Hurdles to Healthcare in NY: Taste of Our Future Under a Multi-Tiered System?

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At Clinic, Hurdles to Clear Before Medicaid Care

By RICHARD PÉREZ-PEÑA

Published: October 17, 2005

Atop a rise on Burnside Avenue in the Bronx, the Morris Heights Health Center looms above a bustling stretch of storefronts offering arroz con pollo and cheap clothes. The clinic is a crucial medical safety net for tens of thousands of people, many of them struggling.

It is a place of solace and deliverance and, just as often, futility and frustration, much of it linked to Medicaid, the government insurance program for the poor.

Every day, the clinic sees patients like Crystal T. Shuler, a single mother who has been a Medicaid client several times - and has seen her insurance cut off just as often, for reasons she does not grasp. She comes to Morris Heights, pregnant and without care for months, to make her third recent attempt to enroll. Her first application was rejected for minor mistakes; on her second try, she did not have all the documents she needed to satisfy New York State.

There are also people like Ronald Shinnery, asthmatic and struggling for breath, who embodies an uncomfortable reality for Morris Heights and other communities served by Medicaid: He can be his own worst enemy, ignoring basic paperwork until, for the second time, his insurance expires and his medicine runs out.

Dr. Tomasz Howard's examination of a fifth-grade girl lays bare another chronic problem. He has to explain to her parents that she has an irregular heartbeat, but cannot see a cardiac specialist for almost half a year. New York pays specialists poorly to participate in Medicaid, and many refuse Medicaid patients.

Sixteen months spent inside Morris Heights, listening to patients, clerks, nurses, doctors and administrators, provides a stark education in Medicaid as it is lived at coarse, unpredictable ground level. Those months illuminate Medicaid's sprawling good works, and how they are undermined by inscrutable rules, daunting paperwork, human frailties and, plainly, the puzzling ways New York spends the program's billions of dollars.

For the people who turn to Morris Heights and Medicaid for care, and for those at the clinic who labor to help them, Medicaid's faults and handicaps boil down to three fundamental, dispiriting truths that strike at the heart of its lofty ambitions:

People like Ms. Shuler have trouble getting health care through Medicaid because they do not understand the system, especially the enrollment process. That is one reason about one million eligible New Yorkers are not in the program, according to researchers. New York has recently made enrollment easier, yet it still demands more extensive documentation from applicants than any other state, requirements that can thwart qualified people and, according to experts across the political spectrum, do little to prevent fraud.

Patients like Mr. Shinnery often neglect their care - a failure of responsibility for some, and for others a symptom of lives so chaotic that receiving mail is no sure thing. They disregard paperwork or wait until they are seriously ill to apply; others skip appointments, tests and medications.

Many doctors, particularly specialists, shun patients like the girl with the heart problem, in part because New York ranks at or near the bottom among the states in what it pays doctors to treat people on Medicaid. For a large class of patients, New York pays a specialist $24 for an office visit, the lowest of any state, while poorer states like Mississippi, West Virginia and North Dakota pay well over $100, and Medicare in New York City and its suburbs pays around $200. Medicaid patients at a clinic like Morris Heights thus hunt endlessly for specialists for ailments like diabetes, heart disease and mental illness.

A legacy of Lyndon B. Johnson's Great Society, Medicaid promises that poverty need not consign Americans to live without medical care. It insures more than 50 million people, half of them children, at some $300 billion a year and rising fast.

New York runs the nation's most extravagant Medicaid program, paying $44.5 billion per year to care for 4.2 million people - roughly double, per patient, what the rest of the country spends - and state officials boast that it makes a higher percentage of people eligible, and for more services, than almost every other state. But if the program is huge and in many ways generous, those who work with it - doctors, patients, government officials, health care experts - say that the way the dollars are spent makes little sense.

The program - which consumes more than one-third of the state budget - is vulnerable to fraud and abuse by unscrupulous providers, wasting billions of dollars annually, experts and government officials say. But New York does less than other states to police payments to hospitals, nursing homes and ambulette companies, or to prosecute the guilty.

And yet, life at Morris Heights makes clear how keenly New York scrutinizes ordinary patients trying to get into Medicaid, in the name of ensuring that ineligible people cannot slip through. "We do a better job than we'd do if we didn't have all of these requirements in place," said Dennis P. Whalen, executive deputy commissioner of the State Department of Health.

