When veterinarian James Jarchow was diagnosed with leukemia six years ago, he--like tens of thousands of other Tucsonans--didn't have health insurance, because he didn't think he could afford it.
"When I sold my interest in a veterinary hospital and became self-employed doing research back in 1984," says Jarchow, now 57, "there was a huge change in our household budget. Health insurance was one of the first things to go."
Even when he later re-entered veterinary practice, Jarchow gambled and didn't purchase a medical policy. After the potentially deadly diagnosis, and despite a large fund-raiser held on his behalf, he faced enormous economic hurdles. But Jarchow was extremely fortunate.
"My oncologist was an old client, and wouldn't charge for his services," Jarchow says. "Plus, the people at St. Mary's hospital were really supportive and helped me apply for AHCCCS (Arizona's low-income medical program), and I qualified. Having four kids helped with that."
While the disease has been in remission for five years, and Jarchow now has medical insurance through the practice he works for, his advice to others without coverage is simple: "Get it!"
Ismael Loreto will be doing just that, but only because the small company that employs him will soon begin providing coverage. That was of no help last year, however, after his youngest daughter was born.
The new baby had health problems, including fevers. Loreto could not afford care for his daughter locally, so he and the infant made the 240-mile round-trip drive to Agua Prieta, Mexico, twice a month. There, the legal resident of the United States says, a doctor saw his American daughter for only $14, and they were able to purchase cheap prescription drugs.
While his wife was covered by AHCCCS during her pregnancies, 24-year-old Loreto now makes too much money for the government program. His solution to lacking health insurance is simple: "My wife and I don't get sick."
Although Loreto won't have to pay for insurance under his employer's new plan, the cost of including his wife and two girls under the policy would be $400 a month, a price he says he can't afford.
Forty-year-old Jane Doe, who requested anonymity, studied her insurance options before making a decision. She almost bought a $2,000 deductible policy, but decided instead to become a member of the discount medical service plan offered by the Pima Community Access Program.
"I didn't feel I could stretch my budget for the $90 a month," Doe says of the high-deductible insurance premium.
Of her past experience with medical insurance, she says, "I had it once, but I thought I was throwing money out the window. It didn't pay off for me then."
In frustration, Doe also points out that her mother was dropped by her insurance company a few years ago while she was very sick--a situation Doe describes as "disgusting."
"My mother is now uninsurable," says Doe. "She is just waiting to qualify for Medicare."
Pat Malchow is also angry with insurance companies. The 55-year-old has rarely had medical coverage in the past--only when it was offered by an employer--but wasn't happy with it and doesn't believe she could afford it now, since she is currently self-employed.
"The insurance companies sell you something, then take it away." Malchow says. "When I had insurance, I was more abused by the health industry than when I was without it. I was bounced around, so I take care of myself now."
When she did have a medical problem three years ago--which she describes as, "I felt my stomach rip"--Malchow went to a doctor. Even though she told him she didn't have much money, she ended up paying almost $400 out-of-pocket for tests. Dissatisfied with her treatment, she eventually turned to alternative medicine.
Malchow, who says she's better now, isn't motivated to look at her medical insurance options.
"Any extra money I have, I spend on healthy food and exercise," she says.
Like Malchow, 36-year-old Steve Leon is gambling that he will beat the odds by staying healthy, and that he won't need insurance to pay for the potentially enormous expense of an emergency. Leon says he has never had medical coverage because of the cost; he hasn't been to a doctor in more than 15 years. He says, however, that he has thought about what he would do in a crisis.
"Hopefully, I would get some consideration from the hospital," he says. "But I figure I won't pursue my medical options until something happens."
Downtown artist David Aguirre is also unsure of what he would do in an emergency. Without medical insurance, which he believes he can't afford, he says he has accepted the responsibility for his own health maintenance.
"I hadn't had a check-up in 20 years," the 50-year-old ceramist says, "but my asthma flared up recently. So I traded a sculpture to see a doctor." For his required medication, Aguirre went to Nogales, Sonora, and bought it cheaper than he could here.
When asked what he would do if struck by a debilitating disease, Aguirre ponders the question for a few seconds before replying.
"I'd be in big trouble," Aguirre says. "If the cost was beyond my ability to trade for the medical service, I don't know what I would do."
Almost 1 million Arizonans, or 20 percent of the state's non-senior population, face the same dilemmas as all of the previously mentioned men, women and families. While most of the over-65 population is covered by the federal government's Medicare program, and many low-income households are enrolled in AHCCCS, everyone else has to roll the dice when it comes to medical insurance. For those who can't afford it, or don't believe they need it, the threat of a health crisis coupled with a lack of any insurance can hang over them ominously.
The number of uninsured Tucsonans is difficult to pinpoint. Based on the uninsured estimate for the state--which counts people less than the age of 65 who haven't had insurance for at least 12 months--and Tucson's population statistics, approximately 153,000 non-senior Tucsonans haven't had medical insurance for at least a year. The actual number of uninsured, including those people who have lost insurance within the past year, is much higher.
