Millions more lacking insurance

Millions more lacking insurance
As jobs drain away, so does health care coverage

By Mark Johnson of the Journal Sentinel

Posted: July 19, 2009

This month, Pierre Aterianus is due back at the doctor for twice-a-year tests of his high cholesterol, but he may stay home and simply hope he isn't heading toward a heart attack or stroke.

Aterianus, who is 57 and lives in Whitefish Bay with his 23-year-old daughter, was laid off in January from his engineering job. For almost seven years he had worked at InSinkErator, the Racine-based manufacturer of household garbage disposers.

Today, he has only catastrophic insurance, which runs out in two weeks. He is waiting to learn whether BadgerCare, a Wisconsin Medicaid program, will cover him.

Like others who are losing their jobs in the tough economy, he faces the unforgiving calculus of the unemployed.

Aterianus receives about $1,550 a month in unemployment compensation. The mortgage eats $900, real estate taxes another $500 to $600. At best, that leaves $150 a month to pay all his other expenses including utility bills, food and health care.

His last regular doctor visit cost $597.50.

"If BadgerCare doesn't kick in, I'm just going to have to hope my diet is good and just hope for the best," Aterianus said. "I'm going to have to go without because of the cost of the tests and doctor visits."

For millions of Americans counted among the long-term uninsured, such decisions have been a way of life. But for a sizable group, being without a job and insurance is a new, deeply distressing condition. There is little agreement on the number of uninsured, but the best recent figure may be the 45.7&enspmillion people that the U.S. Census Bureau counted as uninsured for 2007.

About half of those are the long-term uninsured, including those with jobs that simply don't offer insurance, said Len Nichols, a health economist who directs the health policy program for the New America Foundation. "They're literally an underclass."

The number of Americans who went through 2008 without insurance probably won't be available until August or September, but Nichols estimated that the 45.7&enspmillion figure has now risen "well into the 50s."
Middle class hit hard

And because this recession has hit the middle-class hard, there appears to be a striking new image to illustrate the national struggle for health care.

"People who run community health centers - the safety net - are seeing people in business suits on cell phones while they're in line to get seen," Nichols said. "They're on the phone because they're trying to get job interviews."

As they have grappled with this abrupt change in circumstances, many have begun to view health care as more luxury rather than necessity - a shift that doctors in Milwaukee have been witnessing in the last few years, but especially in the last nine months or so. Patients are waiting longer to go to the hospital, which means when they do enter the exam room their illnesses are more advanced.

"People are coming in here sicker than in years past, and you have to think why that is," said Robert Pachner, medical director of Columbia-St. Mary's Urgent Care unit. "Given the economy, you can connect the dots."

The decision to put off treatment is not an easy one, especially for patients with chronic health problems such as high blood pressure and high cholesterol, said Karen Fickel, executive director of Froedtert & Medical College of Wisconsin Primary Care Group.

"If you have to choose between food and preventing a heart attack or stroke five years down the road, that's a hard choice," Fickel said. "Most people are going to choose to eat today."

Fickel said when patients come to the hospital these days, often they don't have one symptom to discuss, but rather a laundry list of a dozen or more. "They're just stockpiling problems until they feel like they have enough to warrant a visit."
Fear of high bills

For those who have lost insurance, the very act of going to the doctor can be frightening.

"I would say in general, I've seen a huge number of people who have lost their medical insurance who are not coming in for a lot of conditions they would have in the past," said Fred DeBoe, a family doctor for 26 years who works with the Aurora Medical Group.

"I'm seeing people who are afraid to come in," he said. "I saw a very, very ill woman who had just lost her insurance and did not want to come in. She was very sick and had to be hospitalized. We had to talk her into doing that because she thought she'd get stuck with the bill."

The pressure of trying to survive without insurance or with high co-pays and deductibles appears to be affecting a great variety of health care decisions, changing the behaviors of both blue- and white-collar workers.

Some patients are trying to save on medications.

"I saw another woman who was triaging her own drugs," DeBoe said, "deciding which she could afford and which she couldn't."

Yet another patient, a man with high blood pressure, had seemed to be making progress when DeBoe saw him a year ago.

"We had his blood pressure pretty much under control," DeBoe said. "When he came back in his blood pressure was very, very high. I came to find out that he just couldn't afford his medicine."

DeBoe and other health care workers have said that such decisions can end up backfiring, leading to more severe health problems and more expensive treatment than the patients would have faced had they not tried so hard to cut costs.

The woman who was deciding which drugs she could afford for her diabetes and high blood pressure has declined and is now close to requiring dialysis, according to DeBoe. The patient who stopped taking his blood pressure medications is now at risk of suffering a stroke or heart attack.
Tough decisions

Charles A. Bomzer, an oncologist with Oncology Alliance, said many of his patients are white collar, yet they too have found themselves struggling with health care decisions. Patients have told him they cannot afford cancer medications. Women have been forced to get their mammograms through assistance programs.

"I've had people who say, 'I'm going to lose my insurance in the next three weeks. Can we do as many of the things as we need to do now, because I won't be able to do them once the insurance runs out?' " Bomzer said.

Other patients are postponing follow-up visits, a decision that can have critical consequences.

"It's a real problem because many of the things we do in oncology rely on measurements of tumor masses, and those measurements rely on things you can't see or feel," he said. "If you have lung cancer that's spread to the liver, we need to look at the spots on the liver to see whether they're shrinking or the same size. We need to see so we know if our treatment is effective."
Counseling available

When patients have problems paying for medications, Bomzer directs them to the practice's social service staff. Even those who are referred to him for an initial visit and do not have insurance will get treated, Bomzer said. Uninsured patients meet with staff from social services and patient clinical accounts in order to learn what bills they can expect and what options are available for payment.

Social service workers help patients apply for grants from independent foundations that assist with out-of-pocket costs for prescription medications and also with some chemotherapy expenses.

"Many insurance companies are now offering to pay only a percentage of a drug. If you have to pay 25% when the price is $5,000 or $6,000 for a prescription, that's insurmountable. People just can't afford it," said David Straseski, lead oncology social worker for the Oncology Alliance.

And those are people who have insurance. About six months ago, Straseski told his staff, "Brace yourself." They were going to see more uninsured patients, he said.

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