In July 8, 2007, Grant Frank spent 36 hours at the Med. It cost him $28,417.54.
At 4 a.m., he woke up to what he describes as "the worst pain of my life." He fumbled for his phone and called his father. "I've got to go to the hospital," he said. Soon, he was doubled over in the stark waiting room of the Med, signing a form in which he verified his lack of health insurance and agreed to pay off any medical bills to the best of his ability.
After five hours in the waiting room, with the pain in his abdomen getting worse, Frank was called to an examination room. He was diagnosed with a gallstone, and because of the high toxicity of bile stored in the gallbladder and the risk of rupture, doctors opted to remove his gallbladder immediately. When he came out of surgery a few hours later, Frank was given a brief convalescence in a semi-private hospital room and was discharged by the end of that night.
"We got the bill a month later," Frank said. "It said to pay as soon as possible and that I could set up a plan, but all their plans were things that I couldn't do — like $400 a month. At that point, I was making about $800 a month. My rent was $350, and my car insurance was $125. With food and living expenses, it didn't leave me much to pay them."
Frank is not alone in his experience. In 2008, 27 percent of Americans age 18 to 34 were without health insurance, according to the U.S. Census Bureau. That's compared to 18 percent of those age 35 to 50. The highest concentration of uninsured adults are those age 20 to 25, a group typically undergoing the pivotal transition from parental or university-based coverage to employment-based or private insurance.
Jessamyn Bradley, 24, finished graduate school at the University of Memphis in May 2009, but she hasn't had insurance since well before that.
"When I graduated from Middle Tennessee State University with my bachelor's, I was dropped from my parents' insurance because I was over 18 and no longer a student," Bradley said. "I guess that's been about three years, and it's terrible, terrible, terrible. I haven't had my teeth checked in over two years, and whenever it's time for an eye exam, my mother foots the bill. And heaven forbid when it's time for my annual pap smear."
Besides the risk of sudden illness, young adults have the highest rate of injury-related emergency department visits. When an accident happens or serious illness strikes, the uninsured and underinsured (those who have some health coverage but are not protected from high health costs) are left with medical bills they cannot pay. A 2007 study by the American Journal of Medicine reported 62 percent of all bankruptcy cases were medical-related. Even more startling, three quarters of those debtors had some kind of health insurance.
Where the System Breaks Down
The status quo is bleak for patients and costly for providers. At the Med, the Mid-South's safety-net hospital, uninsured or underinsured cases are far from unusual. The Med treats patients regardless of coverage or ability to pay, not only patients from Memphis but from throughout a five-state region. According to Judy Briggs, executive director of revenue cycle, uninsured or "self-pay" patient visits made up 31.8 percent of the hospital's potential revenue for the 2009 fiscal year. The hospital must absorb whatever portion of that revenue goes unpaid.
When uninsured or underinsured patients receive treatment at the Med, the hospital handles the billing process in a variety of ways. An in-hospital representative from MedAssist checks to see if the patient qualifies for Medicaid or Social Security. If the patient is the victim of a crime, he or she could receive up to $30,000 in assistance from the Crime Victim Fund. If the patient is below the poverty line, the case could be considered "charity care." If the patient does not fall into one of these categories, he or she is responsible for setting up a payment plan, like the one Frank was offered. As a last resort, a court can garnish a patient's wages after the provider sues the patient for the bill.
According to Frank, the payment plans offered by the Med were unrealistic, and the collection agencies were unrelenting. His mom agreed to pay off the separate $2,375 bill for doctors' fees, but the bulk of Frank's medical debt remained. A court decision was made to garnish his wages, then after just one paycheck, the garnishments stopped. Now, Frank said he's waiting for the hospital to make its next move. In the meantime, his credit report bears the stain of his exorbitant medical debt.
Government-aid eligibility requirements, which are based on age, income level, and/or disability, leave a pocket of people exposed to the risk of medical debt. Many young people, like Frank and Bradley, who are new to the job market, fall above the poverty line — and therefore above the cutoff for government aid — but below the income level necessary to survive a serious financial blow. In many cases, jobs available to entry-level workers don't provide health insurance, and individual policies are prohibitively expensive.
Bradley works full-time at a chiropractic clinic but is paid hourly and receives no health insurance from her employer. "I have a gym membership through work," she said. "But I have to pay for private insurance."
Many uninsured young adults utilize nonprofit health clinics, like Memphis' Church Health Center and Christ Community Health Services. These organizations provide basic health care for uninsured Memphians. Fifteen percent of all uninsured patients who rely on the Church Health Center for health care are between 18 and 34, many of them uninsured after they "age out" of TennCare eligibility. Unfortunately, because walk-in visits are first-come, first-served, the clinics aren't able to handle every patient who seeks help.
