First of two parts
Miwako "Micky" Tooley did what she was supposed to do.
For years, the Findlay-area woman spent tens of thousands of dollars on medical insurance premiums. Then she got the letter.
Her insurance company dropped her. The reason? At 60, she was too old to cover. At first, she and her husband figured they would risk it for a few years. She was almost 65, why not wait until she qualified for Medicare and hope for the best?
Hope collided with reality when she felt a lump in one of her breasts. With weeks left before her policy expired, she rushed to get as much covered care as she could, but by late last year she was on her own.
Chemotherapy, radiation treatment, and other medical expenses have all come out of the meager savings of her and her husband, who now estimate they've accumulated $70,000 in medical bills.
"No one is interested in a 61-year-old with cancer. No one will touch me," she sighs.
She is not alone when it comes to big bills or being without health care. About 44 million Americans are uninsured, according to independent estimates from federal agencies and the Kaiser Family Foundation.
In 1997, the United States spent $1.1 trillion on health care, or about 13.5 percent of the nation's gross domestic product. Last year, it spent $1.5 trillion, or 14.9 percent of the country's GDP. Government actuaries predict that by 2013, the nation will spend $3.36 trillion on health care, or 18.4 percent of its GDP.
To get some perspective, $1.5 trillion would buy 38,461 new stadiums such as Fifth Third Field at $39 million apiece. It would be enough to give everyone in the United States $5,113 each or send everyone in the country to the Spider-Man 2 movie 552 times.
For the average American family with the median household income of $42,409, the increases have meant steep increases in what they and their employers have paid for health insurance. Last year, the average premium for a family of four was $9,086, up from $6,348 in 2000.
As more Americans join Mrs. Tooley without insurance - or struggle to pay bills with the coverage they do have - there are signs of growing frustration. The Gallup Organization reported in January that for the first time since 1992, when Americans are polled about urgent health problems facing the country, the cost of health care is No. 1, ahead of issues such as cancer, obesity, and smoking.
Mrs. Tooley stands behind the counter of the convenience store she and her husband, Joe, run. The building, built in 1860, used to be a one-room school house. Customers wander into the store throughout the morning, greeting the couple by name. Some buy pop, beer, or lottery tickets.
An old baseball cap covers Mrs. Tooley's thin hair, which is beginning to grow back after several bouts of chemotherapy. Just one big winning lottery ticket sale, and maybe that commission would help pay off some of her medical bills.
Lottery tickets aside, about the only sure bet in health care these days, experts say, is that costs will keep going up.
Workers only pay a portion of America's total health costs, about 27 percent of the premiums, industry experts say. But as the overall amount increases, so does the out-of-pocket expense for families. These increases have, and continue to be, faster than the rate of wage increases - meaning many Americans are not able to offset increasing health costs.
The aging Baby Boomer generation, rising obesity, and drug and technological advances have sparked much of the increase in costs, health analysts say. For example, Toledo Hospital, one of the 5,000 hospitals in the United States, last year spent $2 million more than the year before inserting heart stents to open blocked arteries. That is great for those with heart problems, but someone has to pay that $2 million.
"Americans want it now, and we want the best," says Alan Brass, president and chief executive officer of Toledo Hospital's parent company, ProMedica Health System. He says he is alarmed at the rising costs and number of uninsured. "We have to do something. We can't control our own appetite [for medical services]."
Though complaints about health costs have been around for decades, some are beginning to wonder how much longer costs can keep soaring.
"It's getting worse and it's getting worse rapidly," says Dr. Arthur Kellerman, chairman of the department of emergency medicine at Emory University in Atlanta. "The only question in my mind is what happens first. Does it get bad enough that the public and politicians deal with it? Or does something break first? By that I mean, we have a catastrophic failure of the system. That could easily happen."
He says many of his colleagues across the country "openly speculate that it will take a catastrophic failure somewhere to give everyone a wake-up call."
Dr. Kellerman points to some ominous warning signs: Public hospitals in Los Angles and Detroit narrowly avoiding bankruptcy. His own hospital, as well as Atlanta's other six hospitals, frequently have to stop accepting new patients in their emergency rooms because they are overflowing.
It is not quite that bad in northwest Ohio, but Mr. Brass, says "day in and day out" many area residents without insurance show up at the area's hospital emergency rooms.
Mr. Brass says the rising number of uninsured, and underinsured, in America is "becoming a critical problem." He says some estimates predict in two years the number of uninsured could climb to 51 million. That is more than the combined population of Ohio, Michigan, Pennsylvania, Indiana, Kentucky, West Virginia, and Iowa. Hospitals, including his, are struggling to absorb those unpaid costs and that trend cannot continue unabated, he says.
"It's a pretty scary situation," Dr. Kellerman agreed. "The only thing that amazes me as an ER doc is why the press, the public, and the politicians aren't a lot more alarmed than they are now."
Dr. Kellerman was the co-chairman of a task force appointed by the Institute of Medicine, which advises the federal government and others, to examine the issue of the uninsured. The group issued a report earlier this year calling for universal coverage of all Americans. The other co-chairman was Mary Sue Coleman, president of the University of Michigan.
