Michael Moore's latest media blitz has ensured that his mug, and his movie, would be everywhere this summer (including — look! — the cover of Creative Loafing). But the build-up to SiCKO lacks the conspiracy-laden, self-aggrandizing stamp we've come to know and love from previous Moore escapades like Roger & Me and Bowling for Columbine. Maybe it's because his subject this time around is the disastrous state of U.S. healthcare; as he said on a recent visit to Oprah, the problem is a matter "of we, not me."
The health-care story is everyone's story; the health and financial ruin of one eventually shakes the web that connects us all. And health-care disasters are not limited to the elderly, ethnic minorities or families living in poverty. As the following personal accounts suggest, young people can find themselves without insurance for a variety of reasons, from lifelong disease to hubris to pure bad luck. When they do, they're at the mercy of a system that all but builds walls to keep them from adequate care. I know – one of those stories is my own.
There are alternatives and people with good ideas. People like Bea Dreier, executive director of Tampa's Judeo Christian Health Clinic; Dr. Don Wedemeyer, a general-practice physician with an innovative practice in Seminole Heights; and county services that serve the needy in both Hillsborough and Pinellas. But the question remains, voiced eloquently by Dreier: "From the very beginning, we've seen patients come in desperate for care. I thought, 'Why aren't these people revolting in the streets?'"
Ben Hardisty: Bad Breaks
Ben Hardisty, 27, isn't an average Gen-Xer. In fact, as a person with fibrous dysplasi, he's one in 80,000. He was diagnosed at 8 years old with the hereditary condition that makes his bones easily breakable. It's a "big deal in med schools. They probably won't see it but should know what it is," Ben says.
Before he turned 18, Ben had broken or fractured more than 30 bones. He grew up in Rhode Island; his mother, who had a pottery business, didn't make much money and so was eligible for Medicaid. A good thing, too; she did some investigating and found out that private insurance for his condition would have cost $20,000 a year. Yet on Medicaid, he was taken care of by the best doctors at Harvard-affiliated Children's Hospital Boston, even getting to see an expert.
"This is no garden-variety disability," Ben says, laughing from his wheelchair. Last December, he tripped in a downtown St. Pete establishment and broke his kneecap. He went to the ER, and though the doctor who received him said he had to have surgery soon, Ben was referred back to a doctor he had seen the previous year (for a broken arm, which Ben paid for with his school grant money) who was familiar with his condition. Hardisty hadn't had insurance since Medicaid released him; he quickly applied for it online but was denied, though his surgery was to take place in four days. Bayfront proceeded with the surgery despite his inability to pay; his mother had to pay $200 cash, however, for anesthesia. (Anesthesia at Bayfront is the province of private practitioners, and the administering doctor determines payment.)
In the ensuing months, he racked up bills, not just for the surgery but for follow-up care and physical therapy, none of which he could pay. Bayfront started turning him away for services. Since the initial fall, he's been denied Medicaid five times because, he was told, he did not meet disability requirements. Ben explains that if he had sustained a different injury that would have made working impossible— a broken femur, for instance, instead of a kneecap — he would have qualified (he had previously broken both femurs three times as a youth and was covered). An advocate has been working with Ben to figure out how to qualify him for Medicaid.
A recent USF graduate in political science (paid for by loans, grants and scholarships), Ben hasn't worked in four years and lives with his mother. "I can't even get out of the house most of the time. I can't walk around on crutches or my good leg would break," he says. He adds that he read about a new osteoporosis drug that has been said to benefit those with fibrous dysplasi, but he does not have a regular doctor to prescribe it to him. "Our health-care system is so unequal," he says. Hardisty was accepted to USF for graduate study in environmental engineering beginning this fall; he would like to be a biology professor. He believes a position at any university will finally afford him regular care for his condition.
"Mike": Charity Case
Mike, 25, is one of the 47 million Americans without health insurance. Not because of unemployment; in fact, at the time of his accident last year he had a good-paying job. But believing (like many young people) that he was invincible, he preferred a larger paycheck to health benefits through his job.
A bit of a daredevil, Mike (he prefers to remain anonymous, for reasons I'll explain) was out with friends one night driving the curvy roads in the Trinity area. They came upon a street perfect to "test the ability of the cars," and after a quick scan of the road, "exceeded the speed limit," Mike says. "We hit one turn, and the car didn't want to turn. I realized I had lost control of the car." A creek was up ahead, and he says he attempted to roll the window down to prepare for escape. The car flew over the water, landed on the bank and flipped upside down into an adjacent retention pond. Mike and his friend unbuckled their seat belts and escaped through the partially opened window. It was dark, and the water was freezing. "The bottom of the pond was so sooty; it was like grabbing at nothing." Mike took a big breath, and his lungs filled with pond water. "You get very calm when your lungs fill up with water. Somehow I woke up on the side of the ditch, staring at the stars." His passenger also got out of the car alive, and friends in the car that had been following them called paramedics.
