“Thank God I just had cancer, and paid all my deductible,” I thought, when I sprained my ankle.

I was on my way to an interview for this story when I fell, and I was thankful because I had just used up my deductible and could go for X-rays without thinking twice about the cost.

Who else in our society has this kind of freedom from worry, all the time? Well, Mary does. Mary, 49, used to be married to a man who works for a large corporation. She and their daughter are still covered by what Mary calls his “Cadillac” insurance plan. Not only is everything basically covered — except marriage counseling — she also has complete freedom to choose any caregiver or provider she wants.

Of course, Mary lives a healthy life and can afford a gym membership and organic food, which always helps. In 25 years, she has only used her insurance for preventive care.

Another area 49-year-old had, until recently, a different type of freedom from worry. Cindy was diagnosed years ago with chronic depression, lives on the Supplemental Security Income (SSI) benefit for a single disabled adult, $564 per month, and, through Section-8 Housing, pays 30 percent of her income for rent. She also receives Minnesota supplemental aid for $81 per month.

Because she qualifies for Medical Assistance (MA), she’s had complete coverage for years — except that not every doctor takes MA, which pays the provider only 30 to 35 percent. Cindy was not able to get braces for her daughter, but has been able to go for regular checkups and was covered for two surgeries for breast cancer four years ago.

Since the 2003 Legislature, however, the complete MA coverage is no longer there. Now, there’s a $500 per year cap on dental care, exempting emergencies, dentures and extractions for dentures. There are required co-pays for doctor visits, eye exams, glasses, drugs and non-emergency ER visits. Although Cindy says it is sometimes hard to come up with the $3 co-pay, she has managed to be seen for arthritis, vomiting and back pain. An esophogram, MRI and a PET scan were all covered. Drugs she takes for anxiety, depression and arthritis cost her co-pays of $3 (brand name) and $1 (generic). Sometimes if she doesn’t have the money the pharmacist says, “It’s OK.”

When Cindy doesn’t have the co-pay, she doesn’t go. So far, it hasn’t killed her.

State Senator Linda Berglin (DFL-Minneapolis) tells about a woman on MA who got caught in the new regulation. The woman had a case of heartburn bad enough to cause concern. But she didn’t have the $3 co-pay to see the doctor. In the event that her concern was a non-emergency, she certainly didn’t have the $6 co-pay for a non-emergency ER visit. Yes, there are unemployed people, disabled people, people with unusual circumstances who don’t have three, let alone six, dollars.

Heartburn and heart problems can be confused. Before her next check came, she was dead of a heart attack.
It’s hard to imagine why this most vulnerable population should have been challenged by adding co-pays. It’s appropriate that somebody like Cindy should not have to worry about medical bills. Her life is hard enough as it is: She is dependent on medication to be functional and has $475.80 per month to cover everything but rent.
Cindy just finished a training program at the American Indian Opportunity Industrialization Center (AIOIC) and has been job hunting. More income would, of course, mean a chance at a healthier lifestyle.

If she starts to make more than $880 per month, she will no longer qualify for SSI, but will be eligible for medical coverage under Medical Assistance for Employed Persons with Disabilities (MA-EPD). Unlike MA, which requires no premiums, MA-EPD requires premiums that correlate to income level.

She could continue on that plan forever, even if making $5,000 per month, for example, and pay proportional premiums. However, if she were functional enough to make that much money, she would probably lose her disabled classification.

Of all the options for health care in this country, Mary’s is the best. Cindy’s was second best — until the 2003 Legislature. While I am envious of people who have better coverage than I do, I don’t begrudge it to them. Ideally the whole country should have it.

The Safety Net

Minnesota Care is a state program that provides health insurance to people who make too much to be on MA and not enough to afford commercial premiums. It is for people who make from 75 to 275 percent of the Federal Poverty Guidelines (FPG is $749 per month for a family of one) and was designed to make sure that pregnant women and children have complete health coverage. About 145,000 Minnesotans are enrolled.

MN Care was also cut in the state budget-balancing enthusiasm. While low-income children and pregnant women are still top priority, newborns of mothers on MN Care at the time of birth will now qualify for only one year of automatic eligibility rather than two. The biggest cuts affected single adults without children.

