The nation's uninsured — a growing class of people whose recession-fed ranks have swelled to 46.3 million — are central to the health care debate in Washington and the questions about how and whether to get them covered are as vexing and emotional as they come.
Should those without health insurance be required to buy it, and should they get government subsidies to help with the cost? Where will they get the coverage — from private insurance companies or a new government program? How much should they have to pay? Can they be denied for smoking, for having a chronic disease, or for a past heart attack?
While the nation waits for Congress and the White House to come up with answers, those who live without insurance say they are waiting scared.
Patrick Bruce, 61, of Isle of Palms, S.C., says the fact that he's been uninsured since his 2002 heart attack and triple bypass is "always in the back of my mind."
He says he eats right, doesn't smoke and exercises — efforts he hopes will keep him healthy until he qualifies for Medicare in four years. "I hope this health kick that I'm on works," he says.
Others worry about missing cancer screenings that could save their lives or fear that one accident or serious illness will leave them with a lifetime of debt. Some wrestle with whether it makes more sense to save for retirement or pay for health insurance.
"We are the only democracy … the only wealthy nation that allows such hardship for millions of its people," PresidentObama told a joint session of Congress on Sept. 9, in an effort to jump-start his revamp of the health-care system.
Obama has conceded that his plan would not cover all of the uninsured. It also would not provide insurance to illegal immigrants.
Republicans such as House Minority Leader John Boehner of Ohio argue that the government can't afford to spend up to $1 trillion on health care changes. But Obama has pushed for a government-run "public option," saying such a program would help bring costs down for everyone by giving insurance companies some competition.
"Every day, 14,000 Americans lose their coverage," Obama said. "It can happen to anyone."
Numbers from the U.S. Census Bureau for 2008 illustrate the point. About 27% of adults age 18-34 are uninsured. About 13% of those 35 or older are also uninsured. More than half of the uninsured are minorities. Being uninsured isn?t just about being out of work: About 27.8 million people ?without coverage are working, either part or full time.
The uninsured come from different backgrounds, but as a group, they are vulnerable, they are frightened and some of them are angry. These are their stories.
Five faces of the uninsured
Single mom wants quick action on Capitol Hill
A year ago, Porchia Lewis had a full-time job testing sensors used in Fords, Cadillacs and other cars.
Working full time for $11.25 an hour, the single mom, 25, says she brought home enough money to take care of herself and her three children, ages 2, 3 and 6.
Then, the recession hit. No where did it hit harder than in Lewis' hometown of Elkhart, Ind., where the unemployment rate soared to more than 18% as the city's once-thriving recreational vehicle industry bottomed out.
Roughly one in five workers in the area, including Lewis, are out of a job. "I haven't had insurance ever since," she says.
Her children qualify for a state-run insurance program but Lewis says there's nothing available for her. She says she can't afford to buy a policy when she's trying to survive on $329 a week in unemployment benefits, money she continues to get because she's studying for a new career as a medical assistant.
Rent on her tiny apartment is $535 a month, and after she pays her bills, Lewis says, there's almost nothing left.
"There are times when I don't have gas for my car," she says, adding that she never takes her kids out to eat or to a movie. She even potty-trained her baby at the age of two so she wouldn't have to buy diapers.
"I have to be very careful" with money, she says.
Lewis says she has a little asthma that doesn't bother her much any more. It worries her that she can't get physicals, cancer screenings and blood work.
"I know I need to go see a doctor for pap smears and yearly checkups, but I really can't afford to," she says. "If I was to have cancer, I may not know it. That scares me."
Lewis doesn't follow the debate in Washington very closely. She just hopes the politicians do something to help people like her, whether it's expanding Medicaid, the federal program for the poor, offering subsidies to buy insurance or something else.
"I just want something to happen soon," she says.
By Mimi Hall
History of heart disease puts coverage out of reach
Patrick Bruce had a top job in corporate marketing and a big house in Windermere, Fla. His kids went to the finest schools.
In 1992, he says, his family was "living the great American dream."
Today, Bruce rents a 500-square-foot cottage near Charleston, S.C. He shops at garage sales and second-hand stores. And his health care comes from a free clinic for the poor.
Bruce's fall began nearly 25 years ago, in 1985. After 15 years working for Disney, McDonald's and Red Lobster, Bruce decided to go into business for himself. He was covered through his wife's health insurance until 1993, when they divorced. Then he started paying for his own policy at $187 per month.
By 2002 he says he was paying $400 a month. That's when he decided to drop his insurance coverage with plans to reinstate it in a few months' time when a friend said she'd be able to help him get a cheaper policy.
Bruce was fit, had no health problems. What could happen? A massive heart attack in July.
The fees for his triple bypass a bill he has never paid came to $71,000. Bruce, now 61, has been uninsured ever since.
As a self-employed worker, he can't afford the $1,800 or so a month insurance companies have quoted him for someone with a history of heart disease.
