A grim realization

When professionals anguish over making too much money to continue qualifying for health-care assistance, the system is officially in need of fixing

By Tanya Whiton

It’s been hard for me to acknowledge — let alone come to terms with — the fact that I am poor. Though I joke about it with friends, who are, for the most part, also poor, and though I live daily with anxiety about my finances, I’ve not felt I could claim poverty. I’m the only daughter of an upper-middle-class family. I’ve got a master’s degree. If I occasionally can’t afford groceries; if I can’t purchase a new pair of winter boots; if I disregard potentially problematic physical symptoms because I don’t have the money to go to a doctor and I have no access to health insurance, well, that’s my problem, and my fault. I must not be working hard enough.

But here’s the thing: I work full time. I teach three classes for the University of Southern Maine, am a regular contributor to the Phoenix, and a freelance editor on the side. None of these jobs offer benefits, though USM will — after three years. An occasional bag of groceries and new winter boots I can do without in the short term. Access to health care, I can’t.

In my freshman composition classes, I unavoidably help peddle the fantasy that a college degree is a ticket to financial security — most of my kids say they’re in college so they can “get a good job.” Many of them are from working-class backgrounds, and many of them are the first in their families to venture past high school. It seems hopelessly arrogant to tell them they are there to learn how to think, especially when thinking is currently a grossly devalued skill in the marketplace.

In a recent debate, I asked them to look into the class inequities and social perceptions about “how good people ought to lead their lives,” which impact the kinds of health care poor people receive, using an essay written by medical ethicist Howard Brody. Almost all of them had witnessed or experienced a situation in which someone they knew could not afford to care for themselves or a loved one.

But in the classroom discussion, and the papers that followed, a key quote from Brody’s analysis was significantly absent. Though most of my students had identified with the disempowered “laypeople” in Brody’s case studies, they failed to see themselves or their family members in the same role — and so did I.

I found myself returning to this passage again and again, until the academic lens I saw the words through dissolved, and I saw a reflection of my own circumstances — as well as those of my friends who are also artists, attempting to make a living and make their own work at the same time.

 

“. . . this is a way of life shaped by chronic financial inadequacy, uncertain employment, and constant battles with social bureaucracies designed by the middle class to treat the lower class as adversaries. This way of life is further shaped by the relative inability to control one’s environment or plan for the future and by the pervasive temptation of alcohol and other drugs as escapes from this grim realization.”

 

This “grim realization” is one I’ve managed to avoid confronting for several years. Given my background, I’ve had access to advantages many people have not. My parents paid for me to go to college, and have helped me out several times since: paying for an ultrasound when I discovered a mysterious lump; loaning money for a car when I got a job that required I commute. Simply having the expectation that I will someday live a comfortable, secure life has been an advantage of sorts, allowing me to project past the present moment of profound uncertainty into a hypothetical future where I can both do work that matters to me and live well.

This expectation is also problematic, since it creates the kind of internal contradiction that makes it nearly impossible to seek assistance, or avail myself of services I’d always felt were designed for people who really needed them. Not me.

A few years back, a fellow writer, upon hearing I had no access to health care (I was a waitress at the time) suggested I apply for uncompensated care — charity care — through Maine Medical Center. He was certain I was poor enough to be eligible. It was only recently, when I became concerned about a recurring medical problem (and the unmanageable cost of paying for treatment), that I seriously considered this option. My friend said all I had to do was take my pay stubs to the hospital registry.

When I finally called Maine Med, and asked about applying, the man at central reception said procedure had changed a bit: I would need to go to the Department of Human Services and apply for MaineCare (formerly Medicaid), get rejected for that assistance, and then bring my letter of rejection and my pay stubs to the hospital.

I stalled again. DHS, in my mind, was where people who really needed help went. I imagined a waiting room lined with grubby plastic chairs, where I’d sit for hours. It occurred to me that part of the reason I didn’t want to go was because I hoped to keep the illusion of my middle-class-ness in place, and it disgusted me that, consciously or no, I was trying to separate myself from those people.

