The U.S. spends more money on health care than any other country. But the nation's 44 million uninsured face a system of ...

Second-Class Medicine

"I'm seeing two of you," Keeshun Lurk told a visitor. "I have double vision in my left eye." His fingers circled the lump on his neck. "I have bad migraines and an infected lymph node." Lurk, 20, had not seen clearly for a week; his head began throbbing almost a year ago.

Lurk lives in Washington, D.C., three miles from the U.S. Capitol, where for four decades lawmakers have debated but ultimately defeated legislation that would guarantee health-insurance coverage for all Americans. He is one of 44 million people across the country without health insurance--a number that continues to grow, despite piecemeal attempts at reform.

In April, eight months after he first sought treatment, doctors had yet to diagnose the cancer growing in his head.

Lurk's journey through the health-care maze began at the very hospital where he worked, the Washington Hospital Center. He was a "floater," rotating among departments, logging in patients, and keeping track of patient records. But as a temporary worker, he was not offered health insurance.

The pounding in his head began last summer, about the time he started at the hospital; his mood changed from euphoric at the prospect of a new job to lethargic. As the headaches grew worse, he sought help at the hospital's emergency room, where doctors diagnosed migraines and an ear infection and sent him home with prescriptions for Motrin and an antibiotic.

The pain continued, and he began missing work. "I really liked my job," he said. "But I couldn't function." In November he stopped going altogether.

In December he visited the Washington Free Clinic. A nurse practitioner gave him what the clinic later said was an "extensive physical examination" and "patient education." Lurk remembers she told him not to eat too much pork. He missed several scheduled appointments because he said his migraines had gotten better.

By April, Lurk was back at the clinic. This time the clinic asked the Archdiocesan Health Care Network for a referral to a general surgeon for a biopsy of the lump on his neck. The network asks specialists to treat patients referred by community clinics--in essence, it rations specialty care to those who cannot pay.

Dianne Camp, who works for a consumer-health advocacy program and who happened to live in Lurk's apartment building, also pushed for his care. "It was hard to see this young man lying on the floor in pain taking Advil and Tylenol," she said. Camp called a doctor she knew at another free clinic, who finally did a biopsy, but the results were inconclusive. The doctor arranged for a visit to an ophthalmologist, whose clinical judgment told her something was seriously wrong.

By this time so many calls had been made on behalf of Keeshun Lurk that the logjam blocking his care began to break apart. He finally got medical appointments and a CT scan, and he shuttled back and forth among doctors at D.C. General and Howard University Hospital, where he received tests and another biopsy that revealed the cancer at the back of his nasal passage. Lurk is now being treated with radiation and chemotherapy, which doctors say will give him a good chance for a cure.

The next hurdle is paying for treatment. Lurk is too poor to buy insurance and too old for the D.C. Healthy Families program. He was ineligible for Medicaid because his part-time work, and later his unemployment-insurance benefits, nudged him over the income limit. Now that those benefits are gone, he qualifies for Medicaid until his 21st birthday. But that's just a few weeks away. If he can prove he's disabled, he might have Medicaid for another year. After that, who knows?


Swelling ranks of the uninsured

Such is the lot of the uninsured in the District of Columbia and all across the U.S. at a time of unparalleled prosperity in the richest country in the world.

To many Americans, the numbers are familiar--44 million people without health insurance, or nearly 20 percent of the population under age 65. Eighty-five percent of them are working or in families where someone is working, mostly at low-wage jobs that offer no health coverage. Nearly one-third of the uninsured who work are offered coverage by their employer or through a family member's employer but decline it for themselves or their dependents because the price is so high--and getting higher. More than half of the uninsured have been without coverage for longer than two years.

More people are uninsured now than when President Clinton took office eight years ago promising health insurance for every American, and the long-term trend points north. Based on population growth alone, 47 million people will have no insurance five years from now.

