Unemployed and Uninsured in Knoxville, Tennessee

If you've lost your job and your health care, where do you turn?

Zo Howell, age 2, flashes a gummy grin, his tiny mouth full of cream cheese. Eight-year-old Taye is across the room, play-wrestling a Great Dane. Somewhere outside their modest home in northeast Knoxville, a lawnmower growls to a start, nearly drowning out their mother's color commentary. "Turkeyheads," Heather sighs bemusedly, watching her two sons.

Though she can barely conceal her smile, there is exhaustion in the 28-year-old single mother's voice. The past few months have taken a toll on her, she explains. It began when she lost her job at United Healthcare in a round of layoffs last October. "It was a shock," she recalls. "It was frightening. I've never been fired before, not from any job."

Having worked in the company's Member and Provider Services department for the last year, loss of health insurance was one of the first things that came to mind when she received her notice. But she was more concerned for her sons than for herself. "You can't have kids and not have health insurance," she says.

Adding another level of irony to the situation, Heather found herself applying for the program she had previously helped to administer: TennCare. She had access to COBRA continuation health coverage, she explains, but there was no way she could afford its high premiums.

Her sons qualified for TennCare, as did she—until she started receiving unemployment checks in November. "That's when they kicked me off TennCare, because—"

She stifles a laugh. "They said I made too much money."

Since she lost TennCare, Heather says she's been lucky. She's not gotten sick enough to require a visit to the doctor, and she's not had any injuries. She's currently taking classes at Pellissippi State to become a paralegal, and keeps her fingers crossed that the job market will improve in the future. She sounds positive when she mentions a brochure about a free medical clinic in the area she picked up at a recent health fair.

But her body language, the way she nervously twists a strand of long, honey-colored hair around her finger as she talks, tells a different story. "Does it scare me?" she asks, glancing over at her sons. "Yes. But what option do I have? I can't find a job, and I can't afford to pay for health insurance myself."

Critical Condition

These days, gloom-and-doom headlines are the rule rather than the exception. The economic downturn has touched down hard on the local as well as national level, leaving a swath of destruction in its wake with high-profile closings such as Goody's and Image Point, and Sea Ray's mothballing of its Riverview manufacturing plant.

According to Tennessee Housing Development Agency statistics, Knox County's 2008 foreclosure rate was up 89.78 percent from 2007. The county's unemployment rate, 7.2 percent according to data released in mid-March, is the lowest among metropolitan cities in Tennessee but is up 0.6 percent from January. Surrounding counties haven't fared as well, with unemployment rates hovering in the double-digits. Of those, the highest unemployment rate, 18.1 percent, belonged to Scott County, a 7.9 percent increase from last year.

Yet such numbers are merely pebbles, catalysts for a damaging ripple effect that has many Americans struggling to maintain their quality of living. For some, it means cutting back—a scaled-back Christmas, generic brand milk, a canceled family vacation. For others, it means having to choose between groceries and health insurance.

Fortunately for the latter, there are some safety nets in place: free health clinics and other programs that connect uninsured patients with the health care they need at an affordable cost. For the most part, these safety nets aren't new, as the problem of uninsured and underinsured Americans is hardly a recent phenomenon. The challenges posed to these systems by the economy, on the other hand, are unprecedented.

For one, there is a surplus of demand. Approximately 45.7 million Americans are uninsured, including approximately 13 percent of Tennessee residents, according to the U.S. Census Bureau's last count in 2006. While there are no more recent official numbers available, it seems reasonable to project that, considering current economic conditions, the percentage is significantly higher today. At least that is the prevailing observation among area health care officials.

"We don't have any data specific to Tennessee," says Jackie Crumley, communications coordinator of the Tennessee Primary Care Association (TPCA). As a non-profit dedicated to connecting poor and uninsured Tennesseans with a health care home, TPCA manages a network of 136 sites across Tennessee and assists over 270,000 Tennesseans each year. Forty percent of those served are uninsured.

"We're just going on what we're hearing," Crumley says. "And what we keep hearing is, ‘We're swamped,' ‘We're getting killed here,' that kind of thing."