I was also ashamed of the fact that, according to the standards of my “class,” and at the age of 31, I couldn’t take care of myself. Each phone call, each form, each request for verification of my income and proof of my poverty tempted me to bail out of the application process. Yes, I was poor. But supposing I wasn’t poor enough?

One Hundred Percent Poor

In a brightly lit waiting room lined with plastic chairs, I wait for my caseworker to appear at the end of a long hallway composed of small, glassed-in cubicles. I’ve filled out a form requesting access to MaineCare, the state’s recently renamed version of Medicaid — a health-care program designed to cover low-income individuals and families: kids under age 21 and adults over age 65. Prior to October 1, 2002, if you were between the ages of 21 and 65 you had to be disabled or have children to qualify for assistance. As of October 1, however, adults without either a disability or dependents became eligible for MaineCare, too, as long as they can prove they earn less than $739 a month — 100 percent of the federal poverty level for a single person.

A young mother sits at one of several large tables, perusing the Employment Times, and in a chair adjacent to me, a Somali man waits, a manila envelope clutched in one hand. An ancient African woman in traditional garb watches the young woman’s baby crawl across the floor in its pink and white fleece suit, its mouth forming the “O” that precedes a howl.

A tall, skinny white woman stomps across the room and sits down, saying in my general direction: “I’m here for an hour, they’re just calling my name, and now I have to wait some more.”

“That’s bad news for me,” I say, having already waited a half an hour. “They must be backed up.”

“It’s bad news for the next person that gets me,” the woman says.

Just then, the lady behind the counter calls out her name, and asks what she needs.

“I need to find out why one week my husband has Medicaid, and the next week I get a letter saying he’s cut,” the woman says.

The lady behind the counter assures her someone will be out soon to deal with her issue.

After about 45 minutes, a short, wiry man calls my name in a distinct Russian accent, and I gather up my coat, scarf and gloves. “Hello,” he says curtly. “My name is Oleg Kladov.” He turns back toward the long hallway, and we walk to his cubicle, a gray room with a computer on a table and two chairs. I hand him my pay stubs, and he opens a new file for me, explaining as he goes how MaineCare works, what its limitations are, and how DHS’s new, improved computer system has complicated — rather than streamlined — the bureaucracy.

Caseworkers, who usually have a load of about 500 clients, now administer all three of the department’s complex programs: TANF (Temporary Assistance for Needy Families), Food Stamps, and MaineCare. Also, given the wrong configuration of information in a given field, the computer will fire off a letter to Augusta.

“Then somebody’s calling me because their aid got cut,” Kladov says, wearily.

After running my numbers through the system, Kladov explains that I’m over the income limit to qualify for state assistance. I ask him if people take their worries and frustrations out on him — thinking of the woman in the lobby, whose anxiety had clearly given way to rage.

“I don’t make policies, I follow them,” Kladov says, raising his hands in the manner of a man who’s seen it all. “You’ll get your letter from the state in a couple of days. If your income changes, you can come back any time you want.”

In a follow-up phone call to Don Comeau, Program Administrator for the Bureau of Family Independence in Cumberland County, I get some more particulars on the state’s new program for “non-categorical adults.” Since October 1, around 4000 people have become eligible for health care who previously had no coverage. When asked how often people need to reapply, Comeau explains that it differs from case to case: If someone enters MaineCare due to a disability, their case is customarily reviewed a year from the date of entry.

“But if someone is not working (read: non-categorical), we would review it sooner. It’s up to the caseworker.”