Less familiar is what happens to the uninsured when they get sick. "The uninsured are truly an invisible population," says Jane Zwiers, a registered nurse who runs the First Presbyterian Church Health Clinic in Kalamazoo, Mich. "The truth of the matter is no one wants to know about them."

To assess how people without coverage fare in the health system, Consumer Reports undertook a six-month investigation that included interviews with more than 130 doctors, hospitals, clinics, health-policy experts, and uninsured people themselves. The key finding: Millions without health insurance receive second-class health care, if they get any at all. Consider that:

• If you're uninsured in America, the care you get depends on chance--how old you are, what county you live in, what piecemeal programs exist, your diagnosis, how much money you can scrape together. And it depends on your perceived worthiness. Babies and kids are more "marketable" when it comes to claims on the public purse than 20-year-olds like Lurk or millions of older adults, who don't have the same cachet with politicians. Care is often "primitive, irregular, unpredictable, and uneven," says Fitzhugh Mullen, a physician who treats the uninsured at the Upper Cardozo Health Center in the District of Columbia.
• A two-tiered system of care exists for chronically ill patients: the top tier for those who have the means to buy state-of-the-art medications and technology, and the bottom tier for those who do not. Uninsured patients with asthma, diabetes, or hypertension are often denied the care readily available to those who have insurance. "A lot of physicians, even those willing to take uninsured patients, are reluctant to make referrals or do necessary lab testing to deliver the same standard of care," says William Jagiello, a Des Moines physician. So a person in the midst of a seizure gets treatment for the seizure but no investigation to determine the cause. A child in the middle of an asthma attack may be treated with medicine that opens the air passages but won't get medications to prevent future attacks.
• Waiting lists mount and rationing occurs for most specialty care. If you're uninsured and need a dermatologist to remove a mole, a cardiologist to examine your arteries, or even a dentist to treat an abscess, you need advocates who will beg or borrow services or otherwise try to link you to providers willing to give tests and treatment. "We have to depend on favors," explains Dr. Maureen Connolly, the medical director at the Iowa City Free Medical Clinic.
• These problems are intensifying. Welfare reform has meant more people leaving the welfare rolls for jobs--jobs that pay too much to qualify workers for government health coverage like Medicaid but that offer no affordable health insurance of their own. At the same time, health-care providers that in the past have cared for the uninsured in part with leftover money from insured patients have seen those funds squeezed by managed-care cost cutting. In the end, more people need care, but the system is increasingly unable to provide it. "The old social contract has broken down," says Dr. Spencer Foreman, president of Montefiore Medical Center in New York City. "Not that it worked terribly well to begin with."
  
  The result is that the allegorical safety net--emergency rooms, community clinics, pharmaceutical-industry programs, hospital charity care--doesn't catch everyone in need. At Zwiers's clinic in Kalamazoo, 500 people showed up in 1995. This year 5,000 will come. In February, the People's Community Clinic in Austin, Texas, turned away 153 children and 184 women who needed checkups, and told 94 pregnant women they had to wait eight weeks for their first prenatal visit.

The emergency-room myth

During the health-care-reform debate in 1993, Fred Barnes, a conservative commentator, wrote in The American Spectator, "Federal law (Sec. 9121 of the Consolidated Omnibus Budget Reconciliation Act of 1985) requires medical screening of everyone requesting care at a hospital emergency room. If treatment is needed, it must be provided. What this adds up to is 'universal access' to health care in America."

That notion--that universal health care is already available--has stuck to this day. "If they get sick or have an accident, they can go to the emergency room. Everyone in Texas knows they are going to be taken care of," says Dianne Longley, insurance director at the Texas Department of Insurance. "Right now there are not people going without care," echoes Pat Hayes, executive vice president of the Seton Healthcare Network in Austin.

For an uninsured person, health care means the emergency room at Brackenridge Hospital in Austin, Broadlawns in Des Moines, Montefiore in the Bronx, or Henry Ford in Detroit, where the price of treating a sore throat may be three to five times as high as in a doctor's office.

