Just Out of Reach

Meet Laura Parrish, poster child for the uninsured in San Diego County.

Working as a massage therapist, yoga instructor, food server and caterer, Parrish, 35, does well for herself. She makes enough to afford a rented townhome in Mission Bay with two roommates, a small savings account, occasional trips out of town to visit family and nights out with friends.

But she doesn't make enough to afford health insurance.

Earlier this year that might have ruined her financially. After several abnormal pap smears, Parrish's medical care providers at Planned Parenthood in Pacific Beach suspected she had cervical cancer and performed 10 cervical biopsies. Thankfully, they all returned normal.

Because her income is under a certain level, Parrish isn't required to pay for medical care at Planned Parenthood, but she donates whatever she can afford. Although no longer worried about cancer, Parrish sometimes wonders what might have happened if she had been sicker. And she has no idea how she would have paid for treatment.

“Oh my God, I don't know. To be honest I just don't know,” she said. “I have a girlfriend going through chemo-she has cervical cancer. I don't think Planned Parenthood covers that so I would have been in trouble because chemo is extremely expensive.

“I don't know what would have happened,” Parrish continued, reflecting harder on the consequences of being uninsured. “I would have had to do my best to think of something. Probably call my parents, maybe even move from San Diego. There's no way I could afford treatments and live here.”

Now imagine between 550,000 and 700,000 other San Diego County residents in this same situation. According to a variety of estimates, that's about how many people here are uninsured.

Far from being undocumented workers crossing the border to work illegally, studies have found that most of the non-elderly, non-poor uninsured are people just like Parrish: Hard-working, but employed with companies that can't afford to offer health insurance or working in jobs ineligible for coverage. Most can't afford to buy individual insurance on the open market.

Parrish said she certainly can't afford that. Recently she learned non-HMO coverage by Blue Cross would cost her $200 per month. “A lot of it's expensive, and you have to do an HMO and I hate HMOs,” she said.

So why should those with insurance care about the plight of people like Parrish? Because the uninsured effect them in many ways.

The uninsured normally don't obtain regular primary care, so when they become ill they normally get sicker than those with insurance. That means communicable diseases can become more serious as they spread. For example, an uninsured co-worker could spread a more serious illness to an insured colleague, or an insured schoolchild could pass something on to an uninsured classmate, who might become sicker than necessary because the child doesn't have access to a primary care physician for preventative care.

And, those who do have insurance ultimately pay the cost of treating the uninsured, who are rarely able to pay the full cost, if anything, for their care. In San Diego County alone last year, hospitals spent more than $150 million on uncompensated care, and those costs will be passed on to the insured next year in higher health insurance premiums.

Who are the uninsured?

According to a 1999 survey by the California HealthCare Foundation, the non-elderly, non-poor-those with an income of more than 200 percent of the federal poverty level-uninsured are far from the stereotypical lazy couch potato. In fact, the uninsured statewide are: 90 percent U.S. citizens, 62 percent white, 62 percent younger than age 40, 31 percent married, 40 percent homeowners, 29 percent parents and 56 percent computer-owners. Some 92 percent have purchased other insurance, such as auto, home or life, and 22 percent have declined to take part in their employer-sponsored health insurance plan.

“This is a population that isn't what we believe it is,” said Kathlyn Mead, who in addition to being CEO of Sharp Health Plan advocates for the uninsured. “It includes... a number of people who have chosen a flexible or entrepreneurial work style and cannot afford private insurance on the [open] market.”

Or, they earn $10 per hour or less-barely enough to live on in San Diego, let alone enough to afford health insurance here.

Or, they work part-time and aren't eligible for employer-sponsored insurance.

The majority, though, are not offered insurance at work, according to the Alliance Healthcare Foundation, a nonprofit organization that, among other things, educates about and advocates for the county's uninsured.

“The 600,000 uninsured people in San Diego County are probably people that you and I know,” Mead said. “They're young, working, going to college, working part-time. This is a population [for which] one illness could lead to financial ruin.”

Remember Parrish's cancer scare? Had she actually had the disease it could have cost tens of thousands, if not hundreds of thousands, of dollars to treat, depending on its severity.

There are several reasons why the working uninsured remain so. According to the California HealthCare Foundation's survey, 74 percent believe they can't afford health insurance, 48 percent say they're in good health therefore don't need insurance and 43 percent say it's not a good value.

At least 30 percent said they are waiting for a job with coverage because they can obtain medical care for less than what they would pay for insurance.

About 67 percent worry about not having insurance, 29 percent worry about it a lot and about one-third don't worry about it at all.

A community-wide concern

Although only about 5 percent of the increases in the cost of health care can be attributed to caring for the uninsured, according to Mead, it is still an issue about which San Diegans should be concerned because it costs them money and impacts local emergency services.

When those who are uninsured can't pay a hospital bill, first the physicians, laboratories and other care providers cover the cost of care out of their profits. But the next year they charge hospitals and health plans higher rates to make up for it. Then, the hospitals and health plans charge insurers and employers more to make up for their increased costs. And because most employers already struggle to pay the cost of offering health insurance, those premium increases are ultimately passed on to insured employees.