But experts say that kind of cheating is a small part of Medicaid fraud. The problem, says Elisabeth Benjamin, former chief of health law at the Legal Aid Society, is that "the state looks at each applicant as a potential criminal."

Yet the typical people striving to enroll in Medicaid are poor children and their mothers, clients who cost relatively little to cover. Children and able-bodied adults - mostly women - are about three-quarters of New York's Medicaid patients but account for about one-quarter of the expenses. Those costs pale next to what the state spends caring for disabled and elderly patients, who account for more than 70 percent of the spending - partly because New York spends far more than other states on services like nursing homes, home care and hospitals, while scrimping on the most basic form of care, doctor visits.

Devoting more effort to screening ordinary patients than to examining providers "is pretty ludicrous," said Robert Goldberg, a senior fellow at the Manhattan Institute, a conservative group critical of Medicaid. "Where they're looking isn't where the major money is, or where the major fraud is."

But these are facts of life at Morris Heights, where Medicaid is both a daily life-saver and just so much wasted effort.

After two decades in health care, much of that time tending to the poor and grappling with Medicaid, Anita Wilenkin, chief operating officer of Morris Heights, says the program's idealism too often goes unrealized. "It makes things harder than they need to be," she says, and frequently, "what's on paper, what it's supposed to do for people, doesn't get done in reality."

From a modest start in 1981 as the project of neighborhood activists, Morris Heights, a nonprofit, has grown into a mainstay of the area, almost as familiar as the Jerome Avenue elevated train that thunders by. This year, some 45,000 people - the community is a mix of Dominicans and other Hispanics, African-Americans, and pockets of English-speaking Caribbeans, Cambodians, Africans and Arabs - will push through its doors, making 150,000 visits. It has four main clinics, a birthing center and clinics in schools.

Observed day after day, Morris Heights at once confirms stereotypes about the world of Medicaid and confounds them. The people who turn up and who benefit from Medicaid range from illiterate immigrants to college-educated professionals. Some patients grapple with drug addiction and H.I.V., while many have ailments no worse than the flu. Waiting rooms are noisy and crowded, but also immaculate, brightly painted and graced by skylights.

Morris Heights sees its share of cheats, like the worker fired for demanding $75 from people for help with Medicaid enrollment. Enough patients sell H.I.V. drugs on a thriving black market that managers reproach doctors for simply believing patients who say they are infected.

But by many measures, Morris Heights delivers better care to Medicaid patients than they would find in most places in the city, according to insurers, government officials and other doctors. There is a nighttime urgent-care clinic, a mobile clinic that visits homeless shelters, and H.I.V. programs that send workers to patients' homes.

All of it, though, is a challenge. Employees talk of a deep commitment to serving the poor, but also complain about hard work with patients who frustrate them, in a Medicaid system they consider dysfunctional.

First, the Paperwork

On a tropical summer afternoon, Agustín Colón, a 32-year-old with the muscular body of an athlete, shuffles like an old man into a storefront Morris Heights office, his asthmatic wheezing audible across the room.

Mr. Colón, a Dominican immigrant, drops into a chair and explains in Spanish that an envelope arrived from the city, but, though it was in Spanish, he does not read well enough to decipher it. Then his Medicaid card stopped working at the pharmacy and he ran out of medication. He took the envelope to the clinic, and learned that it was his annual Medicaid renewal form; he had missed the deadline.

Hugo García, a Morris Heights employee, tells Mr. Colón that to apply again, he must collect papers proving his identity, income, assets, address and immigration status. Mr. Colón listens impassively, never removing his sunglasses, then shambles back into the heat. Mr. García's co-workers wonder if he will come back any time soon.

He returns hours later, hands full of papers, but still a few documents short. The next day, still laboring to breathe, he turns up with his papers in order. Mr. García completes his application but warns that it will be weeks before he is insured.

A daily parade of people passes through this office, struggling with the one essential demand Medicaid makes to get insurance and keep it: paperwork. Many fail to do it, or do it incorrectly or too late. Some think they have insurance but do not, some have it but do not know it, some lose it and some never get it. Patients like Mr. Colón cycle in and out of Medicaid, causing delayed treatment and duplicated work.

"The whole system is like a bunch of people trying to fill a bucket with a hole in it, working as fast as we can to pour new clients in the top, while they keep dropping out the bottom," said Maura Bluestone, president and chief executive of Affinity Health Plan, a health maintenance organization that participates in Medicaid.