More than half of the 90 million visits to emergency rooms in 1992 were for non-urgent care like sore throats. According to The Commonwealth Fund, a nonprofit philanthropic organization interested in health care, 63 percent of uninsured men and 44 percent of uninsured women between ages 18 and 64 had no regular doctor in 1998.

The emergency room is not a doctor's office, the medical home for most middle-class Americans. It is not the place to get primary care, follow-up care, or care for chronic conditions. At the emergency room, uninsured diabetics receive treatment only when their blood sugar has climbed so high or sunk so low that their life is in danger. Emergency-room physicians don't routinely monitor diabetics' blood sugars or lipids, check their feet, or examine their eyes for signs of impending blindness.

The uninsured who come to the emergency room do get prescriptions--prescriptions they often cannot fill. In Ann Arbor, Mich., emergency-room doctors at the University of Michigan Hospital gave a man suffering from bronchitis and sinusitis five prescriptions. Days later, he showed up at a state-owned mobile van that delivers medical care in poor neighborhoods. "He had heard that we were paying for people's prescriptions," says Lynn Klima, a nurse practitioner who coordinates van services. "Nobody who saw him originally made sure he could get the medications."

Federal law indeed requires emergency rooms to stabilize all those who show up at the door. It is illegal to transfer patients until they are stabilized and out of immediate danger. Between 1986 and 1996, 10 percent of acute-care hospitals violated the law and "dumped" patients--mostly the uninsured--at other hospitals, according to the public-interest group Public Citizen. The group said that the number of violations is probably much higher because many hospitals don't report violations. "Typically we'll get a phone call that they have an undesirable patient. They say, 'We want to send them to you,' and we say, 'Do you really want to do that?'" says Howard Freed, an emergency-room doctor at D.C. General, a public hospital that cares for indigent patients.

The phone call usually comes after a "wallet biopsy"--ER jargon, Freed says, for a hospital's examination of a patient's job, insurance coverage, and ability to pay. Says Freed: "If the biopsy comes back negative, they are sent here." And any place else that will take them.

Jesus Vivas, 21, has lived in Texas for six years. Born in Mexico, he came north to live with relatives and earn his living selling food at construction sites in booming Austin. In January he got a better job, earning $55 a day painting houses that were under construction. Then one day he fell off a ladder. Although he was bent over in pain, his face swollen from a fracture, and his arm frozen in the air, his bosses sent him home rather than to a hospital. "The contractors said they didn't have any money and weren't responsible for the medical expenses," Vivas said through an interpreter.

Later, relatives took him to the emergency room at Brackenridge Hospital, where doctors put a splint on his broken right wrist, gave him pain medication, and referred him to a physician's office. But there, he said, he was told that since he didn't have insurance, no doctor would see him.

Three weeks later he showed up at the People's Community Clinic, which sees all patients even if they have no money. Doctors diagnosed a fracture of his left wrist, too, which they say emergency-room doctors had missed. Vivas's left hand is still stiff, and he has limited ability to move his wrist and a big bill he cannot pay. His medical expenses total some $4,000, including $3,800 for emergency-room services. The law doesn't say that emergency care has to be free.

People's Community Clinic sees a lot of immigrant laborers, documented and undocumented, without health insurance. Recently, the clinic got a call from a construction company that brought in 400 laborers to build a large downtown office complex. The company wanted to know if the clinic provided health care. "Who gained the benefit here?" asks the clinic's executive director, Roseanna Szilak. "The contractor profited because he did not have to bear the cost of providing health-insurance coverage, and the savings could be reflected in a lower bid."


Care at the clinics

In storefront walk-ups, church basements, and community and day-care centers, clinics set up shop to provide primary care for the uninsured, often asking doctors to donate their time. They pull together exam tables and boxes of medicine samples doctors have discarded, and they decorate the walls with colorful posters telegraphing information about vaccines and breast exams.