Carl, 35, is one of those single adults, a man whose life is a textbook case of how to deal with severe depression. He avoids alcohol, sees a therapist regularly, stays physically active and cultivates meaningful friendships. He manages his own business and works odd hours in order to spend time with his child. Between his $25,000 college debt, house payments and child support, he barely makes ends meet. He worries about money a lot.

Carl had been on MN Care for six years when his knee gave out. Living with debt and depression, he was told he would need surgery, which even for the insured means lost work time, loss of income and extra expenses. But, because he had MN Care, at least he wouldn’t incur more debt. No one told him the rules had changed until his physical therapy provider said he wasn’t eligible for coverage.

After the surgery, a MN Care caseworker told Carl that if he had made $600 per month less in income, or received inpatient instead of outpatient surgery, everything would have been covered — information he received too late. Another caseworker told him he could probably get somebody to cover his bills but he might have to “make 60 phone calls.” She advised him to rest between calls. In the meantime, Carl has developed his own physical therapy program based on the advice of two women — who had had similar surgeries — whom he met at a coffee shop.

Carl says, “I do everything right. I work, I pay my taxes and I listen to advice from wiser people. How could this happen?”

A lot of vulnerable adults aren’t as gregarious and likable as Carl, or as educated. Many don’t feel empowered enough to call their leaders, as Carl did. He asked Pawlenty’s office, “Do you think there’s any chance Pawlenty would confront the presidential candidates about health care? The industry has had double digit increases in the past five years!”

With the $5,000 benefit cap, he now will have to buy his usual anti-depressants out of pocket at $300 per month (with MN Care it was $9). He is struggling to get through until January when his MN Care benefits start over. His therapist is concerned he will slip into a debilitating depression. During all of this, Carl still has to pay his premiums.

As Carl hangs on by his fingernails, he maintains his sanity by refusing to consider himself personally victimized by the cuts to MN Care. The bright side, he says, is that “I don’t have cancer.”

What Happened to MN Care?

Minnesota Care is a stopgap measure that fills a need until a better system comes along. Many people feel it provides very good coverage and should be expanded.

Subscribers pay premiums anywhere from $4 for children in lower-income households up to $425 a month for families of three or more with income and assets close to the limit. The average premium in 2002 was $23. In general it covers preventive care, non-preventive care, family planning, immunizations, laboratory and x-ray, outpatient surgery, chiropractic, eye exams, mental health service, emergency room visits and prescriptions. For some enrollees there is a $10,000 limit on hospitalization, of which the subscriber must pay 10 percent for each hospital stay. Many enrollees are eligible for alcohol and drug treatment, medical equipment and supplies, rehabilitative therapy and eyeglasses.

MN Care has been critical to Minnesota’s welfare reform strategy, helping people leave welfare and go back to work without losing health care coverage.

MN Care has been paid for since its beginning, in 1992, by the Health Care Access Fund (HCAF), a 2 percent tax on the gross receipts of all health care and subscriber premiums. For a brief period tobacco taxes also contributed to the HCAF.

According to a state employee who prefers to remain anonymous, “The MMA [Minnesota Medical Association] and other health care lobby groups have hated this tax since its inception and have done everything they could to undermine it.”

She believes the tax is the best solution. “This would tie the funding of the plan directly to the cost of health care, and also provide a dedicated fund that would not depend so heavily on the whim of the Legislature as it would if it were funded out of the General Fund.” She was as shocked as anyone that the “dedicated fund” turned out not to be inviolable.

She said that numerous attempts have taken place in the Legislature to get rid of MN Care. Senator Berglin cited Pawlenty’s 2004 proposal to “do away with MN Care altogether” as the latest attack. Berglin, sounding weary, said she didn’t vote for the proposal to move $450 million over the next four years into the general fund from the HCAF.

She was obviously distressed and angry that the $5,000 benefit cap would affect 3,000 single vulnerable adults, like Carl, per year.

“Some have MS, some have chronic arthritis or diabetes and about 30 percent are mentally ill,” she said.

“These people are caught in a Catch-22 if they work. Since MN Care has been cut, their expenses won’t be covered. Diabetics won’t get their insulin and people like Carl won’t get their anti-depressants. These people now need a program like Medical Assistance for Employed People with Disabilities (MA-EPD), but they are not eligible for Social Security disability until they’ve been without work for six months. If they quit working for six months, their lives fall apart,” she said, describing the humanitarian concern.

