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Nowhere illustrates the complexity of delivering medical care in the era of health-care reform better than Harborview Medical Center’s 47-bed Emergency Department.

As King County’s largest safety-net hospital, Harborview’s specific mission is to care for patients who are most in need, giving it a disproportionate share of patients who are poor or homeless and uninsured.

Last year alone, Harborview provided $219 million in so-called “charity” care, nearly a fifth of all the nonreimbursed care provided in the entire state, according UW Medicine, the organization that manages the King County-owned hospital.

Many of those patients, even ones who don’t have urgent medical issues, wind up in Harborview’s ED.

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The Affordable Care Act is supposed to ease the financial burden of unpaid hospital bills by expanding medical-insurance coverage to those who don’t have it, allowing hospitals to get compensated for the care they deliver to the poor.

The initial results are promising. Harborview and other safety-net hospitals across the nation are seeing plummeting numbers of uninsured patients in their emergency rooms so far this year, reducing charity-care costs and bolstering revenues. Harborview expects to spend $73 million on charity care in 2014, a huge drop compared to last year.

But even with increased reimbursements from the expanded Medicaid program for low-income patients, Harborview still expects to take an overall loss this year because of the cost of providing care for those who remain underinsured or uninsured, UW Medicine spokeswoman Susan Gregg says.

And the ED itself, one of the state’s busiest with 66,000 patients admitted last year, continues to bustle.

One reason might be that the newly insured are emboldened to visit the hospital even more now that they have coverage.

But another explanation has to do with Harborview’s multiple roles.

As the only designated Level 1 trauma center for adults and children in a region that stretches from Montana to Washington state to Alaska, it is the go-to destination for patients with the most complicated and life-threatening of injuries. They come by helicopter, airplane, ambulance and private vehicle, about 5,400 in all last year.

About 3,300 of those trauma patients were transferred from other hospitals to be treated by the sought-after doctors, surgeons and specialists at Harborview, which is also a major teaching and research hospital.

With patients arriving from as close as tent settlements a few blocks down the hill and as far away as Alaska, from close-in poor neighborhoods and wealthy suburbs alike, with conditions from minor to grave, reforms alone may not lead to dramatically fewer people coming through Harborview’s doors, at least not now.

“It doesn’t feel less busy,” Harborview’s clinical director, Anne Newcombe, says of the impact of health-care reform, noting there has been a “slight decrease” in low-income patients coming from the South End who now have coverage for care at facilities closer to home.

Plus, she says, “There’s a difference between having coverage and having access. Some patients just don’t know where to get care.”

Take the case of Debra and Jeff Hardie — who were living in a homeless encampment near Harborview this past summer.

One afternoon, Jeff, 55, brought Debra 48, to Harborview after she complained of severe stomach pain. As she waits to be seen, she lies in a fetal position across chairs in the Emergency Department waiting room with Jeff at her side. This is their de facto clinic, even though both are now covered by a plan Jeff signed up for after the health-insurance mandate went into effect.

The only problem is finding conveniently located primary-care doctors and emergency wards that will accept their coverage, Jeff says. He found a doctor in Gig Harbor, a three-hour journey from Seattle by a series of buses. Debra was still looking.

That’s not the only frustration. Jeff says his plan covers the medication Debra takes as part of her substance-abuse recovery, but he says Harborview won’t fill that particular prescription.

Hospitals around the state are participating in a campaign to reduce the number of people who use emergency rooms as all-purpose clinics, whether by choice or a lack of alternatives. Harborview, for example, employs case managers who work with frequent, non-emergency visitors to set up a care plan that relies more on clinics.

But it’ll take more time, and more available options, for people’s behavior and expectations to fall in line, allowing Harborview to more comfortably fulfill its role as a big-city general hospital while providing the renowned trauma and specialty care it also wants to be known for.

In the meantime, the daily flood of cases competing for the emergency staff’s attention, from hundreds of broken limbs, burns and vehicle accidents to strokes and infections, shows no signs of abating.

Bobbie Harder, of Kirkland, sends text messages to her husband as she tries to take her mind off the unfortunate events that landed her in an emergency bed with a broken leg.

Earlier in the day, Harder was riding her horse Cugie during a veterinary visit, when the animal suddenly reared up and threw her, sending her crashing to the ground.

Now here she lies, holding back a nagging bout of nausea with a hydration foam lollipop a nurse gave her.

“Not the way I thought I’d start my day,” the 56-year-old, says with the dark humor of a survivor.

Her doctor comes in to deliver exam results.

“I have great news — you don’t have any fractures in your spine.”

This qualifies as “great news” at Harborview, where everyday life gets turned on its head in an instant.

But Harder, who has good insurance, is just happy to be here.

“It’s the best place to be for orthopedic trauma,” she says. “And at my age, you don’t have many chances to get it right.”

On another day, Dr. Hugh Foy, a surgeon, and the rest of the ED team rush to a patient who has just been brought in with severe, blunt-force trauma injuries after a fall, which led to cardiac arrest.

Doctors perform CPR on the unconscious patient, switching off every couple of minutes to give each other a rest from the physically taxing maneuver. They try a series of procedures to ease pressure around the patient’s heart and generate a sustained pulse, but nothing works.

Time of death is called and Foy, standing at the sidelines, congratulates the team on a “valiant effort.”

A green divider curtain is drawn around the bed and the patient is covered in a white sheet, one final act of respect.

The patients keep coming.

In another room on another day, 4-year-old Ryker Boswell, of Marysville, fidgets and tears up as doctors inspect the fish hook lodged by his right eye as his mother, Julia Chavez-Boswell, and her boyfriend, Chad Hahn, look on with an emotional anguish that mirrors the little boy’s physical discomfort.

It was supposed to be a day to remember, but not like this.

Boswell was about to go on his first fishing trip that morning when he somehow got stuck with two hooks, one in the face and another in his hand, while playing in a tackle box. A hospital in Marysville transferred him to Harborview, which is known for its pediatric eye-injury care.

Doctors use an ultrasound device to get a fix on the hook’s exact location. Boswell flinches during the procedure; his mother is all tears.

“Just be strong, honey,” she says, trying to calm him — and herself. “I can’t be strong,” the boy says between sobs.

Boswell’s grandparents are in the room, too. “I’m so proud of you,” says his grandmother, Rebecca Chavez.

“He’s our world,” Boswell’s mother says. Her outpouring of emotion causes Hahn to cry, too.

The family is then told that surgery to remove the hook won’t happen for another several hours, making for an exhaustingly long day. The hard-to-hear fact is, far more severely injured patients need attention at that moment. It’s tough news to swallow, but the family comes around.

“It’s just different when it’s you or your family,” Boswell’s mom says. It is a relatively minor medical scenario in the context of the multi-front battle against suffering and tragedy inside Harborview’s ED. But for an injured boy and a mother who simply wants to take away his pain and go home, this moment means everything.

Tyrone Beason can be reached at tbeason@seattletimes.com. Erika Schultz is a Times staff photographer.