The federal government funds some 3,000 clinics, and last year Congress channeled about $1 billion in federal money to them, including a $94 million increase to accommodate the huge demand for services. The number of uninsured people seeking care from these clinics is up 45 percent over the past decade, says Earl Fox, administrator of the Health Resources and Services Administration. Still, there is no money for 12 new clinics and 46 expansions that already have been approved. By contrast, Congress gave nearly $18 billion to the National Institutes of Health for research on treatments and cures for disease--therapies that may never reach the uninsured. Hundreds of other clinics receive no federal money and depend on donations as well as state, local, and private grants.

By the time the uninsured do show up at a clinic, it may be too late. "We see people whose conditions could have been reversed if they had access to care," says Dr. Jim Brand, the medical director at the People's Community Clinic.

Ben Gonzales is one such patient. Old beyond his years and trembling from Parkinson's disease, Gonzales, 57, carried insurance most of his working life. When the cabinet maker for whom he worked laid off workers, he lost his job. His wife's employer, a nonprofit organization, offered coverage for dependents but at a price. When her employer reduced staff salaries across the board, the family had to choose between coverage for Gonzales or their daughter. They guessed wrong.

For a year Gonzales did not seek treatment for gradual weakness, fatigue, poor balance, and episodes of incontinence. When he finally showed up at Brand's clinic, he was sent to a neurologist who agreed to see him for free. The neurologist wrote in his chart: "I can't believe that he has had these symptoms for one year and has not sought help."

Doctors diagnosed cervical stenosis, which causes compression of the spinal cord. An operation might have relieved Gonzales's symptoms, but he did not have one. In the meantime he developed Parkinson's disease. "So far, nobody will operate on him," Brand says.

Care often depends on the assorted pots of money clinics have available. Roberta Feinberg directs two clinics in central San Diego: the Linda Vista Health Care Center and the Mid-City Community Clinic. Her two centers treat 65,000 people each year on a budget of $5.7 million built from 23 different funding sources. Patients must fit a matrix of eligibility requirements set by each funder; in other words, their age, sex, diagnosis, and immigration status must match the criteria.

If a child has an ear infection in January, and the family's income is below 200 percent of the federal poverty level, or $34,100 for a family of four, funds are available to provide the $65 visit for free, including lab work and medicines. But by April, the clinic has spent that money. "The kid suffers unless the mother has money to pay on a sliding fee scale," Feinberg explains. "They manage the condition with Tylenol."

Occasionally, special programs exist to treat people with chronic diseases. The catch: There isn't enough money to serve everyone in need.

In Washington, D.C., La Clinica del Pueblo could enroll only 110 diabetics in a program to help them manage their disease and thus prevent kidney failure, blindness, and amputations. Those who don't participate "are not getting as good care," says Dr. Andrew Schamess, the clinic's former medical director.

Sometimes there is special funding for early detection of disease. But there may be no money for follow-up care and treatment. Feinberg's clinics, for example, get money from the state of California to screen for breast cancer, a high-profile disease popular with lawmakers, but not a dime to pay for mastectomies or chemotherapy. If cancer is detected, the poorest women can apply for Medicaid and hope that their income is low enough. If a woman doesn't qualify, the clinic sends her on to specialists. "We hope to God they'll be kind-hearted enough to take her," Feinberg says.

Some women do lose out. During the four to seven years following an initial diagnosis of breast cancer, uninsured women are 49 percent more likely to die than women with insurance, according to The New England Journal of Medicine.


Begging for specialists

It is Beth Ann Fromm's job as director of Catholic Charities Specialized Service Networks in Washington, D.C., to help cajole the 9,846 specialists in that city into treating the uninsured. "It has been hard to recruit physicians," Fromm says. About 300 donate their services. To get an MRI, patients wait four months; for a CT scan, two months; for general surgery, six to eight weeks. "That's unacceptable but there's nothing we can do," she says.