And treating the uninsured here every year ain't cheap. Last year the Sharp hospital system ate $89 million in care for the uninsured, the Scripps hospital system ate $48.6 million and the UCSD system ate $49 million. (There are two ways to calculate this number; Sharp uses a different method than Scripps and UCSD. If they used the same method, their numbers would be within millions of each other, all in the $48 million neighborhood.)

Most hospitals consider these millions of dollars spent on uninsured care the cost of doing business, but losing this much money every year certainly contributes to why two-thirds of the hospitals in California operate at a loss and why health insurance premiums nationwide have been increasing for the last several years.

According to a New York Times report, health care costs are expected to continue their double-digit ascents for many more years. Health insurance premiums spiked 11 percent last year and are expected to jump another 13 percent this year; employees are paying about 30 percent more in deductibles this year than last year.

The California Public Employees Retirement System, which offers health and retirement benefits to 1.3 million people, has said its premiums will jump 25 percent next year, the Times reported.

“Obviously, these costs are impacts to the overall operating budget of the organization that have got to be covered. It impacts what prices you have to negotiate for those costs with those health plans,” said Michael Barton, head of public policy and governmental relations for Scripps Health.

While few companies are leaving health plans because of their rising costs, “that doesn't mean they're not telling us they're not concerned,” Mead said. It's the next three years-if costs rise the expected 13 percent to 15 percent each year-that concern employers most. They think in that time the double-digit increases will break them.

“In the circles I travel in, I'm hearing the same thing: People aren't losing a lot of business, but they're concerned about [finding] better ways of cost containment [and] keeping premium increases at the lowest possible level. I'm hearing the groundswell of opinions that these kinds of increases won't be able to be sustained over time,” Mead said. “I think it's something we have to try to get ahead of instead of watch and react to it.”

Another cause for concern is that the uninsured normally wait longer to seek medical attention, and when they do, they seek it in emergency rooms because they have no where else to turn. Emergency rooms are required to treat anyone who walks through the door, regardless of that patient's ability to pay.

That means that not only are the patients seeking primary care in emergency rooms usually sicker and in need of more services than the average insured patient, but their presence causes longer waits in San Diego's already-overloaded ERs.

“We have had emergency rooms so full they're on bypass,” Mead said. And according to studies she's seen, more than half of those emergency-room cases could have been seen in a private physician's office or urgent care center.

“But the patient had no where else to turn,” Mead said. “As a community, it's incumbent upon us to identify medical homes for the community so the emergency room isn't used for primary care, so the emergency room staff... is spent on those in emergency situations.”

Another problem with the emergency room is the cost-it's much more expensive than a doctor's office. “It is not where you prefer to care for people. It's more expensive. So not only do you have poorer health, you have more dollars spent. From a planning and effectiveness standpoint, it's one of the worst policies to have,” Barton said.

And of course, those higher costs for emergency room treatments for the uninsured this year will be passed on to the insured in next year's premiums.

The realities

Before joining a program called FOCUS, sponsored by Sharp Health Plan and the Alliance Healthcare Foundation to subsidize health insurance premiums for low-wage workers, it was impossible for Julie Walker to offer coverage to her employees.

“The rates were just so high it wasn't possible to offer that,” said Walker, who operates Obraverde, a cut-flower grower in North County that employs 13 employees during the slow season and 28 in busier months.

The worst part was looking into her employees' faces and knowing they needed and wanted insurance but that she couldn't afford to give it to them. “I hated that part, I really did. I wanted them to be able to have access to health care, adequate health care, regular health care, preventative health care, and I was not able to offer it,” she said.

Sam Ilaian of Same Day Express, a courier and messenger service, had been able to offer health insurance to the tune of $800 per month to cover eight employees. Through FOCUS, the company now pays only $100 per month to cover his workers.

“Before we got that, it was really difficult. It was expensive and we got various rates-they go up and down,” he said. FOCUS is “a lot more affordable.”

Under FOCUS, Walker now offers her full-time employees a benefit she's proud of, and her employees are thrilled. She said they jumped at the chance to secure coverage for themselves and their families for between $10 and $25 per month.

“They were very happy to do it. They're proud to be part of the system, as opposed to a drain on the system,” she said.

Another boon for her business is that her employees are now covered 24 hours a day, seven days a week, by either health insurance or workers' compensation insurance. That decreases the likelihood of an employee trying to fraudulently use workers' compensation benefits for an injury not sustained on the job.

Ilaian says offering health insurance is an incentive that keeps employees on board, and that they were relieved when he took part in the cost-reducing FOCUS program. “They were really happy, and they felt more secure at the job, too,” he said.

While rising costs are a problem and increase the chances health insurance will become unaffordable for her business again in the future, it motivates Walker to work harder to keep this benefit for her employees. “I'd best be on my toes as far as running my business,” she said.

