|
Sunday, November 7, 2004
Meet the uninsured
Copyright © 2004 Blethen Maine Newspapers Inc. | ||||||||||||||
 |
Also on this page: HOW MAINE MEASURES UP | |||||||||||||
Ever mindful of not having health insurance, Mike Martel tried to ignore flashing warning signs - sharp pangs that attacked his abdomen hours at a time, first weeks, then days apart. A couple of years passed before Martel doubled over in pain this July while at his job selling tropical fish at a Saco pet store. Scared of the cost of calling an ambulance but in no condition to ride his bicycle three miles to the hospital, he asked his boss for a lift. "It was an umbilical hernia," the 55-year-old Martel said, of a congenital defect that can worsen in adulthood. "They operated on me the same day." Silently, imperceptibly, the high cost of health insurance in Maine has thrown up walls around low-income workers like Martel who earn too much to qualify for government assistance but too little to afford plans with proper coverage, or any at all. Nearly 11 percent of Mainers go without insurance - lower than the national average but the highest rate in New England, according to the U.S. Census Bureau. That's one in eight non-elderly adults who run the daily risk of financial hardship for themselves or their families should an accident or serious illness strike. Martel was stuck with a $16,000 bill after his operation and overnight stay at Southern Maine Medical Center in Biddeford - more than he makes in a year working full time. After he submitted his pay stubs, the hospital reduced the bill by a third. "It'll be years before I can pay it off," said Martel, who is using money he sets aside for groceries. "It might be the rest of my life. I can only put a few dollars in it each month." It is difficult to generalize about the experiences of the uninsured when they number over 130,000. They range from young people with low-wage jobs to people who could afford insurance and decide to hedge their bets. On the other end of the spectrum are people eligible for public assistance but unaware of the fact, or unwilling to take it. A 2002 survey by the Muskie School of Public Service shows that the vast majority, however, earn up to three times the federal poverty level - $28,000 for single people and $56,550 for a family of four - putting them outside the bounds of government help. They include people who are self-employed, on disability or in between jobs. Others work for companies that don't provide coverage. In Martel's case, his employer offers health benefits for $100 a month, but he says he can't afford it on an income of "less than $15,000" a year. What many uninsured individuals do share is a poorer quality of life and potentially shorter lifespans. The Institute of Medicine traced lack of insurance to delayed diagnoses, life-threatening complications and, ultimately, 18,000 premature deaths in this country each year. A glimpse inside any emergency room in Maine finds people with a health problem they neglected too long. "It may be somebody coming in, not able to walk because their feet are swollen and they find out they have heart failure," said Joy Moody, nursing director of the emergency department at Maine Medical Center in Portland. The ranks of the uninsured in Maine rise when including people who went without insurance at some point in the last year. This is often a consequence of transitions between jobs or the end of seasonal work. Unlike Canada and other industrialized nations with government-sponsored universal health care, about two-thirds of Americans are covered by employers. Only the poorest, the oldest and seriously disabled residents can count on insurance through government programs. Though not captured by surveys, there are also countless Mainers struggling to pay for the coverage they have. Even with insurance, many are seeking charity care or taking on debt because their deductibles are too high. Others are on the brink of dropping coverage. It is not hard to see why. Health insurance premiums for a family through an employer shot up by 77 percent between 1996 to 2002, while median household income rose by just 6 percent, according to an analysis by the Governor's Office of Health Policy and Finance. COSTS HIGH, INCOMES LOW Health care costs are rising throughout the country, but precipitously so for a state as poor as Maine. It now ranks 10th among states in total per capita health costs and 37th in average household income, according to the governor's office. That has resulted in higher premiums, particularly in the individual market. A nonsmoking 25-year-old Portland man would have to pay Anthem Blue Cross and Blue Shield of Maine $384 a month for a plan where coverage kicks in once he reaches a $250 deductible, after which he would pay 40 percent of charges until he spends a total of $1,250. He could get coverage for as little as $70 a month, but insurance wouldn't cover him until he spent $15,000 out of pocket. For a nonsmoking 50-year-old Portland man, the same plans would cost $480 and $87 respectively. "Insurance is priced so high - it's just not worth it for me," said Nathan Sullivan, a 21-year-old biochemistry student from Newcastle, who will be dropped from his parents' plan once he graduates from college. "It's not worth it until I find out I have medical issues." Health analysts say this is part of Maine's problem. Healthy, young adults in the insurance pool help dilute risk and drive down premiums. There are other reasons cited for Maine's high insurance costs:
The mandates cited as most expensive include a provision that requires insurers to cover anybody who wants to buy a policy regardless of how sick they are and how costly they would be to cover. That mandate is coupled with another that forces insurers to charge everyone in a specific area the same price without regard for a person's health history. Conservative groups prefer ditching those mandates and concentrating the sickest patients into a high-risk pool, with the intent of driving down costs for everybody else.