Staffers at other clinics also underscore the difficulty of obtaining specialty care and say they have to prioritize their patients. "Is this the one we should send for an MRI or should we sit on this?" Zwiers says she asks herself. Each time a patient needs a specialist, clinic workers flip through the Rolodex to find someone they haven't asked in awhile. Feinberg is blunt: "You have to beg. I've had people say, 'I'll take one patient a month or two a month.' They'll say, 'I'm very busy,' and I say, 'This is what you have to do to give back to the community because you have that Ferrari parked outside.'"

Once a doctor says yes, patients sometimes face agonizingly long waits for diagnosis and treatment. In December Schamess, now a deputy director at the D.C. Department of Health, examined a woman who appeared to have cancer of the cervix, and referred her to the Archdiocesan Health Care Network for a specialist. In February, she saw a gynecologist who definitively diagnosed the disease, but in late April, she was still waiting for a hospital to donate time in an operating room for surgery to rid her of the cancer. Says Schamess, "It has always been shocking to me that hospitals make so few services available to the uninsured."

And some people just don't get specialty care, or even surgery, unless it's done on an emergency basis. Dianna Schroder, 51, cleans buses for a living. She has arthritis, migraines, an anxiety disorder, and high cholesterol. Doctors say she can work only four hours a day, which gives her monthly take-home pay of $400. Her employer, the Coralville, Iowa, Transit System, pays half of the health insurance premium for part-time workers. But that means she would have to pay $122 a month. And when her financial decisions are as basic as choosing between shampoo and a carton of eggs, insurance is out of the question.

One day last year her left side became weak and numb. Her mouth drooped. She made her way to the Iowa City Free Medical Clinic, where a doctor diagnosed a stroke and sent her to a specialist. "The doctor said he normally would have run tests," Schroder recalled. "He said there wasn't anything that he knew of where I could get free testing. He said that if I had insurance or money, there were some tests he'd run and the only thing he could do was give me aspirin."

No one checked her carotid arteries for blockages that could signal the risk of another stroke--standard procedure for someone with her medical history. "What are you going to do?" she asks. "You hope you don't have another stroke, and if you do, you hope you survive it."


Searching for dentists

On a morning last February when the thermometer sank to 0° F, 30 people had lined up by 8:15 outside the Hope Medical Clinic in Ypsilanti, Mich. More came when the doors opened. This day the clinic was accepting new patients for dental care, a service in short supply for low-income people across the country. In the first hour, the clinic took in 45 new patients and turned 27 away. Hope turns down 100 each month.

The oral health of those they do accept is so bad that the typical patient needs seven visits just to stabilize his or her condition.

In Washington, D.C., "there hasn't been any ongoing program that integrates screening with dental checkups," says Robert Cosby, executive director of the Non-Profit Clinic Consortium. Four health-care programs in the district recently screened 15,000 children ages 2 to 8 for dental problems. The screening turned up only 2,000 children who had received any care at all. Says Cosby, "Now you have an ethical dilemma: Where do you send them and who pays for the care?"

The 3,000 federally funded clinics can meet only 6 percent of the need for dental care. Some clinics have trouble wooing dentists to work in their facilities; others consider dental services expendable in the face of what they believe are more pressing medical concerns.

At the dental clinic at Broadlawns Medical Center in Des Moines, the staff keeps no waiting list; they worry about offering false hope. The wait for major dental work for adults would be three to four years.

Even poor people who have insurance--primarily those with Medicaid--can't get dental care. Medicaid is a federal-state program that offers a comprehensive package of benefits to 41 million Americans. But doctors are allowed to turn away Medicaid patients, and many do, particularly dentists. They say the states pay them too little. In the District of Columbia, for example, dentists receive $31 to X-ray, examine, clean, and apply fluoride to the teeth of a child under 15 insured by Medicaid. They can get more than $100 from other payers.


