Let me present a story from the front lines of the health care wars. This particular skirmish occurred last week at a hospital in Madison County.

A 22-year-old man came to the emergency room in extreme discomfort. He was unable to urinate. He explained that the condition was neither chronic nor uncommon. He had been in an automobile accident when he was 16, and his urethra, the tube leading from the bladder, had been torn. Although it had been surgically repaired, it sometimes becomes clogged.

He has no health insurance, so when this happens, his only recourse is to seek treatment at an emergency room.

Temporary treatment, in other words. Temporary treatment involves running a catheter into his bladder. The clogging is caused by scar tissue from the earlier surgery, and the proper treatment would involve more surgery to remove the scar tissue. Obviously, that is not something that can be accomplished in the emergency room. Nor is it something an unemployed 22-year-old can afford.

So the decision was made to do a catheterization and send the young man on his way — until the next time his urethra became clogged.

This is not the best way to deliver health care, but it is the sort of decision that front-line health care workers are required to make when the uninsured use the ER for primary care. It is also why hospitals might charge you seven bucks for an aspirin. That is called cost-shifting. When the uninsured are treated, somebody has to make up the cost.

But the catheterization did not go smoothly. When the catheter ran into the scar tissue, the ER doctor decided to back off. Perhaps this would require somebody with more specialized skill. The ER doctor called the only urologist at the hospital. There is one other urologist on staff, but he does not maintain an office at the hospital.

Doctors generally blame a shortage of specialists on Madison County's reputation as a venue favorable for malpractice lawsuits.

So the only urologist available was summoned. He walked out through his own crowded waiting room — there is a sunny side to practicing in a venue many avoid — and went to the ER. He sized up the situation. This was a little more difficult than a standard catheterization, but it could be done. He told the ER doctor what equipment he would need.

That won't be possible, an ER nurse said. She reminded the doctors that hospital policy precludes complicated procedures in the ER. That's because the emergency room is already overutilized, partially because the uninsured use it for primary care. Anything more complicated than the simple catheterization would require an operating room, and that would require the patient first being admitted to the hospital.

The emergency room was already backed up.

But so was the office of the urologist. If he were to take responsibility for admitting the patient to the hospital, he would have to conduct a full medical evaluation of the patient, dictate a report and arrange for transportation to the operating room. Then do the operation. It would be hours. And all for an uninsured patient.

Call me if you decide I can do the procedure here, he told the ER staff. Then he left.

Two hours later, after some back-and-forth between the ER staff and hospital management and the urologist, the decision was made to do the procedure in the emergency room. The urologist successfully catheterized the young man.

Later, I spoke with the young man's mother. She told me her husband had a union job that provided very good benefits. In fact, when the young man was in the automobile accident six years ago, they were living in Oklahoma and insurance provided for everything. "He got great care," she said.

But when he turned 21, he was dropped from the family policy. He was suddenly uninsured with a serious pre-existing condition. Also, he was unemployed.

His mother said he wants to join the Army, primarily for the health insurance, but recruiters have indicated that his medical problems might stand in the way. But that is not yet definite, his mother said. It still might happen.

Meanwhile, the urologist has recommended a specialist in St. Louis for the surgery that the young man needs. But the mother told me she is not sure if the family can afford it.