Healthy alternative

ZAREPHATH, N.J.-Three years ago, if you had asked Amal Gurguis whether she was worried about a crisis in health insurance, she probably would have said no. The thirty-something mother of two small children was covered under her husband's health insurance policy, which he had through his employer.

But when her husband suffered a massive coronary on her son's second birthday, Amal's life changed. She lost her husband and joined the ranks of the uninsured.

Although the particulars of Amal's story are unique, the arc of her story isn't. And whether she knows it or not, Amal has become a rope in the tug of war between those who want the United States to adopt a single-payer, Canadian-style health-care system, and those who want to give consumers more choice and responsibility for their health care. For Amal is one of "the uninsured."

Who are the uninsured and how many are there? The numbers are plastic, bending to meet ideological needs. The U.S. Census Bureau says 44 million, and liberals like the sound of that. The Capital Research Center's David Hogberg subtracts noncitizens, those making more than $50,000 who presumably could afford insurance, and those eligible for Medicaid, and ends up with about 12 million-and that number sounds better to conservatives. The Robert Wood Johnson Foundation notes that the uninsured tend to be younger, foreign-born, and employed.

Amal's story highlights the major problem with an employer-based health-care system: When an employee loses his job or gets too sick to work, he and his family often lose their insurance. The connection between health insurance and employment emerged from a quirk in American history rather than any grand design. During World War II, Franklin Roosevelt instituted wage and price controls. Since employers could not attract workers by raising wages, they began offering health insurance coverage as a backdoor way to increase wages. When the IRS ruled that the benefits weren't taxable, they became even more popular.

Until recently employers and employees both benefited from the constant super-sizing of benefits. Insurance plans grew increasingly generous, covering more procedures until insurance came to resemble pre-paid medical care rather than protection against unforeseen risks. Insurance shielded people from the true cost of their health-care decisions. Since it didn't matter to insured people whether they went to a doctor who charged $100 or $50-their out-of-pocket expense was the same-costs spiraled and to keep up, insurance premiums increased.

Some employers dumped their insurance programs. Others adopted "managed care" policies, which tried to hold down costs by micromanaging doctors and negotiating low reimbursements for services.

Meanwhile, people like Amal found it hard to buy individual health insurance policies. Policy-makers in New Jersey, where Amal lives, have so generously defined the benefits required for a standard policy that individual insurance is beyond the reach of all but the affluent. Individuals purchased 220,000 policies in New Jersey in 1996, but only 90,000 in 2004.

Both sides of the political divide have offered ideas about how to help Amal get access to health care. Liberals want to expand Medicare to include younger retirees and have the children's health insurance program include low-income parents. Conservatives advocate using tax policy to give individuals the same power to buy insurance that large employers have (see below). Congress in 2003 allowed individuals to create Health Savings Accounts that combine high-deductible insurance policies intended to cover major medical needs with savings accounts that allow people to save pre-tax money for routine medical needs.

But while congressional Democrats and Republicans debated big-picture ways to help Amal, a pair of northern New Jersey doctors, John and Alieta Eck, actually helped heróand were positioned to do so because of a disaster.

In September 1999, while the Ecks were in a group studying the history of Christian poverty-fighting and wanting to put their faith into action by providing charity medical care, Hurricane Floyd roared up the East Coast and left a massive trail of destruction from North Carolina to New Jersey. The hurricane caused the Raritan River to crest, flooding adjacent buildings and giving the Ecks an opportunity to rent a flood-damaged building for $1 per year if they would renovate it for clinic use.

A team from Zarephath Community Church completely redid the small building, turning it into a modern clinic with two examining rooms, two bathrooms (including one that is handicapped-accessible and equipped with a shower in case the building is later used to provide housing for the handicapped), reception, and intake rooms. Volunteers included an 80-year-old man who did all the tiling in the bathrooms. Donations from doctors and businesses furnished the clinic.