Instead, he pays $34 a month for a cholesterol-lowering drug and gets his blood pressure checked at the clinic. He watches his weight. But he gets no cancer screenings, no colonoscopies or prostate tests.
If Congress doesn't pass a bill that helps make insurance affordable, he can enroll in Medicare at 65.
"I'm not necessarily a big Obama fan," says Bruce, a self-described lifelong Republican until his heart attack. "But when he was talking (on Sept. 9 to Congress), it was like he was talking to me."
By Mimi Hall
Earns too much for free care but not enough to buy
Ratana Lim says he plays by the rules.
Born in Vietnam and raised in Los Angeles, Lim says he went to the University of California-Berkeley, "got a degree and got a full-time job" and yet he can't afford the health insurance he needs.
"I'm a little bitter about it," says the 31-year-old account executive. Lim works full time for a natural foods company that stopped offering insurance to its 15 or so employees early this year.
Lim says he makes $48,000 a year, not a ton of money for someone who lives in West Hollywood, Calif., a small celebrity-laced city nestled between Los Angeles and Beverly Hills. He estimates about a third of his income goes to pay the rent. Private health insurance would cost him about $700 a month, he says, because he has a pre-existing condition, HIV.
"I don't know how my health is right now," says Lim, who is single and can't afford the drugs that can keep people with HIV healthy for many years. "I haven't even had my teeth cleaned in several years. There are basic needs I haven't met."
Lim says he now makes too much money to qualify for care at a state-run free clinic, something he used when he was unemployed.
He says he's not sure what to do about the situation. He doesn't want to leave California, but he says he may have to go live in another country that provides health insurance to all of its residents if a new health care bill doesn't bring down costs substantially so small companies and individuals can afford coverage.
Obama says his plan would require all but the smallest companies to provide health coverage to workers and ban insurers from denying insurance to people with pre-existing conditions.
"There's a voice inside me that says I need to move to Canada," says Lim, a U.S. citizen. "I also have a sister in France, so I'm thinking about that."
By Mimi Hall
Lacking coverage, she fears return of cancer
Cindy Shawcross fears the cancer she beat back last year, but without insurance the 38-year-old can't afford the scan to confirm she's still in remission. Instead, she waits and worries.
A former paralegal who lives in Fargo, N.D., Shawcross lost her job and her health coverage in July after a car accident forced her to take time off work. Now, she's concerned her past health 6struggles will make it impossible to buy insurance.
"I didn't make any of these choices," says Shawcross, a Mexican-American who survived thyroid cancer. "They were made for me."
Insurance companies that deny coverage because of pre-existing conditions have become a leading issue in the health care debate this year. A July survey by the non-partisan Commonwealth Fund found 36% of people who tried to buy insurance on their own, or 12.6 million people, were denied or charged more because of prior health problems.
Shawcross knows it's important to keep a policy active to avoid being denied coverage. When health benefits weren't offered at a previous job she spent all of her retirement savings on a $600-a-month policy that allowed her to temporarily continue her coverage. Now, there's no money left for health care.
So when her doctor recently ordered an ultrasound scan to ensure that her cancer was gone, Shawcross agreed but then called later to cancel the appointment. She is also waiting to address a lump she found in her breast until she can find an organization that will provide a free mammogram.
Shawcross says she supports efforts to change the health care system specifically a provision that would prohibit insurers from denying coverage for prior conditions. Without that, she says, she isn't sure what she'll do.
"I'm scared. I've already had cancer once," she says. "I'm scared of leaving my children."
By John Fritze
After expenses, little left even for the middle income
As a legal secretary who worked only at big law firms, Alexandra Mitchell had top-notch health insurance all her life. Two years ago, she left her $85,000 -a-year job in Dallas and moved out of state for nine months to care for a nephew who needed help.
She couldn't afford the $625-a-month payments to continue insurance through her old firm. When she got a temporary job in Arkansas at a small engineering firm, she couldn't afford their insurance rates either.
So, she went without, figuring that when she got back to Dallas, she'd get another job at a big firm and she'd have health insurance once again.
But when Mitchell got back to Texas in the summer of 2008, the recession had started taking a toll on the job market. "I could not find a job in a law firm to save my soul," she says.
After doing temp work for a year, she finally landed a full-time job just weeks ago.
"Things are looking up," says Mitchell, who is single. But she's still not back where she started.
Her new job is for a one-lawyer practice and there's no health insurance offered. She earns $60,000 a year in an expensive urban area that she says only "gets you this: a relatively safe neighborhood, a car that works most of the time and a way to feed yourself."
So Mitchell, 49, has decided to go without health insurance. She says there's little money left over after she pays her bills, "never mind saving for retirement."
If Congress passed subsidies or tax breaks for people like her, Mitchell says she might be able to pay for a health insurance policy. In the meantime, she says she'll soon look around again for coverage she can afford, but she doesn't expect to find it.
"This isn't just happening to poor and/or uneducated people," she says. "It is happening to middle-income people by the millions."
By Mimi Hall