danger signs lurking on the books: Income from operations was down 28 percent from the first half of 2003. The hospital’s provision for “doubtful accounts”—money it is owed but will probably not be able to collect from patients who did not qualify for charity care—had jumped 21 percent over the same six months in 2003. Administrators haven’t been shy about identifying the cause. “In the 2003 Texas legislative session, significant changes were made to the CHIP and Medicaid eligibility criteria,” the hospital’s management wrote in its six-month audit this past July. “The impact of these changes was seen in the quarter and in the six months ended June 30, 2004, as the volume of CHIP admissions declined 27 percent. . . compared to comparable periods in 2003.”

Spreadsheets aren’t the only place where red flags are being hoisted. As recently as 2001, Children’s was rated number seven in the country, according to the prestigious rankings in Child magazine. A year later it failed an accreditation survey by the Joint Commission on Accreditation of Healthcare Organizations, scoring below the average for the first time in its history. That same year it was left off of Child‘s rankings and hasn’t been included since. The accreditation score has subsequently been raised to slightly above average, and the hospital fully expects the current survey to go more smoothly. But for an institution that has always prided itself on being state of the art, the 2002 results were a major disappointment. Such problems are difficult to attribute directly to an emergency facility glutted with uninsured patients, but it isn’t unreasonable to wonder if the growing number of uninsured kids in Texas has forced one of the state’s best hospitals to spread itself too thin.

WHAT IS NOW THE CHILDREN’S MEDICAL CENTER DALLAS has always had an overabundance of good intentions. The hospital is actually the result of four children’s facilities joining forces shortly after World War II: a Dallas “baby camp” for kids with gastrointestinal problems, the Bradford Memorial Hospital for Babies, the Richmond Freeman outpatient clinic, and the Children’s Hospital of Texas. After the merge, the resulting institution developed a simple, eloquent mission statement: “To make life better for all children.”

For most of its first fifty years or so, Children’s succeeded, expanding in tidy little increments, each new building block made possible by philanthropy from city fathers or a generous line of credit from the banks some of them ran. The former was always enough without being lavish; the latter was always paid back promptly and in full. Through the years the hospital became a modest pioneer: One of the first pediatric intensive-care units in the nation was opened here in the fifties, and a decade later, Children’s started the first pediatric day-surgery program. By the late seventies, the hospital was still a small and somewhat anonymous not-for-profit pediatric facility with one hundred or so beds, 450 employees, 35,000 outpatient visits a year, and $16 million in gross revenue. It was a kind of throwback, an oversized mom-and-pop operation that paid its bills in cash, on time, and never came close to outgrowing its market.

In the eighties Children’s began taking advantage of the increased federal funding for teaching hospitals. (Children’s has served as a teaching hospital for nearby University of Texas Southwestern Medical School since the mid-sixties.) The new money allowed the hospital to provide exotic services such as organ transplants, sickle cell anemia treatment, and trauma care that could not be found anywhere else in the region. It also allowed the hospital to grow. Since the late eighties, it has almost tripled its bed capacity, and it now fields more than 300,000 outpatient visits a year. Aside from owning the busiest pediatric emergency department in the country, Children’s has built one of the largest cystic fibrosis units, and its liver and heart transplant programs are envied for their success rates. The hospital has also treated a number of “celebrity patients,” such as the conjoined twins from Egypt who were miraculously separated last year.

All the while, Children’s has remained a hospital that treats the indigent and the uninsured. Until recently, that mission was manageable, but with the advent of managed care, both private and public carriers became stingier about doctor’s office visits, the medications they covered, specialty referrals, and co-pays. About the only place this wasn’t true was in emergency care, where both private and public insurers were traditionally happy to pay nearly 100 percent of the charges. And by the turn of the century, more and more patients who didn’t have life-and-death conditions—up to three out of four—began to show up at the Children’s ER. So did the number that did not have insurance—up to fifty a day.

While last year’s CHIP cuts certainly exacerbated that problem, no one can accuse Children’s of being caught by surprise. Ever entrepreneurial, Children’s has spent the past decade trying out alternate strategies to handle its increased ER traffic. In 1997 it began diverting less serious cases to First Care, a large new clinic that sits adjacent to the ER on the hospital’s second floor. But the plan has turned out to be another example of “If you build it, they will come”; when word spread that First Care also treated the uninsured, it quickly became as crowded and overrun as the emergency room.

Two years later, hospital management tried to redirect patients to its new satellite facilities such as the Physicians for Children at Bachman Lake, in northwest Dallas, an anonymous-looking part of several strip malls along busy Northwest Highway. The Bachman area clinic was its own bold experiment in health care. Staffed by four bilingual doctors, it was designed by Children’s management as an alternative to the ER for low-income families. Unlike the ER, though, the clinic demanded that some form of payment be provided, whether Medicaid or CHIP or just cash. When CHIP was fully funded, the clinic flourished during its first two years of operation, serving more than six thousand patients a year and still breaking even, a minor miracle for a facility specializing in treating the working poor. But last year’s CHIP cuts siphoned off many of the Bachman clinic’s steady clients. Many of them began to stream back to the Children’s ER.

Now Children’s is running out of options. The growing popularity of the hospital has forced it into a schedule of almost exponential expansion. In just the past four years, the ER has been expanded, and six floors with an additional 132 beds have been stacked onto one of its towers. There may be a point where Children’s good intentions don’t make sound business sense anymore. Hospital administrators call this a “negative payer mix,” meaning that the cost of the uninsured patients becomes a drag on the revenues brought in by the paying ones. This is one reason why Children’s has recently become even more aggressive in expanding its satellite facilities. But unlike the Bachman clinic, the envisioned seventy-bed Children’s Medical Center Legacy, in Plano, is intended to massage the Dallas area’s more affluent suburban communities. Children’s latest efforts to deal with the uninsured, in other words, is to increase profits among the insured. “You have to go find where the insured patients are,” says the hospital’s senior vice president of business development, Patricia Winning. “It’s one of the only ways we can continue to help all children.”

ONE EVENING THIS PAST SUMMER, I found some of the Children’s ER residents hanging around the L-shaped counter. They were joking and grousing about how long it had been since they’d treated anything but a wheezer. Then a call came in from EMS: Paramedics were transporting a ten-year-old girl who’d been riding in the backseat of a car when her brother, who was driving, lost control and rammed through a fence and hit a tree.

A palpable buzz filled the room as doctors and nurses rushed to the rear of the facility, where the ambulance portal is located. The patient arrived, strapped tightly to a gurney. A team of doctors inspected every square inch of her. Vitals were checked; x-rays taken. A social worker hovered about to calm the parents; a chaplain was on call. Surgery was notified to ready an operating room upstairs.

As the attending physician on duty, Abramo was called to the trauma room to look over the girl and pass judgment on the diagnosis of the residents. After a brief consultation, the injury was confirmed. “She’s one very lucky little girl,” Abramo concluded. “All she has is a broken arm.”

More-severe cases have certainly been handled in the Children’s ER over the years, but it was still inspiring to witness actual emergency medicine being practiced in the emergency room. It wasn’t an hour later, however, that I found Abramo back in another treatment room, examining a young boy who’d hurt his finger while playing. It was hardly even bruised.

“You take them as they come,” he said, shrugging. “Sometimes there’s no place else to go.”