The Uncovered

How New York’s Uninsured Really Survive

The fundraiser at Life on Bleecker Street is off to a slow start. The Verve's 'Bittersweet Symphony' all but echoes through the near-empty club. A few dozen guests stand by the bar, sipping beers, while the evening's volunteer entertainment, a karaoke punk band, waits for more people to arrive before beginning their set.

'I guess no one likes me,' says Dr. David Ores, the evening's host, as he surveys the abandoned dance floor. Or perhaps it's just that a party to raise cash for prescription drugs, as this one is meant to do for Ores's uninsured patients, can be a sad affair. What's more, the majority of guests at this early-winter gathering are the uninsured themselves, who can only manage to put a few bills in the coffee can at the entrance, so the cash-drawing potential is depressingly limited.

Still, Ores—or Dr. Dave, as his patients like to call him—is one of the bright spots in a city where more than one in four adults is uninsured (that's 50 percent higher than the national average). Without access to the daunting system that pays for health care, the uninsured are more likely to die, experience adverse health outcomes, and require more emergency hospitalization than insured Americans, according to a study just released by the American College of Physicians.

But the more than 1 million uninsured New Yorkers are not accepting their medical fates quietly. Instead they make their way in an alternative medical universe, where herbal apothecaries, advanced bill-dodging techniques, and low-cost community health centers take the place of claim forms and ID numbers.

There, in the realm of medical have-nots, Dr. Dave is liked very much—at least by the patients he treats regardless of their ability to pay. "He's great," says Ro, a 24-year-old who has never had her own health insurance. Just the other night, Ro went to him after a broken glass cut a gash in her side during her bartending shift. "I didn't want to go to the emergency hospital because I knew I would be paying at least $400," says the reed-thin woman, who wears a tiny stud in her nose and jeans ripped at each knee. "I've been to the hospitals for tonsilitis and things like that and they just charge you a ridiculous amount of money."

With the presidential election brewing, we're beginning to hear more about the ever-widening pool of uninsured—at least from the Democrats. Bill Bradley promises to build on the current employer-based insurance system by offering subsidies to the uninsured. Gore, who has criticized Bradley's plan as too expensive, says he would expand government insurance programs that already serve poor and elderly people. Bradley has called Gore's proposal "definitely timid."

Given that each of the two plans would likely leave more than 10 percent of the country still uninsured, it is safe to say they're both timid. Indeed, the problems of any system that falls short of universal coverage come into sharp relief with even a cursory look at the enormous obstacles people without insurance face in taking care of themselves.

Consider that, even as the candidates trade barbs about their plans, Betty Collins is staring down a $25,000 hospital bill. A 57-year-old beautician who lives in Bedford Stuyvesant, Collins was covered for much of her life through her husband's job with Brooklyn Steel. Since he stopped working for the company almost 10 years ago, though, she has been mostly uninsured. And so it was that Collins ended up getting emergency surgery when she came down with appendicitis almost six years ago—and forking over $100 a month toward the debt ever since.

Coming out of the $1000 or so she makes each month and the pittance her husband picks up "doing this and that," the payments leave little for food and rent, let alone private health insurance. Yet Collins and her husband, who is also uninsured, still make too much to qualify for medicaid, the government health program for the poor. They work, as almost 70 percent of uninsured New Yorkers do, but neither of their jobs provides benefits.

Without them, Betty Collins has taken to using herbs to cure her asthma and digestive troubles, which include an ulcer. "God has a made a plant for everything that can be wrong with you," she says, noting that herbal treatments are often cheaper than their pharmaceutical competition. "But I still have problems. I just pray that whatever I have will go away," says Collins, breaking into a laugh, as if the whole matter is hilarious. In eight years, she notes, she will qualify for medicare. "But, who knows," she says, laughing even harder. "I may not live that long."

For many others, the problem is not qualifying for medicaid, but getting it. Supporting three children on just over $600 per month, Vanessa Washington meets the financial requirements for the program. But, because she stopped reporting to her workfare assignment three years ago—a violation of the strict rules the Giuliani administration has applied to entitlements—she lost her welfare benefits and, along with them, her health coverage.

Without medicaid, Washington periodically goes to her local health center, which, because it receives government subsidies, is able to provide her with birth control pills at low cost. It's been four or five years since she's had "a real, real physical" though. "I just try not to get sick," she says.

Jennifer Kramer, a 30-year-old book researcher, has instead tried to prepare head-on for the possibility of illness. Because she couldn't afford a whole year of insurance coverage, "I signed up with an HMO for a month and then scrambled to get all the tests and care I could in that time," says Kramer, who went through monthlong all-you-can-visit periods twice. Unfortunately, her body didn't comply with the plan. Just days before her first one-month coverage period was about to begin, she developed "a biblical case of boils," which required an immediate trip to the emergency room that cost her more than $600.

