This is Covering the Uninsured Week, a national initiative to call attention to the 45 million Americans who do not have health insurance. The Roanoke Times is exploring how the issue is playing out in our region.

In part 2 of this series, we examine the issue from a business perspective and look at what kinds of programs are in place to help people without insurance.

Linda Nichols says she probably wouldn't be alive today if it weren't for the Free Clinic of Franklin County.

Since 1992, Nichols has gone to the Rocky Mount clinic for primary care. The clinic has helped her get the medication she needs to treat her diabetes and high cholesterol.

Without the clinic, "I would have to get two or three jobs to support myself, medical-wise."

The 50-year-old, who works 39 hours a week as a $6-an-hour security guard, would like to find a better job with benefits. But she said those jobs aren't easy to get.

"They ask people to have a high school education, and I only went to 11th grade."

Nichols is one of the estimated 20.4 percent of people in Southwest Virginia who are uninsured. That means as many as 267,140 people in Southwest Virginia did not have health insurance in 2001, according to a study from the Virginia Health Care Foundation.

According to the study, an estimated fifth of Southwest Virginia residents did not have health insurance in 2001, the last year for which estimates are available. Nearly half of uninsured Virginians make more than $30,000, according to that Virginia Health Care Foundation report.

Nichols also is one of the millions of Americans who work and still lack insurance. National census figures show that more than eight in 10 uninsured people are part of working families, a category often described as the working poor.

An estimated 45 million Americans lack health insurance, according to U.S. census figures from 2003, the last year for which figures are available. More than 56 percent of uninsured people from the ages of 18 to 64 worked full time, according to census figures. (Children and the elderly are more likely to be insured under programs such as Medicaid, SCHIP  known in Virginia as FAMIS  or Medicare).

"People think of free clinics as sort of for the welfare sector," said Karon Jones, executive director of the Free Clinic of Franklin County. "But that isn't really the case. These are people who are working, but at low-paying jobs."

Or they may have been laid off from factories such as Lane Co., she said. (In 2001, the company eliminated 550 jobs in Rocky Mount.)

People are uninsured because they either can't afford health insurance on the job, they lose their job and their insurance, or they can't afford to pay for health insurance on their own, said Dr. Jody Hershey, medical director of the New River Health District.

Others may lose their insurance because of retirement, divorce or shift to part-time work. Some may choose not to buy it, gambling that they won't have health problems. Still others with pre-existing health conditions may find it too expensive to buy insurance as an individual.

Uninsured people are less likely to get treatment for medical problems, three times more likely to not fill a prescription because it costs too much, and four times as likely to require avoidable hospitalizations and emergency hospital care, according to Hershey.

At the same time, uninsured people are less likely to seek medical care when they need it, which can create worse problems, Hershey said. The Institute of Medicine reported that in 2002, about 18,000 deaths of people ages 25 to 64 could have been prevented if they'd had health insurance.

In this region, doctors, free clinics, hospitals, universities and other programs have served by default as a safety net for some of the people who lack insurance, Hershey said.

"But I don't think it's comprehensive. I don't think it's well-integrated. I think it's a patchwork fragmentation of institutions and financing and programs that vary dramatically from place to place," Hershey said.

Interviews with health care practitioners show that the population without insurance in Southwest Virginia is changing and reveal some of the largest remaining gaps in care for people without insurance.

When Jones first started working at the Free Clinic of Franklin County in the early 1990s, the average patient was a 30-year-old female, who was often single, had children and worked part time, she said.

In the past three or four years, middle-age men have become the largest patient population at the clinic, said Jones, a registered nurse who is now the clinic's executive director.

"The change in patient population is a direct effect of the loss of jobs, unaffordable insurance premiums and an aging population," Jones said.

Some of the men can't afford insurance on their salaries, Jones said. Others have chronic diseases such as hypertension, diabetes or heart disease that have progressed to the point that the men can't work anymore and they are waiting to qualify for disability or Medicare, she added.

The board of directors also is starting to address the Franklin County clinic's ability to provide health care despite citizenship status, an issue that has recently arisen there, she said.