The real drug problem

At La Clinica de la Esperanza in Des Moines, Mark Sundet, a physician's assistant, counts out pills for Leonardo Lopez, a dishwasher at a local steak house who works full time, earning $6.25 an hour. He has no health insurance. Lopez, 59, has diabetes and blood pressure that spikes one day and dips the next.

On this day the clinic's supply cabinet held enough samples of Capoten to treat his erratic blood pressure, but doctors had already given away the Glucotrol he needed for his diabetes. So they gave Lopez a prescription. "If we don't have a sample, that's the best I can do," Sundet says. Doctors had no assurance he would fill it. Thirty percent of those without health insurance don't fill their prescriptions, because of the cost, according to the Kaiser Family Foundation's Commission on Medicaid and the Uninsured.

Clinics do what they can to supply medicines, sometimes paying for them out of their own budgets but most often relying on the goodwill of nearby physicians who donate unused samples left by pharmaceutical salespeople. "For a program like ours it's a daily struggle," says Julie Tiplady, administrator of the Packard Community Clinic in Ann Arbor, Mich. "People can't get the medication they need."

Clinics are never sure about what samples they'll have on hand. Every month the First Presbyterian Church Health Clinic in Kalamazoo, Mich., holds a drug roundup. The clinic sends faxes to doctors, asking for leftover samples. "Drug runners"--volunteers armed with garbage bags--go out and scoop up the medicines, then return to the church basement to see what has come in. Glucophage, for example, a popular medication for treating diabetes, often turns up short.

Relying on samples can result in compromised care. When a clinic doesn't have what a patient needs, the patient goes without until another batch comes in, or doctors substitute medicines that are less ideal. Nick Yphantides, the physician who runs the Escondido Community Health Center in San Diego, says he prefers to treat patients with Glucophage, which can improve lipid levels. But because free samples are scarce and patients have trouble paying for the medicine on their own, he prescribes an alternative that is more difficult to take and can cause low blood sugar, but which is a fraction of the cost. Yphantides says he has had to hospitalize asthmatic children to bring their asthma under control simply because the clinic had no nebulizers, which deliver vaporizing medication to the lungs.


Drug-company largess

Some clinics turn to pharmaceutical companies, whose patient-assistance programs supply free medicines to a small slice of those who need them. A spokesman for the Pharmaceutical Manufacturers Association says that in 1998 these programs were offered by some 50 drug companies and served 1.5 million people, adding, "Our companies are committed to making sure that people who can't afford their medicines can get them."

But they can make it difficult. Some companies limit the number of patients a doctor can enroll. Sanofi Pharmaceuticals allows each doctor to refer only six patients a year to its drug-assistance program. Sometimes it takes weeks to determine eligibility and send the drugs. Some companies require patients to prove how much they earn by showing only pay stubs, not tax forms. That's often hard for someone who is paid in cash. And applications can be lengthy and difficult to complete; the one from Glaxo Wellcome is four pages, each 17 inches long.

"Some of our working people with no insurance have been turned down because they are over the income limit," says Jean Lyndes, a retired nurse who volunteers at the Hope Medical Clinic in Ypsilanti.

Boehringer Ingelheim Pharmaceuticals turned down Bobby King, 51, who has severe hypertension and emphysema and needed a $42 inhaler to help him breathe. "As you can understand, voluntary programs of this nature must be established within certain guidelines to ensure their continued existence and to ensure that we can help the truly indigent. The maximum income has been exceeded," the company wrote in its denial letter. At Boehringer Ingelheim, truly indigent means having an annual income of $9,000 or less. Bobby King, a house painter, earns between $10,000 and $12,000.


The big squeeze

Not only are the uninsured deprived of the basic standards of health care available to those with insurance, they are also being squeezed as never before to pay for the care they do get.

