It was late September, and Travis George, a 27-year-old Waynesville resident, was almost done mowing his grandmother’s yard. With just five minutes left, his foot accidentally slipped right under the mower, chopping off three of his toes and part of his foot.

George was rushed to Mission Hospital in Asheville, where doctors performed surgery and cleaned up the gaping wound. A month later, George had to undergo skin graft surgery.

George was able to get Medicaid to pay much of the $30,000 bill, and he received about $1,000 from his grandmother’s homeowner’s insurance, but $7,000 must come out of his own pockets.

Unfortunately, George has not been able to find a new job after being laid off from his job as land surveyor last Christmas.

Now he’s caught in the middle. George no longer qualifies for unemployment, since he is no longer able to work. Yet he cannot receive disability benefits because he will be able to return to work in less than a year.

“Ever since I got hurt, I have no income,” said George.

George said he almost didn’t qualify for Medicaid because of his wife’s income as a bank employee. While her health insurance covers their two children, George said adding him to the policy would result in outrageous costs.

“She would end up paying more for our family’s insurance than she would take home,” said George “It’s unreal.”

For George, the problem with the health care industry is tied to the greed of insurance companies. Despite taxpayers picking up the tab for part of his medical bill, George said the government should not be responsible for everyone’s health care.

George supports opening up competition among insurance companies across state lines to lower prices instead.

“I don’t think the government should make everybody pay,” said George. “I had a terrible accident, trying to get help as I can, but the rest of it I’m responsible for. That’s the way it should be.”

Two Waynesville companies recently decided to assist George by holding a chilly cook-off fundraiser to raise donations for his $7,000 payment.

“That’s helped out a little bit,” said George. “Other than that, I don’t know how I’m going to pay that balance.”

Bridget Nelson, 40, graduate student at Western North Carolina

Nelson was required to get health insurance after enrolling at WCU though she said not having insurance previously didn’t bother her.

“I view insurance companies as legalized organized crime.”

Nelson considers herself a healthy individual who would probably only use health insurance for medical emergencies.

While working for a nonprofit, she once faced the awkward situation of receiving good insurance coverage through her employer but being unable to extend that coverage to her two children. Nelson eventually acquired Medicaid benefits for her kids, which helped cover costs when her daughter broke her arm.

In Nelson’s view, health care reform should be a national priority. She said a single payer system would make more economic sense than the current wars in Iraq and Afghanistan.

“We’ve spent trillions on apparently useless wars, so if you’re willing to spend on that but not health care, there’s a priority problem.”

Amy Tucker, 24, server at Ryan’s Family Steak House in Sylva

Tucker is on her father’s company health insurance policy but has a $5,000 deductible, which means she usually pays for “pretty much everything.”

Tucker says she is against the health care bill. “I don’t think that it should be free for everyone,” said Tucker, “[But] everyone should have some kind of coverage.”

Tucker said she’s more in favor of an assistance program than universal health care.

Sunshine Cochran, 33, server at Ryan’s Family Steak House in Sylva

Cochran is considering buying health insurance through her job, but as of now, she has none. She said the health insurance rates through Ryan’s are pretty reasonable. “I just gotta make sure it fits my budget.”

Cochran has received Medicaid benefits when she was pregnant with her five kids, who are all on Medicaid now. But she is still paying off a $15,000 debt she incurred after breaking her arm in a car racing accident.

Cochran was able to pay the $900 upfront cost, but she hopes to avoid landing in the same situation in the future.

“I try to stay away from getting hurt.”

Kirk Childress, 22, manager of Black Rock Outdoor Company in Sylva

Childress will soon get a monthly allowance for health insurance after being promoted to manager at the store. Before that, however, Childress did not have health insurance of any kind. For Childress, the choice was between paying for health insurance or paying for a car. He chose the car.

“I’ve always been healthy. I’ve never had a problem.”

Childress says his approach to health care has been more reactive than pro-active. He once had a serious spider bite that needed to be treated. A friend’s father, who happened to be a doctor, was able to call in a prescription for antibiotics to take care of it.

Childress said those who cannot afford health care should be given the minimum for family doctor visits and emergencies, but he said most people should purchase health care for themselves.

Sheryl Rudd, 49, and Dieter Kuhn, 54, co-owners of Heinzelmannchen Brewery in Sylva

Rudd and Kuhn choose not to pay for health insurance, relying on natural medicine and wellness instead. They had been paying monthly premiums for a policy with a $5,000 deductible but decided to drop the insurance.

“Nothing was being covered,” said Rudd, adding that the insurance company would not help pay for her to see her preferred doctor.

Kuhn admits that not having health insurance places more responsibility on the individual to stay well and handle any resulting financial responsibilities.

When it comes to health care reform, Rudd said she is not in favor of placing more burdens on businesses through regulations.

“That’s not fair,” said Rudd. “That takes my choice away.”

Instead, Rudd would like to see everyone in the country get the same health insurance that Congress receives.

“But what they’re proposing, I’m against,” said Rudd.

In an effort to boost recruitment of doctors to the region, hospitals across Western North Carolina are following in the footsteps of a national trend to employ physicians in-house.

Historically, doctors set up independent, private practices.

