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OAKLAND, Calif. – Like thousands of people who leave prison every year in California, Stanley Riley has serious health problems and no money for treatment.

Parolee Stanley Riley, right, greets fellow parolee Anwar Fuller on San Pablo Avenue in downtown Oakland, Calif., on Thursday, March 17, 2011. Riley has high blood pressure and diabetes, and since being released from prison after 13 years has had trouble getting access to health care. (Jane Tyska/Bay Area News Group)

During his 13 years of incarceration for robbery and an assortment of drug crimes, he could count on getting medication for high blood pressure and diabetes. But when he was released in 2008, all he got was a standard issue three-month supply.

“That scares you,” Riley, 54, says. “They already knew I was going to have a problem. They already knew it was not going to be that easy.”

Now help is on the way. In coming months, local governments in California stand to gain tens of millions of dollars in federal funds to care for the indigent, including ex-offenders.

Alameda and Contra Costa counties expect substantial assistance. Santa Clara and San Mateo counties also hope to qualify. State officials estimate 500,000 people without health insurance will benefit, beginning as early as June.

Expanded indigent-care is expected to help many of the 130,000 former inmates discharged every year in the state, as well as the mainly impoverished communities where they move upon release. The newly freed arrive home in neighborhoods in Oakland and Hayward, Richmond and Antioch, bringing high rates of chronic and communicable disease and serious mental illness.

The federal aid results from an agreement that state officials negotiated with the Obama administration to get early access to funds under the health care overhaul law. Officials in Alameda County say they could receive an extra $35 million a year on top of the roughly $100 million the county spends annually on indigent care. While details have yet to be fully worked out, they intend to spend a chunk of the new money on the formerly incarcerated.

“The reentry population is a perfect target,” says Alex Briscoe, director of the .

The initiative is seen as a bridge to 2014, when the health law sets in motion a massive expansion of Medicaid, the federal-state program for the poor that in California is called Medi-Cal. Among others, low-income single adults will qualify for Medicaid for the first time – a major policy change that would help ex-offenders who struggle to find jobs and health insurance.

The boost in federal funding couldn’t come at a better time. Many programs that provide services to former inmates are underfunded – and could see an explosion in demand: Tens of thousands of inmates may be released if the U.S. Supreme Court this year upholds a lower-court decision to .

Oakland and other communities had taken steps in recent years to address the health needs of former inmates. Alameda County pours $1 million annually into the nonprofit Healthy Oakland clinic on San Pablo Avenue to help a few thousand each year. But that was barely scratching the surface, with many thousands more going without care.

The East Bay is home to some of the highest concentrations of ex-offenders in the state. About 6,500 people, or 5 percent of the 130,000 released every year from state prisons, are paroled to Alameda County.

“We have an opportunity to say, ‘This is not working, and in one of the most progressive counties in America, we will do business differently,'” says Raymond Lankford, executive director of Healthy Oakland, and pastor of the Voices of Hope Community Church. Nonprofits like his would likely benefit from the new federal money.

Parolee Stanley Riley is photographed on San Pablo Avenue in downtown Oakland, Calif., on Thursday, March 17, 2011. Federal funds are expected to be coming to the state to assist with indigent health care. (Jane Tyska/Bay Area News Group)

Stanley Riley is an example of how the system can work differently. His story also shows how much time, resources, personal attention and commitment are required.

Healthy Oakland intervened soon after his release from prison in 2008. A representative visited a drug treatment center where Riley, a recovering heroin addict, was living, and offered everyone there $25 if they would drop by the clinic.

Riley took the money – and soon also got the diabetes medicine he needed.

Today, one of his most important supporters is another former inmate and heroin addict, William Grajeda, co-founder of a West Oakland nonprofit called The Gamble Institute that helps former inmates return to the community.

Grajeda, a pastoral counselor certified in helping people with a history of drug and alcohol abuse, runs a kind of ministry on wheels, putting a thousand miles a week on his Toyota. He has taken Riley to church, helped him register for classes at Merritt College, and after a recent relapse, got him enrolled in a detox program to avoid a parole violation that would return him to prison.

“Going to college? Me? Come on!” Riley says in disbelief of his own good fortune. “I got positive people in my life now. I got somewhere to go when I wake up in the morning.”

Not all former inmates are so committed or supported. They’re often apathetic about their health, studies have shown, even when they have serious disease.

High Infection Rates

Authorities at the Santa Rita Jail have long seen repeat offenders with HIV returning in much poorer health than when they left – even though AIDS drugs and support are widely available at community clinics.

Rates of hepatitis C infection in Alameda County are so high among long-term injection drug users that relatively few bother to get tested or seek treatment. “The attitude is, ‘Everybody has it so who gives a (darn)?'” says Dr. Diana Sylvestre, an internist in West Oakland, who has seen 3,000 people with hepatitis C over the past decade, many of them .

Former inmates often are key players in the efforts of counties to expand indigent care. Half the 40-person staff at Healthy Oakland has seen the inside of a prison or jail including several who do community outreach and recruit at weekly meetings at the county parole department. They include Shawn Vasquez, a one-time drug dealer nicknamed “The Boss Man” who used to hold forth from the Heartbreak residential hotel on San Pablo at the peak of the crack cocaine epidemic in the 1990s.

Williams

Another is Donald Williams, Lankford’s brother who ended up in prison, off and on for 20 years, starting in the 1980s. Among other duties, Williams acts as the designated driver of the organization’s van, occasionally picking up former inmates from San Quentin under a program that connects newly released inmates with medical care.

Glenn Hopkins got a ride from Williams when he was discharged in December and was soon signed up for the county indigent care program, which could help him get medications for his schizophrenia and bi-polar disorder.

Only 28 years old, Hopkins has been in prison for armed robbery and violating parole by allegedly assaulting the pregnant mother of his child. After his release, he says he planned to enroll in community college to become a welder. Williams encouraged him “to stay focused on what you got to do.”

“I got people in my life that was trying to discourage me,” Williams says, recalling his own up-and-down experiences on the street. “I just separated myself. That is what really helped me, changing my environment. That is hard. This old environment, this unhealthy environment, it calls me. It calls me every day.”

As for Hopkins, he made an appointment for a follow-up visit last month, and in what Williams said was an auspicious start to his new life on the outside, kept it.

Under federal funding rules, local officials will have some flexibility in deciding who qualifies for help. Both Alameda and Contra Costa counties, for example, are proposing to include people who earn as much as twice the poverty level, or $21,780 annually for single adults.
But the money comes with strings that could trip up some counties looking for help. For one thing, it is available only if counties maintain their existing funding for indigent care; the idea is to make sure that the federal money is used to expand programs rather than supplant local funding.

The programs will also have to offer a fuller range of benefits, including coverage for mental health treatment. Provider networks will have to be more extensive, and hospitals will have to meet new tests for their accessibility. Those that pass will be reimbursed by the federal government at a rate of 50 cents for every local dollar spent.

Stressed budgets – and the fact that money must be spent upfront to get the federal match – are putting some counties in a quandary. With the more generous and expensive coverage requirements, Santa Clara County is proposing to limit eligibility in its new indigent-care program to people earning just 75 percent of the poverty level. The county is happy for the federal support, but “it is not the silver bullet,” says Michael Lipman, acting director of planning, contracting and business development for the Santa Clara Valley Health & Hospital System. A less-generous health plan will be available for those with higher incomes.

New Money Fuels Bigger Programs

Health policy experts see the deal that California made with Washington as bringing the reality of reform to people sooner rather than later. “This is a jump start on getting at least a significant portion of individuals into the system now rather than waiting for three years,” says , a professor at UCLA and associate director of its Center for Health Policy Research.

San Mateo is hoping to use the federal funds to offset the cost of substance abuse treatment for hundreds of uninsured residents.
Contra Costa expects the total number of people eligible for its program to grow about 50 percent to about 18,000 people within a year. “We are banking on the fact that promises were made, and the money will follow,” says Dr. William Walker, director of the county’s health services agency. “We are out there … moving ahead.”

Anticipating a surge in enrollments, Briscoe, the Alameda County health director, wants to expand access to care with clinics in schools, churches and fire department sub-stations.

Lankford

Lankford is hoping to open a sister clinic in East Oakland by the summer. And a network of churches in Southern California is looking to replicate his model with locations in several counties throughout the state including Solano.

To advocates for ex-offenders, this would be money well spent, a way to start steering public funds away from what they view as costly, failed policies of the past that have focused on punishment and incarceration rather than rehabilitation and wellness.

“These are people, by and large, that we have systematically failed in terms of almost every public institution that was responsible for them,” says Junious Williams, chief executive of the Urban Strategies Council, a community and advocacy group that has advised Alameda and Contra Costa counties on health care polices for parolees and probationers.

“We put them in jails and prisons for long periods of time, and we failed to rehabilitate them. They are right back on the streets, and most of them are in as bad or worse shape than when we sent them away,” he says. “It is short-sighted not to figure out how to break the cycle, if no other reason, because we just don’t have the money anymore.”

rickschmitt@comcast.net

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Matt Sissel of Iowa City, Iowa, proudly served in Iraq as a combat medic. But he says he objects to being “conscripted” into an overhauled federal health care system.

The uninsured artist is riled about a provision in the new health law that would require him to purchase insurance or pay a penalty starting in 2014. Last July, he filed a lawsuit to have the landmark act declared unconstitutional. “I don’t want the federal government dictating my personal financial decisions,” says Sissel, 29. “It can’t even run its own budget.”

In attacking the law in the courts, Sissel has plenty of company. A number of interest groups, state officials and ordinary citizens are seeking to have the health care law struck down in federal court. 

Today, a federal judge in Michigan ruled that the mandate that individuals buy insurance is constitutional. U.S. District Court Judge George Steeh turned down a request from the Thomas More Law Center to issue an injunction blocking the government from taking any further action implementing the law. The non-profit law firm, based in Ann Arbor, often brings anti-abortion cases.  Steeh was appointed by President Bill Clinton. Legal action is heating up elsewhere as well:

— This week or next, a federal judge in Pensacola, Fla., is expected to issue a preliminary ruling on perhaps the most prominent lawsuit. Brought by the governors or attorneys general of 20 states, the lawsuit seeks to have the act declared unconstitutional.

— — On Oct. 18, the Republican attorney general of Virginia – who has compared the Obama administration’s regard for states’ rights to the tyranny of King George – heads back to court for another round of hearings with a federal judge who recently turned down a Justice Department request to throw the case out.

The burst of litigation has the framers of the law and the Obama administration playing defense. Many scholars, such as Charles Fried of Harvard Law School, argue that the law is on firm legal footing. But there is no quick resolution in sight, and it may take a year or two, and a trip to the U.S. Supreme Court, for all the lawsuits to get sorted out.

Still, that might be a quicker route to upending the law, or parts of it, than a threatened GOP repeal effort in Congress. Even if Republicans pick up more seats in November, they’ll have a tough time getting major changes past President Obama.

Under the health care law enacted in March, more than 32 million additional Americans are expected to get insurance, either through an extension of Medicaid, the state-federal program for the poor, or through exchanges where low- and moderate-income individuals and families will be able to purchase private insurance with federal subsidies.

The law’s ambitious sweep has made it a target for those who see it as an unjustified expansion of government. Plaintiffs challenging the law include a variety of religious groups, the nation’s largest small-business trade association, and a who’s who of conservative legal activism.

Sissel, for example, is represented by the Pacific Legal Foundation, a Sacramento-based legal watchdog group that supports limited government, property rights, and free enterprise.

Liberty University, the fundamentalist Lynchburg, Va., college founded by the late Jerry Falwell, has filed a lawsuit claiming that exemptions from the law for religious groups are too narrow and violate freedom of religion under the First Amendment. The Tucson-based Association of American Physicians and Surgeons, which opposes government intervention in health care, also has sued.

Several Cases, Similar Views

In many cases, the lawsuits make similar arguments. Several contend, for example, that a provision of the law requiring most people without health insurance to get coverage or pay a penalty exceeds the power of Congress to regulate interstate commerce under the Constitution.

The states, in the Florida lawsuit, also are challenging a provision of the law that greatly expands Medicaid. They claim the changes will cost them billions of dollars and wreck their budgets for years to come.

Justice Department lawyers say the lawsuits are without merit and premature. The penalties for people without insurance won’t take effect until 2014, and the states won’t have to start picking up any of the costs of the expanded Medicaid until 2017.

But the critics say the changes are so profound, that the courts should act now. The law will “transform our nation beyond recognition” and “arm Congress with unbridled top-down control over virtually every aspect of persons’ lives,” the states have argued in court documents in the Florida case.

Florida Attorney General Bill McCollum said in an interview that if the individual insurance requirement is upheld, there is no end to what the federal government might require people to do. “The government could … force us to buy a General Motors car or put our money in a government-owned bank,” he says.

Justice Department lawyers respond that the law was well within the power of Congress to enact. In court papers in the Florida case, they have described the law as “an important but incremental” extension of federal regulation of the health-care market.

Supporters of the law say healthy people must be required to buy coverage to offset higher costs that insurance companies face under the new law – otherwise, insurance will be too expensive for everyone.

