Many in Middle Class Turn to County for Medical Help : Care: Even among the employed, lack of insurance is a problem. As firms cut benefits, pressure on system worsens.

By SONIA NAZARIO and DOUGLAS P. SHUIT

Oct. 30, 1995 12 AM PT

TIMES STAFF WRITERS

The bleeding gash on Sabino Cianciullo’s forehead tipped off his wife. He had passed out again. For three months, the carpenter had been trying to hide the obvious: Something was horribly wrong with his body.

Driving down the street, the world would go blurry. At home, he says, “I’d find myself face down on the floor. And I’d figure: I don’t have no insurance.”

The 63-year-old Cianciullo had always worked and been provided medical insurance, but was between jobs. Believing he would soon die, he avoided seeing a doctor because he did not want to run up medical expenses that would leave his wife burdened with debt.

After chewing him out, Cianciullo’s wife dragged him to one of Los Angeles County’s public hospitals. They corrected his irregular heartbeat with a pacemaker; the lung cancer the hospital also detected is being treated--successfully so far--with chemotherapy. “I could have been dead if it wasn’t for this hospital,” he says, lifting his eyeglasses to wipe away tears as he clasps his wife’s hand at the county’s Olive View Medical Center.

Increasingly, not just the poor, but more middle-class Angelenos are turning to the county’s public hospitals and clinics as their only lifeline. “The public perceives these as hospitals of last resort, a place only the desperate and scum of the earth come to,” said Dr. Carl Schultz, an emergency room attending physician at Harbor-UCLA Medical Center. Many, Schultz says, think public health facilities serve only illegal immigrants, the homeless and drug abusers sucking up billions in taxpayer largess.

Yet half of the nearly 800,000 who each year walk into Los Angeles County’s hospitals and clinics are employed or in working families. Three-fourths of patients are U.S. citizens or legal residents.

In California the problem is particularly acute, as employers have aggressively cut health care costs and are leading a nationwide drive to slash job-based health insurance. The proportion of California companies offering insurance to their employees dropped to 51.5% in 1993 from 56% four years earlier, leaving more than a quarter of a million additional people to fend for themselves when illness strikes, a UCLA study found.

Already, Los Angeles has the largest proportion of uninsured of any major American city. Moreover, in Los Angeles County, nearly a third of those under the age of 65 are uninsured, almost twice the rate of the rest of the nation.

The reason, in part: An unusually large number--one in four residents--are employed by small companies, many in the service sector. Such employers are least likely to provide health insurance. Another factor: the loss of benefit-rich aerospace, banking and manufacturing jobs.

“I’m seeing more middle-class people” thrust into the county’s threadbare health network, says Olive View Medical Center nurse Margaret Barnes, standing in a crowded waiting room where she sees many workers in their 50s who have been laid off to make room for younger, cheaper employees. “They say: ‘It never occurred to me that I would be in this situation.’ ”

Once in the network, the patients’ perceptions of county care range from gratitude, as in Cianciullo’s case, to frustration or even anger about the level of care, impersonal treatment and wasted hours in waiting rooms that often eat up an entire day.

As Shirlene Owens, 59, rolls her wheelchair one recent Friday into the county’s Mid-Valley Comprehensive Health Center in Van Nuys, her fright is palpable. Sharp, pulsing stomach pains and soaring blood sugar levels have driven the diabetic to the county clinic. Owens has already been turned away by the private clinic she had long used, where she was told that without medical insurance she needed cash up front. Her husband, Harold, 61, lost his job and health benefits as an aerospace machinist when Lockheed Corp. shut down its Burbank plant. He found another job, but lost that as well.

“My old clinic told me they weren’t a charity and I had to go to the county,” said Owens, who has been confined to a wheelchair since a childhood bout with polio. She adds that the couple has just $250 in the bank.

After what she complains of as a long wait, nurses give her medication to get her diabetes under control, check her stomach, and tell her she’ll have to come back for more tests.

Even for those who work, skyrocketing insurance rates, often $150 to $550 a month, by some estimates, price them out of private health insurance. Many of those with insurance aren’t safe, either: A study this month said 29 million Americans with private insurance in 1994 were underinsured, risking out-of-pocket expenditures of more than 10% of their family income in the event of a catastrophic illness.

In addition, companies increasingly are asking new employees to wait as long as one year before their health benefits kick in. A 1994 survey found that among employers with 200 or more workers, 62% of health plans made new hires wait for coverage. Nearly as many of the health plans excluded pre-existing conditions and pregnancy coverage, usually for a year or more.