"Everybody still sent me bills for a while, but there's no way I could pay," said Fuller, 59, of South Portland, who got insurance several years ago when he began working in the kitchen of the Bugaboo Creek steakhouse chain. The state estimates that unpaid medical bills and charity care add up to more than $275 million a year. Hospitals and doctors, who experience further losses when they are insufficiently reimbursed for MaineCare or Medicare patients, shift costs onto insurers. Ultimately, the costs are reflected in higher premiums. Individual policy-holders, who do not benefit from group rates or employer contributions, feel the increases most deeply. "Absolute total disbelief" is how Allen Holmes, a 41-year-old accountant from Rockland, reacted after he was mailed a notice that his family's policy would jump from $1,033 to $1,553 under a proposed increase by Anthem for its line of HealthChoice products. "I wondered to myself how would it be possible that they would think that they could get away with something like this because it's so far ahead of any inflation factor," he said. EXPANDING MAINECARE The state has gradually expanded MaineCare, its Medicaid program, to stop the ranks of the uninsured from swelling. Aggressive campaigns to enroll children in the program have slashed the uninsured rate from 15 percent, averaged between 1995 and 1997, to the 7 percent averaged between 2001 and 2003, according to the Maine Kids Count project. A planned expansion by Gov. John Baldacci's administration in April could increase the current MaineCare population of 256,000 by 14,000 adults - what amounts to one in five Mainers. It will cost an additional $33 million annually, $11 million of which will be covered by the state and the balance by the federal government. While all parties concur that covering the uninsured is good, there is disagreement over how much more the state can sink into insurance for its residents. Critics of MaineCare expansion say that the state can barely afford to tend to its current MaineCare population, let alone increase it. A budget deficit this year led the governor to propose eliminating MaineCare funding for a number of adult services, such as rehabilitation for brain injury patients. Lawmakers, assailed by angry patients and advocates, kept services but tightened access to them. Problems loom ahead. A fiscal 2005 shortfall projected across the state's Health and Human Services Department amounts to more than $37 million, Commissioner John Nicholas recently reported to lawmakers. Pointing out that the uninsured rate has held steady despite expansion, the Maine Heritage Policy Center, a conservative think tank, theorizes that broader income-eligibility requirements encourage people to drop their private insurance for MaineCare. The Maine Equal Justice Project, which advocates for low-income Mainers, counters that MaineCare is picking up people who are being edged out of the employer-based system. In recent years, double-digit rate increases have forced firms to drop coverage or increase their employees' shares. The demise of hundreds of manufacturing jobs, which traditionally come with good benefits, also has forced Mainers into low-wage, service sector jobs that typically do not offer health insurance. This is evident in Franklin County, where the closing of several shoe factories over the last five years left more than 600 without jobs and increased the flow of patients to the community clinic for the uninsured. "Franklin County unemployment is terrible and that just lent itself to a lot of people to go without health insurance," said Charlie Woodcock, director of Franklin Health Access, which provides free care to county residents. Searching for a long-term solution, the state in 2001 commissioned a report on the economic feasibility of a Canadian-style single-payer system, where the government would pay for everybody's health care. That year, single-payer supporters in Portland organized a successful, nonbinding referendum to support the concept of universal health care, by framing health care as a right for every American. But even those sympathetic to the idea said covering all Mainers would still not fix runaway spending in health care. DIRIGO HEALTH AMBITIOUS Then Baldacci entered office in 2003 and announced a health reform initiative called Dirigo Health. Signed into law in June of that year, Dirigo Health drew national attention by attempting to tame health care costs, make insurance more affordable and improve the quality of health services all at the same time. One of the most controversial of Dirigo Health's reforms calls for hospitals to voluntarily hold down their budgets and makes it more difficult for them to build new medical facilities or buy equipment expensive enough to trigger a state review called Certificate of Need. The Baldacci administration also unveiled a health insurance program called DirigoChoice that will be administered for the state by Anthem when it launches in January. DirigoChoice features 100 percent coverage for preventive services and discounts premiums for people making up to three times the poverty level. "If it is implemented as it is intended with its multipronged approach, it's the best way to bring down costs. You're taking as many strategies and combining them together so you're maximizing the benefit that you get," said Hilary Schneider of the advocacy group Consumers for Affordable Health Care. But critiques of the reform act highlight fierce philosophical differences over how to revamp the health care system. How involved should government be - and how much should be left to the free market? "Adding more regulatory bureaucracy is not going to be benefit direct patient care," said Mary Mayhew, the Maine Hospital Association's vice president of government affairs. Outrage has met the ideas bandied about by the governor-appointed commission charged with studying Maine hospitals and finding cost savings. The chair of the commission has suggested merging a couple of smaller community hospitals with larger ones and dividing the hospitals into regional groups to be overseen by oversight boards. A final plan has yet to be voted upon and will be presented to lawmakers in December. Others say that true savings in the health care system will be realized only if consumers are cost-conscious, and they fault the Baldacci administration for not promoting tax-free health savings accounts in which consumers pay for routine medical services themselves. Leftover money in the account rolls over to the following year. A small but growing number of companies are providing the accounts to workers, paired with lower-cost, higher-deductible plans for major expenses. Critics worry, however, that the accounts will move employers away from traditional health insurance, benefit the healthy and wealthy and lead patients to make ill-informed health care decisions in order to save money. As the debate over health insurance rages on, it's clear that those who need it most are not part of the conversation. Mike Martel says he has a notion of political discord over health insurance, but does not know the particulars. He, for one, has never heard of DirigoChoice. Feeling like he is out to fend for himself, he pays attention to his health, riding his bike everywhere he goes, and running six miles on some days. He gets free medication from the Biddeford Free Clinic for high blood pressure detected during his summer trip to the emergency room. And he hopes nothing else happens to him. "I'm a pretty optimistic person," he said. "But you never know when something's going to hit you from behind."
Staff Writer Josie Huang can be contacted at 791-6364 or at:
|
||||||||||||||
