EDITOR’S NOTE: This six-part series on health care reform is a joint effort of the Denton Record-Chronicle and graduate students from the University of North Texas Mayborn School of Journalism, along with professor George Getschow, formerly with The Wall Street Journal and a Pulitzer finalist.
On a crisp November morning, cars slowly fill the parking lot of a clinic on Loop 288 in Denton. At 7:30 a.m. a woman signs in at the computer check-in station before her appointment. She is in good spirits as she punches in the necessary information. Her last appointment showed no irregularities and she expects the same results this time.
Check-in complete, a clinic employee ushers her to the back room.
She’s not seeing a physician before starting another long day of work. Nor is she visiting a health care facility.
She is donating plasma at BioLife Plasma Services — and using the procedures at the Denton branch as an early warning system for any urgent health issues.
At 54, Frances “Frankie” Rodriguez says she would buy health insurance if she could afford it. Because she doesn’t have health insurance, the blood screening at BioLife gives her some peace of mind and supplements her income at $50 to $60 per week.
“I figure they would tell me if something were really wrong,” Rodriguez says. “Then I would do my best to find the cheapest doctor around. I’d ask my co-workers, ‘Where’s a doctor that would do some cheap blood work?’ Or look in the phone book and start making some calls.”
In no way should the services administered at BioLife, including the initial physical and the blood and plasma screening, be used as a substitute for a doctor’s physical, according to company spokeswoman Sonja Gaston.
“BioLife is not a hospital or ambulatory care facility and does not provide medical care, treatment or see patients,” she said in an e-mail.
She explains that, of the vast number of ailments that could be found in a client’s blood and plasma, BioLife only checks for a small percentage of them, including HIV, hepatitis and syphilis.
Linda Goelzer, spokeswoman for Carter BloodCare, said that information means a lot to the donors.
“We get comments from our donors that being a regular donor saved their life, too,” Goelzer said.
Few people get their blood iron levels or blood pressure checked as often as regular donors do, and changes in those numbers can signal something is wrong. But that’s no substitute for a doctor’s care, she said.
Between two jobs cutting hair, Rodriguez works roughly 60 hours per week. She relies on her bi-weekly plasma donation to supplement her income as well as to substitute for certain elements of a doctor’s physical. She doesn’t consider being insured one of her highest financial priorities.
Right now, she has more immediate obligations than health insurance.
“Two of my sons have kids, so I try to help them make ends meet,” the grandmother says. “With their everyday life situations — both of my sons have lost their homes because of not having a job.”
Every penny earned
For Rodriguez, trading some financial obligations for others is the norm.
She is not alone.
Rodriguez ranks among the 1.37 million people in the Dallas-Fort Worth region without health insurance, despite the fact that she works more than one job, according to the Texas Medical Association. The working uninsured is a well-represented demographic in Texas, which has the highest rate of uninsured people in the country at 25 percent.
The working uninsured’s do-it-yourself strategies for health care can vary. They rely on blood screenings administered by plasma or blood donation centers to alert them to a potential problem. They buy generic forms of over-the-counter insulin to conduct ill-defined diabetes treatments. They take aspirin to try to thin out blood clots. They pop their own joints back into place and accept the lingering pain.
In March 2010, Congress passed the Patient Protection and Affordable Care Act, which seeks to help people purchase affordable health insurance through state-run exchanges. Specifically, the new law does this by eliminating the ability of insurance companies to deny coverage because of pre-existing conditions, and by implementing sliding-scale premiums so people earning wages at or slightly above the poverty level can have maximum access to health care.
David Shipler, author of the national bestseller, The Working Poor: Invisible In America, has spent years interviewing and writing about those who hover around the poverty line and how they stay afloat.
“Every penny they earned they spent on rent, electricity, transportation, food, etc., with nothing left to guard against a problem they didn’t have,” Shipler said. “When you are poor and live close to the edge, your time horizon tends to collapse, and your ability to act preventively or anticipate hypotheticals declines.”
Freelance Denton auto mechanic Greg Bailey, 36, has little financial cushion for unexpected health problems. He recalls moving his arm up above his head one morning while lying in bed, a motion he normally wouldn’t even think about. This time, however, the movement was accompanied by an eye-squinting “crunch” as his shoulder popped out of its socket.
But instead of rushing to the emergency room, Bailey gritted his teeth and pushed his arm back into its shoulder socket. The mishap occurred four years ago, and Bailey has been living with chronic pain in his shoulder ever since. Still, he hasn’t even thought about seeing a doctor. He says he can’t afford one. As a part-time mechanic and part-time theater screen cleaner, his take-home pay averages about $2,000 a month if he works 50-hour weeks.
Most of Bailey’s income is gobbled up by rent, food, gasoline, telephone and Internet service and for traveling to movie theaters around the country in connection with his screen-cleaning business. Despite his aching shoulder and other health problems, he says he can’t imagine purchasing private health insurance at an average cost of about $5,000 a year when he can take care of himself.
While Bailey disagrees with the mandates of the new health care law, specifically the individual mandate to carry insurance by 2014, he views being insured as something that would improve the quality of his life. Whether in need of a checkup or urgent care, his two options are either to treat it himself or go to the emergency room and go into debt.
And that obligation can perpetuate a cycle of working jobs that not only make it hard to live a healthy lifestyle, but also may not provide for a chronic health condition.
The new law will provide more than 30 million uninsured Americans with at least some form of coverage, depending on their income. People earning a salary at 2.5 times the federal poverty level or below — about $27,000 per year, or roughly what Bailey and Rodriguez earn — will be required to pay a maximum annual premium of $2,180, or about 8 percent of their annual income.
