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If you don't have health insurance, it doesn't matter whether you live in the city, the country or the suburbs. It doesn't matter what race you are or what you do for a living. You will be equally worried about how you will afford your medications, or pay for a doctor's visit or a hospital bill for an emergency.

The worry overshadows your life. So you don't go to the doctor. Or you put off going to the hospital, even if you are having a heart attack. You don't like being sick, but you hope that if you wait long enough, you might get better and avoid a costly medical bill. But usually, you get sicker. Your delay ends up costing both you and the health system more. You and many others may even die prematurely.

I know. I see these kinds of patients every day.

I have watched people in their 20s or 30s die, just because they did not have health insurance and did not receive proper care. I've had patients who come to see me for the first time with advanced cancer who will die needlessly, all because they ignored their symptoms and avoided doctors because they could not pay their medical bills.

I now practice in rural Vermont, but for a decade I treated mostly uninsured patients at two inner-city clinics in Buffalo.

Many of my patients in Buffalo were too sick to work, and so had no health insurance. Some were covered by Medicaid, the health program for the poor. But for those who recovered enough to hold a job, their salaries usually made them ineligible for public programs. Health insurance through their employer was typically not offered or was too expensive for someone earning a minimum wage.

Without health insurance, patients with chronic illnesses stopped taking their medications or having regular check-ups. As a result, they would get sick again, and, eventually, lose their job.

Two of my patients, a brother and sister, suffered this cycle of indignity several times. Both had juvenile diabetes, a chronic disease requiring constant care. George was 18 months old and Tina was 7 when diagnosed. But for most of their lives, they had health benefits only intermittently.

Periodically, they would be eligible for Medicaid, which would pay for the insulin and supplies to control blood sugar and prevent complications like heart and kidney disease and blindness. But both Tina and George wanted to work. They worked when they were well enough, but then would lose their Medicaid coverage. Tina lost her coverage four or five times in the seven years she came to our clinic.

The clinic provided free insulin. But it was almost worthless to Tina and George, because they could not afford the $2 a day for the finger-prick testing kits that would tell them how much insulin to use. Diabetics like Tina and George need to check blood sugar levels at least four times a day. Because they did not, their blood sugar levels were always askew.

George eventually went blind, and was unable to work. Then his kidneys failed, and he died at age 21. A year after George's death, Tina had a baby. But because she could not properly manage her diabetes before she became pregnant, her baby girl was born with complications and died after spending five months in the neonatal intensive care unit.

A year later, Tina, at age 25, had a heart attack. She died on the operating table after bypass surgery.

With adequate health coverage and proper medical care, Tina and George probably could have lived longer and led more productive lives. Although there is no cure for juvenile diabetes, it is a condition that can be controlled. George might have kept his eyesight. Tina's baby might have lived.

With health insurance, many people might avoid heart attacks, strokes and other consequences of unchecked chronic disease. One of my patients had diabetes, high blood pressure and high cholesterol. One day, not surprisingly, she arrived with chest pain. An electrocardiogram showed that she had probably suffered a heart attack.

I advised her to go to the hospital, but she refused. She could have died but was more concerned that her five children and two grandchildren would be saddled with her medical bills.

I gave her some medications in the clinic and sent her home. I kept in close contact with her and luckily, she pulled through. Many of the uninsured are not so lucky.

Both my inner city and rural patients want to stay well and take their medications, but they can't without health insurance. Their fear of humiliation, shame and bankruptcy from unpaid medical bills outweighs their fear of dying.

Lack of money should not dictate whether someone gets to stay healthy and live a long life or die young. But under our current system of health care, it does. Is this what we want for America?

DEBORAH RICHTER, M.D., is a physician in private practice in Vermont. She formerly worked in the Geneva B. Scruggs Health Care Center and the Mercy Health Center in Buffalo.

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