Civil Law

It took a hurricane for Trudy Robinson to realize how much she took health insurance for granted.

A teacher for 22 years, she had covered her family through a policy with the New Orleans school district. When she, her husband or her children got sick, Robinson didn't worry about the bills.

Earlier this month, that sense of security ended. Along with 7,500 other school district employees, Robinson learned she was losing her medical coverage and her job. Now she doesn't know how she'll pay for care.

"It's just such a burden," said Robinson, whose home in New Orleans' Lower 9th Ward and everything in it were ruined by Hurricane Katrina. "You work all your life and you count on that protection. Except something like this comes along, and then it's gone."

Tens of thousands of people struggling to recover from Katrina are learning what it means to slip into the ranks of the uninsured and how hard it can be to climb out.

Many common events--a divorce, a death, a job change, a serious illness, company layoffs--can lead to economic dislocation and the loss of job-sponsored health insurance, the primary source of medical protection for most U.S. families.

The storms that swept through the Gulf Coast highlighted just how easily it can happen, surprising and alarming many who thought they could rely on employer-sponsored health coverage.

Grace Lomba, 60, a high school guidance counselor, discovered in November that she has early breast cancer. Her insurance policy with the New Orleans school district is being canceled at the end of January.

"My home and my car, I can replace those if it comes to that," she said. "But having no health insurance, that makes me very nervous, wondering if I'm going to get the treatment I need."

Blue Cross and Blue Shield of Louisiana estimates that 200,000 men, women and children in the state who had health insurance through the workplace will lose those benefits as financially stressed organizations terminate staff or go out of business altogether.

Experts believe this is one of the largest groups to lose medical coverage because of a single event in the nation's history.

An underinsured state

Even before the hurricanes, 866,000 of Louisiana's 4.4 million residents were uninsured--a function, in part, of high poverty rates and lower than average rates of employer-sponsored coverage. Now, the situation is expected to worsen as employers cut costs in an effort to survive.

"What these hurricanes have demonstrated is that having insurance for most adults is only as good as having a job ... and that relationship can be tenuous," said Dr. Fred Cerise, who heads Louisiana's Department of Health and Hospitals.

Louisiana has done what it can to help, given scarce resources. Immediately after the storm, state officials required insurance companies to keep medical policies active even if premiums hadn't been paid. But those rules expired at the end of November, and now companies such as Blue Cross and Blue Shield of Louisiana are preparing to cancel policies if employers don't pay their bills.

"We have exhausted what we can do to keep people's insurance in force, and we are very concerned what will happen next," said Gery Barry, the company's chief executive.

One possibility is that displaced workers will drift in and out of temporary jobs, sometimes having medical coverage and sometimes not. This phenomenon, known as "health insurance churning," is widespread, new research shows.

In an analysis of two years of data, researchers at Columbia University's Mailman School of Public Health found that more than 20 percent of Americans younger than 63, or slightly more than 50 million people, go through periods without insurance that typically average less than a year. The study was published in September by the Commonwealth Fund, a nonpartisan foundation working to improve health coverage.

By contrast, 9 percent of Americans, or about 20 million people, were considered chronically or permanently uninsured.

These periods in and out of coverage testify to instability in the job market, especially for low-income workers. Even if short in duration, gaps are risky for people with underlying medical conditions, who are less likely to see a doctor and receive follow-up care during those periods, the authors note. Those who are the most seriously ill may have difficulty securing new coverage.

Employment outlook is bleak

In Louisiana, no one knows how many uninsured workers will be able to find new jobs, how long it will take them to do so or whether those positions will provide medical benefits.

Next year, employment is expected to decline by 279,000 jobs from 2004 levels in New Orleans alone, according to the Louisiana Economic Outlook, prepared by economists Loren Scott and Jim Richardson.

Few newly unemployed people will opt to purchase insurance on their own, experts predict.

"If you've been displaced by a hurricane, you're not going to be able to afford it," said Wilson Boveland, director of member rights for United Teachers of New Orleans, a union.

For jobs that remain, benefits may be reduced.

"It is hard to see how a business struggling to recover can even be as generous as it was in the past," Don Smithburg, head of Louisiana State University's public hospital system, recently told a meeting of public hospital executives.

Making matters worse, the city's hurricane-devastated health care system is poorly prepared to take on the burden.

Charity Hospital, a renowned public institution that served the uninsured, was damaged beyond repair and has closed its doors indefinitely, leaving the burden of caring for this population to others. Meanwhile, thousands of doctors have left the area, and eight local hospitals remain closed.

At Ochsner Clinic Foundation, one of three New Orleans-area hospitals that continued operating during and immediately after the hurricane, the number of patients who have no way of paying for care has tripled, said Warner Thomas, its president. Other institutions report similar increases.

"The fewer paying patients there are, the harder it will be to rebuild adequate clinical capacity and serve the medical needs of citizens returning to this region," said Barry, who has lobbied the federal government to provide financial assistance to help displaced workers pay health insurance premiums.

Waiting for federal help to materialize may be the only option state officials have at the moment.

But for Elaine Maldonado, a 52-year-old single woman who has lost her job of 17 years and her health insurance, waiting for care could be fatal.

Maldonado was told she had breast cancer after a mammogram in March. Choosing aggressive therapy, she had her right breast and several lymph nodes removed.

Expensive medicine

Since then, Maldonado has been taking Arimidex, an expensive hormone blocker that could help prevent the cancer from recurring. The medication costs $300 for one month's supply; with insurance, Maldonado was paying $35.

Hurricane Katrina destroyed Maldonado's home in St. Bernard Parish, just outside New Orleans, and flooded the ceramics component division of Spectrum Control Inc., where she worked. Spectrum Control laid off Maldonado and 137 other workers at the Louisiana division at the end of October, according to human resources manager Bob Bowles.

Now that she's uninsured and living in Isabel, La., Maldonado has to pay for her Arimidex prescription on her own and for visits to doctors to monitor her condition.

Her unemployment check of $200 a week is barely enough to cover rent, food, car payments and gas, much less those expenses.

Because she's a single adult, Maldonado doesn't qualify for Louisiana's Medicaid program for the poor. Because she has breast cancer, private insurance companies won't offer her coverage.

And because she's living on the edge financially, she can't afford to continue coverage under COBRA, a program that lets most workers pay the full cost of their insurance for an 18-month period.

"I'm so scared," Maldonado said on a recent morning when she had only 10 pills left and no money to pay for another month's supply.

"I'm a responsible person. I've worked all my life. I never dreamed I could be in a situation like this.

"It just seems that every door that gets open gets shut again when I try to get help. How long can this go on?"

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jegraham@tribune.com