In addition, they argue that dismantling the statute would hurt the poor, and would be a first step in rolling back laws dating to the New Deal that have given the government broad authority to regulate the behavior of individuals and states.

“These lawsuits have been mounted by people whose objective is to change constitutional law,” says Simon Lazarus, public policy counsel for the National Senior Citizens Law Center, a non-profit legal and educational firm that advocates for low-income older adults. To hold that the health reform law is unconstitutional would require “massively consequential changes in the Constitution as it has been plainly understood.”

Disagreement, Even Within State Governments

In some states, Republican and Democratic officials are slugging it out over their differing stands on the lawsuits.

In Washington state, for example, the state Supreme Court next month will hear a case that seeks to force the state’s Republican attorney general, Rob McKenna, to withdraw from the multistate lawsuit in Florida.

The hearing was set after the Democratic city attorney for Seattle, Pete Holmes, complained that state law prohibits McKenna from representing Washington in court without the support of the governor. Washington’s Democratic governor, Chris Gregoire, opposes the lawsuit. McKenna, considered a frontrunner for the governor’s race in 2012, says the law is on his side.

In Iowa, Republican Brenna Findley, is looking to unseat Democrat Tom Miller as attorney general, in part by vowing to join the Florida lawsuit if elected. This week,. Findley is hosting Virginia Attorney General Ken Cuccinelli at several campaign events. “Ken has led the way in fighting the federal takeover of America’s health care system,” Findley says in a message to supporters on her campaign’s Facebook page. “Don’t miss this opportunity to speak to Brenna and Ken about this important issue!!”

Miller, a seven-term incumbent, says the case is weak, and that joining the lawsuit would be a waste of resources. “Above all else, an attorney general has to follow the law and do things that are consistent with the law,” he says in an interview. “You don’t go ahead and file a lawsuit because you disagree with the policy.”

Even conservatives acknowledge that Congress has broad powers under the Constitution. But they say the authority kicks in only when there is already some ongoing activity to regulate.

“The Supreme Court has never said Congress has the power to make you engage in economic activity,” such as buying insurance, says Randy Barnett, a professor of constitutional law at Georgetown University Law Center in Washington.

States can require citizens to buy auto insurance or fire insurance for their homes – but that is because they have broad police powers under the Constitution that Congress does not have, he says.

Sissel figures the auto insurance he is required to maintain under Iowa law will cover his medical bills if he gets in an accident. He’s prepared to cover other bills out of his own pocket.

Healthy and trying to start an art business, he thinks his decision is rational. “There are all sorts of tragedies that can befall us in life. We can’t spend all of our time worrying about the statistically improbable,” he says.

Defenders of the individual-insurance mandate say people who don’t carry insurance impose a cost on society. If people get sick and don’t have insurance, they say, the public will have to pick up the tab.

“People not buying health insurance … they have not removed themselves from the marketplace. They have inserted themselves in the marketplace in perhaps the most aggressive way,” says Steven Schwinn, a law professor at John Marshall Law School in Chicago.

Medicaid Costs At Issue

Another point of contention involves the Medicaid expansion. Many states already spend a quarter or more of their budgets on Medicaid, and some fear the cost will rise dramatically as the new law takes hold.

David Rivkin, a Washington lawyer representing the states in the Florida case, says there comes a point where the cost crosses a line. By turning the states into “financial wards of the federal government,” he says, “you can vitiate state sovereignty.”

But several studies have predicted the overall cost to the states will be relatively small compared with the huge influx of federal dollars and the benefits residents will get from having insurance for the first time.

The states also do not have to accept the money, and can withdraw from Medicaid, although Rivkin and others say that is not a realistic option, given how the public has come to depend on the program.

“Does that mean the more money the feds give (the states) the less control it has over how those dollars are spent?” says Brad Joondeph, a professor at Santa Clara University law school.

The argument “seems backwards,” he says. “You end up with a perverse rule.”

In Florida, Judge Roger Vinson has said that he’s leaning towards dismissing several counts in the states’ lawsuit, but that he would allow “at least one count” to proceed.

Vinson has already scheduled a follow-up hearing for December, when he’ll give what’s left of the case a closer look. He’s expected to issue a final ruling early next year, touching off a round of appeals.

The states want to move the case along as quickly as possible, to capitalize on what they view as public disenchantment with the law. They hope that public concern will shade how the lawsuit is viewed by the courts. They also believe that they can get the case before the U.S. Supreme Court before major features, such as the individual mandate, become effective in 2014. They believe that helps their cause because there will be less of the law to undo.

Barnett concedes that the Supreme Court usually bends over backwards to uphold laws of Congress. But if the law turns out to be highly unpopular, he thinks the high court will be open to “valid constitutional objections.”

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Michael Rhoads seems just the sort of person who would benefit from health care overhaul legislation.

He and his wife, working parents of two children, lack health insurance, which they say they cannot afford. At the same time, the combined annual earnings of this southwest Philadelphia family are such that they do not qualify for Medicaid, the state-federal health insurance program for the poor.

Congress is seeking to bridge the gap they face. But Rhoads says the likely cost of the solution would still be beyond his family’s budget.

“Health care for everyone – that sounds wonderful,” says the 35-year-old, an outreach coordinator for a low-income community health clinic. “In reality, when it comes down to it, it is another big bill that just doesn’t fit.”

His is a dilemma that faces many of the millions of Americans who are intended beneficiaries of the overhaul: they make too little, and yet too much, to capitalize on the legislation’s signature features.

In an effort to reduce the ranks of the uninsured, Congress is proposing to expand Medicaid for the poorest Americans, and to provide subsidies to millions of others to help buy private coverage. But a sizeable number of those who would qualify for subsidies–especially people who would be right above the Medicaid cutoff–could still find health care unaffordable; premiums and out-of-pocket costs like deductibles and co-pays could add up to hundreds or thousands of dollars a year.

Those who miss the cut for Medicaid face sharply higher costs in a private insurance plan. “You have a very steep cliff,” says Judith Solomon, a senior fellow at the Center on Budget and Policy Priorities in Washington. Many might have to choose between insurance and necessities like rent and food, say experts such as Richard Curtis, president of the Institute for Health Policy Solutions in Washington.

“These are not people with discretionary income,” says Curtis. “Asking them to pay any substantial share (of insurance costs) I worry about that.”

To be sure, millions of vulnerable Americans would get a safety net if legislation now headed to House-Senate negotiations becomes law. Both chambers of Congress are proposing to raise the income limits for Medicaid, and to include adults without children for the first time. Those moves alone would add 9.5 million childless adults to the program under the Senate bill.

But a large chunk of the uninsured population would just miss the Medicaid expansion. According to the Kaiser Family Foundation, 7.2 million adults earning less than twice the federal poverty level — about $21,000 for an individual and $44,000 for a family of four — would earn too much to qualify for the expanded Medicaid envisioned by the Senate. Millions more have incomes slightly above that level. (KHN is a part of the foundation.)

At the core of the overhaul is a requirement that most individuals and families obtain health insurance or else risk a federal fine. Under the Senate bill, that penalty would reach as much as $750 per person, or 2 percent of household income, whichever is greater, although there would be a “hardship” exemption in cases where the cost of premiums totaled 8 percent or more of income.

In general, employees would have to purchase the insurance offered at their work, assuming it meets certain minimum standards. A series of “exchanges” – private marketplaces regulated by the government – would be set up to offer coverage to people without insurance or to those whose insurance at work is expensive. Some small businesses would also be given access to purchase insurance for their employees.

People earning up to four times the poverty level – about $43,000 for an individual and $88,000 for a family of four — would receive federal subsidies to help them buy policies on the exchanges. The subsidies would operate on a sliding scale that would require those at the upper end to pay a larger share of their income to get coverage, although even those at the lower end would have to foot some of the costs.

Source: Kaiser Commission on Medicaid and The Uninsured using U.S. Census data.
(click to enlarge)

Georgetown University’s Center for Children and Families assessed the prospects for several Philadelphia-area families under the overhaul based on their current earnings and insurance status. The analysis is pegged to the Senate bill, which most political analysts consider the likely blueprint for any final health legislation that Congress approves.

The families examined for this article most likely would qualify for the exemption – and if they chose to take advantage of it, would be left in the same place they are now: without health insurance.

Rhoads and his wife have been uninsured for most of their adult lives. They live along the Woodland Avenue corridor, one of the city’s toughest areas, with above average crime and joblessness. And they never seem to have enough money to pay their bills, much less to buy health insurance.

They go to the doctor only when they are so sick that they cannot work. Over the years, Rhoads’ wife, 32, who asked that her name not be used to maintain her privacy, has incurred large unpaid emergency room bills. Recently, she developed a case of the H1N1 virus and sought treatment at a medical clinic called the where Rhoads works part-time, trolling for clients at homeless shelters and food kitchens.

“I’m trying to feed my kids. I’m not thinking about paying medical bills,” she says, through a surgical mask. The couple has two daughters, 13 and 15. Both receive free care under a program for children in low-income families known as the Children’s Health Insurance Program, which would continue to operate under the Senate – but not the House – overhaul legislation. Their household income is about $40,000 a year; she is currently the main bread winner, working as a certified aide at a nursing home.

Her employer offers health insurance, but to cover the two of them, even the cheapest option would cost about $350 a month, which they say they cannot afford. The cost is high enough to make them eligible for a government subsidy to purchase insurance through one of the new exchanges. Under the Senate bill, however, they would also be expected to contribute about $200 a month toward the cost of the premiums, or about 5.8 percent of their income. Co-payments and deductibles would likely add several hundred dollars more to their annual health care bill.

Rhoads says the benefit is nice but still unaffordable. His wife says she does not understand a system in which she would have to set aside part of her paycheck to cover insurance premiums, and then have to pay again, to cover deductibles and other shared costs, whenever she visits the doctor. “You know, I feel like that is where you are ripping me off,” she says.

Danielle Simmons, a medical assistant and student at the Community College of Philadelphia who is also uninsured, could be in more perilous shape. Under the Senate bill, Simmons, who says she earns about $36,000 a year, would have to pay about 8.1 percent of her income, or about $246 a month, for her share of premiums on a government-subsidized insurance policy.

A single parent, Simmons, 23, says she already has more bills than she can handle. She pays $840 a month for her five-year-old to attend a Christian pre-school program. (Like the Rhoads’ children, her daughter qualifies for CHIP.) The heating oil bill for the house she shares with her sister is expected to hit $4,000 this winter. She has $15,000 in unpaid student loans.

Adding another expense, even to cover health insurance, she says, “would not be on my radar.” Instead, she tries to keep on top of her health using her medical knowledge and self-discipline. Diagnosed with lupus, an auto-immune disorder, Simmons says keeps her condition under control through careful diet. She also is zealous about hygiene and prays a lot.

The potential gaps in coverage underscore how budget considerations have been driving the debate in Washington. While they want to cover as many people as possible, lawmakers are also trying to keep the tab below $900 billion over a decade, a marker set by President Barack Obama.

The Senate bill would cost less – and be less generous — than the House measure. Affordability looms as a major issue for the two chambers to negotiate. As it stands, the Senate would expand Medicaid to include people earning up to 133 percent of the federal poverty level, currently about $33,000 for a family of four; the House would raise the ceiling to 150 percent. The Senate bill is also much less munificent when it comes to subsidies. A by the Urban Institute this month found that the poorest and sickest families qualifying for subsidies under the Senate bill could end up having to pay as much as 13.4 percent of their income on health care costs – nearly double the 7.6 percent they would pay under the House version.

Mahawah Sillah owes $20,000 for emergency-room care. There is a backlog for state health aid, she can’t afford insurance offered by her employer, and federal changes are unlikely to help. (Laurence Kesterson/Philadelphia Inquirer)

To cushion the blow, the Senate would help individual states set up basic health plans for low-income individuals and families who don’t qualify for the expanded Medicaid. How well those programs might work is far from clear. A comparable idea already in place in Pennsylvania, known as , has seven times more applicants than enrollees because of funding shortfalls related to the state budget crisis.

Mahawah Sillah, a diet technician at a Philadelphia hospital, who has diabetes and hypertension, is one of those waiting for help. She earns about $41,000 a year, and has three children. Her earnings are about 185 percent of the poverty level; in theory that makes her eligible for the basic health assistance from the state but she is stuck in the backlog. Her children are covered by the CHIP program.

She also appears unlikely to gain much from the pending overhaul legislation. She makes too much money to qualify for the planned Medicaid expansion. With monthly mortgage and child-care payments, and thousands in legal bills for her husband’s immigration problems, she says she can’t afford the insurance offered by her employer.

The Senate bill would require her employer to kick in some money to help her buy insurance. But she would still face about $200 a month for premiums – about double what she says she can currently handle.

A few months ago, Sillah, 40, landed in the emergency room, after a fall that was related to her high-blood pressure, and incurred a $20,000 bill, which she says she cannot pay. Lately, she has been hearing from bill collectors, who want to know when she is going to start paying off the debt. Her prescription for dealing with her own personal health care crisis: “I screen my calls,” she says.  

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When it comes to political, social or health causes, elder abuse has not had the star power of some other movements focusing on the rights of vulnerable people.