These are national problems, but groups that research Medicaid have studied them most closely in New York. At any time, more than one-fifth of the people eligible for Medicaid in New York are not enrolled, according to studies by the United Hospital Fund and the Urban Institute, liberal policy research groups. Experts have long estimated that 40 to 50 percent of New York's Medicaid patients lose their insurance yearly, often by failing to complete annual renewal forms, though most remain eligible and enroll again, months or years later.

That was once true, state officials say, but no longer. They say they cannot cite a current Medicaid drop-out rate, but contend that it has declined sharply in the last few years, as New York has made paperwork easier, and enrollment has grown. The state has abbreviated long applications, allowed community groups and H.M.O.'s to sign people up, and introduced renewal by mail.

H.M.O.'s, clinics and policy researchers say that those changes have helped, but that serious problems persist. Several H.M.O.'s say about one-third of their Medicaid members still leave the program annually.

When asked why such problems arise, in hundreds of interviews, patients, clinic workers, insurance executives, policy researchers and state officials replied with a complaint that could not be more consistent if it were rehearsed: Too many people who need Medicaid are bewildered by it.

Of course, even people with private insurance can have trouble understanding its requirements, but getting Medicaid insurance is usually more complex, and must be repeated annually.

People seeking Medicaid in New York must provide extensive documentation and fill out detailed applications - paperwork that many have trouble even understanding, and that provides opportunities for mistakes. They find that Medicaid is really several programs within one, and often do not know which part they belong in. Many patients do not understand when their insurance begins and expires, or what their relationships are to the H.M.O.'s that oversee their care.

Kathryn Kuhmerker, the deputy state health commissioner who oversees Medicaid, said such confusion was unavoidable. "This is an extraordinarily complicated program, and I don't think that there's any way to simplify and still meet all the requirements" set by the federal government and the State Legislature, she said.

All states demand a great deal of information from applicants, but what sets New York apart are documentation requirements that policy researchers say are probably the most stringent in the country.

While 14 states allow Medicaid applicants to state their incomes without documentation, and most accept one or two pay stubs as proof, New York demands four consecutive stubs or an employer's letter on company letterhead. The federal government says New York is one of just four states that require documentation of citizenship or immigration status from nearly all applicants. Researchers say New York may be the only state that does not simply require a Social Security number, but rather asks to see the card.

Advocates for the poor say the rules are especially troubling because the state does not need most of the documentation: It verifies the claims on its own, through sources like government databases and bank records. The state already has some of the proof it asks people to produce, like tax returns and driver's licenses.

State officials counter that the information they can verify independently is often out of date. And Mr. Whalen said, "We would probably disagree that it's overly burdensome for people to produce vital records."

Enrollment Confusion

New York's basic Medicaid application, fairly typical of those around the country, is six pages, with another six of instructions. The questions are mostly reasonable, but the detail and complexity can trip up even experienced health care workers. The application, for example, delves into obscure areas like whether a friend helps with the rent, whether a renter pays for heat, and even what kind of heating fuel a home uses.

For people who move frequently and often have little education, Medicaid's yearly renewal process is a particular burden - even receiving and comprehending forms and letters that warn of impending deadlines can be an obstacle. Patients are required to tell the government if they move, but many are unaware of the rule and are knocked out of the program.

Insuring all the eligible people who are not in Medicaid would cost a couple of billion dollars each year. But even most critics of the program do not accuse New York of a conscious attempt to save money by suppressing enrollment - a charge that they and others have made against some other states. Rather, they say, the obstacles in New York reflect a broader ambivalence about aiding the poor.

"We think of Medicaid as a welfare program, so it's given grudgingly," said James R. Tallon, president of United Hospital Fund, a New York-based liberal research group. This is in contrast to views of Medicare, the federal health plan for the elderly, which is a widely accepted program used mostly by middle-class people, he said.

A handful of states have tried simplified applications and found that enrollment rose sharply without a major increase in fraud. Federal regulators have found that in every state, care for ineligible patients accounts for less than 2 percent of Medicaid costs. People who study the program - and not just those who advocate more services for the poor - say that letting patients who do not belong into Medicaid is not a major problem. But they say that focusing on such people is politically safer than cracking down on cheating by hospitals, nursing homes and doctors, who wield great lobbying power in Albany.

Mr. Goldberg of the Manhattan Institute says he believes that not many ineligible people enroll. "I don't think there's any question that most of the fraud is provider-driven, not patient-driven," he said.

Kemp Hannon, Republican chairman of the State Senate's Health Committee, added that even if ineligible people slip through and are treated for illness, "the public health has been well served. Is that what you really want to worry about?"