Though she also had to wait up to six weeks for some of her appointments, which limited the amount of care she could cram into a month, she managed to see a gynecologist, an internist, and a viral specialist in one short month. Still, Kramer admits her scheme is less than perfect. "It ended up costing a lot of money for what I got," she says.

J.R., an uninsured former building manager, takes more of a "by any means necessary" approach to health care. She just narrowly missed qualifying for medicaid when she applied a few months ago. "They said I made $23 too much," says J.R., who describes herself as "a sickly, asthmatic-type person" who is "too honest when I'm filling out those forms."

But even without medical coverage and a steady income, J.R. gets herself to the dermatologist and other specialists when she needs to. When asked just how she manages, J.R. recalled what she did when her asthma flared up two weeks ago. "I got sick, so I went outside and hustled me some money and went to my asthma specialist." J.R. says that she doesn't consider herself a prostitute, but "If I go outside and I see a man and I need some money, I'm going to do what I got to do."

If her tactics are relatively rare in the world of health care, J.R.'s determination and resourcefulness are not. The uninsured often report waiting for hours to get low-cost care, making inconvenient journeys to clinics and public hospitals that will treat them, and drawing on their creativity to fight for decent care.

Living on some $3,000 she earns yearly teaching kids to read and a $1400 monthly stipend she gets for her disabled son, Lucy Aponte makes too much to qualify for medicaid. Nevertheless, Aponte, who has a heart condition, found herself scheduled for surgery last year to replace her pacemaker, which was found to be defective.

But when she explained to her doctor's secretary that she had no insurance, "she said, 'You don't have medical coverage, so your surgery has been canceled,' " says Aponte. The news spurred Aponte—who was teaching a literacy course at the hospital during this time—into an all-out advocacy campaign on her own behalf, which included calling the offices of TV journalist Diane Sawyer and taking her case to the president of the hospital.

She did finally get both the surgery and, for the time she was in the hospital, medicaid. Aponte still ended up with a $1171 bill from the hospital, however, which she says she was unable to pay. Nor can she pay for a new pair of glasses, so, since she broke her old ones, she's been wearing a pair her sister bought in a department store. "They give me a headache," says Aponte. "But they're better than nothing."

Indeed, lack of health coverage often becomes a matter of comfort. Jimmy Ling, a 28-year-old father who works in a bike shop, has had lower back pain ever since high school, when "two guys hit me at the same time and I landed on my tailbone." But, because he has had no health insurance since his football days, Ling has just lived with the pain. It was only when he was offered a free X-ray as part of a health promotion that anyone noticed that two disks in his lower spine were rubbing together. The radiologist recommended physical therapy, and Ling set up an appointment, but canceled it when he learned he'd have to pay almost $200.

"I just stretch on my own as much as I can," says Ling. "It's not worth the money."

Without treatment, as much as a third of the uninsured end up getting treated in hospital emergency rooms at least once a year partly because they've missed opportunities to treat conditions in their early stages, according to a 1998 survey by the Commonwealth Fund. The uninsured also end up in emergency rooms because they don't know of another place to go.

Such is Elisa Ramos's situation. "When I get sick, I just go to the emergency," says Ramos, who is 34 and uninsured and lives "two buses" away from the one doctor she's familiar with in the Bronx. Ramos keeps the bills from these visits neatly folded in her kitchen drawer.

"There's no way I can pay," says Ramos, who lives on $1057 a month in the Hunts Point section of the Bronx. When it comes to necessities, such as the drugs she was recently prescribed for painful muscle spasms in her back, she'll find some way to find the cash, though such outlays can be painful.

"I had to pay $80 for just one prescription," Ramos says in hushed tones. "I'll never forget that, taking out all that cash in the Duane Reade."

Had she known about them, Ramos might have ended up at one of the city's public hospitals or community health centers, both of which provide care regardless of a patient's ability to pay. The public hospitals also offer low-cost prescriptions for the uninsured, as does one community health center, the William F. Ryan Center on West 97th Street, which subsidizes drug costs so patients can get prescriptions filled for only $5.

Or, were Ramos one of Dr. Dave's patients, she might have benefitted from the free drug samples he collects or the subsidy he's hoping to provide through his fundraising. But Dr. Dave's latest extravaganza raised a mere $1200 and, by his own accounts, the doctor is just "eking by." In fact, making as little as he does from medicine, he himself cannot afford health insurance.

"But I have lots of friends who are doctors and can take care of me if necessary," says Dr. Dave dismissively. It's the medical have-nots he's worried about, of course—the hundreds of patients who have come to his office desperate for help. "They get sick. Everyone in the nation is going to get sick at some point, so we should just pay for it."


To find out about the community health center nearest you, call the Community Health Care Association of New York State at (212) 870-2273.

For information about public hospitals, check out the Health and Hospitals Corporation Web site at www.ci.nyc.ny.us/html/hhc or call the Commission on the Public's Health System at (212) 749-1227.

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