A doctor who treats the uninsured and underinsured in America becomes a practitioner in a niche with few medicines or tests and no high-tech studies -- a medical system that specializes in neglect. PNS commentator Wendy Johnson, M.D., is a family practice physician working in a public health clinic in Cleveland, Ohio. Her e-mail address is wendyj@igc.org.

CLEVELAND -- The uninsured are in the public eye again and none too soon. During the past few years, the problem of access to health care may have faded from the political stage, but it has only grown worse for the burgeoning number of people (nearly 45 million at last count) struggling to take care of themselves and their families in an increasingly hostile system. Those of us who treat the uninsured or underinsured have been forced to become specialists in a niche with few medicines or tests and almost no high-tech studies. We become experts at getting a few precious drops from the sea of medical technology that surrounds our patients, but are denied to them.

Often we face problems about which we can do very little:

- The pregnant woman who thought she just had the flu and waited until she couldn't eat or drink to come into the hospital because she couldn't afford a doctor's visit. She miscarried from an overwhelming infection.

- A young mother with a sudden onset of intractable headaches, nausea and vomiting who had to choose between paying the rent and paying for a CAT scan of her brain to rule out the possibility of a tumor.

- The Nicaraguan immigrant who could not afford a mammogram to investigate an ominous mass in her breast.

- And a 35-year-old man with diabetes who doesn't have the money to pay for critical blood testing to monitor his illness.

Simply by living in poverty, these patients share increased risk for

infectious diseases, asthma and complications of chronic illness.

Many patients don't even make it into my office as shown by the higher infant mortality rates and shorter life expectancies in the poorest neighborhoods.

There are no residencies for this "specialty." Many of us trained to do

internal medicine, family practice, pediatrics. We found residencies in inner cities and rural areas so we could learn the combination of social work, advocacy and medicine needed to care for patients in a terribly flawed system.

We know which antibiotics and blood pressure medications are the

cheapest, and often prescribe drugs because we are thinking of cost rather than more medically respectable grounds like efficacy or side-effect profiles. We learn to pare down to the essentials, narrowing our diagnostic studies to a vital few.

We practice at public hospitals or community health centers which

attempt to provide "charity care" to the uninsured -- at least those lucky enough to live near such increasingly rare institutions. We do have a cobbled-together network of hospitals and clinics serving the uninsured, but people still fall through the cracks. Some live too far away, some are immigrants -- with and without papers -- we allow to do our hardest labor while denying them basic health care services. Some have problems like drug addiction or mental illness for which accessible treatments are even scarcer than for other medical problems.

Of course, I don't like to practice medicine this way -- spending an hour on the phone to find mental health services for a patient, begging for free samples from drug company representatives, calling specialists to find one who will let patients pay off their bill $10 a month.

It certainly isn't what I was taught in medical school. But because of

the growing recognition of our two-tiered practice of medicine, we now even have our own professional society, the Association of Clinicians of the Underserved.

Demand for our services is growing as the nation's policy makers show little interest in taking on the lobbyists who represent the private HMOs and insurance companies.

The uninsured are not alone. With more and more for-profit HMOs

controlling access for the insured, a robust bottom-line becomes more important than a robust population. Nearly everyone has a personal tale of health care turned bureaucratic hassle.

No amount of tinkering will cure the for-profit medicine industry. Of

all the presidential candidates, only Bill Bradley has come close to offering a proposal for universal coverage and his idea does little to address the growing power of corporate CEOs in deciding what our health care system will look like in the future. Instead he proposes a vast voucher system which will funnel millions more tax dollars into the coffers of corporate medicine.

In this era of unprecedented prosperity and federal budget surpluses, we must do more.

Two principles should guide health care reform: universal coverage and a move away from for-profit health care. Medicine moguls have botched the job, reneging on their promises of cost-control and greater efficiency. Badly managed Medicaid HMOs are going under leaving struggling public hospitals with millions in unpaid bills. Medicare HMOs engage picking the healthy patients and leave taxpayers to cover those who are actually sick.

It's time to say "enough" to the exorbitant administrative costs of 20-30 percent -- public programs like Medicare cost less than 5 cents of every dollar to administer. With multimillion dollar tobacco settlements, state surpluses from welfare reform, a growing economy and a balanced budget we can have what every other industrialized democracy has had for years: equitable health care for all.

We lack only the will.