Where to get help Department of Human Services, (207) 822-2000. MaineCare is government-funded and free. Income cutoff for single person: $739 per month. Bring identification and proof of income. Ask for MaineCare application — if rejected, tell caseworker you want to apply for uncompensated care.   Maine Medical Center, (207) 871-2433. Uncompensated care is hospital-supported and free, with access to the lower-cost hospital pharmacy. Family practice centers provide more personalized care. Income cutoff for single person: $1108 per month. Bring identification, proof of income and MaineCare rejection letter from State of Maine.   CarePartners, (207) 842-7000. CarePartners has a minimal co-pay and is volunteer-supported, with pharmaceutical benefits and a care manager. Income cutoff for single person: $1292 per month. Bring identification and proof of income.   Portland Community Free Clinic, (207) 874-8982. The Free Clinic is an all-volunteer staff, with free office visits, and a sliding scale for diagnostic tests, X-rays, and hospital-related services. Income cutoff for single person: $1477 per month. Bring identification and proof of income.   For more information about free care and your legal rights, go to Pine Tree Legal’s Web site at www.ptla.org/hospital.htm#cover, or call (207) 774-8211. For a statewide resource directory go to the Consumers For Affordable Health Care Web site at www.maInecahc.org/healthcare/otherprogramsinmaine.htm, or call (207) 622-7045. —TW

One Hundred and Fifty Percent Poor

Several days later, I receive my rejection letter from the Department of Human Services, which says: “The following people can not get MaineCare. TANYA K. WHITON.” I take my letter to Maine Medical Center, and ask at the desk inside the main door where I go to apply for uncompensated care. An elderly man directs me to registration, a long room lined, again, with glassed-in cubicles. When a woman emerges from her booth and ushers me in, I tell her I’m doing a story on the charity-care application process. She yelps, “Oh God — SHELLIE!”

Shellie Hanrahan, Supervisor of Outpatient Registration, appears. A matronly woman in a holiday party outfit — red skirt and white sateen blouse — she ushers me through a cacophony of phones, computers and female voices to her office, a tidy corner room adorned with pictures of her family. Outside her window, a guy on crutches stands talking to another guy who wears an orange hat.

She takes the letter, my driver’s license and pay stubs and brings my file up on the computer — I’d been to the hospital years before, to have my cholesterol checked, after my father had a double bypass at age 55. Hanrahan explains that the hospital can offer uncompensated care to people living at 150 percent of the federal poverty level — $13,290 per year for a single person.

She also says that if I am eligible, I’ll have to reapply every six months, get rejected for MaineCare, and bring my rejection and proof of income to the hospital again. While she inputs my data, I try to shake the tension settling over my shoulders and knotting my gut. If I’m not eligible for this program, what then?

“Supposing I broke my leg,” I say, glancing out the window, “and I hadn’t applied, and I had no insurance.”

“You’d be offered the service,” Hanrahan replies.

But if, at that time, I didn’t qualify, I’d be stuck with the bill.

“How,” I ask her, “does the hospital absorb the cost of people who can’t pay for care?”

“It’s a write off,” Hanrahan says.

According to Tom Cryan, Director of Patient Accounts, in the fiscal year ending September 30, 2001, Maine Medical Center wrote off seven million dollars in uncompensated care, for 16,500 patient visits. The state mandates that hospitals give away care for people at 100 percent of the federal poverty level, but that left thousands of people (like myself) on the margins but unable to qualify — so Maine Med and other area hospitals raised the bar.

Joan Couture, a nurse and Director of Admitting, says there is no cutoff point for free services if a person continues to fall below the income limit. I ask her about professionals who don’t have access to benefits, a growing sector of the population in a state where most people either work for small businesses (who can’t afford to purchase benefits for employees) or are self-employed.

“Usually [they] don’t qualify,” Couture says. “We don’t look at assets — or at what you owe. It’s strictly income-based.” As everyone knows, purchasing health insurance a la carte is generally not an option, even for people who can keep themselves in footwear and foodstuffs. Prices range from $180 to $300 per month.

Looks like you qualify,” Shellie Hanrahan says. “I can print you a card — usually we don’t print a card unless you have an appointment . . .”

