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Mary C. has a job, the best job she’s ever had.

She works as a cashier for a department store chain that prides itself on its employee benefits. Yet Mary has not passed the probationary period to qualify for health insurance coverage.

During a recent routine doctor’s visit, Mary learned she has Type 2 diabetes. When her insurance benefits do kick in, she’ll have a pre-existing condition -- meaning she’ll have to wait even longer for coverage of her diabetes.

So what does she do in the meantime? Prescriptions and doctor visits are expensive, and Mary hasn’t been on the job long enough to save up for emergencies.

Then there are the Joneses. Unlike Mary, they do have insurance.

When Mr. Jones was critically injured in an accident, he had to undergo several surgeries. When infections developed, he had more surgery and his hospital stay increased.

Since the Joneses both work and have health insurance, they assumed they would be okay. Then they got the bills.

Turns out their insurance is going to cover just a fifth of the total medical costs. The Joneses are underinsured, and it will take them years to pay off all the bills -- if they ever can.

Isolated instances? Not at all. While we hear much about the plight of the elderly and high prescription costs, the stories of those working adults between the ages of 25 and 55 who fall through the cracks of the present healthcare system often remain untold.

The number of uninsured workers in Chatham County is high and growing. According to the Georgia Health Policy Center, 60,000 people in the county were without health insurance for one or more months over a 12-month period.

“And 45,000 of them have been without health insurance for two years or more,” says Peter Doliber, director of Community Benefits for Memorial Health University Medical Center. “That figure does include children.”

Sister Margie Beatty is the vice-president for Mission Services at St. Joseph’s/Candler Healthcare System. “We estimate that 80 percent of the uninsured come from families where one or more persons are working,” she says.

“A lot of the time, these people can’t afford the high cost of health insurance or they have other needs that are more immediate,” Beatty says. “Other times, even though people have insurance, the co-pays are so high they can’t afford them.”

A lengthy hospital stay could result in bankruptcy. “Sometimes the cost of care throws the patient into debt,” Beatty says. “Healthcare costs in 35 states are rising three times faster than average earnings.

“We are seeing more uninsured or underinsured than ever before,” she says. “There are so many people in Savannah who are in the service professions. Many of them work for minimum wage and the jobs don’t provide benefits.”

Susan Spellman is the executive director of the Community Health Center. She says the number of uninsured in Chatham County is about same as the national average. “It’s between 17 and 20 percent all over the country,” Spellman says.

A variety of circumstances can leave a person uninsured. “People change jobs or they drop their coverage because the premiums are too high,” Doliber says.

“We estimate that 80 to 90 percent are working,” he says. “Basically, they are either in companies that don’t offer insurance, or companies that can’t afford insurance.”

Some companies that have offered insurance to their employees in the past have been forced to stop as premiums have risen. Others ask the employees to help foot the bill or accept larger co-payments to bring the cost down.

“The cost of health insurance to employees is rising,” Beatty says. “Health insurance has gone up 23 percent. That’s the trend both here and nationally.

“Some people, even if they had insurance five years ago, cannot afford it now,” she says. “One of the things we’ve done is try to look at absolutely every way to accommodate the uninsured.”

“People who work in companies that provide health insurance find that if the health coverage plan goes up 17 percent a year, the company is asking the employees start sharing the cost,” Spellman says. “As a result, there are employees who can no longer afford it.

“Then there is the whole idea that employment has been down,” she says. “The jobs that are being created aren’t jobs with healthcare benefits.”

Patients sometimes find the insurance they have just isn’t enough. “Having insurance does not always equate having access to care,” Doliber says. “Some may not have pharmaceutical coverage, or their insurance is only for catastrophic care.”

Patients who are still on probation at their jobs may have to wait for their coverage to kick in, or a pre-existing condition may leave them without coverage for a year or longer. If an insurance policy requires the patient to see a specific doctor, the wait for an appointment might be as long as six to 10 weeks.

“When you are poor, the last thing you think of is going to the doctor,” Beatty says. “They don’t go until they are really, really sick. By that time, they are going to be a very costly patient.”

Diabetes is one example of a treatable disease. “Without treatment, the patient can have a heart attack or stroke, go blind, have a foot amputated,” Beatty says.

“It becomes much more costly to treat then,” she says. “However, if they are monitored ahead of time and get good maintenance care and education, their health is much better,” she says.

The simple fact is that people who are not insured live sicker and die sooner than those with insurance. “The biggest danger is not being able to afford special care when you need it,” Spellman says.

Not having insurance means medical costs will be even higher than if the patient is insured. “Let’s say someone needs an expensive test, such as an MRI or other imaging,” Spellman says.