Last month, actress Nicole Kidman headlined a congressional hearing on violence against women, and stars of “Law & Order: Special Victims Unit” appeared at a Capitol Hill rally for child-abuse victims. An event sponsored by a coalition of elder abuse groups, meanwhile, featured ordinary senior citizens, recounting in sometimes aching detail how they or their loved ones had been physically and emotionally abused or financially exploited.

The lack of glitter has been reflected over the years in federal support for protecting seniors — which is to say, support has been limited. That may be about to change. As part of health care overhaul legislation, lawmakers are taking steps that would for the first time establish a federal beachhead in fighting elder abuse.

The health care bill would launch a nationwide program of background checks for people who care for the elderly, overhauling a patchwork of state laws that critics say has allowed known offenders to repeatedly end up in positions of trust.

The Senate is considering an even more expansive . It would boost federal aid for identifying and investigating elder abuse at the state and local levels, require long-term care providers to report possible crimes to federal authorities and create new oversight within the Department of Health and Human Services for coordinating state and federal anti-abuse efforts. These provisions, already approved by the Senate Finance Committee, are included in the health legislation that is being prepared for floor debate after Thanksgiving.

With broad support in and out of Congress, at least some of the measures appear to have good prospects for being enacted into law. More than 500 advocacy groups have lined up behind the legislation. It still faces opposition on budget grounds, although proponents say the cost of the Elder Justice Act — about $757 million over four years — is pocket change in the context of a near $1-trillion healthcare bill.

Abuse Victims Face More Risk Of Dying

About 11% of people ages 60 and older suffer from some kind of abuse every year, according to a March study for the , an arm of the Justice Department. Other studies have shown that elderly victims of abuse, neglect and exploitation have twice the risk of dying within a year.

of such abuse abounds. A home aide working near Fresno was convicted of involuntary manslaughter last year after giving an 85-year-old woman a lethal overdose of morphine and methadone and ransacking her house. The caregiver had a history of domestic assaults and drug smuggling.

Last month, a postal worker in San Diego pleaded guilty to one count of felony financial elder abuse after taking more than $50,000 from elderly women on her delivery route. “She was using the economy to pour excuses on herself and borrow money,” said Paul Greenwood, an assistant district attorney. “We found out she was spending a lot of the money in the casinos.”

Financial exploitation of the elderly costs as much as $2.6 billion a year. The problem was highlighted with the October conviction of the son of New York philanthropist Brooke Astor for stealing tens of millions of dollars from his mother while she was suffering from Alzheimer’s disease. But advocates for the elderly say such abuse occurs on a lesser scale much more frequently.

Enhancing the rights of the elderly might seem a no-brainer for lawmakers on both sides of the aisle. After all, people older than 55 constitute the fastest-growing population group in the country. Congress is even aging: The average age of a House member is now 56 years, and for a senator, 61.7 years.

But opponents say they are concerned about runaway federal spending and stepping on the toes of state and local governments. The Elder Justice legislation, first introduced in 2002, was opposed by the Bush administration, which felt it would create a new and unnecessary federal bureaucracy.

Others question the expense and efficacy of background checks when even proponents acknowledge that most abuse is perpetrated by people who are already well-known to the victims. Until last year, the background-check bill, first introduced in the Senate in 1997 by Democrat Herb Kohl of Wisconsin, had never made it out of committee.

Still, opposing such measures can be politically tricky. “Why do you want to beat up old people?” Stephen Colbert demanded in an interview with Republican Rep. Cynthia Lummis of Wyoming on his Comedy Central show “The Colbert Report” in March. Lummis voted against legislation earlier this year that would have made federal money available to state and local elder-abuse prosecutors. She told Colbert, “I am opposed to irresponsible spending.”

“So you want us to beat up old people in a fiscally responsible manner?” he shot back.

Now backers of the legislation have maneuvered to link its fate to the debate over healthcare reform, in which it has become an important consideration for some centrist Democrats, such as Sen. Blanche Lincoln of Arkansas, who is considered a crucial swing vote on healthcare legislation. Lincoln, a longtime member of the Senate Special Committee on Aging, is a co-sponsor of the Elder Justice Act. (The median age of her constituents back home is also one of the highest in the nation.)

Supporters say elder abuse should be addressed in healthcare overhaul legislation because it pushes up healthcare costs and because financial exploitation of the elderly leaves many destitute and reliant on public assistance.

“This is prevention, which is a healthcare issue,” says Robert Blancato, who heads the , an umbrella group for more than 500 groups that support the legislation. They include AARP, the American Bar Assn., and industry groups representing nursing homes and long-term providers, among others.

State and local governments have long been on the front lines of such problems. But many studies have shown a shortage of resources among licensing agencies, long-term-care ombudsmen and adult protective service workers.

“The universal lack of resources, the enormous variation across jurisdictions and the low priority given to elder abuse and neglect make it difficult to see how significant progress can be made without federal standards and financial support,” concluded researchers at Texas A&M University in a report prepared for the Justice Department last month.

Worker Screening

The current health care bills would require states to conduct comprehensive screening of a wide range of people who are working with the elderly, including those in the burgeoning and unregulated area of home-based care.

More than a dozen states, including California and Florida, currently do not regulate those workers. Most states only check the backgrounds of medical workers, such as nurse aides, and only for crimes they committed in their own states. In 2006, a woman who had been convicted in Kansas of pushing an elderly woman out of a vehicle in a carjacking was discovered to be working in nursing homes in Missouri.

The legislation also would require states to establish clear criteria for prohibiting employment of applicants with a history of violent crime. It also would mandate the development of appeals processes for individuals who are denied employment, plus systems in which workers who have been checked and cleared, but who subsequently commit a disqualifying crime, would be terminated.

Even proponents of the new federal standards say they can go only so far. Studies show that most elder abuse takes place in private homes and that the assailants are family members or trusted advisors, in up to 90% of cases.

The challenges increase as more elderly people spend their time at home or in community and group living arrangements. By comparison, teachers and other professionals outside the home act as a safety net in cases of suspected child abuse because they are required to report evidence of abuse to authorities.

“Adult abuse is a lot harder to get your arms around,” says Marsha Greenfield, a lawyer and senior legislative counsel for the American Assn. of Homes & Services for the Aging, a trade group for nonprofit long-term care providers.

“There are many more elderly people both in community and group living arrangements,” Greenfield says. “But they are also a more invisible population because there are so many people in their own homes.”

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Laid off from her marketing job at a managed-care company late last year, Trueman was able to keep her health insurance thanks to a provision in the federal stimulus bill that gave furloughed workers the right to purchase their old employer-based coverage at a 65% discount.  The subsidies, which last up to nine months, were designed to give workers like Trueman time to get back on their feet.

Today, with the job market weak, Trueman is still without a job, and her family is bracing for an uncertain future. With the subsidies, she and her husband, a self-employed attorney were paying a manageable $460 a month for their health insurance; starting Dec. 1, the cost jumps to $1,313.   They can ill afford the increase.  They’re already having trouble making their mortgage payment, and fear they might lose their Northern Virginia home.

“It has really made a huge difference for us,” she says of the insurance assistance, adding that the higher payment “would be a real stretch.” 

Since 1985, a law known as COBRA has given laid off-workers the right to hold onto their employer-based health insurance for up to 18 months so long as they continue to pay the premiums, including payments that their employers used to make on their behalf.

About COBRA Subsidies

The stimulus package President Obama signed into law in February includes subsidies allowing laid-off workers to retain employer-provided group health insurance coverage at a discount.

How much?
Eligible individuals pay only 35 percent of the normal premiums. The remaining 65 percent is paid by the employer, which is reimbursed by the government through a payroll tax credit.

How long does it last?
Nine months.

Who qualifies?
Employees who are involuntarily terminated from Sept. 1, 2008, through Dec. 31, 2009, and who are eligible for continued coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Individuals whose annual adjusted gross income exceeds $145,000 ($290,000 for joint filers) are not eligible.

What kind of coverage?
Employers must provide the same benefits as in your old group plan, although they can offer other plans as well.

How do I apply?
Your employer or its representative is required to give you notice that you may be eligible. You also have to attest in writing that you meet certain criteria. You will have 60 days after receiving the notice to make a decision whether to participate.

What if I have other insurance?
If you are eligible for other group health coverage (e.g., through a new employer’s plan, a spouse’s plan or through Medicare), you are not eligible for the premium reduction.

How can I get more information?
The and the  have special Web pages with additional details.

In the past very few people could afford this option, but the government subsidies have changed that, and now enrollments appear to be growing sharply. Hewitt Associates, a Lincolnshire, Ill., consulting firm, that the rate at which workers were opting for coverage under COBRA had doubled compared with pre-subsidy levels.

Although federal officials do not have figures on the number of people participating in the program, millions have been eligible. The law covers anyone laid off between Sept. 1 of last year and Dec. 31 of this year.

But with the first discounts having gone into effect March 1, many people are about to see the benefit expire, including many who remain unemployed. The Obama administration and some members of Congress are talking about  whether to extend the subsidy.  Some lawmakers aren’t enthused because of budget concerns, but backers say the subsidy is a crucial lifeline for people still hunting for jobs.

Just this week, Rep. Joe Sestak, D-Penn., introduced legislation that would extend from 9 to 15 months the total allowable time an unemployed worker and her family could receive the subsidized COBRA assistance. The legislation would also extend the subsidies to people laid off through June 30, 2010, widening the window of eligibility by six months. A third provision would give an extra six months of undiscounted COBRA coverage to people who were laid off early in 2008 before the subsidy law took effect.

“Federal subsidies for COBRA premiums are making insurance more affordable for millions of unemployed individuals and their families,” says Rep. Nita Lowey, a New York Democrat. “This is not the time for those who have lost their jobs to have to worry about an impending drastic increase in their health insurance costs. Congress should extend these subsidies so the number of uninsured does not grow even further.”

For now, the aid is helping a broad cross section of people with widely varying health and financial situations — from newly minted MBAs to older workers forced out of their jobs after exhausting their disability leave, among other reasons.

A that tracks news and personal experiences with the subsidy has garnered scores of followers. 

Out-of-work professionals are for the Wall Street Journal. 

“I can only be grateful that I am safeguarded by COBRA,” writes a furloughed operations manager at Bank of America, “and hope that I am employed and eligible for medical insurance through my new employer before my COBRA term ends.”

Close to home

My own family got seven months of discounted coverage out of the program after I lost my job as a newspaper reporter last year. The savings: a cool $6,000.  While I am still looking for permanent work, my wife was recently able to find a job with benefits.  (The discounts end when you become eligible for other insurance, either directly or through your spouse.)

Rick Schmitt and his family.

People in the same boat seem to be everywhere. The firm my former company hired to administer the discount program was so flooded with work that it ended up hiring temporary workers – including one that I spoke with who had herself been recently laid off and was looking to take advantage of the subsidy.

But in many cases, the subsidies are, at best, only temporarily easing the stresses facing employees who have been laid off.

A by the American Cancer Society and the Kaiser Family Foundation found that many chronically ill people could not even afford the subsidized premiums. (KHN is a program of the foundation.) Once the full COBRA premiums are reinstated, the study found, many cancer patients face becoming uninsured or forgoing needed treatments.

Indeed, people who become eligible for COBRA are generally older and sicker than the rest of the work force, and have fewer insurance options when they lose their jobs.

You can try to purchase insurance on your own, although that is generally more expensive than an employer-sponsored plan and often comes with limits on basic coverage such as maternity care or prescription drugs.   Some – but not all — states provide a backstop in the form of “high-risk pools” that offer insurance to people who can’t get coverage elsewhere because of their medical history. 

Dale Gardner, who lost his job at a high-technology firm in Virginia last November, says the subsidies have been welcome. 

At the same time, he says that he has been able to replace much of his lost income as a consultant, and that he would not mind paying full freight so long as he can keep his coverage under COBRA.  What worries him the most, he says, is that he won’t be able to find a job with benefits before his right to coverage under an even un-subsidized COBRA expires in 2010.

“Because of our health history,” he says, “coverage for my wife and I is going to be difficult to find at any price.” He says his wife has arthritis and one of his sons has asthma.

“I count myself as fortunate,” he adds. “I have been able to maintain coverage despite the fact that my family has health problems. (But) there are a lot of people who cannot even get that who have worse health problems.”

Some experts say those problems point up the need for broader-based reform of the health-care system.  The subsidies have been “a valuable first step” helping people in need keep their insurance, says Karyn Schwartz, a health-policy analyst at the Kaiser Family Foundation.  “Providing security for all of those who need health insurance will require more comprehensive reform,” Schwartz adds.

Trueman, 51, was laid off in December 2008, after working a year at a unit of UnitedHealth Group that provides managed care for Medicaid enrollees in 20 states.  Before that, she was the executive director of the Coalition for Affordable Health Coverage, a Washington-based industry advocacy group. 

With her background in health policy, she figured getting a new job would be “relatively quick and painless.” But that has not been the case. “I have had a lot of interviews,” she says, “but just clinching the right one has not happened.”