Ilaian says he will be able to continue offering coverage-so long as costs don't spike too much. “With this, what we're having right now, we're OK. Even a little bit increase we will still be able to do it. If this health plan we are having right now stops, it will be impossible to do it,” he said.

A program like this would be a windfall for people like Parrish, who hasn't had an eye exam in 10 years, and although she has pap smears and breast exams at Planned Parenthood every year, she hasn't had a general medical check-up in eight years. “I don't even have a doctor. I don't have a primary physician,” she said.

That came back to bite her a few years ago when she suppressed a strong cough at her waitress job and tore the intercostals in her chest. “I couldn't breath and my manager rushed me to the emergency room. It cost me $250 and I was out of work for a week because I couldn't lift anything heavy,” Parrish recalled. “That whole thing cost me $500 out of my pocket.”

Parrish doesn't stress about not having insurance, but she is extra careful with her body. “I take extra care of myself so I don't get sick. If I do get sick I have friends who go down to Mexico for me to get prescription drugs. God forbid I got into a car accident, I'd be S.O.L.,” she said.

Because she can only afford to see a dentist once each year for cleaning, Parrish brushes constantly and flosses twice a day to guard against any unnecessary dental work. “I got a bridge when I was a young kid. I really have to take care of that,” she added.

Initiatives for change

“With the state budget the way it is, it's very difficult for the state to fund the uninsured burden. Then it falls on the county and... the county doesn't have the funds either,” Barton said.

But there are a handful of initiatives focused on the uninsured and further changes that can be made to help.

FOCUS was a successful, if short-lived, effort. The two-year pilot initiative subsidized low-cost health insurance for 212 local small businesses, helping to insure 1,699 workers. “The thing that didn't work is we weren't able to secure long-term funding for these program subsidies,” Mead said.

However, employers who participated in that program are now more motivated to find affordable insurance to continue offering their employees. Alliance reported recently that 99 percent of the companies that received subsidies want to continue coverage as the program phases out.

Walker, of Obraverde, hopes FOCUS will become a national model. “The way I see it, this is the way it should be done nationally,” she said. “It's almost an absurdity not to be able to have effective health care if you're going to be a productive person in society.”

Another success has been the state's Healthy Families program, which has provided insurance to 200,000 children who didn't have it three years ago when the program began. Under Healthy Families parents contribute to the cost of the insurance. It's not an entitlement program-which many are too proud to use. “It enables low-income working families to take pride in making a contribution instead of taking a hand-out,” Mead said.

Problem is, the expansion of this program has yet to materialize. “In my opinion, at the time it covered children, it should have covered the parents,” Mead said. But it won't happen this year. Early this month Gov. Gray Davis cut $52 million from the state budget that would have covered parents under Healthy Families.

The San Diego Regional Chamber of Commerce is also addressing issues surrounding the uninsured. The chamber formed its health care committee in 1995 and several initiatives have spun-off from that effort. Chamber and business representatives began meeting with county supervisors to raise the issue of affordable health insurance and the committee also developed a series of recommendations about how to bring more affordable coverage to San Diego companies.

One of those recommendations was to form the Business Healthcare Connection, which in July received an $800,000 grant from the California Endowment to begin its work. The BHC is charged with identifying and marketing lower-cost health insurance options to employers, and informing employers about programs the state offers-such as Health Families-that can, if nothing else, insure their employees' children.

Eventually, the BHC will begin to educate small businesses about the costs and tax benefits associated with offering health insurance, said Richard Ledford, vice chair of the chamber's health care committee. The BHC will also work with larger businesses to encourage them to offer health insurance to employees not normally eligible for coverage.

Individuals can make a difference for the uninsured, too, Mead says. “Individuals can clearly have a voice with our state legislature. It's very important for us to weigh in, saying providing health insurance for all is good for our community, for everyone,” she said. “And we can do that in writing, e-mailing, calling [elected officials'] offices, encouraging them to fund the programs that already exist, like the Healthy Families program.”

Individuals can also contact private foundations and charities and encourage them to consider subsidizing insurance premium programs for the uninsured. “Many have policies that they don't subsidize these programs, they do direct patient care only,” Mead said. “We have a real concern about that episodic care. That doesn't promote a medical home, prevention, wellness. Insurance means primary care, preventive care. It makes more sense than episodic care.”

Making donations to community health centers-which provide health care to the uninsured-and organizations that support other so-called safety net providers is yet another way to help. “That gives a message, too, that we're willing to put our money where our mouth is,” she said.

When Parrish lived in Hawaii, where employers are required by law to offer health insurance to all employees who work at least 20 hours per week for four consecutive weeks, she says she was “spoiled” because she had affordable medical and dental insurance that allowed her to see any doctor she wanted for a 10 percent co-payment.

“I really have issues with our medical system” Parrish said. “I think it's ridiculous. Insurance is extremely high. I truly like the way they do it in Hawaii. Everyone there is entitled to insurance, even if you work in Burger King or McDonald's.