But doctors are increasingly being squeezed by rising overhead and lower reimbursements for Medicare and Medicaid patients. As a result, doctors are gravitating toward a new model of being employed directly by hospitals. The hospitals keep the revenue generated from the patients, while providing a steady salary to the doctors.

“It allows them to do what they were trained for, the clinical work, and let someone else handle the administrative side,” said Tim Hubbs, CEO of Angel Medical Center in Franklin.

Whether it’s disciplining chronically late employees, shopping malpractice rates or billing insurance companies, “It is nice to say ‘Hey, can you all just handle that?’” Hubbs said.

Sylva-based WestCare is leading the hospitals west of Asheville in the number of physicians employed in-house. WestCare employs 19 physicians across six practices. Angel Medical Center employs 13, while Haywood Regional Medical Center employs five.

WestCare CEO Mark Leonard said the trend reflects a generational preference among younger doctors. He cited a recent survey of medical school grads at Duke University where 74 percent said they would rather be employed upon graduating than go into their own private practice.

“This really reflects a generational shift on the part of new physicians entering into medicine,” Leonard said. “It was incumbent on us to shift and embrace this new way of doing business.”

Leonard said he understands why the new model is attractive to today’s younger doctors, citing the long shifts doctors pull simply to care for their patients.

“When you put on top of that being a business owner and doing the taxes and the personnel issues, that causes the hours to stack up,” Leonard said. “These new physicians coming out say, ‘I just went to medical school and I want to emphasize the clinical side of medicine.”

Haywood CEO Mike Poore added that young doctors aren’t eager to follow the rigorous on-call schedule that had their older peers chained to beepers most of their lives. They want a steady salary and more free time.

Balancing autonomy

The only downfall of the model is a potential loss of autonomy. Doctors can suddenly find themselves answering to a hospital CEO, unlike a private practice model where they answer to no one but their patients.

All three hospital CEOs interviewed for this story said they recognize the concern.

“When I go to my personal physician, I don’t want to be thinking that there is a suit in another room influencing how he is going to care for me, my wife or my children,” Leonard said. “I want his decision to be based on what’s in my best interest as a patient.”

At WestCare, Leonard said he has laid the foundation of trust between physicians and administration and a collaborative decision-making model, which should in turn allay such fears.

“I am not a physician. I did not go to medical school. I am going to rely on and trust the physician’s judgment when it comes to clinical decision-making,” Leonard said.

Hubbs also pledged a hands-off management style when it comes to medical care.

“If a physician says I think we need a CAT scan on this, we are not going to second guess that,” Leonard said.

For Dr. Bruce Lobitz, an ER doctor who joined a team of hospital-employed doctors in the Angel emergency room this year, the possibility of hospital administration intruding on his care of patients was a top concern.

“That was one of my hesitations,” Lobitz said, who has found it not to be the case, however. “Here, there is very little of that.”

While it might give some physicians pause, the positves seem to outweigh the negatives.

“There is some trepidation in the loss of autonomy,” said Dr. Charles Trenthem. “But if you look at the trends nationally, this is what’s happening.”

While the nonprofit hospitals in the mountains have a community minded philosophy, larger for-profit hospitals could take advantage of the employment model.

“They do have a profit model, and they do push the providers at all levels to see that one extra patient, to generate that one extra charge,” said Dr. David Farley, an internist at Angel Medical. “I have not seen that be an issue here.”

Hubbs said there are external controls to ensure hospitals don’t prod physicians to order more costly tests than a patient really needs just to boost revenue. The insurance companies or Medicare who get stuck with the bill would notice an outlier ordering gobs of tests, Hubbs said.

There is one upside for patients: fewer bills. Anyone faced with a hospital stay braces for a litany of separate bills trickling in for lab tests, X-rays, various specialists and the hospital itself. Poore said bundled payments — where the bill for doctors is included with the bill from the hospital — is a model that shows promise.

Hospitals employing a critical mass of in-house doctors will often house them in a joint practice, even if they aren’t in the same specialty. It allows for integrated patient care, providing quick access to charts and reducing the chances of two doctors ordering the same test.

“Really it is kind of a data flow issue that is so clumsy in medicine right now,” Farley said. “If you’re housed in the same unit, you can walk down the hall and say ‘What did you think of Mrs. So-and-so this morning? Should I be concerned about this?’ You don’t have that when you are all scattered around in separate pods around town.”

Making the transition

While urban hospitals have launched a large-scale transition toward employing doctors, rural hospitals are using the model primarily to lure new recruits or to stabilize a faltering practice in a specialty the hospital can’t afford to lose within its medical community, said Dr. David Farley, an internist at Angel Medical.

“In this town, most of the employed physicians are the new recruits,” Farley said. “The existing doctors have remained solo, but I don’t think you can predict that will continue.”

Farley said the new model could be enticing to physicians at different points in their career, like a physician nearing retirement who wants to go part-time and no longer wants to deal with the hassle of managing a private practice.

As the new model develops, the result is a hybrid of traditional private practices and hospital-employed physicians within the community, Leonard said. Leonard largely follows the preferences of the doctor being recruited. If there is an existing private practice in the community the doctor wants to join, the hospital simply plays matchmaker.