Down the road, she worries most about a son in college who has a chronic health condition that requires medication. That could make it hard for the whole family to find insurance in the private market. Another problem is that her home state of Virginia is one that does not have a public program for “high-risk” individuals. 

Seeking to exhaust all options, she has lately been reading up on how some drug companies give discounts to the poor or uninsured, to see if her son might qualify.

Come December, when the COBRA discounts expire, “I don’t really know what we will do,” Trueman says. “I hope we have a job by then that has health insurance.”

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Nurses rally in Washington on May 13th to demand better conditions for nurses as well as comprehensive health reform (Chris Zimmer-KHN).

The YouTube video shows Donna Smith pulling on a white hazmat suit and protective rubber gloves. She is going to work, trying to clean up the nation’s health insurance industry.

With a bullhorn in one hand, and a picket sign in the other, she leads a group of a dozen or so activists, similarly attired, marching outside a Chicago hotel on a windy morning last fall.

The “Health Care Hazard Cleanup Team” has come to protest an industry it sees as toxic to the health of Americans. Today’s target is an insurance company trade group that is holding a meeting inside.

“Hey, Hey, Ho, Ho,” a chorus erupts. “Private insurance has got to go.”

Smith is a cancer survivor whose personal experience with insurance has driven her to lead rallies like this one. She is a foot soldier in the battle over health care, and hers is the most radical prescription for reform.

The idea, which advocates call “single payer,” would replace private insurers with a single, tax-funded government program. They envision a system in which every American would be guaranteed coverage, regardless of ability to pay or medical history, and all patients would be free to pick their doctors.

But despite its appeal to many, single payer, as an option in the current debate in Washington, is DOA. More advocates have been arrested on Capitol Hill than have testified at congressional hearings. President Obama, who years ago said he supported the idea of single-payer, now favors bolstering the existing employer-based insurance system.

Related Video

Leading The Single Payer Movement

Without a seat at the bargaining table, single-payer proponents are still looking to influence the process, if only to raise red flags about proposals they say would make the current system worse. The Leadership Conference for Guaranteed Health Care, a coalition of single-payer advocacy groups, is planning a major rally in Washington on July 30 in an effort to demonstrate the widespread support they say their cause has garnered. The event coincides with the 44th anniversary of the enactment of Medicare, the federal health program for the elderly, which single-payer supporters consider a model for extending insurance to all citizens.

Some die-hards think that Congress may still turn to a single-payer plan in the event other proposals unravel. Ultimately, they believe they will prevail, because, they say, it is the only plan that expands coverage to the 46 million Americans without insurance while putting a lid on spiraling costs.

“It is really unethical for us to settle for or put forth a placebo which we know is not going to be successful in curing the disease,” says DeAnn McEwen, an intensive-care nurse in Long Beach, Calif., and a member of the California Nurses Association, a politically powerful union that supports single payer. “You just can’t compromise your principles.”

“I am not discouraged,” adds Quentin Young, national coordinator for Physicians for a National Health Program, a group of 16,000 doctors who support single-payer. “It is going to happen because we cannot afford not to do it.”

Most political experts say a single-payer plan is not feasible in the current environment. Public ambivalence about the role of government combined with the upheaval that would result from dismantling the current insurance system make radical change highly unlikely, they say. In addition, there would be strong opposition from congressional conservatives who vigorously dispute the rosy picture of single-payer benefits described by advocates.

The decision not to consider a single-payer scheme “speaks to the pragmatism not just of the Obama administration but the Democratic leadership in the House and the Senate,” says Jonathan Oberlander, a health policy expert who is now a visiting scholar at the Russell Sage Foundation in New York City. For them, a single-payer plan “would be too controversial,” especially when they’re trying to reassure anxious Americans that they can keep their existing insurance if they like it.

But for proponents, the failure of a single-payer proposal to advance shows the grip that the health care lobby has on the political process in Washington. At best, in their view, current options on the table amount to tinkering with a failed system; at worst, they further empower an already entrenched insurance industry.

Rep. John Conyers Jr., D-Mich, who has sponsored a single-payer bill, says the year-end deadline set by the White House for enacting reform legislation has made it even harder for proponents to make their case. He says he hopes to insert wording in any final bill that would make it easier for states to set up their own single-payer plans.

Some single-payer advocates, knowing their plan is dead, want Congress to include a government-run insurance option as part of overhauling the health system. Others, says Oberlander, fear it would “hurt the cause of single payer” partly because it “would defuse pressure for change.”

Passionate, if quixotic, the campaign for single-payer has a wide cross-section of supporters: There are nurses and doctors who say they are tired of seeing their patients denied care for lack of insurance; health-policy experts such as Marcia Angell, the former editor of the New England Journal of Medicine, and several dozen members of Congress who have lined up behind Conyers’ bill.

There also are frustrated ordinary citizens looking to make a statement. A newsletter publisher in West Virginia had his wife, a belly dancer, perform at a rally this spring to bring attention to the cause.

There is even a single-payer rap song. Sample lyric: “Come from the land of milk and honey, insurance companies are addicted to money.”

Smith, 54, may seem an unlikely candidate to lead an attack on the health-care status quo. She grew up in suburban Chicago in what she describes as “a very Republican family.” Her father was a pharmaceutical salesman. Her mother campaigned for Donald Rumsfeld when he was a congressman from suburban Illinois.

(Chris Zimmer-KHN)

Like many other single-payer supporters, though, she comes to the fight seeing herself as a victim of the insurance system.

She and her husband landed in bankruptcy court, she says, snowed under by bills when he had a series of heart attacks and she developed uterine cancer. She was a newspaper editor in South Dakota; he was a machinist. Besides jobs, they had plenty of health insurance, or so they thought.

She became a full-throated single-payer advocate after she and her husband were featured in “SiCKO,” the 2007 Michael Moore film about the health care crisis.

Attending the New York premiere, she ran into a busload of nurses who saw the event as a vehicle for promoting a single-payer plan. The nurses persuaded the Smiths to come along on a road trip to other cities where the film was being released.

“Seeing the intensity of purpose the nurses showed for the issue was eye-opening,” she says. She began speaking to groups around the country about her film role and her personal experience, and even testified before Congress. The California nurses made her an organizer and legislative advocate in their Washington office.

A single-payer system, Smith says, is an elegantly simple solution.

Private insurance and federal programs such as Medicare and Medicaid would be rolled into a single national health program. People would pay taxes instead of premiums to finance the system.

Millions of middle-class families would see the cost of health-care decline, supporters contend. As with some other proposals Congress is considering, the rich would pay more. Billions of dollars in administrative costs and executive salaries would be saved by eliminating the tangle of for-profit insurers. Those savings, the thinking goes, would be large enough to cover most if not all of the nation’s uninsured.

But that is a provocative thesis. Some health-care experts say those savings are vastly over-stated, and that single-payer advocates don’t have a plan for dealing with rapidly rising health-care costs that are at the root of the crisis. “It is nonsense, absolute nonsense,” says Stuart H. Altman, professor of national health policy at Brandeis University. “The reason health care costs are high is that we spend a lot of money on health care. It is not all on the insurance side.”

Critics of single-payer plans say they would concentrate too much power in government, including decisions on which treatments qualify for funding. And as taxpayer-funded programs, opponents argue, they’d face budget-cutting pressure that could lead to rationing of care.

Robert Book, a senior research fellow at the Heritage Foundation, puts it more strongly. He wrote in an April issue brief that a “single payer system” would inevitably result in lower payments for physicians and other health care providers, which ultimately would lead to “reduced access and lower quality health care for future generations” of Americans.

Countries with national health programs, says Uwe Reinhardt, a health policy expert at Princeton University, have tended to short-change them. “There is a tendency to under-fund them,” he says, “and so care ends up falling short of the ideal.”

Smith concedes that single-payer may not be perfect but she says it is far superior to any other proposal out there. She is a relentless and ubiquitous promoter of the cause – blogger, street activist and talking head. You can see her on YouTube donning her hazmat outfit or being interviewed about single payer by Bill Moyers on PBS.

She has helped produce a series of videos aimed at dramatizing aspects of the health care debate. She appears in one video speaking from downtown Chicago in the shadow of the Blue Cross Blue Shield headquarters. The building is getting a major facelift.

“In a single payer system you won’t see waste like this,” she says in the video. “We won’t need to build massive structures that keep the for-profit engine going.”

Smith says she has spoken in 42 states and the District of Columbia about the virtues of single-payer. In a regular column on the Internet, she has compared the damage caused by the health insurance industry to the Holocaust. She signs her posts: “Donna Smith, American SiCKO.”

Her overarching message is that people who are responsible and financially secure can be wiped out when a health crisis hits. “I did everything I was taught to do as a middle class person,” she says. “I was educated, worked hard, raised my kids Yet when illness hit that was not enough.”

Smith says she is now cancer free. She also has insurance through the nurses’ union. Her husband, who has Medicare through a private plan, is having continuing health problems, and is wrestling again with his insurer.

She admits she is frustrated with the way Congress has dismissed what she views as the most just and noble option for reform.

“Women’s suffrage was not easy. The civil rights struggle was not easy. This one is not going to be easy, and it is probably not going to be won right now,” she says.

“But I still have tremendous hope,” she adds. Ultimately, she says, paraphrasing words of Martin Luther King Jr., “the long arc of history bends toward justice.”

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This story is a collaboration between Kaiser Health News and .

Laid off last fall and left to find $1,400 a month for continued family health coverage, I felt as if I’d struck pay dirt when I learned in February that Congress had decided to spend billions helping millions of Americans like me retain our insurance.

The promise of a 65 percent subsidy on the premium looked like my own piece of bailout heaven. But nearly two months later, we’re still waiting for our lifeline.

Some of us have continued ponying up large premiums on the promise that we will get refunds down the road. We’re now hearing that, in some cases, the discounts may not fully kick in until this summer, and even then they may not be steep enough to make insurance affordable for many of the jobless.

Considering the way the government poured billions into the banks and insurers such as AIG that got us into this mess, the handling of the health-care subsidies smacks of a double standard for us ordinary Joes.

The biggest beneficiaries so far seem to be health-care lawyers and consultants who are busy selling advice on how the whole thing is supposed to work. It took a month for the government to come up with guidance on implementing the subsidies. Employers and the firms they hire to manage benefits now face the time-consuming job of identifying people who might be eligible.

With health-care reform high on the agenda of the Obama Administration, the situation offers a glimpse of the difficulties in pushing through any changes in the nation’s health-care system. Given the thousands of different plans, experts say delays are inevitable under even the best of circumstances.

“There are lots and lots of pieces that could break down,” said Karen Pollitz, director of Georgetown University’s Health Policy Institute.

“This is not idiot-proof.”

The subsidies, aimed at helping people keep their employer-provided group health coverage, look to be a good deal. The government is picking up about two-thirds of the cost. The subsidies are tax-free and last for nine months.

Employees have long had the right to continue their group health coverage under a law commonly known as COBRA. But the cost – 102 percent of the full price of the policy – has been beyond the reach of most people.

After I got laid off, I learned I would have to pay $1,403.90 a month to keep my old coverage, roughly the equivalent of what I receive in unemployment benefits from the District.

As much of a budget-buster as that was, our family had few options. My wife, a preschool teacher at our church, does not have health insurance among her job benefits. Because of some health issues – one member of the family has a history of depression, another has residual injuries from a head-on auto accident – the cost of obtaining insurance elsewhere would be prohibitive, experts tell me.

Which is why the stimulus package made me feel like I had won the lottery. As luck would have it, my Nov. 14 layoff date put me squarely within the period Congress set for “Assistance Eligible Individuals.”

Last month, I cut a check for the full amount of COBRA premiums due for part of February and all of March. (My old company paid the cost through mid-February under a severance agreement.)

Knowing a bit about the law, I expected soon to be receiving refunds for my overpayments, followed in later months by bills that reflected the discounts Congress intended. Instead, what I got was a notice from the Minneapolis company my employer has hired to administer the program, indicating that something was up: It mentioned “New COBRA information” and “ARRA 2009” (the acronym for the stimulus law) and said more information would be headed my way soon. It also said I had to fork over another $1,403.90 premium for April or my coverage could be canceled.

I reached out to the Labor Department, subscribing to e-mailed updates about the program. I have learned about bilingual fact sheets, checked out an array of informational posters and flyers and seen a statement from Labor Secretary Hilda Solis. But some basic facts have been hard to come by.

Reading the text of the stimulus law, I discovered that employers have 60 days to cough up refunds or credits to people who paid more than 35 percent of their premiums after the law was enacted.

I also learned, by listening to a two-hour “compliance briefing,” now posted on the Labor Department’s Web site, that the government believes that people like me who had already elected COBRA were legally entitled to the 35 percent rate without further delay. An official suggested people in my position approach our employers.

I asked about this in an e-mail to the Minneapolis firm.

“We are currently working with the Department of Labor and our affiliates,” a customer service representative wrote back. “If you qualify [for the subsidy] you will be re-notified and will have the opportunity to elect COBRA under the new subsidy. Please wait for official correspondence.”

I’m hoping to get that official correspondence sooner rather than later.