Ironically, the vast majority of people who do without medical insurance are either employed or live in households that have a full-time worker. But 35 percent of small businesses didn't offer any medical coverage last year, and even large companies exclude some of their workers.
Other characteristics of the uninsured are that they are generally blue-collar workers, and that members of minority populations are much more likely to lack medical benefits. Nationally, 59 percent of the uninsured have been without any medical coverage for more than two years, and only a small portion of that number is made up of foreigners who are in the country illegally.
Almost 40 percent of the Arizonans who lack medical insurance earn wages low enough to qualify for AHCCCS but haven't joined that state-sponsored program. Another one-third make less than twice the federal poverty level of $18,400 for a family of four--making them eligible for some help--but haven't applied.
Tammy Stoltz, executive director of the Pima Community Access Program, has strong opinions about people who don't take advantage of the free or low-cost medical options available to them.
"They don't think about health care until they need it," Stoltz says. "Instead, they should make a healthy choice today when they don't need it."
Robert Gomez, executive director of the El Rio Health Center, says that 20 percent of the 50,000 people his clinic sees annually are uninsured. To make health care more affordable for them, El Rio uses an income-based sliding scale of service charges with fees as low as $25.
The uninsured are usually billed on a discounted "pay as you go" basis by El Rio, but these charges don't cover the total cost of the center's services. To make up some of the annual $9 to $10 million difference, Gomez says the clinic receives federal and other grants totaling $6 million.
The same approach is generally true for hospital care, but individual physicians are often not eligible for government reimbursements.
The medically uninsured--whether poor or non-U.S. citizens--don't go without help if they seek it.
"If they can't pay, we don't turn them away," says Tara Plese, director of government and media relations for the Arizona Association of Community Health Centers, an organization that represents 36 health clinics with more than 100 sites across the state.
The widely held myth that the uninsured don't pay anything for their medical care is refuted in a report recently released by the Phoenix policy group, St. Luke's Health Initiatives. The report, entitled "Arizona CAN! Coverage and Access," released Winter 2004, found that the uninsured spend an average of $735 a year on health care, which amounts to 35 percent of the cost of services they receive.
But the uninsured don't receive the same amount of services as do people with insurance, getting instead only about half the medical care as the insured. The St. Luke's study states, "The uninsured are 20 percent of the non-Medicare (senior) population, but (receive) 13 percent of the expenditures," in Arizona. The report concludes, "If one doesn't have (medical insurance), one receives less care, and health status is adversely affected."
At the national level, it has been calculated that those without coverage are more than twice as likely to not visit a doctor within a 12-month period, and are less likely to have recommended preventative procedures such as pap smears, mammograms or prostrate exams. Last year, one-third of surveyed uninsured people also indicated that they needed, but didn't get, medical attention. The Kaiser Commission, a Washington, D.C.-based nonpartisan group that has focused on the issue of the uninsured since 1991, concluded in a recent report that the consequences of this lack of attention to medical care are severe. It stated, "They (the uninsured) are more likely to be hospitalized for avoidable health problems," and when they are, they "are more likely to receive fewer services and to die in the hospital than are insured patients."
The commission estimates that the problematic circumstances of the uninsured population between the ages of 25 and 64 contribute to the deaths of 18,000 of them annually. The group also concluded that the U.S. economy loses between $65 and $130 billion annually due to avoidable health problems among the uninsured.
With such dire consequences for those without medical insurance, and with government and low-cost options available to most of them, why do so many people take the gamble and do without? Stoltz of PCAP believes it boils down to personal responsibility, or a lack of it.
For many working Americans, having no medical insurance has a lot to do with where they have a job. Traditionally, people were covered through their employer, but many uninsured now work where it isn't provided. Even if they do, like Ismael Loreto, they might not be able to afford family coverage, which can cost thousands of dollars a year.
The growing segment of the self-employed population also faces severe financial problems with medical insurance premiums. Even with high deductible amounts, insurance can be expensive.
Not surprisingly, the thousands of dollars a policy can cost is the primary reason people cite for being uninsured. At the same time, insurance costs are rising rapidly, with double-digit increases in each of the last three years.
As costs go up quickly, so will the number of those without medical insurance. Their numbers have risen by 10 percent in the last two years alone, and a study by the Health Care Policy Roundtable predicts the 44 million uninsured Americans today will balloon to 63 million within six years, a stunning 43 percent increase.
To combat that trend, and to offer health care options to the more than 150,000 residents of metropolitan Tucson estimated to be without health insurance, several alternatives are available.
For people earning less than the federal poverty level income, Arizona offers AHCCCS. KidsCare, a child-only off-shoot of this program, provides medical, dental and vision coverage at no more than $35 per month, total, for those less than the age of 19 from households with incomes up to twice the poverty level.
The Pima Community Access Program is a nongovernment alternative, available to those earning between 100 and 250 percent of the federal poverty income figures.
"PCAP is a buying discount program," says executive director Stoltz. "It's not a substitute for insurance, but gap coverage. It's not free, nor is it for everyone."