When a doctor joins an existing practice, they are often expected to make an upfront investment.

“They buy in to do their fair share,” Poore said.

In Haywood County, both models exist within the same orthopedics office. Western Carolina Orthopedic Specialists has three doctors, two of whom own the private practice, while a third, Dr. Gerald King, is an employee of the hospital.

The hospital pays Western Carolina Orthopedic Specialists a management fee to covers King’s share of overhead, from office space to secretarial staff. The hospital also pays Kings salary.

In exchange, the hospital gets 100 percent of the revenue generated from King’s patients. It also benefits from having an orthopedist in the county who will bring business through the doors of the hospital. The hospital was suffering from a chronic orthopedist shortage that led patients unable to get appointments locally to take their business outside the county.

Haywood Regional Medical Center recently bought out Haywood Women’s Medical Center, the only Ob-Gyn practice in the county. The hospital now owns the practice and the doctors are employees of the hospital.

It was one of the first moves toward hospital-employed physicians in Haywood. The Ob-Gyn practice was a good starting place for several reasons, Poore said.

For one, doctors who deliver babies have some of the highest overhead.

“The malpractice is unbelievably high,” Poore said.

But the service is so crucial, no well-rounded hospital could afford to be without it.

“Our goals was to keep a viable Ob-Gyn practice in Haywood County,” Poore said.

Buying out an existing practice is more complicated than setting up the arrangement from the get-go with new hires. The process took six months and required outside consultants to help arrive at a fair purchase price.

Getting squeezed

The new model is particularly attractive to doctors in a climate of decreasing reimbursement rates for Medicare and Medicaid patients. Doctors take a bigger hit in rural areas, where a higher percentage of patients are likely to be on Medicare or Medicaid. It makes the offer of employment — and the steady salary that goes with it despite the poverty level of patients — an even more important recruiting tool in rural areas, according to Dr. Charles Trenthem, an anesthesiologist and chief of staff at Angel Medical Center.

“If we weren’t employing physicians and subsidizing their practices, the health care in Western North Carolina would suffer,” Trenthem said.

Angel Medical recently got a special “critical access” designation for its hospital that gets it a higher reimbursement rate from Medicare and Medicaid. Physicians employed by the hospital also enjoy the higher reimbursement rate, since billing is done by the hospital itself.

The issue is particularly acute in emergency room settings, where doctors are likely to see a higher number of patients without insurance who have no means to pay their bills.

While ER doctors theoretically treat patients without regard for whether they can pay, it can influence doctors on a subconscious level, said Dr. Bruce Lobitz, an ER doctor at Angel. But as a hospital-employed physician with a steady salary regardless, it makes it easier for doctors to ignore a patient’s ability to pay when providing care.

“I don’t care about the patient’s payer status. The hospital takes care of all that,” Lobitz said.

The hospital is left to absorb the hit, which can be a problem for rural hospitals already operating on a paper-thin margin, Trenthem said. The model also saddles hospitals with the upfront investment of setting up a new doctor and shouldering the risk if patient revenue falls short.

“Costs are being shifted to these smaller hospitals,” Trenthem said.

But given the trend, they had no choice but step up to the plate and adopt the model.

“The days of a physician going out and hanging a shingle are kind of over now,” Trenthem said.

A long-awaited affiliation of the hospitals in Haywood, Jackson and Swain counties will become official in January 2010.

That’s when a newly created hospital company, dubbed MedWest Health System, will take over day-to-day operations for Haywood Regional Medical Center and WestCare’s two hospitals: Harris Regional in Sylva and Swain County Hospital in Bryson City.

At the same time, the two companies will enter into a management contract with Charlotte-based Carolinas HealthCare System, which currently runs 29 hospitals in North and South Carolina.

HRMC and WestCare officials say joining forces with each other and with Carolinas HealthCare will bring many benefits, whether it is gaining expertise in hospital management or buying medical supplies in bulk.

With the country mired in a recession and possibly headed toward an overhaul of the health care system, some hospital board members see the need to partner up sooner rather than later.

“It’s a no-brainer. Something’s gotta happen,” said Fred Alexander, chairman of WestCare’s board of trustees. “What do you want to be in the storm, the aircraft carrier or the two little PT boats?”

HRMC officials were especially optimistic about the new venture, likening their company to a phoenix rising and making multiple allusions to the “dark days” when Haywood Regional failed federal inspections and lost its Medicare status, followed by an exodus of private insurance companies. The hospital was forced to cease all but emergency operations, touching off a financial and public relations crisis.

“We’ve come a long way,” said Mark Clasby, chairman of the HRMC board.

“It’s a new day,” said HRMC CEO Mike Poore. “We are no longer looking toward the past. We are looking toward the future.”

Vying for CEO

In the next few weeks, the new board of directors for the joint venture will have to decide who will become MedWest’s CEO. Both HRMC CEO Mike Poore and WestCare CEO Mark Leonard are vying for that position though they publicly downplay the competition.

“This is the right thing for all of our communities,” said Poore. “That’s more important than if I’m the CEO or Mark is the CEO.”