The current average annual premium for a private Texas health plan is between $4,000 and $5,000, according to Texas Health Insurance 360, a premium comparison website — much more than the maximum payment required under the new law.
Based on the 2010 federal guidelines in the reform legislation, people earning $14,000 per year or less will likely pay a maximum premium of about 2 percent of their income. The maximum out-of-pocket payment will likely be limited to $1,983 — very little when compared to the cost of even one day in a hospital.
Glassblower Steven Blakely, 33, knows something about hospital debt. Last September, Blakely was camping with friends in Homer, Alaska. He had been feeling sick for the past two months, and had noticed steady weight loss. Normally 200 pounds, he had dropped down to 140 pounds in less than two months. He also noticed he was urinating excessively — a symptom his father, who has Type 1 diabetes, had warned him about.
Because Blakely didn’t have health insurance, he put his symptoms in the back of his mind and hoped they would go away.
One day while walking his bike back to his campsite, he blacked out on the side of the road and collapsed. He doesn’t know how long he was lying there, but once he woke up, he managed to make it back to his campsite and schedule an appointment at the Seldovia Village Tribe Health Center.
“I should have just gone to the ER,” he says. “But at this point I was thinking I could still save some money by going to this little sliding-scale native clinic.”
The clinic could not admit him for two days, so he waited in bed until time for his appointment. At this point, no longer in denial and sicker than he had ever been, Blakely’s friends, with whom he had gone camping, were taking care of him however they could. They brought him water and food and made sure he didn’t black out again.
“Normal blood sugar levels are somewhere between 80 and 100 milligrams,” he says. “When I got to the clinic and told them my symptoms, they knew immediately to check my blood sugar. Their instruments only measured up to 400 milligrams, and mine was higher than that.”
The clinic confirmed that he had Type 1 diabetes and rushed him to the only emergency room in Homer.
Blakely spent a day and a half there before being sent to the intensive care unit for closer monitoring for another three days. When his health finally stabilized, he was given counseling about how to treat his disease and released from the hospital.
Blakely still does not have health insurance and treats his diabetes himself. He spends about $150 a month for discount insulin and blood-sugar monitoring strips. He re-uses his needles. His glassblowing business, from which he earns about $1,500 a month, takes care of all of his bills but leaves little room for anything else. The debt he amassed from his hospital visit — several thousand dollars — makes his financial situation bleak.
Worse than before
Kristyn Ingram, a pediatric anesthesiologist at the University of Texas Southwestern Medical School in Dallas, said that while it’s admirable that Blakely is doing his best to take care of himself, he is missing a wide range of other clinical treatments that diabetics require.
“They need screening for elevated cholesterol on a yearly basis,” she said. “[They need] blood tests to ensure optimum glucose management, and at least yearly physical exams to monitor for signs of end-organ disease, which are frequent complications of diabetes.”
But even if Blakely wanted to buy health insurance right now, his diabetes renders it moot. Health insurance companies are still allowed to deny him coverage based on his pre-existing condition until 2014. Though the new health care law established in June 2010 that people with pre-existing conditions could join a temporary high-risk insurance pool, eligible members must have been insured for at least six months prior to applying.
The new law emphasizes preventive care and provides subsidies to individuals and employers that take advantage of preventive care because it is cheaper than emergency care. The new law includes $15 billion for the Prevention and Public Health Care Fund, a trust fund to pay for significant preventive programs nationwide over the next 10 years unless Congress agrees to an $8 billion cut proposed in November by leading Democrats.
Ingram has seen many patients who didn’t, or couldn’t, take advantage of preventive care. During her residency, she often saw patients with untreated diabetes who had conditions ranging from infections to ischemic bowel syndrome.
“We did multiple toe, foot and leg amputations secondary to complications from uncontrolled diabetes,” she said, adding that all of these situations could have been avoided with a simple yearly visit to a doctor.
Shipler said some of the problems can be attributed to a lack of education about the best possible health care options.
“People struggling with low incomes are often too stressed and too busy to follow complex public issues closely,” he said. “There has been so much posturing, propaganda, and downright lying about ‘Obamacare’ that it’s a wonder anyone — even people who follow the news — has an accurate picture of it.”
He emphasized that with the new law must come educational outreach from employers, medical personnel and anti-poverty workers to point people in the right direction. He predicts that is likely to happen as the 2014 deadline approaches.
Book author Shipler tied the working uninsured’s “do-it-yourself” mindset to the American culture’s tendency to equate money with success. Excessive media images of the wealthy strengthen that mentality and can lead to a feeling of powerlessness among those people who don’t have much money, he said.
The phenomenon “creates a sense of marginalization for many Americans who are camped on the outside looking in,” he said. “The sense of powerlessness feeds the inability to make wise choices in anticipation of unwelcome events, such as illness.”
The new law, if upheld by the U.S. Supreme Court, will require almost everyone in the country to purchase some form of insurance by 2014. People can opt out and pay a fine instead, but the amount increases each year. In 2014, the individual fine for declining health insurance will be $95, or 2 percent of the person’s taxable income, whichever is greater. In 2015, the fine increases to $325, and rises again to $695 in 2016.
In this regard, Shipler has his doubts about the new law.
“I worry that the subsidies will not be generous enough to support families who are above the Medicaid threshold,” he said, “and that many will just pay the tax penalty, which will be much less than the insurance premium. Such families may be worse off than before, still uninsured and now penalized by the IRS.”
Staff writer Peggy Heinkel-Wolfe contributed to this report.