Mr. Whalen agreed that such fraud was minor, which he said "speaks to the strength of the front-end part of the system, where we take a look at eligibility."

The last several years have given rise in New York to "facilitated enrollment," a mini-industry of thousands of people at clinics and Medicaid H.M.O.'s who, without charge, fill out applications for people. Morris Heights has seven people doing this work in the office where Mr. Colón sought help, a converted convenience store a block from the main clinic.

The acknowledged master is Theresa Solano, 51, a short woman with a wide grin and plenty of opinions. She has a striking memory for clients' names and problems, and for Medicaid's little wrinkles: how to get applications expedited, how to get expenses covered retroactively.

"These people we see, I've been where they are: immigrant, poor," she says. A native of Honduras, Ms. Solano married, raised three children and put herself through college while working jobs as a nightclub hostess and a union organizer. She offers patients a mix of sternness and sympathy, reassuring them about their health and lecturing them about meeting deadlines and teaching their children English.

Her work tests the limits of patience, as when Diane Watson sits beside her on a summer morning, three small children in tow. The state computer says she was dropped from Medicaid and from the H.M.O. that managed her benefits.

This is news to Ms. Watson, who insists that she never signed up for Medicaid. It is as if they were speaking different languages. Ms. Watson pulls a jumble of Medicaid and H.M.O. cards from her wallet and admits that she does not know what each one does, or what an H.M.O. is.

On a rainy June morning, another patient, Brenda Johnson, 52, edges into the Morris Heights enrollment office, wide-eyed and trembling, and scans the faces there. Ms. Solano shoves aside a stack of papers and beckons the new client to her desk.

Ms. Johnson speaks in a whispered rush. She has breast cancer and no insurance, she says, uncurling her fist to show $350 in medical bills she cannot pay.

If she were insured, she says, the tumor would have been caught sooner, but she dropped out of Medicaid years ago, because "I didn't understand the paperwork, and I wasn't sick, so I let it slide." She reapplied months ago, but nothing has happened.

Ms. Solano taps into the state's Medicaid computer system and finds that, in fact, Ms. Johnson has been insured for two months and delayed treatment needlessly. As she explains, Ms. Johnson's face is a slide show of expressions, surprised to skeptical to perplexed to worried and back again.

Someone, it turns out, has mistakenly put Ms. Johnson into the wrong Medicaid program. She is poor enough to qualify for a more generous part of Medicaid that would pay her recent medical bills, but this one will not.

She shakes her head and says, "I just don't know how I got this messed up."

At Home, Turmoil and Apathy

Susan Billinghurst, a physician's assistant, keeps a drawer full of mysteries she hopes to solve, suffering she hopes to avert.

In the windowless exam room that doubles as her office, she hauls an armload of patient files out of that drawer, thumps them onto her desk and picks up the phone.

Tests show that the patients, all women, may have cervical cancer, which can be fatal, or diseases like chlamydia that could make them infertile. But they do not know it.

Morris Heights has sent letters and left phone messages, urging them to return. But months later, they have not learned what dangers they face, have not had follow-up tests, and have not been warned that they could infect others.

Tracking them down could be a full-time job. Instead, it is something that Ms. Billinghurst, who works in gynecology and obstetrics, does whenever she has a few free minutes. Staff members say a large fraction of their patients never return for test results or follow-up treatment.

"How can you provide care when you can't find people?" asks Ms. Billinghurst, a businesslike 36-year-old native of St. Vincent. "They move, their phones get cut off, they don't get their mail, and they all have a lot of other problems going on."

"But that's not the whole story," she adds. "A lot of them just don't take responsibility."

Treating patients is a haphazard business when many live in turmoil or nonchalantly disregard their own well-being, and the Morris Heights staff members tell of countless examples. Patients turn up less with an air of entitlement than with a shrugging fatalism: Either things will work out, or they won't.

Yanet Veras, 36, knows too well about chaos. An occasional Morris Heights patient, she has lived in the neighborhood for a few years, moving frequently, sometimes to her native Dominican Republic.

She learns just before giving birth to her second child that she is H.I.V.-positive. A few months later, her husband is arrested for his role in a robbery. The family loses his meager income from odd jobs, and soon they stop getting welfare payments.

Mrs. Veras can no longer afford her apartment, so she and Solangea, 3, and the baby, Jonathan, move in with a friend. Soon, they move to another friend's place.