Insurance companies often negotiate the cost of such procedures. “The uninsured will not have the benefit of a negotiated rate. They will pay the full net price,” Spellman says. “Say an MRI costs $2.500. Some insurances will be billed $1,000. The uninsured will get the full bill.”

A lengthy hospital stay can be very expensive. “Certain procedures can only be done in the hospital,” Spellman says. “”If you don't have health insurance, you run the risk of getting a huge bill.

“Young people think that because they are young and healthy, they don’t have any risk,” she says. “But there are car accidents, genetic problems, diseases. How are they going to pay for that?”

“A lot of conditions are treatable if caught early,” Doliber says. “Suppose you have no insurance. During a routine check, you find out you are diabetic. If they catch it early, they can begin treatment and ward off serious complications.”

Some patients who received government assistance in the past are now being denied coverage. As the state continues to trim the budget, programs such as Medicaid and Peach Care will be cut. This affects the most vulnerable patients of all -- the children.

“Peach Care is designed to reach those children who no longer qualify for Medicaid, but whose parents don’t have access to insurance,” Doliber says.

“The premium used to be $7.50 for one child and $15 for two or more children up through age 18. Now the cost is $20 to $25 for one child and the maximum is $70. Some folks drop out because they can’t afford it.”

Even more families may be forced out of Peach Care because the state is going to tighten eligibility requirements. “A lot will be cut off,” Doliber says. “We don’t really know how many.”

In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act, which requires hospitals and ambulance services to treat any emergency patient, regardless of citizenship, legal status or ability to pay.

Some uninsured patients use the emergency room for routine medical treatment. This is costly to the hospital.

“We estimate that of the total number of people who use the ER for routine care, 80 percent could either be seen in a primary care physician’s officer or are indeed sick, but if they had gone to a primary care doctor would not be as sick,” Doliber says.

Care in the ER is expensive for patients with insurance, too. Many insurance policies require a $100 or higher co-pay for ER treatment, which often surprises patients, Doliber says.

Hospitals must deal with these issues every single day. “A lot of people fall through the cracks,” Doliber says.

But help is given whenever possible. “What we do first and foremost is ensure that a person can get the care they need to get healthy,” Doliber says. “Then we work with them to find a solution for the cost. Do they qualify for any assistance anywhere?”

Next, the patient’s financial situation is determined. “What can a person reasonably be expected to pay?” Doliber says. “Sometimes it’s nothing, sometimes over time it ends up being a discounted rate.”

Some patients may be set up with a monthly payment. “We do our best to make sure they are not overburdened,” Doliber says.

“A person comes home and gets a big bill and gets overwhelmed,” he says. “We are going to try to help out. We try to have compassion. We have a realistic collection policy and are willing to work with people.”

Yet most hospitals operate at a loss. “We lose tens of millions of dollars every year that we get nothing for,” Doliber says.

Memorial’s Indigent Care Trust Fund pays 20 cents on the dollar for those who qualify. There are some grants that help pay for neonatal care or cancer treatment.

But the hospital has to write-off the remainder of the bill. “We may have $38 to $48 million in costs, but may get $6 million in compensation,” Doliber says. “That is why hospitals are hurting.”

The first step at St. Joseph’s/Candler is seeing if the patient qualifies for assistance. “We have people who are trained to look and see if they qualify for government programs,” Beatty says.

“We connect them with other resources in town that can assist them,” she says. “Medbank is a partner of ours. The Community Cardiovascular Council provides medications and treatment.”

The Community Cardiovascular Council was founded 35 years ago. “It was established because Savannah is in the ‘stroke belt,’” Beatty says. “They go to barbershops and beauty shops to teach hairdressers how to check blood pressure. A patient comes in and gets a blood-pressure check and medications.”

St. Joseph’s/Candler has two outreach programs of its own -- St. Mary’s Community Center and the African-American Health Information and Resource Center. “They provide health information and do some screening,” Beatty says.

Like Memorial, St. Joseph’s/Candler also works with patients who cannot pay. “we have a pretty liberal care policy,” Beatty says.

“We try to determine if the person won’t ever be able to pay,” she says. “If they can pay something, we try to arrange a reasonable payment plan for the person.

“Whatever people can afford, we want them to pay,” Beatty says. “It’s an issue of justice.”

Very high bills on top of a serious illness can make a patient’s condition worse. “We don’t want to cause more problems,” Beatty says. “Your health is holistic. It’s not just the body, but the mind.”

With looming state cuts, the problem is certain to grow, says Beatty. “I think it’s going to reach epidemic proportions,” she says.

The cost of people without healthcare also impacts the local economy. “It has a very big economic impact,” Doliber says. “It results in a lot of job turnover and absenteeism.

“Sick people lose their jobs,” he says. “Some do not get paid sick pay. We have more people living in poverty today and working people who are just one paycheck away from disaster. There is a direct connection between illness and poverty.”