HRMC and WestCare will keep their existing boards, but they will retain autonomy in only limited areas, like approving credentials for doctors. Their main influence will be appointing representatives to the joint MedWest board, which will make most major decisions.

As of now, no name changes are planned for the three individual hospitals. The name “MedWest” will primarily be used for legal and accounting purposes.

“If we try to call this hospital MedWest tomorrow, a hundred years from now, they’re still going to call us [by the same name],” said Poore.

John Young, group vice president for Carolinas HealthCare’s western region, repeatedly stressed that his company was not interested in taking a dictatorial approach in running the three hospitals.

“We believe healthcare is a local event,” said Young. “Healthcare in this community will not be run out of Charlotte.”

Poore said the goal is to expand services locally, rather than send patients off on long trips to receive treatment at affiliate hospitals.

Advantages of partnering

WestCare has already experienced the benefits of affiliation in the past. CEO Mark Leonard said after Harris Regional Hospital integrated with Swain County Hospital, his company was able to improve services and introduce new programs.

Leonard said the goals with this affiliation are the same: reduce cost, improve patient outcomes, and expand services. The hospitals can split the cost of expensive new medical equipment they couldn’t afford otherwise. And by pooling their patient base, the hospitals can attract specialty physicians.

Linking up with Carolinas HealthCare, the nation’s third largest nonprofit public system, would also allow HRMC and WestCare to gain insight on best practices in financial management, staff recruiting, and safety and quality improvement.

Clasby said there are provisions for leaving the joint operating agreement, though he would not give specifics.

But leaving the agreement is far from anyone’s mind at this point, as HRMC and WestCare prepare to deal with a possible overhaul of the health care reform, an aging population, and a shortage in nursing and clinical staff.

“We want to be better strategically positioned,” said Alexander. “The last thing we want to do is just be a rural hospital hanging on by our fingertips.”

The joint board that will run the eventual Haywood Regional Medical Center-WestCare affiliation needs to have a sitting Haywood County commissioner as a permanent member, as one Haywood County commissioner is now suggesting.

Commissioner Mark Swanger worries that the interest of Haywood County’s citizens — who own the buildings and property at HRMC — could be compromised if a commissioner is not on the new joint board. HRMC now operates as a public hospital, and most of its dealings are subjected to the state’s open meetings laws. The new venture with Carolina’s HealthCare System will form a private nonprofit, entitling citizens to very little knowledge about the decisionmaking process.

Swanger’s reasoning makes good sense: “While I don’t doubt the motives of anyone involved in this now, 10 years from now we will have an entirely different cast of characters, so counting on the trust issue is not good business in my view. I think a commissioner needs to be part of the operating agreement so the citizens who have the financial investment in the physical plant of Haywood Regional are property represented.”

There’s little doubt among those who have been following the affiliation of WestCare and HRMC that the board members from both hospitals are working with the best interests of their communities at heart. The driving force here is to provide three communities — Haywood, Jackson and Swain counties — with stronger, better delivery of health care services for many years into the future.

What if, however, some kind of cataclysm occurs at Carolina’s HealthCare and its smaller entities become expendable or begin to be treated as mere profit centers for certain types of specialized care rather than as stand-alone hospitals? Or if a future CEO from Charlotte begins to make decisions without regard to citizens in this region?

The kind of scenario described above is not likely to occur, and we would hope that the board members from this region — whomever they are — would stand up for our citizens. But county commissioners — and most elected officials — typically operate from a different mindset because at any monthly meeting they face reminders that they serve the public’s interest, whether it is someone complaining about taxes or a neighborhood group seeking help about barking dogs disrupting the peace.

This one is easy. Citizens in Haywood County — and those of Jackson and Swain, for that matter — would have another measure of confidence in this affiliation if a county commissioner gets a seat at the table.

While neighboring hospitals count down the days until an affiliation is finalized, Angel Medical Center in Franklin continues to stand alone during a time when independent hospitals are becoming increasingly rare.

Angel Medical CEO Tim Hubbs said the small hospital is doing fine financially and is meeting its mission to serve the community. That said, an affiliation isn’t out of the question if the right one came along.

“That is something we always have to evaluate on an ongoing basis,” Hubbs said. “I don’t think they want to merge for the sake of merging. I think the sentiment is we want a strong local hospital.”

There can be financial benefits in a merger or affiliation with other hospitals, but it can also result in a loss of local control, Hubbs said. The two factors would have to be weighed when considering an affiliation.

“Can we get economies of scale and still have autonomy?” Hubbs said.

Roughly 70 percent of hospitals in North and South Carolina are part of a larger hospital system.

Haywood Regional Medical Center and WestCare, which serves Jackson and Swain counties, anticipate launching a new joint venture in January. The two entities will manage daily operations jointly, yet keep their assets and long-term balance sheets separate. The venture also calls for partnering with Carolinas HealthCare System, a conglomerate based in Charlotte with a network of 23 hospitals.

Angel was engaged in preliminary discussions of a merger with WestCare a few years ago, but it failed to materialize. Angel’s board of directors hesitated for fear of seeing some of their local medical services absorbed by Harris Regional Hospital in Sylva.

“We were afraid the focus would be in Jackson County,” Hubbs said. “We would like it to be in our best interest and not in the best interest of someone somewhere else.”