At some point in this tumult her Medicaid expires, but she does not notice, or remember receiving a renewal form. "There was so much confusion," she says in Spanish.

She applies to recover her insurance, but before it takes effect, she runs out of her H.I.V. drugs.

Eventually, Mrs. Veras becomes one of Ms. Billinghurst's missing patients. Finally, in February, Ms. Billinghurst finds Mrs. Veras, who explains that she has been in the Dominican Republic and returns to the clinic for her test results.

Others live with much less turmoil, and find it harder to blame forces beyond their control when they stumble. Some, like Maria Cuevas, concede matter-of-factly that they could have - should have - done more to solve their problems.

On one visit, Ms. Cuevas, a single mother, says her 9-year-old son, Orosmar, went most of his life without health insurance, though she and her daughter had Medicaid. His birth certificate omitted his first name. She needed to go to court to register his name, but she says she put it off for years. Then Orosmar developed asthma. "I couldn't get him medication because I couldn't pay for it," she says, "so I did home remedies or I gave him some of his sister's medicine, which you're not supposed to do."

Morris Heights workers are torn between sympathy for these patients and frustration at their apathy. Patients are more likely to walk into Morris Heights unscheduled than to make appointments, and they keep only about half their appointments.

Ralph Belloise, administrator of Morris Heights' H.I.V. programs, says the great majority of H.I.V. patients do not adhere to medication schedules well enough to make the drugs fully effective.

When Ms. Billinghurst sets out to track down 15 of her missing patients, her first several calls yield two disconnected numbers, two that ring unanswered, and two answering machines. On the seventh try, success. "Please come in today; this is important," she says. "You're not busy. I promise I won't scold you anymore."

The day turns into a good one. Harsh weather means fewer patients, so she has time to call all 15 women, and she reaches two. Better yet, two women she called earlier in the week appear at her door.

In late afternoon, a pregnant 18-year-old arrives. She tested positive for chlamydia months earlier.

"O.K., so now I'm here, so it's no big deal," she says.

Ms. Billinghurst rolls her eyes. "This is reality," she says. "What can you do?"

The Search for Specialists

Dr. Jadiyi Salim-Ortiz holds little Angel Pérez's surgically reconstructed hand and smiles down at him, but she is fuming inside. Once again, she thinks, she must do bureaucratic battle to have him see the doctors he needs.

Angel, almost 2 years old, was born with a hand that could barely grasp and ears that could barely hear. A series of operations offers hope, but his deformities are so rare that Dr. Ortiz believes they are beyond the range of the limited number of surgeons offered by the form of Medicaid he has.

After some wrangling, Angel has gone to the hand surgeon Dr. Ortiz wanted, but now she learns that there is trouble getting him physical therapy to re-learn how to use the hand. And she predicts, correctly, that finding doctors to fix his ears will mean yet another struggle.

"This is the most frustrating part of a frustrating job," says Dr. Ortiz, 50, a Morris Heights pediatrician. "Why do we have to fight to get these children to specialists?"

A glaring weakness in Medicaid is that many doctors do not participate. In particular, hunting for specialists often means being turned away or waiting for months.

Many doctors complain that the patients are unreliable, skip appointments and show up with expired insurance, but the most common reason doctors cite for refusing these patients is low pay by Medicaid. The problem applies to general practitioners seeing children with earaches, but it is most acute for specialists treating less common ailments, like seizures or kidney failure.

For many years, New York ranked last in Medicaid payments to doctors, and even after sharply increasing some fees early in this decade, it still pays less than all but two states, according to a 2004 report by the Urban Institute and the Center for Studying Health System Change. They found that on average, New York's doctor fees were 45 percent of what Medicare paid for the same services. New York is also the only state that does not pay doctors more for complex examinations than for simple ones, or pay specialists more than internists.

The disparity is most stark for specialists. For a moderately complex office consultation with a specialist, Medicaid in New York pays $24, the lowest of any state, compared with a national Medicaid average of more than $91, according to the Urban Institute. For the same visit in New York City, Medicare pays about $200, and private insurance generally pays somewhat more than Medicare.

New York's low doctor fees make for a striking contrast in a state that spends more than most states for nearly every other kind of service. For each person enrolled in Medicaid, New York spends about two times the national average on hospital care, nursing homes and mental health facilities.

