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Without a Net

Falling through and filling in the health care gaps

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Some might think Smith shouldn't have to worry about the ticket price for her family's emergency health care. Both of her kids are insured. It is the premiums--the 20 percent of medical costs that Smith is expected to pay and the insurance companies' refusal to cover necessary care--that has Smith thinking about bankruptcy. And she is not alone.

In what many call a sick health care system, Smith's insured sons are just numbers: high cost diseases that drain insurance company profits. And the people who cannot access health care are sometimes just numbers. The number of uninsured Americans is estimated around 45 million. Idaho estimates fall around 20 percent.

The emergency room trips forced Smith to forgo coverage for herself and join the uninsured ranks. Her sons are already part of the estimated 90 million underserved or what the late Idaho physician and advocate Bob LeBow called a "critical mass" of people who need help.

Some go without health coverage by choice--a growing trend, says Julia Robinson, a Health Communities Access Program (HCAP) project director. They just cannot afford the coverage, she says. Inflating premiums, Idaho laws that allow insurers to increase their rates by 50 percent a year, high deductibles and the estimated 78 percent of Idaho job openings that do not pay a living wage have forced people like Smith to choose between food or doctor visits. Others do not even get a choice.

It is not just the downtrodden, down-sized, pink-slip survivors trying to live on a shrinking paycheck who feel the pinch and pain of falling through Idaho's health care cracks. The insured, double-income households, full-time workers, young and strong also fall faster than local charities and relief organizations can fill in the gaps.

THE ODD LINK

"We can find ourselves in very desperate straights very rapidly."

"At any point in time, somebody may find themselves in some sort of situation, particularly if you get some sort of desperate illness or are in an accident that impacts your work--which a lot of our insurance is tied to. We can find ourselves in very desperate straits very rapidly," Robinson says.

LeBow called for the "elimination of the odd link between employers and health insurance companies," in Health Care Meltdown: Confronting the Myths and Fixing Our Failing System, his critical analysis of an industry that turns more and more middle-class Americans into "health-care beggars."

That odd link bares its ugly teeth when jobs disappear. Pink-slip survivors know that when a job is gone, the benefits often go with it. August unemployment rates came in at 4.8 percent--six-tenths of a percent lower than the August 2003 unemployment rate of 5.4 percent. Idaho Commerce and Labor reports put the total number of unemployed Idahoans at 35,681 in August. As health-care access advocates see it, those are 35,681 people who likely fell through a big crack in the system.

THE TYPICAL AMERICAN LIFE

"Put one foot in front of the other and things will get better."

Lilly McCoy* had it all. Or at least what some consider the typical American life, she says. McCoy drove to her corporate job in her luxury car and returned to her luxury apartment. There were lazy days around the swimming pool, vacations--what McCoy calls good years. At the end of the day, the expecting mother could hug her healthy children and able-bodied husband.

Then the first shoe dropped.

McCoy's pregnancy became not so typical. Doctors ordered 100 percent bed rest. Work became out of the question. But her husband Dave had a good job, and he could fill in at home when McCoy couldn't.

The bed rest eventually lead to delivery and in 2001 the giddy McCoys welcomed twins into their family of four.

Two weeks later the second shoe dropped.

The heart of McCoy's tiny baby, Joey, stopped working. Surgery orders, six brushes with death, chronic heart failure and over one million dollars' worth of medical care fell under the now three-year-old's diagnosis of Wolf-Parkinson-White Syndrome.

McCoy tells lawmakers every year that Idaho's Children's Health Insurance Program (CHIP) keeps Joey alive. The program foots the specialists' bills, monitoring machines, long stretches at the hospital and over-priced Tylenol tablets. But McCoy says there are still gaps in Joey's health coverage. Qualified caregivers are hard to come by. And that is just one of her worries.

Shoes at the McCoy home kept dropping.

Dave faced a layoff post-9/11. He eventually found work as part of a construction crew remodeling the Boise airport. But good fortune turned into crisis. Dave fell 40 feet and landed tangled with a ladder. Worker's compensation backed out of paying the bills before he could walk or care for himself. His doctors recently classified him as disabled and in serious condition. McCoy says a fully insured person in Dave's shoes would likely find himself in the hospital. Not Dave. He's at home, under the care of his wife. That is the best they could get, she says, because the Social Security Administration recently denied Dave's application for disability benefits.