While Angel has an agreement with Mission Hospital in Asheville to house a medic helicopter at the hospital, there is no official partnership with Mission, Hubbs said. Angel was selected as a base for the medic helicopter largely for its strategic geographic location as a jumping off point for Mission to serve trauma patients in the far west.

Hubbs said no affiliations are on the table right now, but nothing is off the table either.

“I think they are receptive to things that make sense,” Hubbs said of Angel’s board of directors. “If we get to the point we can’t survive without it, then we’d have to consider it, but we are not there today.”

Haywood Regional Medical Center and WestCare are in the final stages of forming a partnership, with plans to launch a new joint venture as early as January.

The two entities will join forces under a new umbrella organization with a single CEO and new board of directors. While daily operations will be merged, the arrangement stops short of a full merger with the assets and long-term balance sheets remaining separate.

Haywood County Commissioner Mark Swanger questioned how the interests of the public will be safeguarded under a new joint venture.

Currently, Haywood Regional is a public hospital. The public and media are allowed to attend hospital board meetings, and finances, policies and nearly all its records are open. The new joint entity will be a private nonprofit, however, entitling the public to only very limited disclosure about operations.

Swanger said the new entity won’t be required to operate in a transparent manner, and thus the public’s vested interest in Haywood Regional could be thwarted.

Swanger expressed his concerns at a county commissioner meeting this week, which was attended by Mark Clasby, chairman of the HRMC board.

Swanger suggested a slot for a county commissioner should be a reserved on the new governing body.

“Has there been thought of having a county commissioner serve on that board to ensure our county government and citizens have as much transparency as possible?” Swanger asked Clasby.

Swanger said he wants to see a stipulation guaranteeing a Haywood County commissioner a seat on the joint operating board written into the bylaws.

“While I don’t doubt the motives of anyone involved in this now, 10 years from now we will have an entirely different cast of characters, so to count on the trust issue is not good business in my view,” Swanger said. “I think a commissioner seat needs to be part of the operating agreement so the citizens who have the financial investment in the physical plant of Haywood Regional are properly represented.”

Swanger asked Clasby to deliver the suggestion to the rest of the hospital board. The current hospital board will continue to exist once the new entity is formed, but which decisions will lie with the Haywood Regional board versus the new joint operation board has not been stipulated.

The new joint board will have 14 members: seven appointed by Haywood Regional and seven appointed by WestCare. County commissioners appoint the members of the Haywood Regional board, which in turn will appoint members to the joint operating committee, giving commissioners a small, albeit twice-removed, measure of control.

The battle over healthcare reform hit home in Sylva last week.

A crowd of more than 50 people gathered on Main Street at the foot of the historic courthouse Wednesday evening holding signs in support of a public health care option.

“We are in a critical time for trying to provide health care for all Americans,” said Carolyn Cagle of Sylva, an organizer of the event. “This debate is about real people. We can’t afford to wait any longer for real health care reform.”

Across the street, a small counter protest set up on the sidewalk. A handful of people waved signs denouncing the health care reform bill, equating it with communism and raising alarm bells over euthanasia.

“No one is saying there shouldn’t be some reform, but the answer is not a government public option,” said Carol Adams, the public relations chair of the Jackson County Republican Party. “The answer is not this bill that will cost trillions of dollars. The whole thing is out of control.”

Those in favor of a public option held candles to honor the millions of people across the country who are suffering because they can’t afford the health care they need. Several people stepped forward to share personal stories of suffering and financial ruin. Their ranks included those who lack of health insurance, but also those with insurance who were denied coverage by insurance companies or faced astronomical co-pays.

Karen Rice of Franklin described losing everything she owned to pay for her husband’s cancer treatment.

“Now I live as a Third world person in a singlewide mobile home. I’ve taken to washing my clothes by hand,” Rice said.

Rice challenged the fear mongering of opponents who suggest euthanasia will be imposed on the elderly.

“Who are the true death squads? The insurance companies,” Rice said, citing the refusal of their insurance company to pay for her husband’s pain medication in his final days of life.

Being let down by insurance companies was a recurring theme by those sharing stories.

“If you have something catastrophic in your life, it can cost you a whole lot of money,” said Martha Yonce of Franklin. Yonce, whose husband was a teacher for 35 years, faced $80,000 in out-of-pocket expenses in a single year despite having good health insurance.

“It more or less prevented us from retiring. We never have been able to catch up,” Yonce said.

Yonce sees competition from a public option and the only way to reform the modus operandi of capitalist-oriented insurance companies.

“I don’t see how insurance companies will ever be pushed to do the right thing,” Yonce said.

Lack of access to preventative care, particularly early cancer screenings, is a glaring failure of the current health care model, according to Marsha Crites of Sylva. Crites shared the story of a friend who couldn’t afford regular colonoscopies and is now dying from colon cancer. Crites shared the story of another friend who is divorcing her husband of 40 years so she can qualify for Medicare.

“These are crimes my friends,” Crites told the crowd.

Crites is still paying off hospital bills of her own that were accrued following a stroke eight years ago. The owner of Harvest Moon Gardens Landscaping in Sylva, Crites is self-employed and didn’t have insurance at the time.