Managed care was supposed to solve the doctor shortage in Medicaid. In the last decade, New York has moved about 60 percent of its Medicaid patients out of the traditional system of paying doctors directly for each service a patient received, and into H.M.O.'s that receive a monthly lump sum from the state for each patient. State officials predicted that the H.M.O.'s would pay doctors better than the state did, drawing more doctors into the system.

It worked, but to a limited extent; the state says the number of specialists treating Medicaid patients through H.M.O.'s has risen 22 percent in seven years, but the number of patients has climbed faster. Those H.M.O.'s pay doctors much more than the state does, but it is still, on average, about 20 percent less than what Medicare pays. Just as important, many specialists do business with just two or three of the 20 Medicaid H.M.O.'s in New York City, making them off limits to the great majority of Medicaid patients.

The result is that the oft-touted generosity of Medicaid in New York, the promise of world-class care, breaks down when confronted by the realities of Medicaid's structure and economics.

The doctor shortage varies enormously from one specialty to another. "Pediatric mental health is the worst," says Irwin Redlener, president of the Children's Health Fund, which provides care to poor children. "There are a quarter of a million kids on Medicaid in New York City on waiting lists to see mental health specialists."

When Dr. Ortiz at Morris Heights sees that one patient, a 14-year-old girl, needs psychiatric treatment for depression, she finds that none is available. While waiting for an opening, the girl attempts suicide and enters a mental hospital.

In the daily lives of places like Morris Heights and their patients, all of this translates into an exasperating pursuit of specialists, a chase best seen from a tiny office in Morris Heights' clinic at 183rd Street and Walton Avenue, where Angelina Ayuso tries to make specialist appointments.

In August, a pediatrician finds the heart murmur in the 10-year-old girl on Medicaid, but cannot tell if the problem is minor or life-threatening. Ms. Ayuso calls Jacobi Medical Center, where a clerk tells her that the wait to see a cardiologist will be four months.

Later, Ms. Ayuso calls Bronx-Lebanon Hospital Center for a middle-aged woman with a lump in her breast. She accepts a mammogram appointment three months away.

A month later, things are worse. On Jacobi's appointment line, a recording tells Ms. Ayuso she will wait 100 minutes on hold.

The occasional patient with commercial insurance "is like a holiday," she says. "It only takes a minute to get the appointment, I can do it online, we get the specialist we want and it's not way in the future."

Things are not so simple for Angel Pérez, the boy at Morris Heights with malformed ears, and his parents, Dominga Rosario and Miguel Pérez. Dr. Ortiz, the pediatrician, protests that the limited doctors available are not adequately qualified. She wants the H.M.O. to pay for him to see specialists who do not ordinarily see Medicaid patients.

Angel was born missing the main bone in his left thumb, leaving it hanging useless. A somber boy, he has a habit of hiding the hand behind his back. His outer ears are just small lumps of skin that cover the ear canals, so he hears and speaks poorly.

Angel, his parents and his two sisters live in a cramped, subdivided one-bedroom apartment near the Grand Concourse. The parents, Dominican immigrants, work long hours, Ms. Rosario in a beauty salon and Mr. Pérez driving a livery cab. They have only a vague sense of their rights under Medicaid.

But they have a formidable ally in Dr. Ortiz, a Paraguayan with a sense of righteous indignation, who is willing to cajole, shame and plead for her patients.

An audacious operation could re-position his left index finger so that it functions like a thumb. After some haggling, Angel's H.M.O. relents, and agrees to pay for Angel to see a hand specialist at the Hospital for Special Surgery, in Manhattan. The surgery is a success, and Dr. Ortiz says Angel needs physical therapy immediately. But it all requires another round of calls, and two months pass before therapy begins.

Dr. Ortiz wants Angel to see ear specialists, but this time, the insurer stands fast, and it sends the boy to its own doctors, who advise a five-year wait for ear surgery. "Every month he cannot hear well, his speech falls farther behind," Dr. Ortiz says. There are more calls, more letters.

Eventually, Medicaid officials agree to remove Angel from the H.M.O.

Still, five more months go by before Angel sees a surgeon who might build him normal-looking outer ears. The family eventually moves to a bigger apartment and Dr. Ortiz leaves Morris Heights for another job, and everything gets put on hold.

Indeed, a year and a half after his parents and Dr. Ortiz started trying to address his problems, Angel, now 3, still has not seen the inner ear doctor.

"It shouldn't be this hard," Dr. Ortiz says.

So it goes at Morris Heights: part marvel, part misery. Medicaid can save a child like Angel from a life of isolation and limitation, but it promises to be a struggle each step of the way.