McCoy no longer drives expensive cars and the corporate job and camping trips are just memories. Her days turned into battles with the insurance companies; her hours became consumed with checking her son's vitals, making sure his heart beats regularly, helping her husband with just about everything. And moment to moment McCoy recites her new motto: "Put one foot in front of the other and things will get better."

Life still lights McCoy's pale doe eyes. And she looks good, people say. It is amazing what some peachy eye shadow, a little lipstick and a smile can do, she says. Most people don't know McCoy is sick. She's got health insurance, "If you can call it that," a pile of doctor bills, and no way to pay any of them.

A BROKEN SYSTEM

"They fight ... with every fiber in their bodies."

About one out of two bankruptcies filed in the United States stems from overwhelming medical debt. Those numbers equaled about half a million medical debt-related bankruptcies in 1999, according to a 2000 study published in Norton's Bankruptcy Adviser.

Some might say those numbers are good news for area bankruptcy lawyers. But for bankruptcy attorney Bart Green, those numbers represent a sick health care industry. He sees his services as a last resort and what some in the push for health-care access call a "safety net."

"I would hate to see what would happen if they didn't have the bankruptcy system," Green says.

Green has seen medical debts as high as $200,000. And he's seen people leave the hospital after 36 hours $25,000 in debt.

"The system is broken," he says. "I think at this point, they need to go to national health care, they need to raise a new generation of doctors who don't think they need to live in $400,000, $500,000 homes."

He notes the supply and demand checks and balances that regulate most industries don't exist in the health-care system. Once upon a time a country doc would trade house visits for a chicken and some eggs. That's not the case anymore, Green says.

"The market forces no longer control costs."

That leads to sleepless nights, soul searching and patients beating up on themselves because they cannot pay their medicalbills, he says. They may be able to pay $40 a month on a bill, but bill collectors may want $200.

"They want their money and they want it now," he says. "If the medical providers would just back off and let people make payments, they wouldn't have to go into bankruptcy."

And bill collectors are relentless, according to the beleaguered Smith.

"There's nothing like coming home after having a baby and your first call is from a creditor. No congratulations."

The $60 for ear drops that the insurance company refuses to pay, the 20 percent she has to pay on doctor bills, all those specialists, it adds up, she says.

At some point collectors go for wage garnishments, and at 25 percent a paycheck, Green says, "They have no choice but to file."

And all the way to bankruptcy court, "They fight against it with every fiber in their bodies."

Many of Green's clients had health insurance. And many of them work. Smith knows health insurance offers no guarantee--her son's insurance provider very vocally threatened to boot the three-year-old off the policy. But what really gets to Smith is that she worked in the health care industry but her employer never offered her health insurance.

HEALTh IN THE HOUSE

"The taxpayers of this state are subsidizing Wal-Mart ..."

State Senator Clint Stennett, (D-Ketchum) went after the Wal-Marts of Idaho during the last legislative session. Stennett sponsored a bill that would have required Idaho employers with 50 or more employees to offer health benefits to anyone who worked over 20 hours per week.

"That was directed at the Wal-Marts and the big box retailers who are shifting the cost of health care to the public by not providing health insurance," Stennett says.

But some of his colleagues were not sold on the idea. They thought Stennett's bill would put too many restrictions on businesses.

"I'm not trying to saddle those businesses. I'm trying to level the playing field," he says.

One of Wal-Mart's advertisements comes to Stennett's mind. It is one of those cheery commercials with a big yellow happy face bouncing around, slashing prices. The yellow face promises "low prices everyday." But Stennett says low retail prices come with a cost, and he knows how the Wal-Marts of the world offer such great deals: Health benefits are not always a part of workers' employment deals.

And when those workers get sick, some may pass the bill on to the state or county.

"The taxpayers of this state are subsidizing Wal-Mart at the detriment of homegrown retailers who provide health insurance to their employees," he says.

Stennett's Wal-Mart bill died in committee.

During that same session, the Idaho Community Action Network, a grassroots low-income community organization, and scores of underserved patients lobbied to repeal a law that allows Idaho counties to place liens on the homes of people who apply for medical bill payment assistance through county indigency health funds. The Idaho Community Action Network (ICAN) told lawmakers the 1996 law forces the insured to foot bigger medical bills, leaves already financially vulnerable people with a black eye on their credit reports and discourages the sick and injured from seeking needed health care. Folks with liens already on their homes feared their roof could get yanked from over their heads at any moment.