Once recovered, Mike sorted out the bills: the lung specialists, the anesthesiologist, the ambulance ride. After three months, he had paid it all off, but no bill had come from the hospital. "I just kept waiting for the envelope from St. Joseph's, just waiting for it to come in the mail and ruin my day." The balance, after the $10,000 his car insurance paid the hospital, was about $50,000. "I was afraid to call," he says, "I was afraid to find out I was that much in debt."
He finally picked up the phone and dialed St. Joseph's and asked for the billing department. The clerk put him on hold and then came back on the telephone. "Sir? Your account balance is zero, paid by charity." Mike's jaw dropped. "I was bewildered, I was happy, I said 'Thank you, thank you, and have a nice day,' then called everyone in my family to tell them what happened."
He says the experience changed his life. "I knew it happened, but you never expect it to happen to you, I mean I'm middle-class, Caucasian and make OK money. It wasn't so much that charity paid the bill; it was that charity paid a bill for me." (That's why he prefers not to give his full name; he's afraid the hospital will discover it's all a mistake.)
When he returned to work, he immediately bought the company health insurance, but soon realized he wasn't happy with his job and has since quit to start his own business and once again is uninsured. Only now, he doesn't smoke, drinks a lot less and has lost over 60 pounds. "I have a tattoo of a phoenix coming out of the water. That was my rebirth."
Me: The Freelancer
I was guaranteed insurance through my dad's state job until I turned 23 or finished college, whichever came first. But I was covered only when I was actually in school. Because I was on the pay-as-I-went plan, I had to take two different semesters off to save. During those semesters, I was uninsured while I worked part-time in retail and waiting tables.
One night, I stumbled down a stairway while wearing foam platform flip-flops; the shoe went one way, my right heel stretched in the other and immediate pain followed. Nothing was broken, I could tell for sure, and I iced it up. A bruise formed from my toes up to my ankle. It hurt to move so I took it easy for a few days, and the bruise subsided.
Though the injury prevented me from jogging or playing basketball, and I couldn't wear heels anymore, I didn't see a doctor until a year later when I was back at school. It was determined that my Achilles tendon had suffered several small tears. I had lost the ability to point the toes on that foot and my waitressing jobs gave me more pain than I knew what to do with, but what choice did I have? I also started having pain in my knees and my hips; my whole body had been thrown out of whack. Luckily I waited tables at bars so I got discounts on self-medication.
Because my foot problems were preexisting, I was only allotted one month of physical therapy, and my PT, who said that wasn't nearly enough for the extent of the injury, saw me as often as she could within that one-month period. I had better luck with my orthopedic doctor who made a plaster cast of my already flat feet and made me orthodics, customized arch supports that realigned my bones. I still had trouble with the tendon, but I had lots of Celebrex, an anti-inflammatory, that kept the pain at bay.
After college, I moved to Seattle to try to pursue a career in nonprofits or media, but because of a tight job market, found myself in the mortgage department of a large corporate bank. I hated my receptionist job, but it had one plus: great medical benefits. I was in physical therapy on and off as needed, got even better orthodics and even started seeing a naturopath through a natural health college clinic who provided an inexpensive herbal equivialent to Celebrex.
But my mental well-being depended on being back in Florida. It was risky — I would be uninsured again. But being back with the folks allowed me to take on work that made me feel good about myself even if it didn't pay well (for my first year in town I was a second-grade tutor for AmeriCorps), and I eventually started part-time and freelance work at Creative Loafing.
I asked other freelancers what they did for medical. When they told me insuring oneself was affordable, I called around and found a policy for less than $150 a month. (Who doesn't spend more than that on beer and lattes?) My deductible is a massive $1,500 (which means I pay out of pocket until that point). But it's worth it.
I received one bill from a lab for $900 before the insurance adjustment. Once it had been adjusted, it was 54 bucks. A V.P. of marketing for the Florida branch of a private insurance firm said, "Even with a deductible, you're saving money and getting better access." He said it was the difference between paying retail and buying in bulk. "People say it's expensive, but when you get sick and have a real problem, it's really expensive to not have it."
The Uninsured: What the Counties Offer
The so-called "safety net of services" — the set of protections available only if you qualify for Medicaid (like Ben), get lucky (like "Mike"), pay the expense of covering your own ass (like me) or work for the right company — is appallingly chancy.
So what are the uninsured expected to do? Federal law has made it illegal for hospital emergency rooms to deny an uninsured person care, but that's hardly a practical solution, and cost gets passed on to those with coverage.
County governments are trying to meet the needs of the poorest citizens.
[Editor's Note: Following the original posting of this story on 6/27/07, corrections were made to clarify that HCHCP is a program of Hillsborough's Department of Health & Social Services . The story now includes those changes.]
Hillsborough’s Department of Health & Social Services administers the Hillsborough County Health Care Plan (also called Hillsborough Health Plan), a full health-care program established by county commissioners in 1991 for people at 100 percent of the poverty level or below. Division Director Ray Reed says the county does not act as an insurance company, but as a "provider of last resort." HCHCP sees 23,000 to 24,000 different people each year, with about 15,000 enrolled in the program at any one time.
County services are contracted out to other organizations and resemble a "tightly managed care program." Clients must choose a primary care physician from one of Hillsborough's four networks: Tampa General, St. Joe's, Suncoast Federally Qualified Health and Tampa Community Health Centers, Inc.
