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It used to be that a job meant health insurance. When illness struck, workers worried about recuperating, not about paying the medical bills.

That was back in the not-so-distant past, when doctors made house calls and patients went wherever they wanted for care.

But the number of Americans without health insurance is rising. And despite a booming economy and low unemployment, a job no longer means health coverage.

New Census Bureau figures show 43.4 million people -- 18.3 percent of the population under age 65 -- lacked insurance in 1997, up 1.7 million from the previous year. That was the steepest increase in five years.

In Erie County three years ago, 77,000 residents were without insurance, according to the Western New York Healthcare Association. That number has grown to nearly 100,000.

"It's an ever-worsening problem, a public embarrassment," said Bill Pike, president of the Healthcare Association.

The uninsured receive inferior health care. Their care, financed by taxpayers and insured patients, is often provided in expensive emergency rooms. And the costs strain safety-net hospitals.

However, more than five years after President Clinton introduced his plan for universal health insurance, the issue has all but disappeared from political debate.

Many of the new health-care have-nots are employees whose employers no longer offer coverage or who can no longer afford what's offered.

"We're seeing coverage decline during the best of times," said Kathryn Haslanger, co-author of a recent United Hospital Fund report on New York's uninsured. "We have a crisis now. You've got to wonder what will happen when the business climate isn't so good."

The health plan for the uninsured is to cross their fingers and hope they don't get sick.

Some people, struggling from paycheck to paycheck, are forced to choose between buying medication or buying food.

Others dig themselves into financial holes so deep with big medical bills that they wonder if they'll ever escape.

Kathleen Herby of Lackawanna is a part-time certified home health aide who makes too much money to qualify for Medicaid, the government health program for the poor, but not enough to afford the health plan at work.

A hospital stay left her with a nearly $4,000 bill that she's determined to pay, although all she can send the hospital is $10 a month.

"I'll probably be in my grave by the time it's paid," she said. Mrs. Herby, 56, and her husband, who works for a marketing company and receives veterans benefits that she can't use, filed for bankruptcy five years ago. They only recently cleared their debts.

"You work, and it all gets divvied up. By the end of the month, the money is practically gone," she said.

There's money for the rent and the car the couple share, but she wonders how she'll pay for a recent Pap smear and mammogram. Her arthritis medication costs so much that she hopes her doctor keeps giving free samples.

"God forbid I get really sick," she said. "I couldn't even afford the ambulance ride."

The ranks of the uninsured are growing even though more employers are offering insurance.

As insurance premiums have increased in price, workers have been asked to contribute more for their coverage. Like Mrs. Herby, an increasing number can no longer afford it, so they drop out of health plans. Low-income individuals who don't get coverage at work or who are self-employed have even fewer options.

If an individual makes more than about $7,800 a year, he can't qualify for government-paid Medicaid. Buying private coverage directly from an insurance company is so expensive today that it is for the most part out of reach.

Meanwhile, there are many more low-income workers since federal welfare reform in 1996 moved millions of people off public assistance and into the work force.

"These people quietly suffer," said Dr. Carlos Roberto Jaen, a physician on Buffalo's lower West Side who directs the University at Buffalo's Center for Urban Research in Primary Care.

"We see proud folks motivated enough to try to make it on their own," he said. "But they live with a sense of always being at risk. When something does go wrong, they're often forced to make terrible choices. Do they take care of a problem or save their money for the rent?"

Earl Wilbur, 52, of Buffalo has faced that choice. He used to sort heavy bags of laundry for a cleaning service but has been unable to work since injuring his back in 1997. He receives $700 a month in workers' compensation. Nearly all of it, about $500, is spent on his mortgage.

Wilbur says he has $3,000 worth of unpaid doctor bills. The financial strain, he adds, has forced him to sell his stereo, TV and car for cash.

"The doctors can stand in line and wait with everyone else," Wilbur said. "I'm not giving up the house. That's all I have."

The uninsured can get medical care, usually from safety-net hospitals and health centers.

But they're less likely to visit a doctor as often as a person with insurance, and they're more likely to neglect chronic medical problems until they turn serious.

The cost of the care they do receive comes partly from taxes and partly from higher medical bills for everyone else.