"These people need care," Jones said. "TB is on the rise. If these people aren't getting care, it's something that's going to spread through the community."

Don Craighead, executive director of the Bedford Christian Free Clinic, said that clinic's typical client is a white female between the ages of 25 and 64.

Eileen Lepro, executive director of Kuumba Community Health & Wellness Center in Roanoke, said the population Kuumba serves has not changed significantly in recent years, though the number of Hispanic clients the clinic sees has gradually increased.

Lepro said the uninsured patients at Kuumba include part-time workers without benefits; small-business owners who can't afford insurance; people who are between jobs or chronically unemployed; and college students.

Dr. Scott Hansen, who also works at Kuumba, said he has seen cases in which children are covered by Medicaid but the parents are not covered. In a few other cases, the parents are covered by insurance, but they can't afford the increase in the premium to add children to their policy and they don't economically qualify for aid for their children, so they bring them to Kuumba for care.

As Hershey described, the range of care options for uninsured people varies widely from locality to locality.

Mental health care has been identified as a major need in the region, Hershey said. Roanoke and Blacksburg both have mental health clinics that provide free care for the uninsured who meet certain requirements.

But Jones said mental health care is a major issue for her patients. Free clinics are largely dependent on the good will of health care professionals who volunteer their time. A psychiatrist does volunteer at the clinic, but the need is so great that it can take three months for a patient to see the doctor, she said. And some of the patients Jones sees are so incapacitated by mental health issues that they cannot function at work or at home.

Several clinic directors also said the lack of dental care is a major concern. In one extreme case, an infection from a lack of dental care spread from the mouth of a patient in his 30s and damaged his heart, Jones said. She also said she sees women who are embarrassed to look for work because of missing teeth.

"You just can't find a dentist," Jones said.

And for all the help a free clinic can provide, it can only provide so much.

Linda Nichols

One of Linda Nichols' lungs was punctured in a bad car accident in 1996; in 1999, she suffered a heart attack. She was treated at Carilion Franklin Memorial Hospital.

She's still paying off the bills for the 14 days she spent in intensive care after the heart attack.

"I just wish I could find a better-paying job with benefits," Nichols said.

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Organizations that provide health care for people without insurance or help people register to sign up for services.

Many of the entities have eligibility requirements for residence and/or income level. Others provide only specific services, such as mental health care.

* Bedford Christian Free Clinic, Bedford, 586-3711.

* Blue Ridge Behavioral Health Care, Roanoke, 345-9841.

* Blue Ridge Independent Living Center, Roanoke, 342-1231 (assists people with disabilities).

* Bradley Free Clinic, Roanoke, 344-5156.

* CHIP (Child Health Investment Partnership), Roanoke, (helps parents register children for health insurance), 857-6993.

* Health Department, New River Valley District. Offices in Montgomery County, 381-7100; Floyd County, 745-2141; Giles County, 921-2891; Pulaski County, 994-5030; Radford, 831-5774.

* Health Department, Roanoke and Alleghany Districts. Offices in Roanoke, 857-7600; Botetourt County, 473-8240; Salem, 387-5530; Vinton, 857-7800; Clifton Forge, 862-4131; Covington, 962-2173; Craig County, 864-5136.

* Kuumba Community Health and Wellness Center, Roanoke, 362-0360.

* Project Access (specialists providing care), Roanoke, 344-4200.

* Free Clinic of Franklin County, Rocky Mount, 489-7500.

* Free Clinic of the New River Valley, Christiansburg, 381-0820.

* Free Clinic of Pulaski County, Pulaski, 980-2931.

* Pro Bono Counseling Program, Blacksburg, 951-4990.

* Rescue Mission Health Care Center, Roanoke, (health care for people who are homeless), 777-7669.

* Roanoke Valley Mental Health Collaborative, Roanoke, 344-0931.

* CHIP of the New River Valley (children's insurance), 633-2518.

* Med-Ride, 888-633-7433.

* New River Community Action, 633-5133.

* Radford University Clinics, 831-7660.

* Radford University FAMIS Outreach Project (health insurance for children), 831-7693.