Under the program--which currently has 6,200 people enrolled--members pay a $40 annual enrollment fee. They are eligible for deeply discounted services from every community health clinic around Tucson, more than 600 specialists and at most of the hospitals in town.
To complete the 10-minute application process for PCAP, Stoltz says, people must provide proof of their income and residency. Currently, the organization is screening 2,000 people each month for both AHCCCS and its own program and has a free, one-year membership offer available for the next 400 qualified applicants. But, Stoltz stresses, the deal is only good through August.
Another price reduction service plan developed to cover hospital expenses was recently unveiled by University Medical Center. Called the "Uninsured Patient Discount Program," this option is offered to patients as they are admitted.
"The discounts are very large, between 60 and 80 percent," says UMC spokeswoman Katie Riley.
The Healthcare Group of Arizona offers a more standard approach to providing medical insurance, but at very affordable rates. This state-sponsored plan currently has almost 3,000 members in Pima County and is open to small businesses and self-proprietors who have been in operation at least 60 days.
Laura Hislop, a public relations spokesperson working with the program, says the premium amounts begin low, and savings can be substantial. She recalls one small business couple that, because of a pre-existing medical condition, reduced their premium payment by 75 percent through the state program.
Hislop says the goal is to create a more affordable insurance option, while also offering coverage to people with pre-existing health conditions who may not be included under typical private insurance policies.
The major drawback of the program is the limited number of medical plans that are offered. To address that deficiency, Gov. Janet Napolitano signed legislation permitting an expansion of these plans a few weeks ago, but that change came at a high price.
Under the provisions of the adopted legislation, starting in September, those seeking coverage will have to have been without medical insurance for at least six months before they become eligible. For that reason, Hislop urges people who may be interested to inquire about the program as soon as possible.
Another possibility for some of the many employed but uninsured people in Tucson is a private industry initiative announced recently. The Affordable Health Care Solutions Coalition, made up of a large number of major corporations, will offer coverage to part-time, temporary and other workers who are now often left out of the system. Among the Tucson employers included are American Airlines, The Home Depot, Texas Instruments and McDonald's.
With these and a number of other options are available to the uninsured, it is not surprising that there is a lot of confusion. "Disjointed" is the label one health care professional put on the overall system, and that reality has helped lead to growing numbers of uninsured and the corresponding medical problems and expenses that result.
By a wide margin, Arizonans believe this issue needs to be aggressively addressed. According to the St. Luke's Health Initiatives report, a recent poll showed that providing coverage to the medically uninsured was the highest health care priority. The results also showed that 55 percent of the respondents supported higher taxes to help pay for this expansion of service.
St. Luke's has offered four models that they believe would increase health care coverage in Arizona. At the national level--to address a situation that has been called a "severe crisis" for more than a decade, since the Clinton administration tried unsuccessfully to confront it--a wide variety of alternatives have been suggested. Whether proposed by politicians or nonpartisan groups, these ideas seek to confront the challenge of providing medical insurance to all Americans.
Given the highly charged political nature of the debate, and the trillions of dollars involved, some favor a government-controlled program, while others champion modification of the current private-sector dominated system. The Kaiser Commission summarized the various approaches to include:
· Build on programs like AHCCCS to cover more low-income people;
· Encourage through tax credits or other incentives the expansion of work place-provided medical insurance; and
· Use tax credits to promote the purchase of coverage by individuals.
Former Speaker of the House Newt Gingrich advocates what he calls a "market mediated" process, which would "structure the financial system to ensure that no one is blocked from health and health care by lack of money."
Democrat presidential candidate Dennis Kucinich doesn't mince words when responding to proposals like this.
"Right now, the insurance and pharmaceutical companies own us," his Web site reads. "We need to take our health care system back."
To do this, Kucinich supports what he calls "Enhanced Medicare for All," a national health insurance program that would be phased in over 10 years. To pay for it, the Ohio congressman would basically reappropriate the hundreds of billions of dollars that both government and businesses are already spending on providing medical care.
At the other end of the political spectrum, the U.S. Senate Republican Task Force on Health Care Costs and the Uninsured recently released a report that called for using tax credits and government financial assistance to make private insurance more affordable. They also want to increase the usage of federal Health Savings Accounts, which are currently problematic due to the tight eligibility restrictions of the program. Finally, the Republicans support providing more funding to community health centers, like El Rio, which serve the uninsured.
Gomez from El Rio, however, is a proponent of universal medical coverage. But he laughs when pointing out that so was Franklin Delano Roosevelt, which shows how politically realistic that proposal may be.
Calling the present medical insurance system "outrageous," artist Aguirre says, "It's a matter of national priorities, and they're not right. Something is wrong with the system."
Adds Jane Doe, "Health care in America is driven by economics, and I hate that. The system is sick, but is driven by profit-seeking."
Veterinarian Jarchow thinks voters need to pay attention in November to a candidate's position on this issue, saying that he believes a lot of people are being let down.
"When election time comes," he says, "support people who support universal health insurance."