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By Tom Jennings

Being without health insurance in America is becoming more common. More than 44 million people are uninsured - some temporarily, many long term - with the large majority holding jobs that no longer provide a health insurance policy.

Our story begins in Abilene, a West Texas town with a history of oil, ranching and agriculture. After the Texas oil bust of the late 1980s and early '90s, Abilene hit hard times. Now reeling from the third year of drought in a row, agriculture and ranching have also been devastated. Like the rest of the nation, however, Abilene is enjoying economic good times generated by the service sector, where jobs are often low wage and without benefits like health insurance.

Jody Beal is an example of the old West Texas economy. At 62, Jody is approaching retirement after a lifetime in the oil business as a logging engineer. After the oil bust, he found jobs where he could, with his employers providing health insurance for him and his family through 1996. Since then, he has had to travel abroad to find work. He gambled that he would be able to make it without health insurance until he was 65, when he would automatically qualify for Medicare.

But Jody lost that bet. He suffered a heart attack, and now he and his wife Sandy are saddled with a mountain of debt - $125,000. Their life savings are gone, and Sandy, at age 57, is scrambling for work. She has been forced to do door-to-door selling - pitching advance funeral arrangements. The Beals' case is one that epitomizes what health policy experts call the plight of the "near elderly." Too young to receive Medicare, but too old or too sick to work, these people are caught without insurance at a time in life when medical care becomes increasingly necessary.

Across town at a stone quarry, Tom Phillips embodies another facet of the US health care economy. Working at low wages and unable to afford the insurance that is offered on the job, Tom is a 42-year-old stone cutter who had a heart attack and bypass surgery three years ago. After leaving the hospital, Tom was told to take regular medications and to visit the doctor for regular checkups. But because he couldn't afford health insurance, he was too intimidated by the prospect of high medical bills to get the necessary follow-up care. Now, three years later, he is back in the hospital being treated for a blocked artery after suffering chest pains on the job.

Tom exemplifies the working poor: the many millions of Americans who live above the poverty level. They don't qualify for Medicaid health coverage, which is for the poor. But they make too little on the job to afford health insurance. Also typical of the working uninsured, Tom put off medical care until an emergency occurred. The result is that patients like Tom get care late in their illness, and that is usually the worst time to attend to a problem. Late care is usually more expensive care, meaning that their care costs them and the health care system more than if they were insured and got early care.

After the failure of the Clinton health plan in 1994, there have been various attempts to deal with America's uninsured. One statewide effort is TennCare, Tennessee's program to expand health care coverage from the base of Medicaid (for people who live at or below the poverty level) to the working poor who have family incomes up to above $30,000 for a family of four.

While TennCare has achieved its goal of expanding health care coverage, it has also been teetering financially since its inception in 1994. One result has been that Tennessee stopped letting new people into the system, pulling back from its original goals and only allowing new coverage to people who are so sick they are "uninsurable" by commercial health plans, and they have no other access to health insurance.

Nine-year-old Joshua Mitchell is an example of the potential of TennCare. Joshua has sickle cell anemia. Covered by TennCare, he receives all the treatment that he needs from Dr. Ernest Turner, Director of Sickle Cell Center at Meharry Medical College in Nashville for his periodic bouts of pain in his joints and muscles. His mother, Angela, however, works at Shoney's, and is uninsured because she can't afford her employer's insurance plan.

Joshua's story reveals the importance of Tenn-Care to someone with a chronic condition. When an attack of sickle cell anemia strikes, his mother usually takes him to the emergency room at Vanderbilt University Hospital and he is often admitted to the hospital for several days. TennCare pays for these visits. However, for a brief period during the spring of 2000, Joshua's TennCare coverage lapsed and Vanderbilt was less welcoming. When Joshua went to the ER, he was given morphine, a cup of Gatorade and then turned away, without admission. "With TennCare, you can get the care you need," says Angela. "Without it, you're out of luck."

Nevertheless at Vanderbilt's renowned trauma center takes care of people regardless of their insurance status. Here doctors use the latest and most expensive lifesaving equipment. The cost of care is high is clinic, and because of TennCare's funding cutbacks, the hospital seems to always be threatening to cutoff this high cost department because TennCare falls far short of full reimbursement for Vanderbilt's service.

One recent car accident victim, Laura Ragsdale, came to trauma's ICU with massive abdominal injuries and stayed there six weeks before being released to a rehabilitation center. Laura was uninsured, but after her injuries Vanderbilt case workers got her into TennCare as an uninsurable. According to Dr. John Morris, Vanderbilt's chief of trauma, problems often arise for TennCare patients during the often costly process of rehabilitation. TennCare's administrators, always watching costs, often provide less care than normal insurance plans. But in Laura Ragsdale's case, doctors insisted she needed extensive physical therapy - and won.

Another major initiative intended to help the unsinsured is the Child Health Insurance Program (CHIP) passed by Congress in 1996. Its goal was to cover at least three million of the nation's ten million uninsured children. But in many states it has had trouble reaching the target population because of red-tape, complex eligibility standards, and difficulty getting the word out to target families. In California, where many of the uninsured are Latinos, an anti-immigrant political climate has deterred people from signing up. But when people do sign up, they report that CHIP - or Healthy Families as it is known in California - is a dream come true.

Take Maria Gumaer, 34, a single mother of two daughters, one of whom, Denika, 12, has asthma. Maria works in the accounts department at a flooring distributor. Like many others, she makes too little to pay for insurance, instead paying for her family's daily needs while trying to take care of Denika's medical bills from paycheck to paycheck. For Denika, the insufficient medical attention for her condition meant that her asthma periodically got badly out of control. Her mother did not even know how seriously ill she was because she could not afford sufficient medical tests. So instead of going to the doctor, Denika suffered through her attacks.

When Maria Gumaer learned of Healthy Families (CHIP), she signed up her daughter for coverage. The Doctor was shocked by the seriousness of Denika's asthma, and gave her strong treatment. Her condition improved dramatically. Her mother was pleased but felt guilty"It hurt me so much to know that my poor child had to struggle for six years not being able to breathe correctly," said Maria Gumaer. "Now I feel so blessed."

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