Ann Stanton says what happened to her brother exemplifies what's wrong with health care in America. Hospital officials, facing a growing demand to care for uninsured patients, just might agree.

Mrs. Stanton's brother, Bill Koehler, 57, of Garfield, died March 7 of a heart attack while driving home from his shift as a pizza delivery driver.

At the time of his death on a Lawrenceville side street, Mr. Koehler had no health insurance -- his paycheck was too small to afford monthly premiums and he made too much to qualify for Medicaid. "They said he would probably qualify if he quit his job," said Mrs. Stanton, who lives in Baden, Beaver County.

In the end, his case wound up in hospital records as one that required a total of almost $10,000 in charity care that had to be written off -- one of a growing number landing in that file.

The University of Pittsburgh Medical Center reported that it provided $169 million in adult charity care and Medicaid reimbursement shortfalls in 2007-08. For the same period, the West Penn Allegheny Health System provided $8.7 million of free care.

And that was before the recession hit.

In a recent survey by the Hospital Council of Western Pennsylvania, local hospital administrators reported a 38.55 percent increase in care they'd provided for free in the last three months of 2008.

"It's free to the patient, but our suppliers, our vendors, our employees all require payment," noted Tom Timcho, president and CEO of Jefferson Regional Medical Center. "We're a business the same as everyone else. We have costs like everyone else."

In Mr. Koehler's case, he knew he had heart problems. He suffered his first heart attack at age 39 in 1990. In 2002, when he had a job repairing televisions, VCRs and other electronics for a small company that offered health insurance, he had a defibrillator implanted at St. Francis Medical Center to treat a heart rhythm irregularity.

His employer closed the repair shop the following year and, after an unsuccessful try to start his own business, Mr. Koehler took the no-benefits pizza delivery job.

Because of his pre-existing medical problems, buying a plan -- the cheapest they found was $500 a month with no guarantee he'd be accepted -- was unaffordable. Medicaid told him that his annual income and tips of about $15,000 made him ineligible for that program.

Still, he had the defibrillator, and it saved Mr. Koehler's life in December 2007 when he collapsed in the pizza shop while mopping the floor. The device fired twice, shocking his heart back into rhythm, and Mr. Koehler regained consciousness before paramedics arrived.

Taken to West Penn Hospital after his collapse, Mr. Koehler was admitted and underwent blood tests, X-rays and an EKG. At discharge, he was given medication to raise his potassium levels and was cautioned that the battery for his defibrillator needed to be replaced soon.

They also helped him apply for Medicaid. A few months later, the application was denied because his salary exceeded their income eligibility requirement for a single person with no dependents.

Eventually, the hospital wrote off all but about $400 of his $6,000 to $7,000 in charges as charity care, something more and more centers are having to do.

With the growth in charity care combined with losses in investment portfolios, which some hospitals depend on to stay in the black, acute care hospitals recorded a 6.3 percent loss in total margin for the first half of fiscal year 2009, reaching their the lowest level in more than 15 years.

That means it is getting harder for hospitals to provide care for people in circumstances similar to Mr. Koehler's, even as ranks of the unemployed and uninsured swell.

Mr. Koehler, who his sister says didn't drink and had stopped smoking in 1990 after his first heart attack, never followed up on the warning about his battery.

"He said, 'I don't have insurance, and that's a very expensive thing to replace. And if they put me in the hospital, I'm not going to get paid,'" his sister recalled.

When his heart stopped 16 months later, it's unclear whether the defibrillator in his chest went off, but the battery was well past its recommended replacement date.

Mrs. Stanton believes that a full cardiac work-up after his collapse in 2007 might have detected problems that would have kept him alive, and her brother's experience has made her a strong proponent for universal health care.

After futile attempts to revive him, Mr. Koehler was pronounced dead at West Penn's emergency department the evening of March 7. As before, the $3,000 in charges for the staff's efforts to revive him was written off as charity care.