Urban public hospitals for the poor (UPHP) throughout the nation have long faced difficulties in financing, staffing, and operations. These difficulties spring from many causes, among which historical, financial, and political factors have been widely recognized. Less appreciated is a fourth factors the “dumping” or rejection of patients considered “undesirable” by voluntary hospitals. A study of outpatient department services in 33 counties containing large UPHPs shows the latter to be providing 12.7 OPD visits per hospital admission, compared to 2.8 visits per admission for the voluntary hospitals. In all these counties, the UPHPs carry a very heavy OPD load (8 to 24 per admission), but the overall volume of OPD services in the county (per 1,000 population) depends mainly on the relative load carried by the voluntary hospitals. This phenomenon of heavier public agency responsibility resulting from the unloading of difficult cases by private agencies is only one instance of a generalized pattern in America, observable also in the field of nursing home care, workmen's compensation, disability insurance, social casework, and other sectors. Solutions require a more equitable distribution of social responsibilities between public and private agencies.