Some said they had no idea what they were signing up for when they agreed to the stipulations of Idaho's County Medical Indigency Care Program.

"Over the years I have had people say to me that they felt that at the time they were in the hospital and asked to sign the application, that it was not adequately explained to them that it would put a lien on everything they owned," Green said.

Some of those patients were told everything would be all right and their medical bills would be taken care of as long as they signed on the line. That is about all they were told, Green said.

Their bills did get paid, but county officials want that money back and say that the state's lien law gives them the leverage they need to recover county cash. The repeal did not pass.

Labor activists also looked to repeal what they called one of the state's more pervasive labor laws as one way to improve employees' access to health care. Tens of thousands of people signed petitions to strike the so-called "right to work" law from Idaho books this year. The 1986 law approved by voters bans mandatory union membership. Supporters of the law have said it could boost employment and the state's economy. But activists with Idaho Citizens to Repeal Right To Work say the law destroys the principle of collective bargaining and workers' ability to negotiate for better wages and health insurance coverage.

"[The law] weakens the unions and we need to make them stronger because they look out for all workers," says Barbara Harris, chair of the 2004 campaign to repeal the law. "Health benefits are part of the package when they negotiate."

Petitioners fell short of acquiring enough signatures to repeal the law in April. But there were victories on the legal front: The state legislature repealed cuts to the Medicaid dental benefit program in 2003; Advocates defeated funding cuts to the Children's Health Insurance Program (CHIP) this year and on the national level, some strong voices helped secure an additional $34 million in federal funds for Idaho's Medicaid program.

A handful of mostly Democratic candidates like Shirley Ringo (D-Moscow) and Nicole LeFavour (D-Boise) ran and were elected this past legislative election on platforms that touted their commitment to accessible health care. Some said they plan to keep health-care issues at the forefront of debate, but access advocates say Idaho can't and won't wait for legislation.

WORKING FOR CARE

"There is no such thing as a specialty care safety net."

Folks at the Garden City Community Clinic greet Crissy Butler with a smile. They all know her name. When she leaves, intake/volunteer coordinator Josh Lunn opens the door so Butler's lopsided body can teeter-totter through.

Butler used to have the walking thing under control. And she used to rise out of a chair with no problem. Years away from retirement age, Butler worked full-time as a therapist for the developmentally disabled. She worked and she worked. And then her body went numb.

She talks of her stroke as if it fell under "Murphy's Law." Sixty days into a new job, and 30 days from the moment her health benefits were to kick in, it happened. The stroke robbed Butler of nearly half her body. Out of work and unable to work, Butler applied for disability benefits.

"I was still in the nursing home when they turned me down. Isn't that something?" Butler says.

A year and a half after the stroke, Butler's application is still under appeal. She strains to get out of her waiting room chair and walks off to an exam room. She says the one visit to a physical therapist since her hospital discharge did not help much, but she credits what she calls excellent primary care at the Garden City Community Clinic to "a God thing."

But sometimes God can only do so much in Garden City. On the evening Butler went into an exam room that looks pretty much like any other exam room and sat in a waiting room that looks pretty much like any other waiting room (minus the loud radio to drown out service eligibility interviews behind a partitioned corner toward the back), clinic volunteers had to turn away four people seeking medical care. It is first come, first served in Garden City.

Only so many volunteers can give time at the clinic. Two to three intake volunteers, two to three physicians and nurse practitioners, three to four nurses, a pharmacist, a pharmacist technician, a social worker and an occasional ultrasound technician and translator make the clinic work on an average Tuesday or Thursday evening between 4 and 7--the only hours the clinic can keep its doors open.

"We look at the staff and that tells us how many patients we can see," says Lorrie Apel, a volunteer RN at the clinic.

Thirty patients move through the clinic in a typical week. The ones who get turned away get a top spot in line at the next clinic opening and a checklist determines if they will go past the waiting room and into an exam room.