Saddling employers with the burden of health insurance doesn’t work, according to Dr. David Trigg, a part-time emergency room physician at Harris Regional and volunteer medical director at the Good Samaritan Clinic in Sylva.

“We are the only industrialized country where employers have to pay for their employees’ health insurance,” Trigg said.

For Allan Lomax of Sylva, the inextricable link between employment and health insurance creates a scary gap every time he’s between jobs.

“It just doesn’t make sense,” he said.

Trigg chastised Congressman Heath Shuler, D-Waynesville, for his opposition to a public option in the health care bill.

“Don’t forget about your Christian ethic you cited when you were elected,” Trigg directed toward Shuler.

Too much government

Meanwhile, those against the bill waved miniature American flags from the other side of the street.

“I feel strongly socialism is coming into our country,” said Ron Gamble of Sylva. “It is not just health care. The current administration is taking over everything. I’m afraid we will lose our personal freedom and personal choice.”

Gamble is self-employed and pays $700 a month for insurance for himself and his wife.

“The health care costs are astronomical. They have to do something,” Gamble said. But the bill currently on the table is being rammed down people’s throats with not enough deliberation and input, he said.

Gamble’s grandchildren are among those who lack insurance, but have had their health care paid for by the government, thanks to either being on unemployment or their status as a veteran. Gamble said it was their choice not to have health insurance, as is the case with many young people, which skews the number of the so-called uninsured.

The opponents argued the number of people who don’t have health insurance is quite small compared to the overall population.

“You don’t change 90 percent of the people’s health insurance to accommodate 10 percent of the population,” said Ginny Jahrmarkt of Sapphire.

Ralph Slaughter, first vice chair of the Jackson County Republican Party, said the bureaucracy needs to be weeded out of the current systems before adding another huge program.

“Before the government tries to add on another social program, we need to effectively and efficiently run the programs we have. Once the government figures out how to do that, this bottom group could be absorbed into Medicaid,” Slaughter said.

An impromptu debate sprung up when a supporter of the health care reform bill strayed across the street to challenge those in the counter protest. A light drizzle fell on and off through the evening, forcing protestors on both sides of the street to don umbrellas at times.

An interesting show of unity emerged between the two camps when health care supporters gathered on the steps of the courthouse with their candles in hand and began singing America the Beautiful — prompting protestors on the other side of the street to join in the song.

This country must pass health care reform that accomplishes two major objectives: providing coverage for everyone and controlling skyrocketing costs. I believe that the bill must include a public option for those who are now uninsured. And just like automobile insurance, anyone who enters the workplace must be required to have health insurance, either from their employer, their own private plan, or from the public option.

Conservatives and liberals alike agree that our health care system is not sustainable in its present form. Employee-sponsored health care premiums doubled in the past nine years, rising three times faster than wages. American families spend more on health care than we do on food or housing. The Congressional Budget Office estimates that if costs keep increasing at the current rate, 25 percent of the nation’s economy will be tied up in the health care industry by 2025.

The fundamental questions for those advocating reform is how can we cover those who now don’t have access to care while controlling costs in an industry where price has become irrelevant? When is the last time you asked your doctor how much a test, an operation or a drug was going to cost?

According to The Wall Street Journal, the current system of employer-provided benefits “has divorced the consumer — the patient — from the real cost of services. It encourages excess spending, runaway lawsuits, defensive medicine (doctors ordering unnecessary tests and procedures out of fear of being sued), and huge malpractice premiums.”

•••

This is a complex issue, and understanding it has become even more difficult amid the tidal wave of misinformation that is circulating. It’s unfortunate for those of us who believe health care reform is critical that this debate is occurring during an economic crisis that has forced unprecedented government intervention into private industry. Both the outgoing Republican administration and current Democratic administrations supported government taking new and expanded roles to stave off a long-term economic disaster. Intervention to rescue the banking and automobile industries, along with Obama’s stimulus package, have further fueled the long-running fear of too much government intrusion.

The health care problems, however, can’t be solved without government intervention. Government is already the major player in the industry through Medicaid and Medicare. But here’s the truth — Obama does not support a government takeover of our health care. That’s not even being discussed and is a complete distortion of reality.

What he does want is a public option for insuring the 45 million people who currently don’t have health insurance. That option is the best chance for controlling insurance premiums, which in turn will prompt the insurance industry to work with health care providers to keep costs down.

There are other major problems on the other end of the healthcare spectrum that must be resolved as part of reform. Many who have insurance are denied coverage or reach their caps when they face serious problems like cancer or heart problems. Also, changing jobs with a pre-existing condition can be devastating, often leading to a denial of coverage or skyrocketing premiums. A plan for affordable portability of coverage must be included in any reform measure that is passed, along with measures that prevent insurance companies from denying coverage just when it is needed most.

Although I think the public option is necessary, compromises can be found. Some are suggesting allowing the insurance companies to develop low-cost plans for those who currently can’t afford care. This plan includes a trigger for a government option to come into play only if the private companies can’t get the job done. The public option is better, but a compromise that earned some Republican support might be the best possible solution — and the only way to get a bill passed.