Simultaneously, the safety nets are experiencing an economic pinch themselves. Many depend on the community for support and are impaired when would-be donors, feeling the pressure to tighten their own finances, opt to downsize their charity giving.

"It's a time when the demand for our services is high, but donations are kind of down," says Nina Boling, development director of local health care ministry InterFaith Health Clinic. "Our projected budget donations are not coming in like they should have."

TPCA and InterFaith Health Clinic aren't alone in their tribulations. Throughout East Tennessee, health care safety nets are being stretched to capacity. Are they big enough, and strong enough, to catch all the uninsured Tennesseans who have fallen through the cracks?

Health Care Refuge

For some safety-net clinics, the events of the last few months have hit them like an open floodgate. Others have had a different experience—something more akin to the eye of a hurricane, an eerie calm almost as unsettling as the chaos surrounding it.

Mark Watt is chief executive operating officer of Dayspring Family Health Center, Inc., which operates two TPCA clinics and one Kentucky Primary Care Association clinic on the Tennessee/Kentucky border. He says he first noticed that something was off after the first of this year, when the number of patients visiting the clinics dropped off steeply.

It wasn't because people were miraculously staying well over the winter months. "People are forgoing health care, either because they're concerned about the economic situation or because they have been impacted by it directly," Watt says.

"Even if individuals aren't directly affected by loss of employment or a cutback of hours, there's just this overwhelming concern about what's going to happen in the future," he continues. "People don't know what's going to happen, so they hunker down and don't spend as much."

Watt explains that preventative health care is often one of the first things to go when people start making discretionary decisions about their spending. If the patients are already sick, they may still avoid visiting the doctor out of concern for the expense of pursuing treatment or purchasing medications. Unfortunately, the results can be even more costly, ranging from clogged emergency rooms to undiagnosed and potentially life-threatening health conditions.

"It happened so quickly," Watt says. "Now we're just trying to manage it retroactively, managing the effects of delayed treatment."

Karen Pershing, director of community assessment and planning for United Way of Greater Knoxville, also emphasizes how important it is for individuals to have a primary health care home and access to preventative medicine.

"When they have a crisis, they have nowhere to go other than local emergency rooms," she says. "That's the most expensive way to administer care. Then, when the bills come in, they can't afford to pay them. It puts financial strain on the individuals as well as the communities. It impacts what we all pay."

Relieving the burden on hospital systems by providing primary health care outside the emergency room setting was one long-term goal of United Way's Medical Home Initiative. Created in partnership with Knoxville Area Project Access, InterFaith Health Clinic, and Cherokee Health Systems, the three-year initiative provides health care at a reduced cost to the working uninsured who aren't eligible for state or federal health care programs.

According to United Way's estimates, there are somewhere between 60,000 and 80,000 uninsured people in Knox County at any given time. Pershing notes that many of these people have jobs. "They may work for a small business that doesn't offer health insurance or in the service industry, but they're getting up and going to work every day," she says.

For them, individual health insurance may simply be too expensive to afford. According to a report released by the Institute of Medicine in February, the average cost of family health care more than doubled from 1999 to 2008, from $1,543 to $3,354, and health care costs have been rising four times faster than wages. Health care is at a premium as there aren't enough providers to satisfy demand.

Since the economic downturn, which sent mass layoffs rippling through the area, the Medical Home Initiative has had cause to clarify its definition of "working uninsured." "If I come in and I've just lost my job, I can get on this program temporarily until I get my next job," Pershing explains. "We know they want to go back to work, and we know they're employable and they're going to be working again. We're just trying to help bridge that gap."

Dennis Freeman, CEO of Cherokee Health Systems, suggests that one key to the Initiative's success is its emphasis on integrated care. "I think the unique thing we do is joining together behavioral and medical services," he says. An emphasis on mental health, he says, is critical, considering the emotional and psychological tolls that unemployment and financial duress can take on an individual.

Freeman notes the beating the Medical Home Initiative has taken in the past few months. "Some of our funding sources have dropped off, so there's not as much revenue coming in. We're trying to be as efficient as we can," he says.