Apel says the clinic needs to tightly manage its donated funds, and those only stretch so far. Applicants with Medicaid, Medicare, CHIP coverage, health insurance and VA benefits are not eligible for care at the Garden City Community Clinic. That means folks like McCoy who have some paltry insurance coverage wouldn't make it past the waiting room doors. For those who do make it, the services are 100 percent free.

Health-care workers and access advocates look to the Garden City Community Clinic as just one Treasure Valley safety net for the poor, uninsured, underinsured and underserved. Others who fall through the cracks are caught on another safety net such as one of the Terry Reilly Health Services clinics, or Family Practice Residency of Idaho.

Terry Reilly Health Services' $13 million annual budget funds more than 100,000 patient visits a year and physicians at Family Practice Residency of Idaho treated chronic illnesses such as hypertension, diabetes and depression over 12,000 times between July 2002 and May 2003. The latter number doesn't include the thousands of visits area patients make to Family Practice for everything from sniffles to asthma to UTIs to congestive heart failure. Family Practice Residency of Idaho provides primary care on a sliding fee scale in 30 languages. But there are still gaps and cracks to fall through.

Butler doesn't know where to find accessible specialty care. She plans to pay for an upcoming doctor visit for more comprehensive treatment with a loan.

"Really, there is no such thing as a specialty care safety net," says Erwin Teuber, executive director of Terry Reilly Health Services.

If a poor, underserved or uninsured patient is lucky, he or she will find a primary doctor who can recommend them to a charitable specialist. Usually the referring doctor needs to do some talking with the specialist if the patient is going to get any payment slack. Sometimes a patient and specialist can work out a payment plan, Teuber says. And there are always tests and medications that can require payment, which is another big gap, health workers say. But sometimes patients cannot work out payment plans. And that is when treatment ends.

"Either the patients feel unwelcome or they are told they're unwelcome and they don't get the care that they need--and in a worse case scenario, they die," Teuber says.

HEALTH ON THE WAY

"But I don't want to paint too rosy of a picture."

"We're all more optimistic than we have been," Teuber says. "But I don't want to paint too rosy of a picture." Some of that optimism comes from a new federal grant aimed at improving the access and quality of health care to underserved Idahoans.

Family Practice Residency of Idaho, in conjunction with local hospitals and health providers such as the Terry Reilly Health Services and Garden City Community Clinic, received a $2 million federal grant. The funds are earmarked to launch a community health clinic in Garden City to serve the underinsured and uninsured in the Treasure Valley.

The Department of Health and Human Services Health Resources and Services Administration (HRSA) is providing the funds over a three-year period as part of the Health Communities Access Program (HCAP).

The funds are also slated to build the infrastructure needed to boost access to health care and launch the clinic. Plans to develop linkages between existing clinics to coordinate and improve heath care are part of the grant objectives. The details include money to launch a system that would enable accessible clinics to share patient records--a key to improving the treatment of chronic illness, says Julia Robinson, HCAP project director. Another project that boosts Teuber's optimism: The creation of a specialist referral system for underserved patients. Altruistic doctors are out there, he says, but coordinated management would organize what is already working. Some doctors are called on again and again and sometimes bear a chunk of charity care work.

"You might be more inclined to volunteer if you can control your time, which is important to physicians," Robinson says.

Initiatives through the Idaho Department of Health and Welfare could help close another gap. Excess funds from the state premium tax fund and some federal dollars are slated for a July 2005 pilot project that would provide heath care benefits for some of Idaho's working uninsured.

"Small businesses simply cannot afford health insurance for their employees," says Ross Mason, department spokesperson.

A maximum of 1,000 people can enroll for coverage through participating small business employers, who are expected to pay half of the insurance premium. The coverage provides the basics, Mason says, including specialty, hospital, pregnancy and hospice care. The coverage would even foot the bill for an organ transplant.

"If this works we'll see if we can improve or expand it in the future," Mason says.

Until the future comes, health-care access advocates and folks like McCoy and Smith are looking forward. It is 14,000 and some days before the next presidential election and some two months before the next legislative session. McCoy will be there, in what she calls her House, your House, our House. And she will tell lawmakers, once again, that CHIP saved her son's life.

For now, Josh Lunn looks for volunteers.

"We need the whole nine yards," he said, closing the Garden City Community Clinic doors just after 7 p.m.

"Wouldn't it be nice to have this facility open all day?"

* Names were changed to protect patient's privacy.

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