MILWAUKEE — Hundreds of plastic bins are stacked like jumbo shoeboxes, nearly scraping the ceiling of a bare-bones room in a former hospital. People sit nearby in rows of chairs, waiting to be matched with a pair of donated eyeglasses from the carefully labeled containers.
It's a slow process at City on a Hill, a nonprofit that runs a monthly free clinic in a poor neighborhood on Milwaukee's north side. Many in the chairs look tired or anxious as they wait for their number to be called.
Then John Patton Jr. shows up.
He sprawls comfortably in his seat, throws his arms on the backs of the chairs next to him, and chats with those nearby. Then he focuses on the volunteer calling out numbers and waits a beat after she calls number 27 before booming out, Bob Barker style, "Number 27, come on down!"
Patton is a tall man with a broken-toothed smile; he uses his showman's voice to good effect in his annual gig as a Salvation Army bell ringer.
He's also an example of the complex interplay between poverty and health. Like many of the country's 46.5 million people living at or below the poverty line, he faces chronic health problems, doesn't get regular health care and lives in circumstances that make him sicker.
He has no regular job, until recently had no health insurance, and has health problems that include high blood pressure, a congenital heart defect, an injured back, gout, depression and the broken tooth. Patton, 51, dropped out of high school in his sophomore year. He says he has been told that he tested at third- or fourth-grade reading and math levels.
He has worked at a foundry, at restaurants, cleaning sports facilities, making commercial frozen pizzas and sorting clothes for a uniform service. In recent years, it's mostly been down to the bell-ringing and odd jobs for neighbors. He loves to read - celebrity bios, comic books, stories about UFOs - but struggles to write. He's lost at a computer keyboard.
He patches together his life making a circuit of neighborhoods near his home, mostly on foot. He knows people at clinics, social service agencies and emergency rooms.
For years he's been stuck in a cycle that is played out all over the country: without a full-time job, he couldn't get health insurance. Without health insurance, he couldn't get regular care or the therapy that might make him employable. Without income, he faced shortfalls and stresses that contribute to his health problems.
During the past several months, he's been trying to work his way out of the cycle by seeking insurance and income.
City on a Hill has been a regular stop for him for two years. He can get a medical check, groceries, clothing, toiletries, a hot meal and prayers offered for him by volunteers. But the once-a-month clinic offers only very basic health care - screenings, prescription medication refills and checkups.
Housed in what was once a large hospital campus, it operates with a small staff and volunteers and serves just over 300 people each month. The old hospital, which began 151 years ago as a charity, is once again a small facility focused on the poor. It once had hundreds of beds and was one of five hospitals serving poor residents in the downtown area. Now only one - Aurora Sinai - is left, and its emergency room is often a first stop for residents.
A 2012 National Health Interview Survey found that nearly 80 percent of adults who visited emergency departments over a 12-month period said they did so because of a lack of access to other health care providers. Emergency rooms, which can't refuse patients, and clinics in poor neighborhoods, which usually don't refuse patients, serve the large urban populations that once had many more local doctors and hospitals.
Before he started going to City on a Hill regularly, Patton usually only sought care when he was sick or injured, and it was frequently at Aurora Sinai's ER. Sometimes he gets care at the hospital's clinic across the street.
Patton is one of nine children. He lives with his parents, a brother and sister in a small house on a well-maintained stretch of Cherry Street, in a neighborhood where more than 40 percent of the residents live below the poverty line. He hasn't been able to afford his own place for several years.
It's a tightknit neighborhood along the half-circle street. Gladys Tatum, 72, lives a couple of houses away and has known Patton since he was a boy.
"He was a skinny, bony thing, but I remember he could draw like a whip," she says. "He was always waving and hollering, 'Hey!' Always drawing out on the circle." He does chores for her. "I called him a son," she says. "I can ask him whatever - whatever I ask him to do and he'll do it. He's very respectful."
Patton's mother was recently diagnosed with breast cancer. One of his sisters was murdered several years ago. Another died in a hospital after being treated for cancer. He says he struggled with drinking when he was younger and sometimes went to the emergency room after being hurt in fights. He has a scarred ear from being hit in the head with a bottle, he says. Another time he crashed while bicycling.