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This story was produced in collaboration with the 

OAKLAND, Calif. – Like thousands of people who leave prison every year in California, Stanley Riley has serious health problems and no money for treatment.

Parolee Stanley Riley, right, greets fellow parolee Anwar Fuller on San Pablo Avenue in downtown Oakland, Calif., on Thursday, March 17, 2011. Riley has high blood pressure and diabetes, and since being released from prison after 13 years has had trouble getting access to health care. (Jane Tyska/Bay Area News Group)

During his 13 years of incarceration for robbery and an assortment of drug crimes, he could count on getting medication for high blood pressure and diabetes. But when he was released in 2008, all he got was a standard issue three-month supply.

“That scares you,” Riley, 54, says. “They already knew I was going to have a problem. They already knew it was not going to be that easy.”

Now help is on the way. In coming months, local governments in California stand to gain tens of millions of dollars in federal funds to care for the indigent, including ex-offenders.

Alameda and Contra Costa counties expect substantial assistance. Santa Clara and San Mateo counties also hope to qualify. State officials estimate 500,000 people without health insurance will benefit, beginning as early as June.

Expanded indigent-care is expected to help many of the 130,000 former inmates discharged every year in the state, as well as the mainly impoverished communities where they move upon release. The newly freed arrive home in neighborhoods in Oakland and Hayward, Richmond and Antioch, bringing high rates of chronic and communicable disease and serious mental illness.

The federal aid results from an agreement that state officials negotiated with the Obama administration to get early access to funds under the health care overhaul law. Officials in Alameda County say they could receive an extra $35 million a year on top of the roughly $100 million the county spends annually on indigent care. While details have yet to be fully worked out, they intend to spend a chunk of the new money on the formerly incarcerated.

“The reentry population is a perfect target,” says Alex Briscoe, director of the .

The initiative is seen as a bridge to 2014, when the health law sets in motion a massive expansion of Medicaid, the federal-state program for the poor that in California is called Medi-Cal. Among others, low-income single adults will qualify for Medicaid for the first time – a major policy change that would help ex-offenders who struggle to find jobs and health insurance.

The boost in federal funding couldn’t come at a better time. Many programs that provide services to former inmates are underfunded – and could see an explosion in demand: Tens of thousands of inmates may be released if the U.S. Supreme Court this year upholds a lower-court decision to .

Oakland and other communities had taken steps in recent years to address the health needs of former inmates. Alameda County pours $1 million annually into the nonprofit Healthy Oakland clinic on San Pablo Avenue to help a few thousand each year. But that was barely scratching the surface, with many thousands more going without care.

The East Bay is home to some of the highest concentrations of ex-offenders in the state. About 6,500 people, or 5 percent of the 130,000 released every year from state prisons, are paroled to Alameda County.

“We have an opportunity to say, ‘This is not working, and in one of the most progressive counties in America, we will do business differently,'” says Raymond Lankford, executive director of Healthy Oakland, and pastor of the Voices of Hope Community Church. Nonprofits like his would likely benefit from the new federal money.

Parolee Stanley Riley is photographed on San Pablo Avenue in downtown Oakland, Calif., on Thursday, March 17, 2011. Federal funds are expected to be coming to the state to assist with indigent health care. (Jane Tyska/Bay Area News Group)

Stanley Riley is an example of how the system can work differently. His story also shows how much time, resources, personal attention and commitment are required.

Healthy Oakland intervened soon after his release from prison in 2008. A representative visited a drug treatment center where Riley, a recovering heroin addict, was living, and offered everyone there $25 if they would drop by the clinic.

Riley took the money – and soon also got the diabetes medicine he needed.

Today, one of his most important supporters is another former inmate and heroin addict, William Grajeda, co-founder of a West Oakland nonprofit called The Gamble Institute that helps former inmates return to the community.

Grajeda, a pastoral counselor certified in helping people with a history of drug and alcohol abuse, runs a kind of ministry on wheels, putting a thousand miles a week on his Toyota. He has taken Riley to church, helped him register for classes at Merritt College, and after a recent relapse, got him enrolled in a detox program to avoid a parole violation that would return him to prison.

“Going to college? Me? Come on!” Riley says in disbelief of his own good fortune. “I got positive people in my life now. I got somewhere to go when I wake up in the morning.”

Not all former inmates are so committed or supported. They’re often apathetic about their health, studies have shown, even when they have serious disease.

High Infection Rates

Authorities at the Santa Rita Jail have long seen repeat offenders with HIV returning in much poorer health than when they left – even though AIDS drugs and support are widely available at community clinics.

Rates of hepatitis C infection in Alameda County are so high among long-term injection drug users that relatively few bother to get tested or seek treatment. “The attitude is, ‘Everybody has it so who gives a (darn)?'” says Dr. Diana Sylvestre, an internist in West Oakland, who has seen 3,000 people with hepatitis C over the past decade, many of them .

Former inmates often are key players in the efforts of counties to expand indigent care. Half the 40-person staff at Healthy Oakland has seen the inside of a prison or jail including several who do community outreach and recruit at weekly meetings at the county parole department. They include Shawn Vasquez, a one-time drug dealer nicknamed “The Boss Man” who used to hold forth from the Heartbreak residential hotel on San Pablo at the peak of the crack cocaine epidemic in the 1990s.

Williams

Another is Donald Williams, Lankford’s brother who ended up in prison, off and on for 20 years, starting in the 1980s. Among other duties, Williams acts as the designated driver of the organization’s van, occasionally picking up former inmates from San Quentin under a program that connects newly released inmates with medical care.

Glenn Hopkins got a ride from Williams when he was discharged in December and was soon signed up for the county indigent care program, which could help him get medications for his schizophrenia and bi-polar disorder.

Only 28 years old, Hopkins has been in prison for armed robbery and violating parole by allegedly assaulting the pregnant mother of his child. After his release, he says he planned to enroll in community college to become a welder. Williams encouraged him “to stay focused on what you got to do.”

“I got people in my life that was trying to discourage me,” Williams says, recalling his own up-and-down experiences on the street. “I just separated myself. That is what really helped me, changing my environment. That is hard. This old environment, this unhealthy environment, it calls me. It calls me every day.”

As for Hopkins, he made an appointment for a follow-up visit last month, and in what Williams said was an auspicious start to his new life on the outside, kept it.

Under federal funding rules, local officials will have some flexibility in deciding who qualifies for help. Both Alameda and Contra Costa counties, for example, are proposing to include people who earn as much as twice the poverty level, or $21,780 annually for single adults.
But the money comes with strings that could trip up some counties looking for help. For one thing, it is available only if counties maintain their existing funding for indigent care; the idea is to make sure that the federal money is used to expand programs rather than supplant local funding.

The programs will also have to offer a fuller range of benefits, including coverage for mental health treatment. Provider networks will have to be more extensive, and hospitals will have to meet new tests for their accessibility. Those that pass will be reimbursed by the federal government at a rate of 50 cents for every local dollar spent.

Stressed budgets – and the fact that money must be spent upfront to get the federal match – are putting some counties in a quandary. With the more generous and expensive coverage requirements, Santa Clara County is proposing to limit eligibility in its new indigent-care program to people earning just 75 percent of the poverty level. The county is happy for the federal support, but “it is not the silver bullet,” says Michael Lipman, acting director of planning, contracting and business development for the Santa Clara Valley Health & Hospital System. A less-generous health plan will be available for those with higher incomes.

New Money Fuels Bigger Programs

Health policy experts see the deal that California made with Washington as bringing the reality of reform to people sooner rather than later. “This is a jump start on getting at least a significant portion of individuals into the system now rather than waiting for three years,” says , a professor at UCLA and associate director of its Center for Health Policy Research.

San Mateo is hoping to use the federal funds to offset the cost of substance abuse treatment for hundreds of uninsured residents.
Contra Costa expects the total number of people eligible for its program to grow about 50 percent to about 18,000 people within a year. “We are banking on the fact that promises were made, and the money will follow,” says Dr. William Walker, director of the county’s health services agency. “We are out there … moving ahead.”

Anticipating a surge in enrollments, Briscoe, the Alameda County health director, wants to expand access to care with clinics in schools, churches and fire department sub-stations.

Lankford

Lankford is hoping to open a sister clinic in East Oakland by the summer. And a network of churches in Southern California is looking to replicate his model with locations in several counties throughout the state including Solano.

To advocates for ex-offenders, this would be money well spent, a way to start steering public funds away from what they view as costly, failed policies of the past that have focused on punishment and incarceration rather than rehabilitation and wellness.

“These are people, by and large, that we have systematically failed in terms of almost every public institution that was responsible for them,” says Junious Williams, chief executive of the Urban Strategies Council, a community and advocacy group that has advised Alameda and Contra Costa counties on health care polices for parolees and probationers.

“We put them in jails and prisons for long periods of time, and we failed to rehabilitate them. They are right back on the streets, and most of them are in as bad or worse shape than when we sent them away,” he says. “It is short-sighted not to figure out how to break the cycle, if no other reason, because we just don’t have the money anymore.”

rickschmitt@comcast.net

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Matt Sissel of Iowa City, Iowa, proudly served in Iraq as a combat medic. But he says he objects to being “conscripted” into an overhauled federal health care system.

The uninsured artist is riled about a provision in the new health law that would require him to purchase insurance or pay a penalty starting in 2014. Last July, he filed a lawsuit to have the landmark act declared unconstitutional. “I don’t want the federal government dictating my personal financial decisions,” says Sissel, 29. “It can’t even run its own budget.”

In attacking the law in the courts, Sissel has plenty of company. A number of interest groups, state officials and ordinary citizens are seeking to have the health care law struck down in federal court. 

Today, a federal judge in Michigan ruled that the mandate that individuals buy insurance is constitutional. U.S. District Court Judge George Steeh turned down a request from the Thomas More Law Center to issue an injunction blocking the government from taking any further action implementing the law. The non-profit law firm, based in Ann Arbor, often brings anti-abortion cases.  Steeh was appointed by President Bill Clinton. Legal action is heating up elsewhere as well:

— This week or next, a federal judge in Pensacola, Fla., is expected to issue a preliminary ruling on perhaps the most prominent lawsuit. Brought by the governors or attorneys general of 20 states, the lawsuit seeks to have the act declared unconstitutional.

— — On Oct. 18, the Republican attorney general of Virginia – who has compared the Obama administration’s regard for states’ rights to the tyranny of King George – heads back to court for another round of hearings with a federal judge who recently turned down a Justice Department request to throw the case out.

The burst of litigation has the framers of the law and the Obama administration playing defense. Many scholars, such as Charles Fried of Harvard Law School, argue that the law is on firm legal footing. But there is no quick resolution in sight, and it may take a year or two, and a trip to the U.S. Supreme Court, for all the lawsuits to get sorted out.

Still, that might be a quicker route to upending the law, or parts of it, than a threatened GOP repeal effort in Congress. Even if Republicans pick up more seats in November, they’ll have a tough time getting major changes past President Obama.

Under the health care law enacted in March, more than 32 million additional Americans are expected to get insurance, either through an extension of Medicaid, the state-federal program for the poor, or through exchanges where low- and moderate-income individuals and families will be able to purchase private insurance with federal subsidies.

The law’s ambitious sweep has made it a target for those who see it as an unjustified expansion of government. Plaintiffs challenging the law include a variety of religious groups, the nation’s largest small-business trade association, and a who’s who of conservative legal activism.

Sissel, for example, is represented by the Pacific Legal Foundation, a Sacramento-based legal watchdog group that supports limited government, property rights, and free enterprise.

Liberty University, the fundamentalist Lynchburg, Va., college founded by the late Jerry Falwell, has filed a lawsuit claiming that exemptions from the law for religious groups are too narrow and violate freedom of religion under the First Amendment. The Tucson-based Association of American Physicians and Surgeons, which opposes government intervention in health care, also has sued.

Several Cases, Similar Views

In many cases, the lawsuits make similar arguments. Several contend, for example, that a provision of the law requiring most people without health insurance to get coverage or pay a penalty exceeds the power of Congress to regulate interstate commerce under the Constitution.

The states, in the Florida lawsuit, also are challenging a provision of the law that greatly expands Medicaid. They claim the changes will cost them billions of dollars and wreck their budgets for years to come.

Justice Department lawyers say the lawsuits are without merit and premature. The penalties for people without insurance won’t take effect until 2014, and the states won’t have to start picking up any of the costs of the expanded Medicaid until 2017.

But the critics say the changes are so profound, that the courts should act now. The law will “transform our nation beyond recognition” and “arm Congress with unbridled top-down control over virtually every aspect of persons’ lives,” the states have argued in court documents in the Florida case.

Florida Attorney General Bill McCollum said in an interview that if the individual insurance requirement is upheld, there is no end to what the federal government might require people to do. “The government could … force us to buy a General Motors car or put our money in a government-owned bank,” he says.

Justice Department lawyers respond that the law was well within the power of Congress to enact. In court papers in the Florida case, they have described the law as “an important but incremental” extension of federal regulation of the health-care market.

Supporters of the law say healthy people must be required to buy coverage to offset higher costs that insurance companies face under the new law – otherwise, insurance will be too expensive for everyone.