To Jaen and other physicians, the system seems absurd.

One of his patients is a 54-year-old self-employed man with diabetes and hypertension who recently had heart-bypass surgery. He typifies what Jaen and his colleagues see daily. The uninsured patient can come for an office visit but can't afford the medication he needs to prolong his life.

"This man is a ticking time bomb for a heart attack or heart failure. But he must depend on us to give him drug samples," he said. "How can you give samples to everyone? It's such a patchwork system. And what about the people who don't bother to walk in my door for care?"

Hospitals will work out payment plans for the uninsured, but they usually don't offer discounts.

Uninsured individuals often fail to pay hospital bills. But those who do will likely pay far more than what an insurance company or Medicare, the government health program for the elderly, would be charged.

"It's terribly unfair," said Dr. Norman Wetterau, a family physician in Dansville.

The Genesee Conference of the Free Methodist Church, an organization of 45 churches, recently surveyed hospitals in this region on the price of common services. Wetterau, who headed the effort, was taken aback by the results.

For instance, an automated blood chemistry profile known as an SMA cost a Medicare patient $12.81. For those without insurance, it cost between $21 and $63, Wetterau found. The cost to Medicare for an abdominal ultrasound was $102. To the uninsured patient, it ranged from $180 to $210. One hospital charged $406.

Hospitals say they aren't singling out the uninsured.

They operate with a complicated pricing system that is based partly on the idea of offering uniform rates. But variations have developed among the charges over the years as hospitals negotiated discounts with different insurance companies, said Pike of the Western New York Healthcare Association, which represents the region's hospitals.

"There's no strategy to gouge individuals," he said. "It's an artifact of a system created with no intention to cause that problem."

For hospitals, growth in the uninsured is a scary prospect.

Hospitals here and across the country have been closing, eliminating beds, consolidating services and laying off workers.

They are straining to make up for lower or stagnant payments from HMOs and the government. They are also losing revenue as health maintenance organizations try to reduce hospital stays and emergency room visits.

The people who run hospitals wonder where they will find the money to operate if more patients can't pay their bills.

At Erie County Medical Center, the region's foremost medical safety net, the cost of charity care has increased from $25.2 million in 1995 to an estimated $36 million in 1999.

ECMC pays for this care with federal and state help, and an annual county taxpayer subsidy. The county subsidy has increased -- $7.3 million in 1995 to $17.4 million in 1998 -- but has not kept pace with actual costs, said Paul Candino, chief executive officer.

"We've got a big budget, but it's lean," he said. "Even if we maintain our current patient activity -- and we're seeing some growth -- we will have to find a way to make more money to make up any increase in uncompensated care costs. I can no longer tell my people to do more with less."

Candino is certain the hospital will see more patients who can't pay because there are more people in the region without insurance.

Programs have formed and expanded to help uninsured children, such as the successful Child Health Plus. But there is little on the horizon to help adults.

Ms. Haslanger of the United Hospital Fund, a research and philanthropic organization, said it's hoped the State Legislature will act next year when the legislation that influences the way hospitals do business comes up for renewal.

Proposals for reform in her group's study include expanding subsidies to small employers to provide workers with insurance and offering premium subsidies directly to low-income individuals.

Others see promise in more homegrown efforts.

"If we don't don't act, the health of our people will crumble, just like parts of our city," said Jenny Bagen, director of women's services at Sisters Hospital.

Sisters Hospital, like other religious hospitals, is trying during tough financial times to continue its mission of serving the poor.

Ms. Bagen suggests tackling the problem locally, rather than waiting for government to impose a solution.

Her plan calls for local businesses to contribute money to create a low-cost regional health insurance program for the uninsured, perhaps with some help from the state. Individuals would contribute a small fee. HMOs would administer the plan. Doctors and hospitals would charge discounted rates.

Pike and other health-care executives like the idea enough that they intend to present it at the next Healthcare Association board meeting, although he acknowledges that it will require unprecedented collaboration.

Even low-cost insurance costs a lot, an estimated $75 per person per month in this case. Still, Ms. Bagen says she believes businesses will pay.

"We are headed toward a health crisis," she said. "There are companies that realize this and see that it's in their interest to do something about it."

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