"I was riding on a bike, on an icy day - drunk!" he says. "I hit a fence. I got up and got back on the bike and rode 20 more blocks. The doctor couldn't believe I got back on the bike. I broke my leg in three places. That shows that alcohol is something else."
His back problems come from a 1998 injury at Grede Foundry, where a chain suspended from a crane moving a dumpster-size container broke loose and struck him in the back.
Asked how he pays his medical bills, he responds, "I don't!" then muses, "I probably got bad credit. They send me bills."
A 2014 Henry J. Kaiser Family Foundation report found one of every three Americans have difficulty paying their medical bills - either they have problems affording bills, or are still trying to pay back bills over time or simply can't pay them at all.
The Kaiser study researchers analyzed 2012 National Health Interview Survey data and interviewed individuals who had problems. They found that many people ended up in debt collections. Hospitals typically refer bills not paid within 90 days to collection agencies.
Often that debt dogs patients and drags down their finances. Medical bills account for the majority of all debt that is referred to third-party collection agents and for 17 percent of debt that is re-sold in the debt-buying industry, the study reported.
Patton was sued by Sinai Samaritan Medical Center for $1,730 in 1995 and by Aurora Health Care for $5,450.39 in 2005.
In the 2005 case record, his response is written on lined paper torn from a spiral notebook. It reads:
Dear Hon Dennis P. Moroney. I John E Patton Jr. is on able to pay the money due to the fact i've lost my job and have no way to pay Aurora Health plus I own the IRS $5,000. I have no studry income at this moment.
Although he did not have regular employment at the time and might have qualified for charity care at a hospital, he didn't realize that was an option. Eventually the collections workers stopped contacting him, he says. "They realized I have no money to pay."
He later found out about an Aurora program that provides free and reduced-cost care for patients who have no insurance or financial problems.
"We'd rather be proactive and have someone who qualifies get help" paying hospital bills, says Mark Huber, vice president of social responsibility at Aurora. He says Aurora works to identify a patient's ability to pay up front and let those who need assistance know about programs available.
Jeff Smith, chief clinical officer, says it's cheaper in the long run to work with patients who have problems paying than pursuing them or turning them over to collection agencies.
After Patton went to the Sinai emergency room with chest pains in February, he wound up in the hospital for four days and left with a diagnosis of atrial septum defect - a hole in his heart. It's a congenital condition that poses no immediate threat, but doctors told him it could make him more vulnerable to stroke should he develop a blood clot.
Though he was enrolled in the hospital's charitable care program, Patton got a bill in March informing him that current and past charges amounted to $23,817.40. Hospital officials told him it was a mix-up and the charges have since been eliminated.
Patton gets free medications at City on a Hill, so in March he arrived at the clinic with a sheaf of prescriptions - one set he got when he was discharged from the hospital and another from a follow-up visit at the Aurora clinic. The volunteer doctor at City on a Hill sorted through the two sets of prescriptions and instructions, trying to decide whether Patton should or shouldn't get antidepressants, whether he should go on a regimen of baby aspirin for his heart, as one doctor had ordered.
Such lapses in communication within and between medical care providers make it difficult for physicians working with patients who don't have a single source of regular care, such as a primary care doctor.
Patton is trying to get Social Security disability benefits for the old work injury. He took a settlement payment of a few hundred dollars instead of pursuing disability at the time - something he now sees as a mistake because his back pain keeps him from being able to stand for long periods or do the physical work he is qualified to do. Disability payments would give him a steady income he's lacked for years.
He applied on his own in November and was turned down. He is getting help on his appeal from Lisa Woodall, a benefits specialist with Milwaukee County Disabilities Services. She says there are hurdles that Patton, and many others, face in seeking disability payments.
"Social Security's definition of disability is a condition that persists for 12 months or more that prevents you from working," Woodall says.
Since Patton worked after the injury, he did not qualify. They are trying to show he qualifies based on his current medical condition.
The lack of continual medical care can weaken the cases of people like Patton, Woodall says.
"A big thing with back injuries," she says, "is that without insurance the person can't get an MRI, and without an MRI you often can't prove the severity of the injury."
In addition, she says, many of those she sees can't get treatment, such as surgery or physical therapy, that might make them well enough to work.
