• Employers, individuals face tough choices on health coverage

HAGERSTOWN — Randy Heavner Sr. runs his own landscaping company. Elton Horst works part time as a janitor.

Both looked into buying their own health insurance, weighed their risks and decided it was too expensive.

Neither counted on having his heart malfunction.

Their stories show the spectrum of assistance that is available for Americans who find themselves in the nightmare situation of needing lifesaving care without any health insurance to help pay for it, and their differing perspectives on health care reform highlight the deeply rooted feelings that split even those who would be affected most by reform.

‘I would have died’

Heavner, 52, of Clear Spring, said that with his family of eight children, he and his wife would have had to pay about $1,200 per month for health insurance. There was no way they could afford that, he said.

The family got by for almost 20 years with Heavner and his wife visiting the Community Free Clinic of Washington County, which serves uninsured patients for free, and their children covered by a state medical assistance program for children of low-income families.

That arrangement met their needs until a few years ago, when Heavner started feeling short of breath and tired all the time. In 2007, he brought up his symptoms at a visit to the clinic, and the staff sent him to Washington County Hospital for some tests.

“They found out my aorta valve was severely shut down and I really had, literally, days or months to live,” Heavner said.

The condition apparently was a birth defect that had gone unnoticed. Doctors said Heavner needed his aortic valve replaced, but when he found out the surgery would cost more than $120,000, he refused to have the work done.

“I wasn’t going to put my kids and family in this financial crisis that I knew we could never pay,” he said. “I would have died if it wasn’t for Dr. Dan McDougal.”

McDougal, a Community Free Clinic doctor, found a surgeon at Johns Hopkins who agreed to do the surgery for free, Heavner said. There would be other bills associated with the hospital stay, but McDougal said he would try to get those waived, too.

Heavner had the surgery in February 2008. Today, he takes a blood-thinning drug to reduce the risk of developing a blood clot due to the artificial valve, and he has his blood checked regularly, but otherwise leads a normal life, he said.

Heavner recently recorded a tribute to McDougal, who has Lou Gehrig’s disease, that was played at a fundraising event honoring the doctor.

“I thanked him for helping me and my family out,” he said.

‘Pretty much blindsided’

Horst, 63, of Hagerstown, said he was a competitive runner for 45 years. At 60, he was running 5K races at a seven-minute mile pace. So when he was laid off from a local furniture company and got a part-time job with Antietam Pediatric and Adolescent Care, he decided to take his chances without health insurance.

“I’ve been healthy all my life and had been very athletic and had made the assumption, which was probably very naive, that my YMCA membership was my health insurance,” Horst said.

In August 2008, Horst was on a machine at the YMCA when he noticed his heart was beating irregularly and decided to get it checked out.

He went to Washington County Hospital, where an echocardiogram showed he had mitral valve prolapse, a condition in which blood pumped from the heart’s left atrium into the left ventricle sometimes is able to leak backward. In severe cases, the condition can lead to heart failure, Horst said.

“This just pretty much blindsided me,” he said.

Horst said he eventually will need surgery to correct the problem, but for now, he is eating a healthier diet, going easy on the exercise and trying to stay out of the hospital until he turns 65 and qualifies for Medicare.

That strategy has succeeded so far, except for one incident in February, when Horst collapsed in his apartment. He was taken to the emergency room, where his heart stopped for 17 seconds, he said.

Doctors said the problem probably was brought on by the beta blocker Horst had been prescribed for the heart condition. Beta blockers lower blood pressure, and Horst already had low blood pressure, he said.

Each hospital visit — the first when he was diagnosed and the second in February — was only one night, but the bills for the hospital stay alone were more than $2,000 each. Separate bills for the doctors who treated him and for the ambulance ride brought his total for the two visits to almost $8,000.

Horst applied for the hospital’s financial assistance program, which provides discounts based on federal guidelines related to income, assets and household size. He qualified for a 20-percent discount.

By making payments totaling about $250 a month, Horst said he has been “slowly gnawing away” at the bills, but the debt still looms.

“I say some people pay on house mortgages, I’m paying on health bills,” he said.

To manage the payments along with his rent and living expenses on a part-time salary, Horst has relied on a roughly $5,000 “nest egg” he inherited when his father died.

“If I did not have that at this point, it would be difficult,” he said. “I even thought about selling my car.”

Assistance gaps

Horst said he applied for medical assistance, but was told he didn’t qualify because of his salary of almost $20,000 a year.

“That apparently puts me above the poverty line or something,” Horst said.

He also looked into buying private health insurance, but found there was no way he could afford it on top of his existing health bills.

Heavner said he, too, had run into problems with medical assistance programs and income guidelines.

After his surgery, the free clinic helped Heavner enroll in a state medical assistance program called Primary Adult Care (PAC), which provides free visits to a primary care provider. However, the program does not pay for cardiologist visits or the blood tests Heavner is supposed to get regularly because of the blood thinner he takes.

While he was enrolled in PAC, he couldn’t go to the free clinic for those tests, either, because the free clinic does not serve patients with any form of medical assistance.

“I would have been better off not having the state program and staying with the free clinic,” he said.

Recently, Heavner lost his coverage under PAC as well as his children’s coverage under the Maryland Children’s Health Program. Income guidelines for those programs take into account family size, and one of Heavner’s children recently turned 18 and no longer qualifies as a dependent, he said.

Heavner said he thought something should be done to make insurance affordable for those caught in the gap between qualifying for assistance and being able to afford private plans.

“I can never understand,” he said. “It’s the people that goes out and tries to work to make a living that can’t seem to afford their medical insurance.”

Heavner said a relative who died from cancer at 38 years old was struggling to raise two children alone, yet made too much money for medical assistance. His own mother sometimes doesn’t eat because she doesn’t have enough money for her prescription medications, he said.

“You’re caught in these positions where you don’t know which way to turn,” he said.

Reform views

Heavner said he believes health care reform is needed, but he has been watching the legislation in Congress closely, and doesn’t like what he’s seeing.

One of his biggest concerns is the effect the reform might have on seniors should a cut to Medicare be instituted to help pay for the legislation.

The AARP has said that none of the health care reform bills that have been introduced by Congress would cut Medicare benefits or increase out-of-pocket costs for traditional Medicare services.

Heavner said he also is concerned about the possibility that illegal immigrants could receive coverage under the reformed system and doesn’t like the idea of taxing people who don’t apply for insurance.

“We live in a free country,” he said. “I never heard such a thing.”

Horst, on the other hand, said he would like to see the country move away from private health insurance in favor of a system where everyone contributes, based on their income, to a public health care fund that would pay for care for anyone who needed it.

“It’d be like our Social Security,” Horst said.

He said the country has a negative knee-jerk response to “socialized” medicine, but the idea of insurance companies profiting from people’s ability to become sick ought to be the more repulsive idea.

“It’s a sad story that we do live in the wealthiest nation in the world and a person can’t assume health care,” he said.

Horst said part of the reason he decided not to buy insurance was that he didn’t want to become “insurance poor,” compromising his own happiness and well-being out of fear of a worst-case scenario.

“I don’t want to have to labor many, many hours just to try to make sure I have health insurance because I believe that’s absurd, but in any case, I’m reaping the consequences now of those values,” Horst said.

Keeping that in mind helps Horst resign himself to the constant threat posed by his heart condition.

“I’m only 63, but I’ve lived a good life, so whatever happens, happens,” he said. “That’s the way I feel.”