Somewhere to Turn

It's 8:30 on a Monday morning in the Knoxville Health Department's Women's Clinic, and already, someone is in tears. "Maybe I should get pregnant so they'll let me be on TennCare," hisses a red-faced patient in her mid-20s, angrily swiping a tear from her cheek.

Her mother glares at the receptionist, with whom they've been loudly arguing for the last half hour. The daughter needs a procedure that doesn't fall under the umbrella of a regular medical exam, and being uninsured, they're worried about how they're going to pay for it. Now they're huddled in the corner, regrouping. "Go back up there," the mother whispers. "At least get the paperwork."

"Why?" the daughter asks, blinking up at her. "Didn't you hear what she said? I don't qualify for TennCare. They'll just turn me away."

Without health insurance, the stress of paying for medical treatment can be as worrisome as the condition requiring treatment. And since they tightened their enrollment belts, resources like TennCare no longer guarantee any reassurance.

Other safety net programs, sensing an increase in unmet needs, have sprung up in TennCare's shadow. One of these is Knoxville Area Project Access (KAPA), a safety-net program piloted by the physicians of the Knoxville Academy of Medicine.

Since it was founded in 2006, in the wake of TennCare's massive disenrollment, KAPA has registered over 10,000 patients and coordinated $17 million in donated health care from local physicians, hospitals, and health clinics. The program leans heavily on the goodwill of area health care professionals, as services are donated to qualifying individuals at little or no cost.

So far, says KAPA Executive Director Kim Weaver, the program has been able to meet the increasing demands placed on it by the community. "Our numbers are really skyrocketing," she says, noting that KAPA's applicant pool has tripled since the beginning of the year. "We've seen people who have never had to ask for any kind of help before come in and ask for help."

In the last few months, a number of the applicants have been recently laid-off people who can't afford individual health insurance on an unemployment check of, at best, $200 or $275 a week. Some of them have access to COBRA continuation health coverage but can't afford the premium; others are confused about whether they're even eligible.

"The thing about COBRA, and we're just hearing this from patients but we're hearing it time and time again, is that they don't have access to COBRA because there is none when the company goes belly up," she says.

COBRA, or the Consolidated Omnibus Budget Reconciliation Act, was passed in 1986 to provide continuation of group health coverage that might otherwise be terminated for a limited amount of time, usually 18 months. The downside is, without an employer paying for part of the premium, it can be pricey.

"Generally speaking, it's very expensive to buy," says Allen Crub, managing lawyer at the Tennessee Employment Law Center. "But if you don't have any other health insurance options, or if you have a pre-existing condition or immediate health care needs, it can be very important."

The recent passage of the COBRA Premium Assistance Subsidy Program, part of the American Recovery and Reinvestment Act of 2009, in February may reel such premiums in to a more affordable level. The program provides for a 65-percent subsidy for COBRA continuation premiums for up to nine months for employees, and their covered dependents, who have been involuntarily terminated between Sept. 1, 2008, and Dec. 31, 2009. According to congressional estimates, the subsidy should help an estimated seven million Americans.

Crub says that, in the case that a company goes bankrupt or out of business, a terminated employee's access to COBRA depends on the company's plan and how it is set up. "That would be something the employee would need to go see an employment lawyer about, to see what provisions the health insurance plan makes for that circumstance," he says.

In either case, terminated employees can take some comfort in the fact that, no matter what their circumstance, there is help available. Some of the programs have eligibility requirements. At KAPA, for instance, applicants must have an income at or below the federal poverty level, be Knox County residents, and have no access to employment insurance or government health plans. Other programs and free clinics turn no one away, regardless of their circumstances.

Remote Area Medical (RAM) is a Knoxville-based relief corps that provides free health, dental, and eye care to people in East Tennessee and beyond. The charitable organization is 100-percent volunteer supported, with a nationwide network of doctors, nurses, veterinarians, pilots and support workers who participate in RAM expeditions at their own expense.