The uninsured do not need to wait until an illness becomes critical to get care. There are places they can go for free or reduced-cost medical care, but they may not know it.

“We have some great programs here -- Curtis V. Cooper Primary Healthcare, the Community Health Center, the Chatham County Health Department and others,” Doliber says. “We will help patients get pharmaceuticals through Medbank.”

Local hospitals and clinics work together to ensure they are not duplicating services so they can use their money most efficiently. “Educating people and supporting community efforts is part of the solution,” Doliber says.

But while Savannah has already taken some steps toward recovery, the crisis isn’t limited to Chatham County. The number of uninsured is growing throughout the United States.

“It’s a big part of the national debate,” Doliber says. “As a nation, we need to take a look at our priorities.

“For right or wrong, back in the 60s, the federal government started a healthcare program,” he says. “You can’t just walk away from that.

“Part of the solution has to lie at the level of government,” Doliber says. “The government chose to step in, it must be a part of the solution, as well.”

Future government programs could take the form of a national health plan, pooling of insurance or medical savings accounts, or a combination of those.

“We have to look at this more closely,” Doliber says. “I don’t believe there is just one solution, but our system is broken. For the government to abdicate the responsibility it has taken on and leave people without a choice is unconscionable.”

Finding solutions might help resolve other healthcare crises. “Why do we have a birth mortality rate that is worse than some third world countries?” Doliber asks. “There is something wrong with the way we are doing things. It’s going to take a lot of courage, something we must raise up to the national level.”

While Doliber says he is “very optimistic all the time,” he admits change may be slow in coming. “Unless access to healthcare rises to a level that has an emotional and economic impact on the right people, change won’t happen,” he says.

Last year, there were about 5,500 patient visits to the Community Health Center, which provides care to people with no health insurance, whether they are working on not. “We treated almost 1,300 people and this year will treat more,” Spellman says.

“They have to work or live in Chatham County,” she says. “If they need primary care, chances are they can come to one of our free clinics.”

It is important to note that the center provides high-quality medical care, Spellman says. “We help them get their medicine,” she says. “We do whatever we can to see they get care.”

There are some financial guidelines that must be met, but everyone who calls for an appointment is seen at least once. “It is very important to make and keep all appointments needed for treatment,” Spellman says. “That is a commitment we ask our patients to make.”

Many local doctors and nurses volunteer to treat patients at the center. Other volunteers are sought, as well.

“We need volunteers with all skills,” Spellman says. “They can put files together, they can schedule appointments, they can take financial information.”

Such programs are important because many uninsured patients don’t have a primary care physician, Beatty says. “A lot are people who go to work every single day or who have worked,” she says. “A lot of people who need care between the ages of 40 and 65 just fall through the cracks.”

That is an area of great concern, Beatty says. “We feel responsible for the people who come to us,” she says.

“We do think patients need preventative care,” Beatty says. “However, our government doesn’t seem to be wise enough to provide that maintenance.”

At a program called State of the Uninsured: What the Future Holds, held last May in conjunction with Cover the Uninsured Week, Memorial Health CEO Bob Colvin said the uninsured often have more health problems than others.

“We know people who are uninsured are twice as likely to report their health as fair,” he says. “We also know that people who are uninsured are more likely to miss eight or more days of work.

“They may have a chronic condition or have difficulty getting care,” Colvin says. “They seek health care in the emergency room, if at all. Many lack medications used to treat chronic illness, leading to catastrophic illness.

“Why so many?” Colvin asks. “Rising health care costs, rising pharmaceutical costs are taking a larger proportion of people’s income.

“It takes over 10 percent of total income to buy coverage for a single person,” he says. “It can be prohibitive to ensure the entire family.”

Colvin praises the clinics that offer treatment to the uninsured. “We’re way ahead of other communities,” he says. “But we also know it’s not enough.

“One of the biggest crises is getting prescription drugs to people,” Colvin says. “We must make sure that a minor acute illness doesn’t become a major acute illness.

“The ER is not where you want to get primary care,” he says. “It’s not the right place to do it. We can do better in this country, and certainly in Chatham County.”

The need for programs has left providers scrambling for funding. Yet even as the need grows, state and federal budget cuts are cutting programs, eliminating them, or changing eligibility requirements.

Memorial Health is a safety-net hospital that does a large amount of charity care, Colvin says. “We’ve done a pretty good job with limited funding,” he says. “But our voices need to be heard. Healthcare is an investment.”

“Uninsured people are more likely to delay care,” says Dr. James Walton, medical director for Community Health Baylor Health Care Systems. “They are more likely to be hospitalized for conditions that could have been prevented. When they are diagnosed, it is too late.

“Poverty creates an injustice,” Walton says. “We need to provide some healthcare to all. It is a huge challenge.”

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