Sharon Moody, 40, found that buying health insurance was no panacea. Without any health benefits at work, she was forced to buy her own insurance. But then she discovered the policy was useless because it didn’t cover any of her existing ailments. She has had to rely on the county’s Harbor-UCLA for two recent major operations.

“These problems were too large for me to handle financially. So I had to go to the county. I had no choice,” Moody said.

In the 1970s, as a nurse at a Los Angeles convalescent home, Moody never worried about being without health insurance. “I never needed to see a doctor. I never even thought about it. I was young. You think you are going to live forever,” she says. Then, still in her 20s, Moody tumbled to the ground while trying to lift a violent patient and damaged a disc in her back. After eight years at the convalescent home, her employer, she said, told her she was no longer needed.

Moody retrained, becoming a hotel management instructor, another job with no employer-based health benefits. After discovering that pains in her groin were from a tumor in her uterus the size of a small watermelon, Moody had a hysterectomy at a county hospital in the early 1980s. On the operating table, she promised herself she would buy her own health insurance, and subsequently paid $300 a month, more than a third of her take-home pay, for a policy. But she canceled the insurance three months later after discovering it excluded everything related to spinal or “female” problems. In effect, she says, she is uninsurable.

When Moody broke her knee several years ago, she used a small inheritance left by her mother to pay a private hospital $1,875 to get the leg X-rayed and set. “I was always used to taking care of myself,” says Moody. In 1994, Moody learned that she had breast cancer and needed a mastectomy. This year, she had to go under the knife for a carpal tunnel operation.

Both times, she went to Harbor-UCLA, which she compared unfavorably to care by private physicians.

“It was degrading. The doctors don’t look at you. They look through you. They act as if you aren’t paying, so they don’t have to do their best.”

Some of these middle-class working people find their way into the system through one of the county’s three trauma centers, which mend nearly two-thirds of those involved in life-threatening car accidents and other medical emergencies.

Others take a calculated--but necessary--risk that they won’t get sick, and land on the county’s doorstep.

Robin Steely, 60, an insurance adjuster for a Glendale firm, sits in a blue vinyl chair in the oncology clinic at Olive View, smoothing her pink shorts as she waits for a checkup and refill of her cancer-drug prescription. Two years ago, she was stunned to discover a fast-growing lump the size of a small egg in her left breast. She was unable to obtain insurance through her company, and her husband, a self-employed cabinetmaker, had no health coverage either. Until then, the Santa Monica couple, who together earn $50,000 a year, had managed to pay cash when they needed antibiotics and for her annual Pap smear.

The lumpectomy, radiation and chemotherapy treatments she received at the county eliminated the cancer and cost $10,000. She believes the same procedures at a private clinic would have been sharply higher and outside her reach. Although payments to the county crippled her credit, the silvery-haired woman smiles at the Olive View nurses and says: “They allowed me to pay as I go.” Patients are asked to pay for their care according to their financial ability, and Steely eventually reimbursed the county out of pocket for the $10,000.

Then there are those who work and get insurance for themselves, but not for their spouse or children, usually because it costs too much to obtain the additional coverage. In Los Angeles, according to the UCLA study, more than one in four children, or three-quarters of a million youngsters, go uninsured. Nearly a third of the county’s clients are children.

When Jeannette Rodriguez, now 5, was six months old, she began to wheeze uncontrollably, gasping for air. “If I would have kept her at home, she would have died,” says her mother, Lillian Rodriguez, 43, who rushed her to Harbor-UCLA’s emergency room. Ongoing treatments and an earlier trip this year for her son Raymond, to have a large wart removed from his foot, resulted in a $6,000 hospital bill. For months, the hospital called her almost every Saturday, demanding payment and eventually ruining her credit, Rodriguez says, after she flatly told them she couldn’t pay.

Rodriguez, director of the San Pedro YWCA after-school program, pays $37 a month for health insurance for herself, but can’t afford $369 more to cover her husband, Ramon, who was disabled in a car accident, and their three children. Half of her take-home pay of $1,200 a month goes to rent an apartment. Telephone, gas, light and food bills eat up the rest.

When her children have a sore throat or cold, they try not to talk so Rodriguez won’t notice. Raymond, 14, recently told her he wanted to go out for his school’s football team. After thinking about it, however, he told his mother he won’t play, for fear of getting hurt and incurring medical bills. “They worry,” she says. “They know I don’t have the money. They don’t tell you they are in pain.”

Los Angeles’ army of working people without insurance is expanding, experts say, because the jobs that are being created most quickly--the self-employed, the part-timers, the temporary and contract workers--are positions least likely to carry health benefits.