In addition, they argue that dismantling the statute would hurt the poor, and would be a first step in rolling back laws dating to the New Deal that have given the government broad authority to regulate the behavior of individuals and states.

“These lawsuits have been mounted by people whose objective is to change constitutional law,” says Simon Lazarus, public policy counsel for the National Senior Citizens Law Center, a non-profit legal and educational firm that advocates for low-income older adults. To hold that the health reform law is unconstitutional would require “massively consequential changes in the Constitution as it has been plainly understood.”

Disagreement, Even Within State Governments

In some states, Republican and Democratic officials are slugging it out over their differing stands on the lawsuits.

In Washington state, for example, the state Supreme Court next month will hear a case that seeks to force the state’s Republican attorney general, Rob McKenna, to withdraw from the multistate lawsuit in Florida.

The hearing was set after the Democratic city attorney for Seattle, Pete Holmes, complained that state law prohibits McKenna from representing Washington in court without the support of the governor. Washington’s Democratic governor, Chris Gregoire, opposes the lawsuit. McKenna, considered a frontrunner for the governor’s race in 2012, says the law is on his side.

In Iowa, Republican Brenna Findley, is looking to unseat Democrat Tom Miller as attorney general, in part by vowing to join the Florida lawsuit if elected. This week,. Findley is hosting Virginia Attorney General Ken Cuccinelli at several campaign events. “Ken has led the way in fighting the federal takeover of America’s health care system,” Findley says in a message to supporters on her campaign’s Facebook page. “Don’t miss this opportunity to speak to Brenna and Ken about this important issue!!”

Miller, a seven-term incumbent, says the case is weak, and that joining the lawsuit would be a waste of resources. “Above all else, an attorney general has to follow the law and do things that are consistent with the law,” he says in an interview. “You don’t go ahead and file a lawsuit because you disagree with the policy.”

Even conservatives acknowledge that Congress has broad powers under the Constitution. But they say the authority kicks in only when there is already some ongoing activity to regulate.

“The Supreme Court has never said Congress has the power to make you engage in economic activity,” such as buying insurance, says Randy Barnett, a professor of constitutional law at Georgetown University Law Center in Washington.

States can require citizens to buy auto insurance or fire insurance for their homes – but that is because they have broad police powers under the Constitution that Congress does not have, he says.

Sissel figures the auto insurance he is required to maintain under Iowa law will cover his medical bills if he gets in an accident. He’s prepared to cover other bills out of his own pocket.

Healthy and trying to start an art business, he thinks his decision is rational. “There are all sorts of tragedies that can befall us in life. We can’t spend all of our time worrying about the statistically improbable,” he says.

Defenders of the individual-insurance mandate say people who don’t carry insurance impose a cost on society. If people get sick and don’t have insurance, they say, the public will have to pick up the tab.

“People not buying health insurance … they have not removed themselves from the marketplace. They have inserted themselves in the marketplace in perhaps the most aggressive way,” says Steven Schwinn, a law professor at John Marshall Law School in Chicago.

Medicaid Costs At Issue

Another point of contention involves the Medicaid expansion. Many states already spend a quarter or more of their budgets on Medicaid, and some fear the cost will rise dramatically as the new law takes hold.

David Rivkin, a Washington lawyer representing the states in the Florida case, says there comes a point where the cost crosses a line. By turning the states into “financial wards of the federal government,” he says, “you can vitiate state sovereignty.”

But several studies have predicted the overall cost to the states will be relatively small compared with the huge influx of federal dollars and the benefits residents will get from having insurance for the first time.

The states also do not have to accept the money, and can withdraw from Medicaid, although Rivkin and others say that is not a realistic option, given how the public has come to depend on the program.

“Does that mean the more money the feds give (the states) the less control it has over how those dollars are spent?” says Brad Joondeph, a professor at Santa Clara University law school.

The argument “seems backwards,” he says. “You end up with a perverse rule.”

In Florida, Judge Roger Vinson has said that he’s leaning towards dismissing several counts in the states’ lawsuit, but that he would allow “at least one count” to proceed.

Vinson has already scheduled a follow-up hearing for December, when he’ll give what’s left of the case a closer look. He’s expected to issue a final ruling early next year, touching off a round of appeals.

The states want to move the case along as quickly as possible, to capitalize on what they view as public disenchantment with the law. They hope that public concern will shade how the lawsuit is viewed by the courts. They also believe that they can get the case before the U.S. Supreme Court before major features, such as the individual mandate, become effective in 2014. They believe that helps their cause because there will be less of the law to undo.

Barnett concedes that the Supreme Court usually bends over backwards to uphold laws of Congress. But if the law turns out to be highly unpopular, he thinks the high court will be open to “valid constitutional objections.”

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Michael Rhoads seems just the sort of person who would benefit from health care overhaul legislation.

He and his wife, working parents of two children, lack health insurance, which they say they cannot afford. At the same time, the combined annual earnings of this southwest Philadelphia family are such that they do not qualify for Medicaid, the state-federal health insurance program for the poor.

Congress is seeking to bridge the gap they face. But Rhoads says the likely cost of the solution would still be beyond his family’s budget.

“Health care for everyone – that sounds wonderful,” says the 35-year-old, an outreach coordinator for a low-income community health clinic. “In reality, when it comes down to it, it is another big bill that just doesn’t fit.”

His is a dilemma that faces many of the millions of Americans who are intended beneficiaries of the overhaul: they make too little, and yet too much, to capitalize on the legislation’s signature features.

In an effort to reduce the ranks of the uninsured, Congress is proposing to expand Medicaid for the poorest Americans, and to provide subsidies to millions of others to help buy private coverage. But a sizeable number of those who would qualify for subsidies–especially people who would be right above the Medicaid cutoff–could still find health care unaffordable; premiums and out-of-pocket costs like deductibles and co-pays could add up to hundreds or thousands of dollars a year.

Those who miss the cut for Medicaid face sharply higher costs in a private insurance plan. “You have a very steep cliff,” says Judith Solomon, a senior fellow at the Center on Budget and Policy Priorities in Washington. Many might have to choose between insurance and necessities like rent and food, say experts such as Richard Curtis, president of the Institute for Health Policy Solutions in Washington.

“These are not people with discretionary income,” says Curtis. “Asking them to pay any substantial share (of insurance costs) I worry about that.”

To be sure, millions of vulnerable Americans would get a safety net if legislation now headed to House-Senate negotiations becomes law. Both chambers of Congress are proposing to raise the income limits for Medicaid, and to include adults without children for the first time. Those moves alone would add 9.5 million childless adults to the program under the Senate bill.

But a large chunk of the uninsured population would just miss the Medicaid expansion. According to the Kaiser Family Foundation, 7.2 million adults earning less than twice the federal poverty level — about $21,000 for an individual and $44,000 for a family of four — would earn too much to qualify for the expanded Medicaid envisioned by the Senate. Millions more have incomes slightly above that level. (KHN is a part of the foundation.)

At the core of the overhaul is a requirement that most individuals and families obtain health insurance or else risk a federal fine. Under the Senate bill, that penalty would reach as much as $750 per person, or 2 percent of household income, whichever is greater, although there would be a “hardship” exemption in cases where the cost of premiums totaled 8 percent or more of income.

In general, employees would have to purchase the insurance offered at their work, assuming it meets certain minimum standards. A series of “exchanges” – private marketplaces regulated by the government – would be set up to offer coverage to people without insurance or to those whose insurance at work is expensive. Some small businesses would also be given access to purchase insurance for their employees.

People earning up to four times the poverty level – about $43,000 for an individual and $88,000 for a family of four — would receive federal subsidies to help them buy policies on the exchanges. The subsidies would operate on a sliding scale that would require those at the upper end to pay a larger share of their income to get coverage, although even those at the lower end would have to foot some of the costs.

Source: Kaiser Commission on Medicaid and The Uninsured using U.S. Census data.
(click to enlarge)

Georgetown University’s Center for Children and Families assessed the prospects for several Philadelphia-area families under the overhaul based on their current earnings and insurance status. The analysis is pegged to the Senate bill, which most political analysts consider the likely blueprint for any final health legislation that Congress approves.

The families examined for this article most likely would qualify for the exemption – and if they chose to take advantage of it, would be left in the same place they are now: without health insurance.

Rhoads and his wife have been uninsured for most of their adult lives. They live along the Woodland Avenue corridor, one of the city’s toughest areas, with above average crime and joblessness. And they never seem to have enough money to pay their bills, much less to buy health insurance.

They go to the doctor only when they are so sick that they cannot work. Over the years, Rhoads’ wife, 32, who asked that her name not be used to maintain her privacy, has incurred large unpaid emergency room bills. Recently, she developed a case of the H1N1 virus and sought treatment at a medical clinic called the where Rhoads works part-time, trolling for clients at homeless shelters and food kitchens.

“I’m trying to feed my kids. I’m not thinking about paying medical bills,” she says, through a surgical mask. The couple has two daughters, 13 and 15. Both receive free care under a program for children in low-income families known as the Children’s Health Insurance Program, which would continue to operate under the Senate – but not the House – overhaul legislation. Their household income is about $40,000 a year; she is currently the main bread winner, working as a certified aide at a nursing home.

Her employer offers health insurance, but to cover the two of them, even the cheapest option would cost about $350 a month, which they say they cannot afford. The cost is high enough to make them eligible for a government subsidy to purchase insurance through one of the new exchanges. Under the Senate bill, however, they would also be expected to contribute about $200 a month toward the cost of the premiums, or about 5.8 percent of their income. Co-payments and deductibles would likely add several hundred dollars more to their annual health care bill.

Rhoads says the benefit is nice but still unaffordable. His wife says she does not understand a system in which she would have to set aside part of her paycheck to cover insurance premiums, and then have to pay again, to cover deductibles and other shared costs, whenever she visits the doctor. “You know, I feel like that is where you are ripping me off,” she says.

Danielle Simmons, a medical assistant and student at the Community College of Philadelphia who is also uninsured, could be in more perilous shape. Under the Senate bill, Simmons, who says she earns about $36,000 a year, would have to pay about 8.1 percent of her income, or about $246 a month, for her share of premiums on a government-subsidized insurance policy.

A single parent, Simmons, 23, says she already has more bills than she can handle. She pays $840 a month for her five-year-old to attend a Christian pre-school program. (Like the Rhoads’ children, her daughter qualifies for CHIP.) The heating oil bill for the house she shares with her sister is expected to hit $4,000 this winter. She has $15,000 in unpaid student loans.

Adding another expense, even to cover health insurance, she says, “would not be on my radar.” Instead, she tries to keep on top of her health using her medical knowledge and self-discipline. Diagnosed with lupus, an auto-immune disorder, Simmons says keeps her condition under control through careful diet. She also is zealous about hygiene and prays a lot.

The potential gaps in coverage underscore how budget considerations have been driving the debate in Washington. While they want to cover as many people as possible, lawmakers are also trying to keep the tab below $900 billion over a decade, a marker set by President Barack Obama.

The Senate bill would cost less – and be less generous — than the House measure. Affordability looms as a major issue for the two chambers to negotiate. As it stands, the Senate would expand Medicaid to include people earning up to 133 percent of the federal poverty level, currently about $33,000 for a family of four; the House would raise the ceiling to 150 percent. The Senate bill is also much less munificent when it comes to subsidies. A by the Urban Institute this month found that the poorest and sickest families qualifying for subsidies under the Senate bill could end up having to pay as much as 13.4 percent of their income on health care costs – nearly double the 7.6 percent they would pay under the House version.

Mahawah Sillah owes $20,000 for emergency-room care. There is a backlog for state health aid, she can’t afford insurance offered by her employer, and federal changes are unlikely to help. (Laurence Kesterson/Philadelphia Inquirer)

To cushion the blow, the Senate would help individual states set up basic health plans for low-income individuals and families who don’t qualify for the expanded Medicaid. How well those programs might work is far from clear. A comparable idea already in place in Pennsylvania, known as , has seven times more applicants than enrollees because of funding shortfalls related to the state budget crisis.

Mahawah Sillah, a diet technician at a Philadelphia hospital, who has diabetes and hypertension, is one of those waiting for help. She earns about $41,000 a year, and has three children. Her earnings are about 185 percent of the poverty level; in theory that makes her eligible for the basic health assistance from the state but she is stuck in the backlog. Her children are covered by the CHIP program.

She also appears unlikely to gain much from the pending overhaul legislation. She makes too much money to qualify for the planned Medicaid expansion. With monthly mortgage and child-care payments, and thousands in legal bills for her husband’s immigration problems, she says she can’t afford the insurance offered by her employer.

The Senate bill would require her employer to kick in some money to help her buy insurance. But she would still face about $200 a month for premiums – about double what she says she can currently handle.

A few months ago, Sillah, 40, landed in the emergency room, after a fall that was related to her high-blood pressure, and incurred a $20,000 bill, which she says she cannot pay. Lately, she has been hearing from bill collectors, who want to know when she is going to start paying off the debt. Her prescription for dealing with her own personal health care crisis: “I screen my calls,” she says.  

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When it comes to political, social or health causes, elder abuse has not had the star power of some other movements focusing on the rights of vulnerable people.