The Ecks in 2003 began offering low-cost medical care to uninsured people who heard about them from their friends, their employers, and even some government agencies. For 10 hours a week Zarephath Health Center (ZHC), 46 miles southwest of New York City, is now open for business, operating with an overhead of $500 a month that covers utilities, phone, and one paid staffer who officially works only during the clinic's office hours. Everyone else, including the Drs. Eck and nurses, volunteers. Patient fees of $20 a visit, for those who can afford it, cover the overhead.

It's clear from the minute a patient enters the clinic that this isn't a government facility, or even a government-funded one. Calligraphied in large letters on one wall is Matthew 11:28-30, which begins: "Come to me, all who are weary and burdened, and I will give you rest."

A new patient's first stop is the intake room to fill out a standard health history and talk to a clinic volunteer about his basic living situation and about whom he can depend on for help. One basic principle at the clinic is: "Look for the people closest to the individual to meet needs-first the family, then the church community, and finally local and state government."

New patients also fill out an income statement where they certify that they have truthfully revealed their income and expenses. Right above the signature line is this statement: "I recognize that other people are donating their time and money so that I can receive care at a reduced rate. I am thankful for this help. People are doing this because they care. I waive my right to sue, but am willing to submit to arbitration to cover future medical expenses if a mishap occurs while I am being treated here." Right away, before any services are rendered, the clinic signals to patients that they are leaving the world of lawsuit-crazy medicine and entering a new world of neighbor helping neighbor.

Since many clinic patients have chronic and untreated illnesses, they are, in general, sicker than the patients the Ecks see at their regular office. On one Wednesday night they saw Ingrid Dahl, a healthy graduate student in gender studies at Rutgers, who needed a physical and couldn't get into a university health clinic. But more often they see patients like Mary, whose job doesn't include insurance.

Mary first came to the clinic because of severe headaches, and an exam revealed that her blood sugar level had soared to 400 (normal is somewhere between 83 and 110). The Ecks provided her insulin and have monitored her sugar levels regularly, as they were doing that Wednesday evening. Before leaving the office, Mary talked with Susanna, the office manager who is also diabetic, and they exchanged tips about managing their disease.

Another patient that Wednesday night was Amal Gurguis, who first came to ZHC with a chronic untreated thyroid condition, high blood pressure, and emotional problems brought on by her husband's death. She could not afford the lab tests required to monitor her chronic conditions. The Ecks had given her a physical and lab tests, and had stabilized her medicines; now they were dealing with her allergies.

When patients with chronic needs can't afford medication, pharmaceutical companies step in to fill the gap. Using special programs designed for the uninsured, the Ecks are able to write prescriptions that the companies fill directly, sending the meds to ZHC in the patient's name. Pharmaceutical representatives who service the Ecks' fee-paying practice have been generous with samples intended for clinic patients. These programs enable the Ecks to care for patients who need medicines like insulin and can't afford the $300-a-month cost.

The Ecks act as advocates for patients who need surgery, negotiating lower rates with specialists and hospitals. Under the present system hospitals charge uninsured patients much higher rates than insured ones, who benefit from the negotiating power of HMOs and other insurance companies. One example: An uninsured patient's hospital bill for a hernia surgery was $8,700, but the Ecks know that the hospital would charge Blue Cross/Blue Shield only $2,100 for the same care, so the Ecks pushed successfully to get the lower rate for their patient. Hospitals deal with the Ecks because they usually would rather collect something than wait months for government reimbursement, or write off the amount as an uncollectible debt.

The Ecks encourage all patients to pay the clinic something; those with little money often donate their time. The Ecks want ZHC to be a model for a system where "people budget and pay for their own health care, but when they are in trouble, they get subsidized by friends, family, and the church." The Ecks point to first-century Christian communities, and a more recent precedent comes from mutual aid and fraternal organizations that provided health care for millions of Americans a century ago.

