They started showing up before dawn. One thought she had pneumonia. Another worried that a trip to the emergency room would mean a second bill for thousands of dollars.
Everyone in the long line outside Charlotte Community Health Clinic in east Charlotte wanted to see a doctor, but no one had health insurance.
At 9 a.m., when the doors to the free clinic finally opened, the first 50 people crowded into the waiting room and started filling out paperwork. Outside, 67 were turned away.
“I'm very sorry,” said clinic staffer Amy Gemereth, who passed out flyers with names of other free health services.
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That was little consolation for Adrienne Waller.
“I've been trying to do this for two months,” said Waller, who moved from Las Vegas in December and hadn't yet found a job.
“I keep getting here earlier and earlier, and I keep getting turned away. This is ridiculous.”
These are the uninsured – more than 47 million Americans who find themselves, at one time or another, without access to health insurance in a country that spends more per capita on health care than any country in the world.
Most of these people have jobs. They just can't get, or can't afford, health insurance.
Nationally, only 18 percent of the uninsured are from families with no one in the work force.
“I didn't realize how close so many people are to the edge,” said Martha Brinsko, a nurse practitioner at the free clinic on Eastway Drive.
“They are landscapers, housekeepers, Wal-Mart employees. Some of them work three part-time jobs. Sometimes I'm overwhelmed at how hard they work.”
At free clinics in the Charlotte area, the demand keeps growing as the economy continues to sour and people lose jobs – and health insurance.
“It's just a Band-Aid,” said Charles Lee, past president of the Eastway clinic's board. “We can't serve them all.”
Most of the uninsured work
The problem is that insurance in the United States is mostly tied to employment.
Employers provide health benefits for about 54 percent of Americans, but the percentage of employers who offer such benefits has fallen from 69 percent to 60 percent since 2000.
That leaves lots of gaps. If your employer doesn't offer insurance and you don't qualify for government programs, such as Medicare for the elderly and Medicaid for the low-income and disabled, you're on your own. Your choices are to buy expensive individual insurance plans or go without.
In North Carolina, three out of four uninsured people are from working families, according to the N.C. Institute of Medicine. Most work in low-wage or part-time jobs.
“These are not people who are lazy,” said the institute's president, Pam Silberman. “They are working really hard and still can't afford health insurance coverage.”
The average health insurance premium for family coverage through an employer was $12,106 in 2007; of that amount, workers paid an average of $3,281. Since 2001, family premiums for employer-sponsored insurance have increased 78 percent, while wages have gone up only 19 percent.
Two-thirds of uninsured Americans have incomes below the federal poverty level, or $21,000 for a family of four. That means, even if their employers offer insurance, they can't afford to buy it, said Jennifer Tolbert of the Kaiser Family Foundation.
And then, of course, there are the unemployed. As Tolbert said: “We are all one layoff away from being uninsured.”
No shot would mean no job
That's what happened to Jocelyn Segura.
At 42, the Charlotte woman was laid off from her job working with the mentally ill in Mecklenburg County. In April, she applied for a job with another agency, but she needed a tuberculosis shot to qualify.
So she went to Charlotte Community Health Clinic on a day when the free clinic was taking new patients.
Segura arrived too late to get in, but she refused to leave and eventually caught the ear of receptionist Brenda DeArmint.
If she didn't get the shot that day, Segura pleaded, she would lose the job.
DeArmint brought her through the crowded waiting area and into an exam room, where nurse practitioner Brinsko gave her the shot for free.
Segura, who had been skipping her blood pressure medicine to save money, was stressed out for other reasons too. Her landlord threatened eviction if she didn't pay $1,200 in rent.
She also had past-due bills from a recent emergency room visit. She had gotten dizzy while driving, because of high blood pressure, and called an ambulance. After six hours and many tests, she got a prescription that she filled for $4 at Wal-Mart. But then she got the ER bill for $1,500.
“I cannot get another bill like that,” she said.
After the TB shot, Segura got the job as a Spanish translator. But she is called to work only a few hours each week.
“I'm struggling,” she said. “I have worked all my life, but … I'm not making enough money to pay my bills.”
Clinics partly fill the gaps
Free clinics are part of a fragile patchwork that fills some gaps in the U.S. health system.
Those who qualify can get primary care, free prescription drugs and education about how to prevent illness or control a chronic disease.
In Mecklenburg, the largest free clinic is Charlotte Community Health Clinic on Eastway Drive at Central Avenue, which has nearly 280 volunteers, including 40 doctors.
More than half of the Eastway clinic's $1 million budget comes from Presbyterian Healthcare, one of Charlotte's two large hospital systems. Presbyterian pays the rent and utilities, provides free lab and diagnostic tests, and pays the salaries of four clinic staffers.Still, the Eastway clinic turns away an average of 150 people a month. Those who can't get in often turn to emergency rooms. But in the ER, they encounter long waits and then receive bills for hundreds of dollars they can't pay.
“The average cost to go to the emergency room for a nonemergency is about $1,600,” said Amanda Berrier, executive director of the S.C. Free Clinic Association.
It would have cost a free clinic about $65 to provide that same service, she said.
Free clinics save hospitals from incurring medical bills for patients who can't pay. “It really does make sense to have a strong free clinic system,” Berrier said, “regardless of what we do about universal health care.”
Not having health insurance increases the likelihood that people will forgo or delay care. And that means they'll be sicker when they're diagnosed.
Blood sugar out of control
Diabetes is one of the biggest problems seen at free clinics.
If patients don't see a doctor and take their medicines regularly, blood sugar levels can get out of control. That can cause kidney damage, blindness and circulatory problems requiring multiple medications and possible amputation.
Sandra Hester, 59, is one of many free clinic patients with high blood sugar. When she arrived at the Eastway clinic earlier this year – unemployed and uninsured for the first time since she was 22 – her blood sugar was nearly four times normal.
She had left her job as assistant manager at a Concord department store in 2006 due to congestive heart failure and diabetes. Because she didn't have insurance or a steady income, she couldn't always afford to take insulin.
At her first free clinic appointment, Dr. Coleman Carter prescribed two different insulin drugs that she got free from MedAssist of Mecklenburg, a community pharmacy for the low-income uninsured. Four months later, Hester's blood sugar was still high, and she had gained weight.
“OK, let's work on getting a few pounds off to bring your sugars down,” Carter said.
She told him she had joined the YMCA and enjoyed water aerobics. “But I'm having problems. Sometimes I get extremely hungry, and I eat.”
Before Hester left the clinic, she signed up for a free weight-loss program. She also sat with health educator Jill Lipson who offered advice on checking her feet twice a day with a hand mirror to avoid scratches that could become infected.
Since then, Hester qualified for Medicare because of her disability. Starting Nov. 1, she won't need the free clinic anymore.
Classes teach prevention
Teaching patients how to manage chronic illnesses and prevent emergency room visits saves time and money for the health-care system and preserves quality of life for patients, said Nancy Hudson, the Eastway clinic's executive director.
Since November, her clinic has offered free diabetes classes that take patients on field trips to the grocery store and teach them to read nutrition labels.
Patient outcomes have improved as a result, said nurse practitioner Brinsko, who tracks patients' blood glucose levels. When she started, the average level was 10, compared to the normal range of 4.4 to 6.4. Six months later, after patients finished the classes, the average had dropped to 7.7.
The savings are incalculable, Hudson said.
“We're saving the function of their kidneys. … We're saving them from having heart attacks. We're saving them from long-term disability.”
Still, Hudson said, free clinics aren't the answer for a fractured health-care system.
“It shouldn't be left to us to figure out how we're going to provide health care for the masses.”