"But even if you can show you can't do a certain kind of work, Social Security will look at the work you've done and say, 'OK you can't do that, but what about other kinds of work?' "
Patton's spelling and writing are childlike. He wasn't sure how to spell the name of one of his sisters and could not subtract $45.72 from $100. So Woodall found it would be very difficult for him to do office work or any job that involved reading, writing or computer work.
Woodall had him fill out the form himself and then wrote in summaries of what he was trying to convey to show the evaluators the extent of his deficits. The initial application for disability benefits takes around six months. The first level of appeal usually takes three to four months, longer if there is a lot of new information being added.
"It's all based on pieces of paper," she says. "That's why it's so important to create an accurate portrayal of a person's life on those pieces of paper."
In addition to illiteracy, many poor patients lack the skills to navigate the health care bureaucracy, including access to a computer or the ability to handle online applications and forms.
Until this year, it was very difficult for childless adults in Wisconsin to enroll in Medicaid. Under provisions of the Affordable Care Act, it became easier and social service workers had told Patton he was eligible. He called numbers he was given and told people he thought he had already applied. He kept saying he was waiting for a call back on it. He was vague on what he had done, what he needed to do, and what was involved.
In February, Woodall finally sat him down at a computer in her office and helped him fill out an application form.
It was a slow process. Patton sat leaning forward, peering through glasses sitting crooked on his head, typing with one finger, long pauses between pecks. He read the sections softly aloud, trying to parse them, struggling to maneuver the mouse.
"OK, so that's it - you need to click 'next,' " Woodall said. "Whoops, let's get out of that - you don't want to click 'Vietnamese.' "
Patton laughed self-consciously and repeated over and over, "Oh, Lord!" as he looked up at the screen and back down at the keyboard.
"Where did I miss the train?" he asked under his breath.
"It's asking if you've ever had TB."
"What the heck is TB? OK, no."
"You're doing it. You're on the train," Woodall said.
Although Patton knows the people and routines of the clinics he visits, he struggles to understand his health conditions. He wonders what the hole in his heart means, why he feels so tired, what the dark marks that have appeared on his skin mean.
Though the medical services at City on a Hill are limited, Patton feels at home there. He likes the fact that its executive director, Diane De La Santos, is always at the door to greet every arrival. There is a woman who comes in regularly on clinic days and is often confused.
"She won't eat!" he says. "She'll sit there and want to talk and talk. But they always make sure she gets a meal. Diane, she so sweet, she'll say, 'Ernestine, eat dear, we'll talk later.' "
Bonnie Tesch, an Aurora internist who has volunteered at the clinic since it started and is its medical director, has seen Patton regularly there for more than a year.
She loves his upbeat spirit, but knows that he faces darker periods, and would like to have him get a psychiatric evaluation.
"If he had regular health care, he might not be so disabled, he might be able to work," she says. "He can't do what he used to do, he would have to go back to school, but he's very smart actually."
The years of unemployment and events in Patton's life have taken their toll. He's spent a lot of time waiting in offices, waiting for phone calls, waiting for a mailed response to a form he's filled out. Although he finally was notified he had been enrolled in Medicaid in April, he was disheartened to learn shortly after that he might have to wait 18 months for a hearing in his disability case.
"I don't know what I'm supposed to do," he says. "Guess I'll just keep doing little odd jobs."
He had a longtime girlfriend until last year. "We never got married. Men - we are chicken. Fear of marriage kept me from doing it." She left him.
"I was crying about her. I used to draw a lot. I used to make my own comic books." He got lessons at the Milwaukee Art Museum when he was in high school, he says, but never found a way to pursue his love of drawing. He used to spend time in the library, or in comic book stores, but lately he hasn't been motivated to leave the house as much.
"There's down spirals - when you're without money trying to get here, get there," he says.
A 2012 Gallup poll found about 31 percent of Americans in poverty reported they had at some point been diagnosed with depression; 15.8 percent of those not in poverty said they had been diagnosed. The poll also found that impoverished Americans are more likely to report asthma, diabetes, high blood pressure and heart attacks than those not in poverty.
"If you or I had a crisis, we would probably have someone to call," says De La Santos. "But if all your relationships are broken, or with people who are in a more precarious situation than you, you don't have that."