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OCALA, Fla. -- It's not unusual for one of the lower-income, uninsured patients at Dr. Segismundo Pares' office to "barter" when they can't afford to pay for an office visit.
The family physician, who hasn't taken on new patients in three years, has accepted food like pies and eggs to settle outstanding bills, while other patients have even done painting.
"You want them to give something so that they feel they're not getting a freebie so they'll come back," Pares said. "A lot will do it, but a lot won't." Some of his patients will "just get in a jam, and we'll write it off," said Pares of delinquent payments, adding that he knows many other doctors have seen an increase of delinquent payments or charity cases.
And while doctors are dealing with more and more non-paying patients, doctors are also dealing with rising malpractice premiums and reductions in Medicare reimbursements. And those problems are making it harder to recruit and retain doctors in the county, he said.
"I think physicians provide a lot of care when they know people need the care. They provide it, and you pay later. Some do. Some don't," said Dr. Chris Grainger, a family physician and president of the Marion County Medical Society.
"I think most physicians are willing to work things out," he added.
Physicians, however, aren't the only ones impacted by the growing number of uninsured Americans. Experts say it's also an issue for hospitals, health departments, businesses and even people with health insurance.
And all Americans, mainly those who do have insurance, end up paying the ever increasing cost of health care.
Nearly 44 million people, including 8.5 million children, in the United States were uninsured in 2002, according to the Census Bureau.
The census noted that 15.2 percent of the U.S. population in 2002 were not insured, up from 14.6 percent in 2001.
Uninsured people around the country "could incur nearly $41 billion in uncompensated health care treatment in 2004, with federal, state and local governments paying as much as 85 percent of the care," according to a study by the Kaiser Commission on Medicaid and the Uninsured.
The study noted that in 2002 17 percent of Florida's 16.3 million people were uninsured.
"It's an increasing burden," said Pares, chief of staff at Munroe Regional Medical Center and a member of hospital's board of trustees.
"I think it impacts the hospitals more than it does the physicians." People without insurance often don't have a primary care physician, so they go to a hospital emergency department instead, said Allison Williams, Ocala Regional Medical Center spokeswoman.
For fiscal year 2003, the hospital's cost for uncompensated care was between $7 million and $8 million, she said.
The cost of uncompensated care has grown, "especially in the emergency department," Williams said. "There was a 23 percent increase in emergency department visits from the uninsured from (fiscal years) 2002 to 2003.
"The trend seems to continue from April '03 to April '04. It's an additional 21 percent," she said.
"We've got to do something about that because our emergency rooms are being overwhelmed by people seeking primary care," said Dyer Michell, Munroe's chief executive officer.
At Munroe, the cost for uncompensated care was $32 million in 2003, said Erl Piscitelli, spokeswoman for the community, not-for-profit hospital.
That amount grew from $26 million the previous fiscal year, she said, adding that it is "projected to increase next year." Michell said several factors could contribute to people going without health insurance in Marion County, which has: a relatively low average income compared to other parts of the state and nation; a significant percentage of people employed by small businesses, which might not provide health insurance; and an abundance of service industry jobs.
The growing number of uninsured people is having an impact on society, Michell said, noting that hospitals still have to cover their costs, including staff salaries and supplies. "Somebody has to pay for that." The federal government, which reimburses hospitals for Medicare and Medicaid, does not cover a hospital's uncompensated costs, Michell said. In Munroe's case, the hospital ends up shifting those uncompensated costs to the 22 percent of patients who have commercial insurance, Michell said.
"It's a crazy system," he added. In addition, many large employers are cutting back or shifting more of the cost to their employees, Michell said. "More people are becoming underinsured or uninsured as a consequence," he said.
A Robert Wood Johnson Foundation study found that at least 20 million working Americans do not have health insurance coverage and that "in every state, adults who do not have health insurance experience significant gaps in medical care compared to those who do." Jaye Baillie, president and chief executive officer of the Ocala/Marion County Chamber of Commerce, said the organization has been concerned for several years about the rising cost of health insurance Surveys of members have shown that health insurance is one of the top three concerns small businesses have, she said.
This year, the state Legislature passed the Affordable Health Care for Floridians Act, which takes effect in July. The act increases the types of plans insurers must provide to small businesses, including a Health Reimbursement Account or Heath Savings Account.
The act will also expand the Health Flex Program throughout the state and is expected to create the Small Employers Access Program, according to the Florida Chamber of Commerce.
"The changes that have been recommended will help small businesses' bottom line and get more uninsured people insured," Baillie said.
"It's a step in the right direction." In recent years, members of Congress and President Bush's administration have backed various proposals to expand access to health care.
While the state's Affordable Health Care act has some items that could help, there is "still a missing link of education," said Jeff Feller, resource development director for the North Central Florida Health Planning Council, which covers 16 counties including Marion.
Between 18 and 21 percent of the population in the council's 16-county area are uninsured. Feller said that the area includes many lower-wage, service industry jobs.
Some employers in the service sector often can't afford to provide health insurance, and many employees must choose between paying for rent and food or health insurance, he said. "In America, we're primarily still driven by health insurance provided by employers." In addition to the uninsured, there's a growing number of underinsured people because of higher deductibles, Feller said.
"We anticipate that it's a growing number and a threat to health," he said, adding many uninsured people are seeking treatment only for catastrophic illnesses and not getting preventive or primary care "We all pay for this. This is not just for the 18 to 21 percent (who are) uninsured," Feller said. "Those costs are passed back on to the paying population." That drives up insurance premiums, and then more people can't afford insurance, he said. "It becomes a vicious cycle. It just becomes self-perpetuating." In Marion County, uninsured patients do have options for health care.
Community Health Services in Ocala provides care to indigent county residents for a nominal cost, said CHS director Darlene Perryman.
People with acute illnesses or injuries are referred to a hospital emergency room, she said.
"We have consistently increased (the number of patients) every year," Perryman said, noting that three CHS nurse practitioners treated 12,142 patients in fiscal year 2003.
This year, it was budgeted for 12,500 patients. Both local hospitals provided $350,000 each to fund CHS, she said. Members of the Marion County Medical Society also volunteer time to treat the indigent through the society's "We Care" program.
CHS works closely with the Marion County Health Department, Perryman said. The health department treats Medicare and Medicaid patients, as well as people without insurance, said director Dr. Nathan Grossman.
"It is true that in times when the economy is hard, obviously the number of uninsured goes up, and the burden on the providers of last resort, like the health department, goes up," he said. "We're always very busy." Uninsured people affect the health department as they do the hospitals, Grossman said.
"It's a burden here like it is in other places around Florida and the U.S. It's not just a Marion County problem." Grossman said.
(Ferdie De Vega writes for the Star-Banner in Ocala, Fla.) Editor Notes: NONE
c.2004 NYT Regional Newspapers