“Go ahead and print one if you can,” I say. Irrational though it may be, I won’t feel as though I have any sort of security, however temporary and subject to cancellation, unless I have the actual card in hand. When Hanrahan returns with my card, which is good through June 6, 2003, I feel relieved. Later on, it strikes me as odd that a small, blue piece of plastic stamped UCB (to signify that I’m a charity patient) would make me feel secure. But it does. At least for the mean time, I can seek some treatment for health concerns I’ve been trying to push from my mind.

Before I leave, Hanrahan suggests that I also apply for CarePartners, another option for low-income people that offers a prescriptions program and a “broader range of services” — and hands me a brochure.

One Hundred and Seventy-Five Percent Poor

CarePartners, which charges a minimal co-payment for office visits and services, is available for (single) people who earn less than $15,505 per year. The significant difference, says Director Phebe King, is that patients have access to low-cost pharmaceuticals and a care manager: a person familiar with available resources who can provide continuity and make recommendations. The organization has a network of around 750 physicians, and makes it possible for members to see a doctor outside of the hospital system.

King emphasizes that current changes in the MaineCare system, what she refers to as the “non-categorical expansion” have opened up possibilities for both CarePartners and uncompensated care — “there’s about $600,000 in the health-care system that wasn’t there before,” she says. Also, as of January 1, 2003, there is a solid chance that uncompensated care will be available to people living at 175 percent of the federal poverty level.

“People need to know that.” she says. “There’s room to expand eligibility.”

I determine to make an appointment with CarePartners. After all, I’ve got my paperwork handy. King also refers me to the Portland Community Clinic, and gives me the number of Nate Nickerson, director of the Division of Public Health.

Two Hundred Percent Poor

The free clinic is an option for a single person earning less than $17,720 per year, who happens to be without insurance or a primary care provider. The “free” part refers to an office visit — diagnostic tests, X-rays, and other work that must be done by area hospitals are billed on a sliding scale. The clinic used to be housed with a larger program — health care for the homeless. “But,” Nickerson says, “there are people who weren’t homeless who felt uncomfortable going there.” I recall my unwillingness to lump myself in with other needy people, and feel embarrassed.

“It’s a stopgap measure in the system for people who are not covered. What you’re seeing is a cobbling together of strategies to help people out in the absence of a universal system,” Nickerson says. “There are certain limitations to getting care in a volunteer setting — [each visit may be with a different provider] continuity is a much more preferable way to get good holistic care.”

He sighs when I ask him what he thinks the chances are of a universal system being implemented in the near future, and says: “I don’t know how to give you the odds.”

Great Expectations

The process of applying for uncompensated care, which, unless there is a change in my fortunes, will be repeated six months from now, was my first in-depth encounter with the social bureaucracies Brody referred to in his essay. Should my financial situation improve, there is a chance that I will, once again, be able to stock my refrigerator and keep my feet dry. It is unlikely, though, that I will continue to qualify for free care, and equally as unlikely that I’ll be able to afford health insurance and access to a doctor on my own. There is, however, a chance I might remain under the umbrella of services created by CarePartners and the Portland Community Clinic.

To be worried about not being poor enough runs so counter to the “pull yourself up by the bootstraps” mentality I was raised with that, once again, contradictory impulses and conflicting emotions occasionally subsume my willingness to face facts. Like a lottery-ticket hopeful, I fantasize that fame will lift me from obscurity and chronic financial woes. Like a rent-to-own customer, I charge necessities on a credit card, disregarding the fact that I’ll pay triple the price over time and with interest. I have internalized those middle-class ideas about how “good people ought to lead their lives,” and, because I have felt helpless to gain control of my own, I have judged myself as “bad.”

“In other industrialized nations,” Nickerson says, “care is available for everyone. Like public education [in this country], for better or for worse, there’s an expectation that everyone will have access to it.”

That expectation is one I hope my students can hold upon graduating from college. But until they can identify themselves in the theoretical and intellectual analysis of inequity, and help fight for change, they, like me, will remain blinded by a myth of middle-class independence that is farther and farther divorced from reality.

Tanya Whiton can be reached at twhiton@prexar.com.