None serves the county exclusively, of course, and TCHC and Suncoast have clinics in multiple locations that provide services on a sliding-scale basis to those who do not meet county qualifications. These neighborhood service centers are one-stop shops with social workers on site to qualify and refer.
The only charge to clients is $1 for prescription drugs. "We rely heavily on generics. And instead of the county paying, Merck donates. We're trying to be efficient government," Reed says. He is quick to point out that HCHCP is funded by a half-cent sales tax, "not by property taxes."
The county health departments in Hillsborough and Pinellas do not deal in general and preventive care, but do refer low-income and uninsured residents to area clinics. “So many agencies offer resources," says Ronalda Hobson, Pinellas’ assistant director of county health. The primary responsibility of the county departments is public health: they offer services in women's health, family planning, STD testing and treatment, WIC and dental for children.
The Free Clinic: Helping Hands
But public health services aren't the only answer, and they aren't even an option for the working poor. In Tampa, one visionary clergyman initiated a nonprofit clinic that has grown and served thousands of patients without depending on government or United Way funding.
In 1972, Reverend Jim Holmes of St. John's Presbyterian in Tampa had some nurses put up sheets to divide up a Sunday school classroom, and once a week anyone in need of medical care lined up. Bea Dreier, a church member and volunteer at the clinic since its inception, says it was "bursting at the seams. People waited on benches outside rain or shine." Within a few years she went from administrative assistant to executive director, where she's been for the past 30 years. The Judeo Christian Health Clinic is now the largest comprehensive free clinic in the Southeastern U.S.
In its first few years, when Dreier says she was running things "by the seat of my pants," the clinic served 7,000 to 8,000 people. As the need grew and more people found out about the place, modulars were added. In 1999, the board raised $1 million to build the current space, which boasts 12 exam rooms, four dental chairs (for extractions only) and an EKG. It has a vision center and a state-licensed pharmacy. The medical staff volunteers at least once a month or more as their schedule permits, coming to the clinic in the evenings after work. Last year, JCHC saw 26,000 patient visits.
Different nights mean different services. Monday nights are for pediatrics, Tuesday and Wednesday for gynecology and so on. "These rooms are always full," Dreier says. "We don't duplicate services offered by the health department. This is a place for people with nowhere else to go," such as the working poor, those working multiple part-time jobs — and freelance writers. (She's suggested I apply for eligibility.)
Qwest and St. Joe's do all the lab work free of charge. The conference room is wallpapered with awards of recognition and framed newspaper stories on various board members and serves as a space for education (dieticians, diabetes management) and support groups.
But despite the success of her clinic, Dreier is angry about the state of health care in the U.S. "Why aren't we, the richest country in the world, supplying care? Those who work in D.C. have the best health care. Why can't the people who pay their salaries have the same thing?"
Because the board doesn't want to be beholden to the government, the board of directors holds private fundraisers, such as the testimonial dinner this past spring at which $130,000 of their $500,000 operating budget was raised. "Those numbers don't include the millions for testing and medical staff who work for free," Dreier says. "Plus we keep a lot of people out of the emergency room, which is the most expensive setting of all."
Doing Well by Doing Good: The Family Doctor
One local doctor with a new private practice is proving capitalism and altruism can indeed be friends. Don Wedemeyer and his wife, Marta, started Global Integrative Family Medicine this year in a Seminole Heights bungalow in an effort to do his part to make healthcare more affordable and return to a higher quality doctor-patient relationship.
He's not currently part of any HMO networks. To keep his costs down, he doesn't employ staff. He makes appointments and checks his patients' vitals himself. And electronic health records "make it all doable."
The latest trend in medical record-keeping technology is a small super-computer barely larger than a Blackberry that allows him to enter patient updates as he sees them or gives over-the-phone consults.
The computer cost around $300 and allows him to have a practice with low overhead by not "taking on the responsibility of employees. Right now we're trying to keep it small."
His practice is a reasonably priced alternative for those without insurance, but for those with coverage, Wedemeyer provides the paperwork they need to submit their claims. "The patient can go through the labor-intensive process and we can do what we like — the medical side — and not be taken away from patient care." Wedemeyer reads stories in medical journals of other family physicians around the country doing the same thing at their practices. He learns from them, he says, "and as we go along."
He acknowledges that new technology can be a double-edged sword; it's "great once the leap has been made, but a tremendous effort to get there."
Larger group practices would have to have computers that communicate with each other, and staff from administrators to nurses and doctors would all have to be trained in how to use the system. And while the doctors are on a learning curve, they're seeing fewer patients. Which "means reduction of income, in addition to the start-up cost."
Wedemeyer anticipates slow growth over time for his practice and works part-time for community clinics in the area and for USF. For the month of July, he'll be in Ecuador with 35 med students, which he says brings unconventional but necessary experience to aspiring doctors.
He is a shining example of what's good in American medicine. He thinks, as Michael Moore says, "of we, not me." And that's the start of what it will take to turn this shipwreck around.
Additional research for this story was done by Arielle Stevenson.
See also
This article appears in Jun 27 – Jul 3, 2007.