•••

One issue that hasn’t been discussed much as part of this health care overhaul is personal responsibility. We can’t cut our health care costs substantially if Americans continue to suffer from chronic conditions that are preventable.

Our children are suffering from an obesity epidemic. Many of us eat too much and exercise too little. Go to any middle school in the country and observe the children. It is a sad thing to see so many who are obviously on their way to a lifetime of battling obesity.

I don’t have a problem paying taxes to provide health care for a working mom who has a full-time job that pays just above minimum wage and doesn’t offer healthcare benefits. I do, however, have a problem paying for those who cause their own health problems by eating badly, not exercising, and perhaps smoking. I’m not sure how it can be done, but we must encourage lifestyle changes that could substantially reduce total healthcare costs.

•••

Healthcare reform has discussed by nearly every administration since World War II, and we have yet to make meaningful headway. Congress has made more progress in the last six months on this issue than ever before, and citizens need to encourage their lawmakers to finish the job.

Health insurance reform has garnered a seemingly incongruous ally: the already well-insured workers of the State Employees Association of North Carolina.

The association held a forum in Haywood County last week to educate state employees on exactly what the 1,017-page health care reform bill entails. The meeting at Haywood Community College was one of several held across the state. The organization did not publicize the meeting to the masses to avoid a big turnout by protestors, but as a result the audience was small, numbering fewer than two dozen.

Will Cubbison, health care campaign director for SEANC, said his organization supported health care reform even though its members have quality health care coverage.

“Many of the spouses and children of state employees are not covered,” Cubbison said.

Speakers rattled off a barrage of statistics to win over the audience, mentioning the million-dollar profits of BlueCross BlueShield, the thousands of people who die each year because they do not have insurance, and the immense amount of time and money insurance companies spend on administration. Meanwhile, they disputed claims raised by opponents that illegal immigrants and abortions would be covered under health insurance reform.

The SEANC representatives directly admonished Rep. Health Shuler, D-Waynes-ville, who does not support H.R. 3200.

Dr. Ed Morris from Macon County, who was a guest speaker at the forum, suggested health insurance for members of Congress should be suspended until a reform bill passed, prompting the audience to break out in applause.

Morris, a family physician, added that he has seen at least two dozen doctors move away from the Franklin area because so many of their patients were unable to pay for their care. Given the lower average income of residents in the mountains, doctors here write off up to 23 percent of their patients.

“So these doctors end up going to Charlotte or Atlanta or somewhere,” Morris said.

Chuck Stone, director of North Carolinians for Affordable Health Care, said while many in the past considered the institution of Medicare as a move toward socialism, Americans now don't think twice about the government-supported health care. Stone asked members of the audience to raise their hand if they opposed Medicare, but no hands went up.

According to Stone, the cost of doing nothing is far greater than reform.

“The current system is unsustainable,” Stone said.

Amy Street thought she could finally afford health insurance this year. But that was before Street’s employer slashed 25 hours from her 40-hour work week.

Street, a 62-year old Waynesville resident, recently applied for retirement and social security benefits, but said while that would help, it’s simply not enough.

When Street was recently told she might have kidney cancer, she fretted about more than her health. She worried she would lose her car and her home trying to scrape up enough money to pay for expensive treatment. Even worse for Street was the possibility of no one being around to care for her disabled daughter.

“I was in shock. Sometimes, I cried. Sometimes, I said wait and see,” said Street.

Luckily, Street learned she did not have cancer, but her continuing kidney problems have driven her to seek on-going care at the Good Samaritan Clinic of Haywood County, one of the few free clinics in Western North Carolina. While she waited for her appointment on a recent afternoon, a fellow patient who did not want to be named said she found out she had cancer just the day before.

Patients like Street represent almost 19 percent of Haywood County residents who are uninsured, a figure that includes 1,400 children.

While the number who can’t afford health insurance is on the rise, free clinics like the Good Samaritan are facing economic woes of their own due to funding cuts, forcing them to scale back services at a time they are needed most.

The Good Samaritan Clinic, which has offices in Waynesville and Canton, has reduced services by 40 percent and is no longer accepting new patients, who once came in droves of 40 each week.

The clinic had 4,500 patient visits last year, but can only afford to see 2,590 this year due to financial constraints.

Haywood County cut half of its funding to the clinic last year and ceased its funding completely this year, although it still allows the clinic to use one of its buildings for just $1 a year.

Donda Bennett, executive director of the clinic, said there’s little the clinic can do but step up fundraising efforts.

“Our budget is cut and dry, as bare as you can make it,” Bennett said. “There’s nowhere to cut it and still provide quality health care.”

No free ride

At a time of increasing need, free clinics across the area have had to turn away patients.

“We’re seeing a huge number of new patients coming to the clinic. People that have either lost their job or lost their insurance or both,” said Jerry Hermanson, executive director of the Community Care Clinic of Highlands-Cashier. Patients there are now waiting as long as three weeks for their appointment, and though the clinic does allow walk-ins, it has had to send away patients “more and more,” Hermanson said.

Haywood County’s Health Department, which sees 1,000 mostly uninsured, Medicare and Medicaid patients each month, no longer offers clinic hours on Tuesdays and Thursdays and has eliminated five positions. The department’s budget has decreased to almost $4.9 million, compared to about $5.7 million last year.