According to University of Alabama historian David Beito, in 1920 nearly one-third of adults over age 20 were members of fraternal lodges that typically contracted with a general practitioner to provide medical care to members who paid one or two dollars a year for coverage of themselves and their families. For example, on the Lower East Side of Manhattan "500 doctors had contracts with Jewish lodges alone. During the 1920s, there were an estimated 600 fraternal societies among blacks in New Orleans that offered the services of a physician." By the 1930s, though, "lodge practice" faced increasing competition from insurance companies, government programs, and medical associations that "launched an all-out war against lodge practice. . . . Old relationships of voluntary reciprocity and autonomy [gave way before] impersonal bureaucracies controlled by outsiders."

Whether clinics like Zarephath signal a return to mutual aid, as the Ecks would like, depends a lot on forces beyond their control. Will Congress enact policies that encourage innovation and provide incentives for doctors to provide charity care? All doctors aren't like the Ecks, but the existence of only 17 low-cost clinics like ZHC in New Jersey shows both a lack of incentives and the presence of disincentives.

Many doctors who have the time and inclination to help are averse to putting themselves at risk. A newly implemented law, the Free Clinics Federal Tort Claims Act, allows federal health officials to declare volunteer free-clinic doctors to be, for purposes of malpractice insurance, employees of the Public Health Service. That should help attract doctors, especially retired or unemployed physicians who don't have malpractice insurance, to serve at free clinics.

Free malpractice insurance isn't a panacea, though, because clinic doctors face additional risks, including the demand of some state medical examiners for "perfect note keeping" and other practices of defensive medicine that may not be realistic under crowded clinic conditions. Many doctors don't want to bother. Unless they can get state-level legal indemnity, it's not worth the risk to them.

John Eck offers charity care "with fear and trepidation," realizing that an avaricious litigant or power-wielding bureaucrat could make his life miserable-and the larger question is whether policy-makers will value the sacrifices of doctors like the Ecks and make it more likely for others to volunteer. But for now, Amal Gurguis breathes easier, knowing that as long as Good Samaritans like the Ecks exist, she won't be left on the side of the road.

Is there a solution?

A bipartisan panel of 24 political, corporate, and health industry leaders began meeting last October to seek consensus and draft health-care proposals palatable to both Democrats and Republicans. Kate Sullivan Hare of the U.S. Chamber of Commerce told The New York Times, "This effort holds as much promise as any I've participated in over the last decade, probably more." But the group, which includes leaders ranging from the liberal Families USA to the conservative Heritage Foundation, has not yet disclosed a specific plan.

The conservative Cato Institute, arguing that current medical insurance programs create no incentive for smart consumerism and lead to massive waste, is proposing dramatic privatization of health care and the expansion of health savings accounts. Left-wing Democrats such as Rep. John Conyers (D-Mich.), though, continue to insist on killing private programs by requiring all to pay for and accept governmental health care.

Some Democrats have shown a willingness to drop the one-size-fits-all attitude that characterized their party's approach during the 1990s. Meanwhile, some Republicans have softened considerably their initial push to clamp down on state spending-this despite pleas from conservatives who point to lessons learned in the successful welfare budget cuts of 1996.

The Bush administration's proposed 2006 cuts to federally funded Medicaid are modest at best, trimming what the Congressional Budget Office estimates will amount to one-half of 1 percent over the next 10 years. The Bush budget proclaims that Medicaid "will continue to grow at a robust rate." Most observers agree, however, that mere status quo growth of a Medicaid program that promises far more than it can deliver will not solve the ever-increasing crisis.

Health costs are also crippling small and large businesses. General Motors Chairman Rick Wagoner last month said the American automaker spent $5.2 billion on health care in 2004, hurting it in international competition.

Seeking to find some middle ground, Republican governors such as Florida's Jeb Bush and South Carolina's Mark Sanford have proposed restructuring Medicaid rather than scrapping it. They suggest vast use of health savings accounts whereby Medicaid users could keep whatever money they do not spend, providing incentive for prudence.

Many Democrats, however, continue to insist that Medicaid is not the problem, and they favor expanding the current system to any adult below the official poverty line. Other Democrats have proposed federal grants to states for the establishment of insurance purchasing pools. It may be left to voters to break the ideological impasse, and to compassionate physicians to develop alternatives for those in poverty.

-Mark Bergin