RAM hosts one free clinic each month at venues throughout the nation and the world, including an annual trip to Guyana in South America. The corps keeps a number of planes, ranging from a substantial Douglas C-47/DC-3 to a small Cessna 150, in a hangar at nearby Island Home Airport. Aviation is used to carry people and equipment into areas that may be difficult to reach by road.

Though most of RAM's expeditions take place in rural locales, urban areas with fast-growing uninsured populations are now welcoming RAM's presence as well. A weekend clinic in January at the Jacob Building here in Knoxville treated 1,520 people hailing from four different states, utilized the support of 570 volunteers, and administered over $146,000 in free medical care.

When it comes to treating patients, Tennessee Director Ron Brewer says that RAM doesn't ask questions. "We say for ourselves that we treat the underinsured and uninsured, but when they come through the door, we don't ask them if they have insurance," he explains.

RAM's home base is a former elementary school in South Knoxville, converted into offices and storage space. In one room, donated medical supplies are stacked to the ceiling and are inventoried on the former classroom's chalkboard. Another houses eyeglass lenses, filed neatly in boxes labeled with cryptic codes. Another contains medical records from each of RAM's clinics. The most recent file box bears the number 561.

And every record within every file box bears its own story. Brewer recalls a woman who cried when she saw the leaves on the trees through her new glasses, and a grown man who threw his arms around him in gratitude after a dentist fixed his toothache. Hearing Brewer's words, it's easy to imagine that it's a third-world country he's talking about, not America.

Saving Safety Nets

Dr. Tom Keun Kim, founder of the Free Medical Clinic of America, is seated at his desk in the tiny office he shares with his nurse and business manager. Funded solely by volunteer help, personal donations, and grant assistance, Kim's Christian ministry has provided no-cost primary care to almost 6,000 patients since its inception in 1993.

For Kim, the clinic is a labor of love—and frustration. Today, though he's on his lunch break, the physician can't seem to relax. He used to see between 25 and 28 patients per day, but since the beginning of the year, that number has grown to between 35 and 40.

"Sometimes I have to be a five-minute doctor, sometimes a one-minute doctor," Kim says in his lilting Korean accent. "This is why I'm so tired at the end of the day."

The Free Medical Clinic is located in a nondescript white building on Chapman Highway. Though it's quiet now, by the end of Kim's break his waiting room will be full of patients once again. Kim explains that although he originally intended to treat only the working uninsured, he's recently been forced to reconsider the criteria. "I broke my own rule that they have to work," he says. "Our economy is in a recession, everybody is talking about losing jobs, so I change my heart to open the door to those people."

Though Kim doggedly treats his patients, day in and day out, he asserts that he is treating the symptoms rather than the problem—only part of which he attributes to the government. Instead, he places accountability on the American people.

"If Americans quit smoking, eat half, and walk more, in 10 or 20 years we'll save a trillion dollars, I guarantee it," he says. "Every morning, afternoon, I preach this to my patients. ‘You're problem is not the cold, the cough, the back pain. Your problem is the smoking.'"

Kim says overweight patients have broken his clinic's scale eight times. He pulls open a desk drawer to reveal a dozen or more packs of cigarettes that he's confiscated from patients. He makes the patient write his or her name inside the pack and calls them regularly to check up on their efforts to quit.

Kim's advocacy of a paradigm shift in the way Americans treat their health, as opposed to merely counteracting poor lifestyle choices with advanced medicine and surgical techniques, is at once radical and obvious.

Kim says it saddens him when patients come in who haven't taken their blood pressure pills or insulin or thyroid pills for months because they can't afford it. "The middle class, their health is the most important thing, right? They're able to pay monthly premiums for insurance, and they know that when your health is broken everything is gone," he says.

"But the lower class, their health care priorities are bottom because they have no money. Their top priorities are paying bills, groceries, gas, while their own health, life or death, is at the bottom. Is this right or wrong?" His voice rises, his face suddenly flushed with anger. He pushes his chair away from his desk in disgust and stands up. "I'm serious! Somebody tell me, is this right or is this wrong?"

Updated to specify Sea Ray's mothballing of its Riverview manufacturing plant.