Then she described the cost of the cuts. “Now, as they try to live without their medication, they end up being hospitalized, or having emergency care, which is much more expensive than their medications would be.”
Regardless of whether the changes should have happened or not, the fact is that they did. If Carl had looked up MN Care on the internet (if he had a computer) he would know that these changes were in effect. But since he was sent to different caregivers for different services and wasn’t told he wasn’t covered, he believed that he was. He wonders if his Minnesota Care caseworker knew. What if he had known about the $5,000 cap? Would he have forgone surgery and gone on disability?

The Cross-Your-Fingers Option

Between 8 and 9 percent of the people in Minnesota — 14 percent nationwide — have no health insurance. Nothing.

Brixton is one of Minnesota’s uninsured. Estranged from her family of origin at 15, living on disability for chronic back pain at 19, she struggled to earn a college degree as a single mother. She got MA at the beginning of her pregnancy, in 1991. She said the care was wonderful and people came to her house and talked to her about nutrition and even taught some cooking. In 2002 she started working full-time and was soon earning too much to qualify for MA. After rent, food and college debts, there wasn’t much left of her paycheck. She couldn’t even consider paying the insurance premiums offered through her work.

During the summer of 2003, almost immediately after she got the letter saying she’d been cut from MA, she began to have abdominal problems. She had pain, was nauseous and couldn’t eat for several weeks. The rug had been pulled out from under her and she was unable to check out her symptoms, which escalated until she ended up in the emergency room.

The diagnosis was gallstones, and the recommended treatment was immediate surgery. They said she might die if they didn’t get the gall bladder out right away. Her son was at home sleeping and didn’t even know she was gone, so she went home. It was a no-brainer to decide against surgery, since it cost thousands of dollars.
She went online and did a crash course in gall bladders. The next day she drank quite a few doses of a cleansing tonic she made with olive oil and lemon juice. It cost $5. And it worked.

Brixton has decided to continue without medical insurance. She plans to live in as healthy a way as possible. The biggest problem is and has always been dental care. When they had MA she would call one dental office after another asking, “”Do you take MA?” On her own, the cost of dental care is out of reach. Her son has been to the dentist once in his life.

American Health Care Cost is Exorbitant

It is the common problem we never discuss with our neighbors — getting caught in some kind of bureaucratic health-care snafu, or having difficulty paying deductibles (especially the second and third year in a row when the savings are gone), or just “practicing medicine” ourselves because we can’t afford to seek care, or getting caught in legislative cuts to our government-regulated health care programs.

Sometimes the results are tragic. Eighteen thousand Americans this year have died from lack of health care, and nearly 100,000 have died from preventable accidents from poor health care.

Kip Sullivan, a national expert on health care issues, has written a book whose title sums it up: “The Health Care Mess.”

In an engaging style with graphs, charts and documentation, Sullivan demonstrates that there is indeed a problem with our health care system. Historically, he shows that health care has become a mega-industry since 1930, and that originally nonprofit hospitals and the health insurance companies have become highly profitable corporations. He writes about managed care, the origin of HMOs (health maintenance organizations) and why they don’t work. He explains what’s wrong with the MSA (medical savings account) idea: “… a type of health insurance which relies on huge deductibles to get people to reduce their use of medical services …”
Sullivan emphasized that the unnecessarily high cost of health care in this country is the biggest problem with the system, no matter who pays for it.

Americans assume that, since their health care is so expensive, it must be state-of-the-art, just as we assume a $100 pair of shoes are better quality than a $20 pair. Instead, he said, “our health care is so expensive because it is more wasteful.” “There are high fees and high prices, excessive administrative costs, excess capacity and price gouging by some doctors, all drug companies and most equipment manufacturers.”
Sullivan and 77 percent of Americans favor a universal, Canadian-style health care, called “single-payer” care, which he calls “Medicare for all.” He says if what people spend now on premiums, out-of- pocket payments and taxes were spent on a unified system of health care, it could easily be paid for.