"I think the thing that struck all of us is if you go back 20 years, the problem is getting worse," Ms. Coleman says. "Even with good economic times, like the late 1990s, the number of uninsured was 38 million."
She says that means even with the recent improvement in the U.S. economy, there is still bound to be millions of uninsured or underinsured Americans.
The 16-member task force published six reports. Some of the findings include:
Ms. Coleman says those with health coverage should not get too comfortable:
"If you live in a community with a large uninsured population, even if you have coverage, you're at risk because it puts the hospitals at risk," she says.
The United States is the only industrialized country to rely on the private sector to provide most of the health coverage for its citizens. Good or bad, one result has been the United States spends the most of any country on health care, both nationwide and per person. America spends about $5,000 a person on health care, compared to $3,300 for the next closest country, Switzerland, which has government-run health care.
The results of these differences are mixed. One simple measure is to compare average life expectancy. Last year, the average life expectancy in this country was just over 77 years. In Canada, which spends about $2,800 per person on health care - or about 60 percent of what the United States spends - average life expectancy is 80.
Some critics of rising U.S. health-care costs point the finger at administering health care, including the cost for insurance companies and bill collectors at hospitals. That administrative cost is staggering, according to Uwe Reinhardt, a health economist at Princeton University who just published a study on U.S. health-care spending.
"We spend about $300 billion annually on administration, which is three times what it would cost to cover all the uninsured," he says. "There is just simply no excuse for it. I think Americans are just plain stupid to tolerate this kind of administrative nightmare. This is madness."
Not necessarily, according to Robert Moffit.
"We spend a lot of money on health care," he says. "But is this necessarily a bad thing?"
Mr. Moffit is the director of the Center for Health Policy Studies at the Heritage Foundation, a Washington think tank that favors free-market health care.
He says that though there are too many people without health insurance, one can't deny the American system has produced most of the advances in health technology, including most of the drug advances.
Mr. Moffit admits that Canada, which regulates the price of health care, keeps prices down. "But when is the last time Canada had a breakthrough drug in any category? I'm not trying to be flip, but if you step back and look at the broad question of are we spending too much, the problem is we don't know," he says.
David Cutler, a health economist at Harvard, has had a small role in advising Democratic presidential candidate Sen. John Kerry. He says, like Mr. Moffit, he does not think the fact that the United States spends a lot on health care is a bad thing.
"What we do today in health care is more intensive and thus more expensive," he says. "And it's helped; premature newborns are more likely to survive and heart patients live longer. The biggest problem is not that spending more is bad, but that we don't have mechanisms in place so that everyone can afford it."
Mr. Cutler says the problem of the uninsured is getting worse and will eventually cause the U.S. health-care system "to implode. It really is a crisis."
Tom Volk is a business owner. He's healthy. His balance sheet isn't.
He runs Ohio Belting and Transmission in Toledo, founded in 1913, and employs 10 workers. He is proud of his company and his workers.
But as Mr. Volk sits in a conference room with his corporate manager, Ginny Francis, pain mixes with anger as he tells his story.
Pain at the feeling that he is letting his employees down, anger because he does not know what else he can do.
"We always prided ourselves on offering big-company benefits: 401(k), health benefits. But the last three years, each year we took huge downgrades in coverage and still took 30 to 40 percent premium increases," he says. "We ask why, and all they say is, 'We need an increase.' Well, where is all the money going?"
Why, he asks, does competition force his company to sell catalytic converters today for $40 compared to more than three times that a few years ago, and yet he pays more for health care each year and ends up getting less?
He pulls out a sheet of his company's health-care costs:
All of these changes, he says, have come without any major health claims from any of his workers.
"Toledo is made up of people like me, and we're getting killed," he says.
He grows more angry when he is asked what he thinks about arguments made by those like Mr. Cutler and Mr. Moffit, who point out the advances made possible by the American health-care system.
"If they have brand new hospitals and yet we can't afford to go there, what's the point?" he asks. "We have people here not going to the doctor because they can't afford it, or they're not taking their pills."
Ms. Madden just sighs.
"I'm healthy and I'm thankful," she says. "I just hope I die in my sleep."
If health-care costs are not a political issue this year, they should be, she insists.
"I think the war in Iraq is the big thing, but people here are just trying to survive," she says.
Micky Tooley is not optimistic that the government - whether controlled by Republicans or Democrats - will help her anytime soon. So she and her husband will continue working every day and put off taking a vacation. After all, they have not had a vacation in more than 30 years of marriage, why start now, Mr. Tooley jokes.
Mrs. Tooley just crosses her hands in front of her. She has not given up, she says, on doing what you're supposed to do.
"I don't want to be a deadbeat. I'm going to pay it," she says. "It's hard, but I'll do it."
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Miwako "Micky" Tooley did what she was supposed to do. For years, the Findlay-area woman spent tens of thousands of dollars on medical insurance premiums. Then she got the letter. Her insurance company dropped her. The reason? At 60, she was too old to cover.