Recent layoffs of hospital personnel at the George Washington University Hospital, where I am a resident physician, and at Howard University Hospital are a clear indication of the gravity of the health care crisis in Washington, (and in any major U.S. city). Depending on the location, city hospital emergency rooms are put in the position of providing basic health care to a large share of the city's indigent population, for which the hospitals are minimally reimbursed. Consequently, these hospitals are losing money and are forced to cut costs (i.e., layoffs), possibly compromising their standard of care. Some emergency rooms may be forced to close down entirely, an alternative we cannot accept.

A temporary solution might be to distribute health care costs incurred by hospitals in caring for the indigent equally to all hospitals in the city (a sort of no-fault approach). It seems unfair that hospitals such as GW and Howard by virtue of their location should take the brunt of this expense, while hospitals serving a predominantly affluent population, such as Georgetown and Sibley, provide relatively little. All hospitals should have as their goal providing adequate health care to the general population. They should also be willing to share equally in the costs of providing such care.

JON MAZUR Washington

The editorial "Caring for the Poor: Who Pays?" {June 5} identifies an issue of catastrophic proportion. However, it is important to acknowledge that this problem affects all health care providers, not just hospitals.

With hospitals under increasing financial pressure to reduce length of stay, community-based providers such as the Visiting Nurses Association are being asked to provide ever increasing amounts of uncompensated care. In some areas, home care agencies have dropped out of the Medicaid program or limited the number of Medicaid patients they will accept. Patients then remain in the hospital inappropriately or are discharged without proper aftercare only to be readmitted to the hospital again.

In the District, home care providers are being reimbursed at a fraction of the actual cost of providing service. The problem is exacerbated by higher costs related to serving a Medicaid population with a disproportionate share of drug-related problems, including the need for paid escorts in some neighborhoods. These are our most needy and most vulnerable patients, but providers cannot bear the entire burden without fair compensation for services rendered.

PAUL L. RIGER Executive Director, Visiting Nurses Association Washington