Last month, actress Nicole Kidman headlined a congressional hearing on violence against women, and stars of “Law & Order: Special Victims Unit” appeared at a Capitol Hill rally for child-abuse victims. An event sponsored by a coalition of elder abuse groups, meanwhile, featured ordinary senior citizens, recounting in sometimes aching detail how they or their loved ones had been physically and emotionally abused or financially exploited.

The lack of glitter has been reflected over the years in federal support for protecting seniors — which is to say, support has been limited. That may be about to change. As part of health care overhaul legislation, lawmakers are taking steps that would for the first time establish a federal beachhead in fighting elder abuse.

The health care bill would launch a nationwide program of background checks for people who care for the elderly, overhauling a patchwork of state laws that critics say has allowed known offenders to repeatedly end up in positions of trust.

The Senate is considering an even more expansive . It would boost federal aid for identifying and investigating elder abuse at the state and local levels, require long-term care providers to report possible crimes to federal authorities and create new oversight within the Department of Health and Human Services for coordinating state and federal anti-abuse efforts. These provisions, already approved by the Senate Finance Committee, are included in the health legislation that is being prepared for floor debate after Thanksgiving.

With broad support in and out of Congress, at least some of the measures appear to have good prospects for being enacted into law. More than 500 advocacy groups have lined up behind the legislation. It still faces opposition on budget grounds, although proponents say the cost of the Elder Justice Act — about $757 million over four years — is pocket change in the context of a near $1-trillion healthcare bill.

Abuse Victims Face More Risk Of Dying

About 11% of people ages 60 and older suffer from some kind of abuse every year, according to a March study for the , an arm of the Justice Department. Other studies have shown that elderly victims of abuse, neglect and exploitation have twice the risk of dying within a year.

of such abuse abounds. A home aide working near Fresno was convicted of involuntary manslaughter last year after giving an 85-year-old woman a lethal overdose of morphine and methadone and ransacking her house. The caregiver had a history of domestic assaults and drug smuggling.

Last month, a postal worker in San Diego pleaded guilty to one count of felony financial elder abuse after taking more than $50,000 from elderly women on her delivery route. “She was using the economy to pour excuses on herself and borrow money,” said Paul Greenwood, an assistant district attorney. “We found out she was spending a lot of the money in the casinos.”

Financial exploitation of the elderly costs as much as $2.6 billion a year. The problem was highlighted with the October conviction of the son of New York philanthropist Brooke Astor for stealing tens of millions of dollars from his mother while she was suffering from Alzheimer’s disease. But advocates for the elderly say such abuse occurs on a lesser scale much more frequently.

Enhancing the rights of the elderly might seem a no-brainer for lawmakers on both sides of the aisle. After all, people older than 55 constitute the fastest-growing population group in the country. Congress is even aging: The average age of a House member is now 56 years, and for a senator, 61.7 years.

But opponents say they are concerned about runaway federal spending and stepping on the toes of state and local governments. The Elder Justice legislation, first introduced in 2002, was opposed by the Bush administration, which felt it would create a new and unnecessary federal bureaucracy.

Others question the expense and efficacy of background checks when even proponents acknowledge that most abuse is perpetrated by people who are already well-known to the victims. Until last year, the background-check bill, first introduced in the Senate in 1997 by Democrat Herb Kohl of Wisconsin, had never made it out of committee.

Still, opposing such measures can be politically tricky. “Why do you want to beat up old people?” Stephen Colbert demanded in an interview with Republican Rep. Cynthia Lummis of Wyoming on his Comedy Central show “The Colbert Report” in March. Lummis voted against legislation earlier this year that would have made federal money available to state and local elder-abuse prosecutors. She told Colbert, “I am opposed to irresponsible spending.”

“So you want us to beat up old people in a fiscally responsible manner?” he shot back.

Now backers of the legislation have maneuvered to link its fate to the debate over healthcare reform, in which it has become an important consideration for some centrist Democrats, such as Sen. Blanche Lincoln of Arkansas, who is considered a crucial swing vote on healthcare legislation. Lincoln, a longtime member of the Senate Special Committee on Aging, is a co-sponsor of the Elder Justice Act. (The median age of her constituents back home is also one of the highest in the nation.)

Supporters say elder abuse should be addressed in healthcare overhaul legislation because it pushes up healthcare costs and because financial exploitation of the elderly leaves many destitute and reliant on public assistance.

“This is prevention, which is a healthcare issue,” says Robert Blancato, who heads the , an umbrella group for more than 500 groups that support the legislation. They include AARP, the American Bar Assn., and industry groups representing nursing homes and long-term providers, among others.

State and local governments have long been on the front lines of such problems. But many studies have shown a shortage of resources among licensing agencies, long-term-care ombudsmen and adult protective service workers.

“The universal lack of resources, the enormous variation across jurisdictions and the low priority given to elder abuse and neglect make it difficult to see how significant progress can be made without federal standards and financial support,” concluded researchers at Texas A&M University in a report prepared for the Justice Department last month.

Worker Screening

The current health care bills would require states to conduct comprehensive screening of a wide range of people who are working with the elderly, including those in the burgeoning and unregulated area of home-based care.

More than a dozen states, including California and Florida, currently do not regulate those workers. Most states only check the backgrounds of medical workers, such as nurse aides, and only for crimes they committed in their own states. In 2006, a woman who had been convicted in Kansas of pushing an elderly woman out of a vehicle in a carjacking was discovered to be working in nursing homes in Missouri.

The legislation also would require states to establish clear criteria for prohibiting employment of applicants with a history of violent crime. It also would mandate the development of appeals processes for individuals who are denied employment, plus systems in which workers who have been checked and cleared, but who subsequently commit a disqualifying crime, would be terminated.

Even proponents of the new federal standards say they can go only so far. Studies show that most elder abuse takes place in private homes and that the assailants are family members or trusted advisors, in up to 90% of cases.

The challenges increase as more elderly people spend their time at home or in community and group living arrangements. By comparison, teachers and other professionals outside the home act as a safety net in cases of suspected child abuse because they are required to report evidence of abuse to authorities.

“Adult abuse is a lot harder to get your arms around,” says Marsha Greenfield, a lawyer and senior legislative counsel for the American Assn. of Homes & Services for the Aging, a trade group for nonprofit long-term care providers.

“There are many more elderly people both in community and group living arrangements,” Greenfield says. “But they are also a more invisible population because there are so many people in their own homes.”

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Laid off from her marketing job at a managed-care company late last year, Trueman was able to keep her health insurance thanks to a provision in the federal stimulus bill that gave furloughed workers the right to purchase their old employer-based coverage at a 65% discount.  The subsidies, which last up to nine months, were designed to give workers like Trueman time to get back on their feet.

Today, with the job market weak, Trueman is still without a job, and her family is bracing for an uncertain future. With the subsidies, she and her husband, a self-employed attorney were paying a manageable $460 a month for their health insurance; starting Dec. 1, the cost jumps to $1,313.   They can ill afford the increase.  They’re already having trouble making their mortgage payment, and fear they might lose their Northern Virginia home.

“It has really made a huge difference for us,” she says of the insurance assistance, adding that the higher payment “would be a real stretch.” 

Since 1985, a law known as COBRA has given laid off-workers the right to hold onto their employer-based health insurance for up to 18 months so long as they continue to pay the premiums, including payments that their employers used to make on their behalf.

About COBRA Subsidies

The stimulus package President Obama signed into law in February includes subsidies allowing laid-off workers to retain employer-provided group health insurance coverage at a discount.

How much?
Eligible individuals pay only 35 percent of the normal premiums. The remaining 65 percent is paid by the employer, which is reimbursed by the government through a payroll tax credit.

How long does it last?
Nine months.

Who qualifies?
Employees who are involuntarily terminated from Sept. 1, 2008, through Dec. 31, 2009, and who are eligible for continued coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Individuals whose annual adjusted gross income exceeds $145,000 ($290,000 for joint filers) are not eligible.

What kind of coverage?
Employers must provide the same benefits as in your old group plan, although they can offer other plans as well.

How do I apply?
Your employer or its representative is required to give you notice that you may be eligible. You also have to attest in writing that you meet certain criteria. You will have 60 days after receiving the notice to make a decision whether to participate.

What if I have other insurance?
If you are eligible for other group health coverage (e.g., through a new employer’s plan, a spouse’s plan or through Medicare), you are not eligible for the premium reduction.

How can I get more information?
The and the  have special Web pages with additional details.

In the past very few people could afford this option, but the government subsidies have changed that, and now enrollments appear to be growing sharply. Hewitt Associates, a Lincolnshire, Ill., consulting firm, that the rate at which workers were opting for coverage under COBRA had doubled compared with pre-subsidy levels.

Although federal officials do not have figures on the number of people participating in the program, millions have been eligible. The law covers anyone laid off between Sept. 1 of last year and Dec. 31 of this year.

But with the first discounts having gone into effect March 1, many people are about to see the benefit expire, including many who remain unemployed. The Obama administration and some members of Congress are talking about  whether to extend the subsidy.  Some lawmakers aren’t enthused because of budget concerns, but backers say the subsidy is a crucial lifeline for people still hunting for jobs.

Just this week, Rep. Joe Sestak, D-Penn., introduced legislation that would extend from 9 to 15 months the total allowable time an unemployed worker and her family could receive the subsidized COBRA assistance. The legislation would also extend the subsidies to people laid off through June 30, 2010, widening the window of eligibility by six months. A third provision would give an extra six months of undiscounted COBRA coverage to people who were laid off early in 2008 before the subsidy law took effect.

“Federal subsidies for COBRA premiums are making insurance more affordable for millions of unemployed individuals and their families,” says Rep. Nita Lowey, a New York Democrat. “This is not the time for those who have lost their jobs to have to worry about an impending drastic increase in their health insurance costs. Congress should extend these subsidies so the number of uninsured does not grow even further.”

For now, the aid is helping a broad cross section of people with widely varying health and financial situations — from newly minted MBAs to older workers forced out of their jobs after exhausting their disability leave, among other reasons.

A that tracks news and personal experiences with the subsidy has garnered scores of followers. 

Out-of-work professionals are for the Wall Street Journal. 

“I can only be grateful that I am safeguarded by COBRA,” writes a furloughed operations manager at Bank of America, “and hope that I am employed and eligible for medical insurance through my new employer before my COBRA term ends.”

Close to home

My own family got seven months of discounted coverage out of the program after I lost my job as a newspaper reporter last year. The savings: a cool $6,000.  While I am still looking for permanent work, my wife was recently able to find a job with benefits.  (The discounts end when you become eligible for other insurance, either directly or through your spouse.)

Rick Schmitt and his family.

People in the same boat seem to be everywhere. The firm my former company hired to administer the discount program was so flooded with work that it ended up hiring temporary workers – including one that I spoke with who had herself been recently laid off and was looking to take advantage of the subsidy.

But in many cases, the subsidies are, at best, only temporarily easing the stresses facing employees who have been laid off.

A by the American Cancer Society and the Kaiser Family Foundation found that many chronically ill people could not even afford the subsidized premiums. (KHN is a program of the foundation.) Once the full COBRA premiums are reinstated, the study found, many cancer patients face becoming uninsured or forgoing needed treatments.

Indeed, people who become eligible for COBRA are generally older and sicker than the rest of the work force, and have fewer insurance options when they lose their jobs.

You can try to purchase insurance on your own, although that is generally more expensive than an employer-sponsored plan and often comes with limits on basic coverage such as maternity care or prescription drugs.   Some – but not all — states provide a backstop in the form of “high-risk pools” that offer insurance to people who can’t get coverage elsewhere because of their medical history. 

Dale Gardner, who lost his job at a high-technology firm in Virginia last November, says the subsidies have been welcome. 

At the same time, he says that he has been able to replace much of his lost income as a consultant, and that he would not mind paying full freight so long as he can keep his coverage under COBRA.  What worries him the most, he says, is that he won’t be able to find a job with benefits before his right to coverage under an even un-subsidized COBRA expires in 2010.

“Because of our health history,” he says, “coverage for my wife and I is going to be difficult to find at any price.” He says his wife has arthritis and one of his sons has asthma.

“I count myself as fortunate,” he adds. “I have been able to maintain coverage despite the fact that my family has health problems. (But) there are a lot of people who cannot even get that who have worse health problems.”

Some experts say those problems point up the need for broader-based reform of the health-care system.  The subsidies have been “a valuable first step” helping people in need keep their insurance, says Karyn Schwartz, a health-policy analyst at the Kaiser Family Foundation.  “Providing security for all of those who need health insurance will require more comprehensive reform,” Schwartz adds.

Trueman, 51, was laid off in December 2008, after working a year at a unit of UnitedHealth Group that provides managed care for Medicaid enrollees in 20 states.  Before that, she was the executive director of the Coalition for Affordable Health Coverage, a Washington-based industry advocacy group. 

With her background in health policy, she figured getting a new job would be “relatively quick and painless.” But that has not been the case. “I have had a lot of interviews,” she says, “but just clinching the right one has not happened.”

Down the road, she worries most about a son in college who has a chronic health condition that requires medication. That could make it hard for the whole family to find insurance in the private market. Another problem is that her home state of Virginia is one that does not have a public program for “high-risk” individuals. 

