washingtonpost.com
Map divides the insured from the sidelined
Many in affluent areas are struggling Growing need squeezes access to medical care

By Carol Morello
Washington Post Staff Writer
Monday, November 9, 2009

For people lacking health insurance in the Washington region, where they live can make all the difference in getting affordable health care.

The District makes it easy, with its taxpayer-funded health insurance for everyone within generous income restrictions. But about 10 percent of eligible adults remain uninsured, and the city wants to find and enroll them.

At the other end of the spectrum is Prince George's County, where recent Census Bureau statistics show that one in five working-age adults is uninsured. Many are the working poor, who have to choose between getting a checkup and buying groceries. Five free clinics in the county treated 6,000 people last year, a small fraction of the uninsured.

The census statistics underscore wide regional differences in how many people are uninsured. Health-care professionals say there also are gaps in health, measured by such data as how many people are tested for serious diseases and how many children are born prematurely. A report this spring by the Metropolitan Washington Council of Governments found that average life expectancy ranged from 72 in the District to 81 in Montgomery County.

A lack of health insurance is not the only factor determining whether people have access to care. But many clinics that provide free or low-cost health care to low-income residents say they are flooded with people who have let their health slide, often for years, because they have no insurance.

"Free clinics are not adequate to address the need," said Kelley Woodward, medical director of the Alexandria health department and the lead doctor for COG's report on community health status indicators. "There's a huge shortage of services for people without health insurance. The clinics are all overwhelmed."

Of particular concern are adults 18 to 64. Children can be covered under federal and state programs, and seniors get Medicare. Most adults get no help. Clinics report a sharp increase during the recession in the working poor and unemployed patients.

"They're people who had really good jobs and who have lost really everything," said Michelle Schuler, executive director of the free clinic in Prince William County, where 17 percent of working-age adults are uninsured. "It's humbling for them to have to ask for help. They think the situation is going to change, and so they go without their medications for hypertension or diabetes. By the time they realize things aren't turning around and they come to us, they're very sick."

Some of the area's most affluent counties have relatively high numbers of uninsured residents. In Montgomery, 16 percent of working-age adults lack insurance, according to the census estimates. In Fairfax, it's 13 percent.

Prince George's has the most. Donald Shell, head of the health department, estimates that 150,000 of the county's 820,000 residents, including children and the elderly, are uninsured.

"Prince George's is in a quagmire," Shell said. "Many residents, though they are employed, have incomes too high to qualify for Medicaid." So some go without insurance.

Residents earning more than $27,562 for a family of four do not qualify for care at one of the five clinics run in the county by Greater Baden Medical Services, a nonprofit group. "So many people are, like, a dollar over the cutoff," said Sarah Leonard, executive director of Greater Baden. "We have a lot of people struggling to get by in an area where living costs are high, and they're not able to get coverage. So they just don't get care at all."

Shell said the county is considering opening a primary-care clinic at the county hospital, where the uninsured could seek care for one-fifth the cost of going to the emergency room.

Costs have waylaid many a plan.

Only an infusion of $1.2 million in federal stimulus money kept the Prince William Community Health Center from closing its doors. The center served 6,000 people last year, Director Liz Sykes said. Many are jobless or uninsured working poor who have part-time or entry-level jobs. At the free clinic, which is open two nights a week, Schuler said she has seen more homeless patients in the past seven months than in the previous 15 years.

Montgomery set an ambitious goal of caring for 40,000 uninsured residents -- half the estimated total -- at a network of "safety net" clinics. Five years later, the county is halfway there and the clinics have waiting lists.

County Council member George Leventhal (D-At Large), who heads the panel's health and human services committee, said most of the uninsured are working-class people and recent immigrants. Council member Duchy Trachtenberg (D-At Large) said a growing number are divorced women 55 to 64. many forgo health insurance in the face of more pressing needs.

"The cost of living is so high," Leventhal said. "If you're making discretionary decisions, you pay the rent or groceries or health insurance."

The District boasts the most comprehensive health coverage in the region -- and some of the biggest health challenges. It has the region's highest rates of low birth weights, premature births, breast cancer, heart disease and AIDS, for example.

Julie Hudman, head of the city's Health Care Finance Department, said the District has fewer uninsured adults because of its high eligibility levels. Its Healthcare Alliance program covers almost 55,000 adults who make up to 200 percent of the federal poverty level, or $36,620 for a family of three. Fully a third of the adults in the city are covered under Alliance or Medicaid.

Under Alliance, patients have no premiums and no cost sharing. Prescription drugs cost the patient $1. Everyone is eligible, including newly arrived and undocumented immigrants.

"Our goal is to have everyone covered," Hudman said. A survey is being done to determine why some people haven't enrolled.

Woodward, who headed the COG study, said hospitals are providing a lot of primary care that the clinics cannot handle, particularly in emergency rooms.

"Having a fifth of adults without health insurance is a huge problem," he said. "Having people in our community who don't have the health care they need while others readily have access to it is not a comfortable thing for me as a physician."

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