Historically, hospitals have covered the costs of charity care out of money insurance companies paid on behalf of people covered under their policies and out of federal government reimbursements made on behalf of people on Medicare. Through the Medicaid program, states often gave hospitals that served the poor extra payments. In other words, people with insurance were subsidizing the care of those without.

But today much of the extra money is gone, a result of lower payments to providers by managed-care companies and the Balanced Budget Act Congress passed three years ago, which reduced federal payments to hospitals for care given to Medicare beneficiaries and indigents.

Lower payments to hospitals and doctors mean HMOs can offer lower premiums to employers, the major buyers of health insurance, which in turn may require their employees to pay less. And lower Medicare payments mean lower federal expenditures and theoretically, lower taxes.

"Employers say, 'Why should I fund those who are not my employees when it may be society's responsibility?'" says Dr. Neil Schlackman, senior medical director for Aetna U.S. Healthcare, a managed-care company that has been a leader in ratcheting down fees to doctors and other providers. "Whose responsibility is it to cover the uninsured? If indeed we as a country decide it's the country's responsibility, we should fund it in some way."

But cost cutting has squeezed all those in the system who had counted on the extra funds to care, in part, for the uninsured. The American Hospital Association says that 34 percent of the country's 5,000 nonspecialized hospitals are now "under stress," meaning that they are operating in the red. A substantial number of those facilities care for the poor and uninsured. As for doctors, it's a struggle to give care to indigent patients and keep a practice afloat, says Austin physician David Wright. "It was the insured patients who helped provide a cushion for the uninsured. You could make it up in the long run. You can't do that now."

And so more and more, providers are hounding the uninsured to pay.

Champaign, Ill., is a microcosm of how the big squeeze plays out. The Frances Nelson Community Health Center, the only federally funded nonprofit clinic for the poor and the uninsured in the area, notified patients that the clinic was at risk of losing its federal grant if it did not collect patient fees. Then it got tough, warning patients that it would give no more routine appointments to anyone who had an account in collection until the account was paid in full, and there would be no future appointments for anyone who had filed for bankruptcy and owed money to the clinic.

"The ultimate coercion is denial of treatment to make them pay a bill," says Claudia Lennhoff, director of Champaign County Health Care Consumers, an advocacy group. "In some months they get access and in some months no access, depending on how fast they pay off the bill."

The bill, of course, isn't merely a deductible or a co-payment--it's the entire cost of care; there is no insurance company to share the cost. Bills for care in doctors' offices and hospitals are often far higher than what an insurer would pay for the same services on behalf of someone with coverage. The uninsured have no one to broker deals for their care. So patients with very low incomes help subsidize the lower premiums for more affluent patients who do have insurance.

When the uninsured, and sometimes people who are insured, cannot pay, many turn to bankruptcy. In 1999, more than 500,000 families who filed for bankruptcy had medical problems, and more than 300,000--or one in four filers--identified an illness or injury as a reason for filing. Many had bills exceeding $1,000 that insurance did not cover.

Some people just avoid more debt by avoiding more care. "The safety net isn't free," says Maura Bluestone, who heads the Bronx Health Plan in New York City. "They all bill, and they all use collection agencies to go after people. Once you've had that experience, you think twice about going back."

Some who are desperate have resorted to a kind of "neighbor insurance," more reminiscent of the Great Depression than the age of high-tech medicine. In March residents of Clarinda, Iowa, a town of 5,104 near the Missouri River, held an auction and soup supper that raised about $5,000 for Sharon Wells, 55, who is uninsured and has lung cancer. Medicaid now pays some of her bills. "I think my benefit money will be enough to keep me from being badly in debt," she says. Still, collection agencies call.

At the other end of the state, Dr. Connolly at the Iowa City Free Medical Clinic believes that for the poor and uninsured, the solution involves something far bigger than soup suppers. "We need to rethink what is right," she says. "Is it right for people who have insurance to get everything paid for and people who have no insurance to get nothing paid for? They don't even get the basics."