“They won’t give you health insurance because we just work three hours” a day, said Luz Manzo, 30, a part-time cafeteria worker for the Los Angeles Unified School District, an employer known for cutting health care costs by hiring large numbers of part-timers. As she nervously awaits test results on a lump in her right breast in the Women’s and Children’s Hospital at County-USC Medical Center, Manzo says she, like many others, would like full-time work with health benefits.

Manzo lives in a one-bedroom apartment near Downtown Los Angeles with her husband, a construction worker, who also has no health benefits, and four children. At the end of the nerve-racking day, she learns that the lump is probably not cancerous. “It’s like a great weight has been lifted,” said Manzo. She has been gratefully turning to the county for pediatric care and immunizations for her children, Manzo says, for 15 years.

Experts say more people will be put in the predicament of relying on public health facilities as fewer employers offer health benefits.

In the past decade, the burgeoning number of uninsured people has been cushioned by the parallel growth of Medicaid as Congress expanded coverage, said Dr. Steven Schroeder, president of the Robert Wood Johnson Foundation, a leading health care research group. But now, proposed Medicaid cuts by Congress could whack $4.8 billion from Los Angeles County’s Medicaid benefits between 1996 and 2002, according to Health Access, a nonprofit health policy group. A study this week by Consumers Union, an advocacy and research group, said that up to 12 million Americans could lose their health coverage as a result of the proposed Medicaid reductions.

“When we talk about the safety net now we are not just talking about the poor, we are talking about [protections for] the middle class as well,” said Schroeder. “The real poor get covered with Medicaid, but the working poor who don’t qualify because their incomes are too high are on their own.”

He adds: “There is a very thin line between the insured and the uninsured. Anyone can lose their insurance, and it can happen almost overnight.”

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About This Series

In this series, The Times goes behind the scenes of Los Angeles County’s massive public health system as it tries to resuscitate itself after a near-fatal collapse brought on by too many patients, too little money and too many questionable decisions.

* Sunday: How the nation’s second-largest public health system ended up at the brink of disaster.

* Today: Who really uses the system, and why many working people must depend on the taxpaying public--not their employers--to bankroll medical care.

* Tuesday: Behind the Thin White Line: the view from inside the operating room.

* Wednesday: The hidden costs of public health care--and how private hospitals are trying to lure Medi-Cal patients away.

* Thursday: From New York to San Diego, a look at how other large metropolitan health systems are coping with the present--and thinking creatively about the future.

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Who Uses County Health Facilities?

About half of the county’s 763,000 clients in fiscal 1993-94 were employed workers or were a part of a working family. Here are some related percentages:

Insurance status

Had no health insurance: 61%

Covered by the state’s insurance program for the poor, Medi-Cal: 36%

Had private insurance: 2%

Had Medicare or another form of health coverage: 2%

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Gender of Users

Men: 42%

Women: 58%

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Employment status of users and their dependents

Employed: 49%

Retired: 0.1%

Not employed: 51%

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Latinos Most Likely to Lack Health Coverage

Percentage of group that is uninsured

Latinos: 39%

Whites: 18%

African-Americans: 25%

Asian-Americans and Pacific Islanders: 28%

Source: U.S. Census, UCLA Center for Health Policy Research, School of Public Health; 1994 data.

An Epidemic of the Uninsured

A greater proportion of Los Angeles County residents are uninsured than in California and the nation as a whole. One reason is that residents here are less likely to receive insurance through their employers.

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L. A. COUNTY 1990 1993 Receive insurance from employer 46% 39% Uninsured 28% 27% CALIFORNIA Receive insurance from employer 47% 45% Uninsured 20% 21% UNITED STATES Receive insurance from employer 53% 50% Uninsured 15% 17%

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Source: U.S. Census 1994, UCLA Center for Health Policy Research, School of Public Health; 1994 data

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In all, 85% of Los Angeles County’s uninsured are workers and their dependents. Among Los Angeles county workers younger than 65, the self-employed are least likely to have health insurance.

Self-employed: 43%

Full-time workers: 22%

Part-time workers: 36%

Small firms in Los Angeles County are least likely to provide medical coverage to their employees. (Percentage of uncovered workers).

Firms with fewer than 25 employees: 46%

Firms with 25-99 employees: 34%

Firms with 100-499 employees: 26%

Firms with 500 or more employees: 12%

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Who Are the Uninsured?

Many working people in Los Angeles County lack medical insurance coverage. Here are breakdowns of uninsured workers by job category and income.

PERCENTAGE OF WORKERS WITHOUT INSURANCE