While government support is important to free clinics, contributions from individuals are just as vital. The Community Care Clinic of Highlands-Cashier has seen donations from individuals fall 20 percent below what was budgeted this year.

The Good Samaritan Clinic of Haywood County is reaching out to individuals and local churches but is still below target.

“A lot of people just think, we’ve been around since 1999, so surely we’ve figured it out and are able to support ourselves,” said Bennett. “Some people might not just realize it totally depends on individuals and organizations.”

While securing grants would certainly help, these types of clinics face tough competition.

“Most grantors want to fund something new and innovative and fun,” said Bennett. But when free clinics can’t even afford basic operational costs, it’s hard to pursue creative projects like the ones that attract potential grantors

Becky Olson, executive director of the Good Samaritan Clinic of Jackson County, also acknowledged that securing grants has been a bigger struggle this year with less money and more competition.

“At this moment, I’m working on four different grants to get a little piece for here, a little piece for there,” she said. The clinic is also trying to get more doctors to volunteer to expand the clinic and accommodate the increase in demand for services.

Meanwhile, the Community Foundation of Western Carolina has recognized the needs of clinics like Good Samaritan and the Community Care Clinic, and provided assistance through its Recession Response grants.

And the Good Samaritan Clinic of Haywood County is receiving help from churches that have stepped up and added the clinic to their budgets.

Dalton’s Christian Bookstore in Waynesville is teaming up with the clinic for nearly three months, to offer customers an opportunity to donate to the clinic, while the clinic will go in and do blood pressure checks on customers.

Good Samaritan continues to give presentations to a lot of churches to hopefully raise awareness about the clinic’s existence, as well as its troubles.

Turning to the big guys

Good Samaritan has been in talks with Haywood Regional Medical Center for two months now to see if the hospital can contribute financially to the clinic, as well as donate medical and office supplies.

HRMC already donates thousands of dollars annually in free laboratory and radiological services to the clinic each year.

“The hospital really realizes that we are struggling right now. By us cutting services, it puts them in a situation where they have to see more people who are uninsured,” said Bennett.

For every patient who does not pay up for an emergency room visit, it costs the hospital an average of $400, according to Good Samaritan’s research.

Carole Larivee, a retired nurse who works part-time at HRMC and volunteers at Good Samaritan, said helping the clinic would be beneficial for the whole community.

“The hospitals can’t turn people away who come to the ER. By the time they get to the ER, treatment is very, very expensive because they had to wait so long,” Larivee said. “Even before I was with Good Samaritan, I would see people admitted to the hospital because they couldn’t go to the doctor for preventative care. They had to get very, very sick.”

By the time the patient got to the ER, it would sometimes be too late, she said. “Whereas, if they had been seen regularly, what was wrong with them could have been treatable.”

Hermanson said about 10 to 12 percent of patients at Community Care Clinic would go to the emergency room if the clinic were not open. But most of the patients he sees at the clinic do not say they would have rushed to the nearest hospital.

“We ask every patient on every visit, ‘If we weren’t here, where would you have gone?’” Hermanson said. “The vast majority of patients say we wouldn’t have sought treatment.”

Catch-22 for the underserved

Carmine Rocco, health director at Haywood County Health Department, emphasized the need for the public to do their best to stay healthy, especially now.

“As more folks become uninsured, it’s even more crucial now that people do what they can personally to help reduce the risk factors that they have control over,” said Rocco.

The underlying issue, though, is that uninsured people who face a chronic condition have trouble managing what would be easy to handle — if they could afford care.

“Most people don’t worry about prevention if they feel well,” said Hermanson. “They may be diabetic and not treating it. Promoting wellness is a great thing, but getting it accomplished is another.”

Hermanson said one of the first patients at his clinic came in with a blood sugar level of more than 500, when 105 is the highest end of normal.

“It’s people like that who end up in the emergency room,” he said.

Street confirmed that it has been difficult for her to stay healthy without insurance.

“It’s really frustrating because you want to be ahead of the game to keep yourself healthy, but you can’t afford to do that,” she said. “It’s disheartening.

Even when patients get in through the door at swamped clinics, some have concerns about the quality of care.

Cynthia Teesateski, 49, said she worried that health care available to the uninsured might not stand alongside the care offered to patients backed by insurance companies.

Street said the urologist she was referred to did not fully inform her about her kidney troubles. It was only after she hunted down information on the Internet that she discovered more about her condition and decided to schedule another appointment at Good Samaritan.

Even if she wonders sometimes about the care she receives at clinics, Teesateski said she glad to have someplace to go to – for now. “As I get older, what’s going to happen? Will I have any place to go?” she asked.

Donna Brooks, a 46-year old patient at Good Samaritan in Canton, said she doesn’t worry about the care she receives at the clinic she refers to as her “lifesaver.” She has even become good friends with her doctor there.

Brooks is an avid supporter of the clinic and hopes it will make it through the recession.

“There should be no reason for these clinics not to stay open,” Brooks said. “If they don’t, not only me, but hundreds of people, are going to be in a world of hell.”