“[Medicare] spends 3 percent on overhead while Blue Cross and Blue Shield spend about 20 percent,” he said.

“Medicare has no marketing costs, doesn’t harass doctors like managed care … doesn’t underwrite for research and number crunching, doesn’t make profits, doesn’t lobby, and there are no obscene salaries.”
Senator Berglin gave another reason to support universal health care: The current system costs taxpayers a lot of money.

“We do have universal health care — it’s called the emergency room, the most expensive care there is,” she said.

Rhoda Gilman is one of the founders of MN Universal Health Care Coalition (MUHCC), whose goal is to develop universal single-payer health care starting with Minnesota. The group advocated a bill for a state-operated single-payer system proposed by Leo Foley (SF339). They hold meetings once a month at the COACT (Citizen Organizations Acting Together) office at 2429 University Avenue West in St. Paul.

Another group advocating universal care is Physicians for a National Health Program is a national organization, made up of 10,000 doctors. They view the problem in the United States as partly philosophical.

“We alone treat health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need.”

“We endorse a fundamental change in America’s health care — the creation of a comprehensive National Health Insurance (NHI) Program,” the PNHP states. “Such a program — which in essence would be an expanded and improved version of Medicare — would cover every American for all necessary medical care. Most hospitals and clinics would remain privately owned and operated, receiving a budget from the NHI to cover all operating costs. Investor-owned facilities would be converted to not-for-profit status, and their former owners compensated for past investments. Physicians could continue to practice on a fee-for-service basis, or receive salaries from group practices, hospitals or clinics.”

They envision a national health insurance program that could save at least $150 billion annually by reducing costs of overhead, profits and administration. They envision a system that could expand access to coverage and reduce costs. “It would squeeze out bureaucratic waste and eliminate the perverse incentives that threaten the quality of care and the ethical foundations of medicine.”

What’s Standing in the Way of Universal Care?

Everyone has heard the negatives about health care in other industrial countries. My friend Wendy, who lived in Montreal for two years, loved the health care system but said she also heard people talk about loved ones who died while waiting for treatment. My friend Tim in Spain said he knows people who are addicted to seeing the doctor; a friend of his goes “Every 10 days, and I’m not kidding.” He also says he has heard the system runs consistently in the red. While he and Wendy love the care, he tells one story of incompetence. Once, in the middle of the night, he was having trouble breathing, and called the nurse who makes house calls. The guy came to his apartment, put his ear to Tim’s chest to listen to his heart — and fell asleep. When Tim stopped laughing he could breathe again.

My sister, Janet, tells what would sound to many like a horror story. In 1964, she and her husband, Orvin, set off to Newfoundland, the eastern-most island of Canada, to teach school for two years. She promptly shattered her elbow playing ping-pong. At 4 p.m. she and her husband drove to a nearby 20-bed regional hospital whose doctor served 35,000 people. Personnel took X-rays and tried to make her comfortable for the night. The next day she and her husband drove 90 miles, 60 of them unpaved, to catch an airplane to St. John’s. Finally, more than 24 hours later, she went through a three-hour surgery. For two weeks she convalesced in a ward on the top floor of the hospital where the water came through the roof when it rained — everyone had buckets on their beds to catch the rain. The nurses were kind and decent. My sister was not interested in finding fault with the no-frills system and was grateful for an excellent surgeon. The payment for one year of health care for one person was $10. You could call this scenario rustic and inaccessible, but not inadequate.

While there are drawbacks to universal care as it is practiced in other countries, there are also drawbacks to the way a huge segment of our population’s health coverage ranges from inadequate and nerve-wracking to nonexistent. This low-level stress pervades society and contributes to violence and discord in our collective worldview.

We need universal health care because it is the right thing to do. The way it gets set up in this country doesn’t have to be the way it is set up in another country. Our terrain, our culture, our mentality, our standard of living and our integrity aren’t going to change overnight if we suddenly have universal care. We won’t suddenly have one hospital every 200 miles. And we will still have kind and decent caregivers.

Because our culture breeds people who want to take charge, for better or for worse, the system could be created in a number of ways. It wouldn’t have to be exclusively government-run, for those who would rather die than put their health care in the hands of the “enemy.” There’s a lot of talent for business and for government in this nation. The system could use the best of both worlds.