"We have to turn people away every day," said Burt Waller, executive director at Christ Community Health Services. It's a situation compounded by the increase in uninsured young Memphians seeking treatment at the clinic. The number of young adults age 19 to 34 who were treated jumped 10 percent from 2007 to 2008, a "significant increase" according to Waller.
The socioeconomic makeup of the patients is shifting as well. "We have seen an increase in the number of middle-class people coming to our clinic, because so many people are losing their jobs and, subsequently, their health insurance," said Marvin Stockwell of the Church Health Center.
Waller suggests that the local increase is part of a larger economic trend. "Companies are using a lot more contract and part-time employees," he said. "People change jobs more often, especially in today's recessionary economy, and fewer companies are offering full benefits." In fact, 46 percent of people age 18 to 34 are not covered by employment-based insurance, according to the Census Bureau.
Waller said the system starts to break down when patients seek more complicated treatment for serious illnesses. The Christ Community clinic and other health centers in Memphis accept walk-ins, but for specialty surgeries or procedures, treatment can be costly and appointments hard to make. People put off seeking care until they absolutely have to, then when they come in, their problem has often already reached a more severe — and more expensive — level.
If Frank had possessed some form of private insurance, the financial blow would have been less severe. Insurance plans such as HumanaOne's Monogram, offer a low-premium, high-deductible "catastrophe" insurance. The company's marketing of the plan focuses on young, generally healthy consumers and is advertised as "ideal for recent college graduates or graduate students."
So why wouldn't young people sign up for these plans?
"Affordability," Frank said.
For many young adults, even the minimal coverage for basic health care does not always seem worth the premium. Monogram, which does not include dental insurance or cover lab work, X-rays, and emergency room visits until the deductible is paid, has an average premium of $40 a month, or $480 a year.
In addition, subscribers must pay for all prescriptions up to $1,000 and hospitalizations up to $7,500. The plan covers a routine annual physical, immunization and pap smear, but all other doctor visits are on the patient's tab. Many young people don't see the point of paying a monthly premium if basic doctor visits are out of pocket anyway.
Heidi Park, 29, works for the University of Memphis as a contracted researcher and has no health insurance coverage. She has opted to pay for her own medical costs.
"Some health concerns earlier in the year led me to visit the doctor for the first time in many years," Park said. "I paid out of pocket, and it was not pretty."
The "Young Invincibles"
A national organization called Young Invincibles (younginvincibles.org) has co-opted the pejorative title often used to dismiss the young and uninsured. The group is working to dispel the myth that young people consider themselves invincible and is trying to educate and galvanize uninsured young adults.
Armed with startling statistics about their demographic — more than half of all young adults between the ages of 20 and 29 are overweight or obese; the highest prevalence of human papilloma virus is among women age 20 to 24; and one-third of all HIV diagnoses are made among young adults — the organization hopes to turn the public perception that young adults don't need or want health care.
According to a recent survey conducted by the Department of Health and Human Services, 28 percent of uninsured young adult men and 40 percent of uninsured young adult women reported not receiving at least one needed health-related service in the prior 12 months, because they could not afford it.
"At that age, you don't think about health insurance, because you're mostly well and you don't have that much money to lose," 9th District congressman Steve Cohen said. "You don't think about getting sick when you're young. You think about raising hell."
Cohen is an outspoken proponent of a health-care reform bill that would give everyone, even young adults, regular, affordable access to doctors. He sees it as the first step to curbing high medical costs.
"You have to have a more holistic approach toward the patient to see that they stay healthy," Cohen said. "Beyond that, I think you need a public plan to keep the health-care companies' prices from continuing to rise."
Cohen remains optimistic about a plan that controls costs via a "public option." "I think we're going to have a bill," he said. "That's what President Obama desires and what the majority of the Democratic caucus desires."
Recent polling suggests it's what the majority of the public wants as well. But even if a bill passes, it will take time to phase in fully. What should young uninsured Memphians do for now?
"We focus on prevention to keep people healthy before they get sick," Stockwell said.
Cohen's advice is practical but not too reassuring in the short-term: "Buckle your seatbelt," he said. "Don't talk on your cell phone when you're driving. Try to live a healthy lifestyle. Don't drink and drive."
Forty-four years after President Lyndon Johnson signed Medicare into law in an effort to spare elderly Americans from "the terrible darkness of despairing poverty" caused by rising medical costs, we are now faced with a generation of young people who may be consigned to bankruptcy or years of paying off hospital bills because of an unexpected injury or illness. It is no less frightful a prospect for the next generation of Americans to face crippling debt at the outset of their adult lives.