Seeking to exhaust all options, she has lately been reading up on how some drug companies give discounts to the poor or uninsured, to see if her son might qualify.

Come December, when the COBRA discounts expire, “I don’t really know what we will do,” Trueman says. “I hope we have a job by then that has health insurance.”

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Nurses rally in Washington on May 13th to demand better conditions for nurses as well as comprehensive health reform (Chris Zimmer-KHN).

The YouTube video shows Donna Smith pulling on a white hazmat suit and protective rubber gloves. She is going to work, trying to clean up the nation’s health insurance industry.

With a bullhorn in one hand, and a picket sign in the other, she leads a group of a dozen or so activists, similarly attired, marching outside a Chicago hotel on a windy morning last fall.

The “Health Care Hazard Cleanup Team” has come to protest an industry it sees as toxic to the health of Americans. Today’s target is an insurance company trade group that is holding a meeting inside.

“Hey, Hey, Ho, Ho,” a chorus erupts. “Private insurance has got to go.”

Smith is a cancer survivor whose personal experience with insurance has driven her to lead rallies like this one. She is a foot soldier in the battle over health care, and hers is the most radical prescription for reform.

The idea, which advocates call “single payer,” would replace private insurers with a single, tax-funded government program. They envision a system in which every American would be guaranteed coverage, regardless of ability to pay or medical history, and all patients would be free to pick their doctors.

But despite its appeal to many, single payer, as an option in the current debate in Washington, is DOA. More advocates have been arrested on Capitol Hill than have testified at congressional hearings. President Obama, who years ago said he supported the idea of single-payer, now favors bolstering the existing employer-based insurance system.

Related Video

Leading The Single Payer Movement

Without a seat at the bargaining table, single-payer proponents are still looking to influence the process, if only to raise red flags about proposals they say would make the current system worse. The Leadership Conference for Guaranteed Health Care, a coalition of single-payer advocacy groups, is planning a major rally in Washington on July 30 in an effort to demonstrate the widespread support they say their cause has garnered. The event coincides with the 44th anniversary of the enactment of Medicare, the federal health program for the elderly, which single-payer supporters consider a model for extending insurance to all citizens.

Some die-hards think that Congress may still turn to a single-payer plan in the event other proposals unravel. Ultimately, they believe they will prevail, because, they say, it is the only plan that expands coverage to the 46 million Americans without insurance while putting a lid on spiraling costs.

“It is really unethical for us to settle for or put forth a placebo which we know is not going to be successful in curing the disease,” says DeAnn McEwen, an intensive-care nurse in Long Beach, Calif., and a member of the California Nurses Association, a politically powerful union that supports single payer. “You just can’t compromise your principles.”

“I am not discouraged,” adds Quentin Young, national coordinator for Physicians for a National Health Program, a group of 16,000 doctors who support single-payer. “It is going to happen because we cannot afford not to do it.”

Most political experts say a single-payer plan is not feasible in the current environment. Public ambivalence about the role of government combined with the upheaval that would result from dismantling the current insurance system make radical change highly unlikely, they say. In addition, there would be strong opposition from congressional conservatives who vigorously dispute the rosy picture of single-payer benefits described by advocates.

The decision not to consider a single-payer scheme “speaks to the pragmatism not just of the Obama administration but the Democratic leadership in the House and the Senate,” says Jonathan Oberlander, a health policy expert who is now a visiting scholar at the Russell Sage Foundation in New York City. For them, a single-payer plan “would be too controversial,” especially when they’re trying to reassure anxious Americans that they can keep their existing insurance if they like it.

But for proponents, the failure of a single-payer proposal to advance shows the grip that the health care lobby has on the political process in Washington. At best, in their view, current options on the table amount to tinkering with a failed system; at worst, they further empower an already entrenched insurance industry.

Rep. John Conyers Jr., D-Mich, who has sponsored a single-payer bill, says the year-end deadline set by the White House for enacting reform legislation has made it even harder for proponents to make their case. He says he hopes to insert wording in any final bill that would make it easier for states to set up their own single-payer plans.

Some single-payer advocates, knowing their plan is dead, want Congress to include a government-run insurance option as part of overhauling the health system. Others, says Oberlander, fear it would “hurt the cause of single payer” partly because it “would defuse pressure for change.”

Passionate, if quixotic, the campaign for single-payer has a wide cross-section of supporters: There are nurses and doctors who say they are tired of seeing their patients denied care for lack of insurance; health-policy experts such as Marcia Angell, the former editor of the New England Journal of Medicine, and several dozen members of Congress who have lined up behind Conyers’ bill.

There also are frustrated ordinary citizens looking to make a statement. A newsletter publisher in West Virginia had his wife, a belly dancer, perform at a rally this spring to bring attention to the cause.

There is even a single-payer rap song. Sample lyric: “Come from the land of milk and honey, insurance companies are addicted to money.”

Smith, 54, may seem an unlikely candidate to lead an attack on the health-care status quo. She grew up in suburban Chicago in what she describes as “a very Republican family.” Her father was a pharmaceutical salesman. Her mother campaigned for Donald Rumsfeld when he was a congressman from suburban Illinois.

(Chris Zimmer-KHN)

Like many other single-payer supporters, though, she comes to the fight seeing herself as a victim of the insurance system.

She and her husband landed in bankruptcy court, she says, snowed under by bills when he had a series of heart attacks and she developed uterine cancer. She was a newspaper editor in South Dakota; he was a machinist. Besides jobs, they had plenty of health insurance, or so they thought.

She became a full-throated single-payer advocate after she and her husband were featured in “SiCKO,” the 2007 Michael Moore film about the health care crisis.

Attending the New York premiere, she ran into a busload of nurses who saw the event as a vehicle for promoting a single-payer plan. The nurses persuaded the Smiths to come along on a road trip to other cities where the film was being released.

“Seeing the intensity of purpose the nurses showed for the issue was eye-opening,” she says. She began speaking to groups around the country about her film role and her personal experience, and even testified before Congress. The California nurses made her an organizer and legislative advocate in their Washington office.

A single-payer system, Smith says, is an elegantly simple solution.

Private insurance and federal programs such as Medicare and Medicaid would be rolled into a single national health program. People would pay taxes instead of premiums to finance the system.

Millions of middle-class families would see the cost of health-care decline, supporters contend. As with some other proposals Congress is considering, the rich would pay more. Billions of dollars in administrative costs and executive salaries would be saved by eliminating the tangle of for-profit insurers. Those savings, the thinking goes, would be large enough to cover most if not all of the nation’s uninsured.

But that is a provocative thesis. Some health-care experts say those savings are vastly over-stated, and that single-payer advocates don’t have a plan for dealing with rapidly rising health-care costs that are at the root of the crisis. “It is nonsense, absolute nonsense,” says Stuart H. Altman, professor of national health policy at Brandeis University. “The reason health care costs are high is that we spend a lot of money on health care. It is not all on the insurance side.”

Critics of single-payer plans say they would concentrate too much power in government, including decisions on which treatments qualify for funding. And as taxpayer-funded programs, opponents argue, they’d face budget-cutting pressure that could lead to rationing of care.

Robert Book, a senior research fellow at the Heritage Foundation, puts it more strongly. He wrote in an April issue brief that a “single payer system” would inevitably result in lower payments for physicians and other health care providers, which ultimately would lead to “reduced access and lower quality health care for future generations” of Americans.

Countries with national health programs, says Uwe Reinhardt, a health policy expert at Princeton University, have tended to short-change them. “There is a tendency to under-fund them,” he says, “and so care ends up falling short of the ideal.”

Smith concedes that single-payer may not be perfect but she says it is far superior to any other proposal out there. She is a relentless and ubiquitous promoter of the cause – blogger, street activist and talking head. You can see her on YouTube donning her hazmat outfit or being interviewed about single payer by Bill Moyers on PBS.

She has helped produce a series of videos aimed at dramatizing aspects of the health care debate. She appears in one video speaking from downtown Chicago in the shadow of the Blue Cross Blue Shield headquarters. The building is getting a major facelift.

“In a single payer system you won’t see waste like this,” she says in the video. “We won’t need to build massive structures that keep the for-profit engine going.”

Smith says she has spoken in 42 states and the District of Columbia about the virtues of single-payer. In a regular column on the Internet, she has compared the damage caused by the health insurance industry to the Holocaust. She signs her posts: “Donna Smith, American SiCKO.”

Her overarching message is that people who are responsible and financially secure can be wiped out when a health crisis hits. “I did everything I was taught to do as a middle class person,” she says. “I was educated, worked hard, raised my kids Yet when illness hit that was not enough.”

Smith says she is now cancer free. She also has insurance through the nurses’ union. Her husband, who has Medicare through a private plan, is having continuing health problems, and is wrestling again with his insurer.

She admits she is frustrated with the way Congress has dismissed what she views as the most just and noble option for reform.

“Women’s suffrage was not easy. The civil rights struggle was not easy. This one is not going to be easy, and it is probably not going to be won right now,” she says.

“But I still have tremendous hope,” she adds. Ultimately, she says, paraphrasing words of Martin Luther King Jr., “the long arc of history bends toward justice.”

This <a target="_blank" href="/news/single-payer/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

This story is a collaboration between Kaiser Health News and .

Laid off last fall and left to find $1,400 a month for continued family health coverage, I felt as if I’d struck pay dirt when I learned in February that Congress had decided to spend billions helping millions of Americans like me retain our insurance.

The promise of a 65 percent subsidy on the premium looked like my own piece of bailout heaven. But nearly two months later, we’re still waiting for our lifeline.

Some of us have continued ponying up large premiums on the promise that we will get refunds down the road. We’re now hearing that, in some cases, the discounts may not fully kick in until this summer, and even then they may not be steep enough to make insurance affordable for many of the jobless.

Considering the way the government poured billions into the banks and insurers such as AIG that got us into this mess, the handling of the health-care subsidies smacks of a double standard for us ordinary Joes.

The biggest beneficiaries so far seem to be health-care lawyers and consultants who are busy selling advice on how the whole thing is supposed to work. It took a month for the government to come up with guidance on implementing the subsidies. Employers and the firms they hire to manage benefits now face the time-consuming job of identifying people who might be eligible.

With health-care reform high on the agenda of the Obama Administration, the situation offers a glimpse of the difficulties in pushing through any changes in the nation’s health-care system. Given the thousands of different plans, experts say delays are inevitable under even the best of circumstances.

“There are lots and lots of pieces that could break down,” said Karen Pollitz, director of Georgetown University’s Health Policy Institute.

“This is not idiot-proof.”

The subsidies, aimed at helping people keep their employer-provided group health coverage, look to be a good deal. The government is picking up about two-thirds of the cost. The subsidies are tax-free and last for nine months.

Employees have long had the right to continue their group health coverage under a law commonly known as COBRA. But the cost – 102 percent of the full price of the policy – has been beyond the reach of most people.

After I got laid off, I learned I would have to pay $1,403.90 a month to keep my old coverage, roughly the equivalent of what I receive in unemployment benefits from the District.

As much of a budget-buster as that was, our family had few options. My wife, a preschool teacher at our church, does not have health insurance among her job benefits. Because of some health issues – one member of the family has a history of depression, another has residual injuries from a head-on auto accident – the cost of obtaining insurance elsewhere would be prohibitive, experts tell me.

Which is why the stimulus package made me feel like I had won the lottery. As luck would have it, my Nov. 14 layoff date put me squarely within the period Congress set for “Assistance Eligible Individuals.”

Last month, I cut a check for the full amount of COBRA premiums due for part of February and all of March. (My old company paid the cost through mid-February under a severance agreement.)

Knowing a bit about the law, I expected soon to be receiving refunds for my overpayments, followed in later months by bills that reflected the discounts Congress intended. Instead, what I got was a notice from the Minneapolis company my employer has hired to administer the program, indicating that something was up: It mentioned “New COBRA information” and “ARRA 2009” (the acronym for the stimulus law) and said more information would be headed my way soon. It also said I had to fork over another $1,403.90 premium for April or my coverage could be canceled.

I reached out to the Labor Department, subscribing to e-mailed updates about the program. I have learned about bilingual fact sheets, checked out an array of informational posters and flyers and seen a statement from Labor Secretary Hilda Solis. But some basic facts have been hard to come by.

Reading the text of the stimulus law, I discovered that employers have 60 days to cough up refunds or credits to people who paid more than 35 percent of their premiums after the law was enacted.

I also learned, by listening to a two-hour “compliance briefing,” now posted on the Labor Department’s Web site, that the government believes that people like me who had already elected COBRA were legally entitled to the 35 percent rate without further delay. An official suggested people in my position approach our employers.

I asked about this in an e-mail to the Minneapolis firm.

“We are currently working with the Department of Labor and our affiliates,” a customer service representative wrote back. “If you qualify [for the subsidy] you will be re-notified and will have the opportunity to elect COBRA under the new subsidy. Please wait for official correspondence.”

I’m hoping to get that official correspondence sooner rather than later.

This <a target="_blank" href="/insurance/paying-for-cobra/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">