Melinda Eilering sat on her bed at St. Elizabeth's Hospital and stared through the second-floor window. She felt scared. In the next hour she would begin chemotherapy.
A month before, Eilering, 56, of Collinsville, had no idea that the painful swelling in one foot was a symptom of cancer.
But the numbers from her biopsy not only confirmed the cancer had spread to her lymph nodes; they were alarming enough to convince her oncologist that chemotherapy should begin without delay.
"I'm scared that when I get chemotherapy I'm going to get sick," said Eilering, of Collinsville.
But other concerns weighed equally on Eilering, a sales associate at a department store in Fairview Heights. Although her employer offers health insurance, Eilering chose not to buy it. Doing so would have taken too much of her paycheck.
In sum, Eilering had gambled and lost. She faces expensive medical treatments and a long trail of doctor and hospital bills with no insurance and no idea of how she will pay for them.
An estimated 47 million Americans lack health insurance, according to the U.S. Census Bureau. That number is expected to rise to more than 50 million when the federal government releases the latest numbers Thursday.
President Obama has proposed overhauling America's health-care system, the goal being to make health care affordable and available to everyone. As a result, the proposal's supporters argue, the nation would save tens of billions of dollars annually through early intervention, greater efficiency and lower administrative costs.
For example, 15 percent of private health care costs in America is spent on administrative costs -- a by-product of the nation's nearly 20,000 health insurance plans.
In contrast, Medicare's administrative overhead is about 3 percent, on a par with the overhead costs of health insurance programs in Europe and Canada.
Even so, Obama's proposal has divided Congress and the nation, often resulting in contentious and highly charged town hall meetings.
For those who lack health insurance but suffer from a serious medical condition, the trade-off for staying alive is often financial ruin.
Terry Krick, 50, of Millstadt, suffered a heart attack in 2001.
In early 2005, he lost his job at a Millstadt factory, which meant the loss of his employer-subsidized health insurance. Now he must pay out his own pocket for the health insurance known as COBRA. Expensive and temporary, it lasted only 18 months.
Krick has since held and lost four jobs. He blames that on employer concerns about the costs of health insurance for his heart condition. Meanwhile, he's had to pay for all his medical care.
"I had $45,000 (saved)," he said. "I ran my money completely out."
Today, Krick lives with his mother, who has taken out a $20,000 loan against her house to finance his medical care. The costs include a recent trip to Barnes-Jewish Hospital in St. Louis for a staph infection that cost $3,200. That bill was on top of other unpaid bills from physicians and hospitals.
"They're jumping all over me. They want their money," Krick said. "You got to give people insurance or you'll be out in the street."
Eilering had applied for disability insurance to pay for food, rent and other necessities while she undergoes her cancer treatment and recovery. But a letter from the insurer indicated she might not qualify.
"I'm worried they're going to deny me" because of her cancer diagnosis, she said.
Eilering's grown daughter, Rebecca Eilering, dabbed at her eyes with a damp Kleenex. The weight of all the bad news and uncertainty of recent weeks had suddenly overwhelmed her in the hospital waiting room. Something burst inside, like a paper bag ripping apart, and all the anxiety and worry of the past month came tumbling out.
"Nothing is working," she sobbed. "We're jumping through all these hoops. We're doing everything we can, but nothing is working."
Later, upstairs in her mother's hospital room, Rebecca summed up their future:
"I'm worried about everything. I'm worried about how we'll live day to day," she said. "Everything's in limbo. We don't know what we'll be doing a week from now, a month from now, two months from now."
Many rely on charity care
The Eilerings' situation underscores the plight that tens of millions of working Americans find themselves in.
Peeled to its core, their problem is this: If you're too sick to work, then you obviously have no health insurance through an employer, and often times can't qualify for private health insurance.
And if you need health insurance after you've been diagnosed with a serious illness, such as heart disease or cancer, it can often become prohibitively costly, if not impossible to get.
For many, their only options for getting health care is to pay for it out of their own pocket -- the No. 1 reason Americans file for bankruptcy -- or depend on charity care.
Doctors and hospitals write off tens billions of dollars each year in bills that cannot be collected. The national average cost of so much uncompensated care, in the form of write-offs and cost-shifting onto private health insurance, is an estimated $1,000 per family, said Tim McBride, associate dean for public health at Washington University, in St. Louis.
"So in a sense, we're all paying for this problem," McBride said.
For St. Elizabeth's Hospital, this means $44 million worth of charity care each year, according to Kevin Shrake, the hospital president.
"It's a huge number," Shrake said. "It's part of the reason health-care reform is a huge issue right now."
Despite the cost, Shrake said, patients without insurance are welcomed at St. Elizabeth "because it is our mission that anyone who comes through our doors gets treatment, regardless of their ability to pay."
Mark Turner, president and chief executive of Belleville Memorial Hospital, said recently his hospital also honors a similar commitment to providing care for the uninsured.
"Access to hospitals is not a problem," Turner said during a recent public forum on health care reform. "It's paying for care, that's the problem."
Melinda Eilering's plight as a worker without private health insurance places her in "that terrible middle place" where she's not poor enough to qualify for Medicaid, or old enough to qualify for Medicare, but too poor to pay for her medical bills, said Laura Weil, the health advocacy program director at Sarah Lawrence College in Bronxville, N.Y.
"It's a Catch-22 in many ways," Weil said.
To further complicate the problem, the nation's economic slump has accelerated employers' efforts to cut costs by trimming health-care benefits, a trend that has led to higher worker premiums, co-pays and deductibles.
As a result, the portion of people with employer-provided insurance has dropped by 10 percent over the last decade -- from nearly 70 percent to about 60 percent, McBride said.
"That's the problem you run into in a recession," he said. "You have both increased demand for government programs because people are losing their jobs and they have other hardships, and then you have the revenue side going down, so you create a huge government deficit."
Difficulties in getting insured
Terry Krick's difficulties in getting health insurance underscore a feature that sets America's health-care system apart from the world's other richest nations: Insurance companies can refuse to offer coverage based on pre-existing health conditions.
That distinction stems from the way America's health insurance market is dominated by corporations seeking to maximize profits and shareholder value, said Pauline Rosenau, a management policy professor at the University of Texas Health Science Center in Houston.
To accomplish both, they pursue a strategy of excluding coverage for the sickest, most high-risk customers "because a few sick people can account for a huge amount of your medical cost that you have to compensate for," Rosenau said.
In contrast, under a universal health-care system, no one can be denied basic coverage. Insurance companies can still earn profits, but that would require adoption of the models found in The Netherlands and Switzerland, whose governments have spread risk around by turning their national populations into giant risk pools.
For this to happen in the United States, the federal government must impose a two-fold mandate, according to McBride, the Washington University professor. First, insurers must accept people with pre-existing conditions. And second, consumers must carry some minimum form of health insurance in much the same way motorists are required to have liability insurance.
The biggest cost of the Democrats' health care reform effort -- $1 trillion over 10 years -- would consist of subsidies for low-income and middle class people, as well as a big expansion in those eligible for Medicaid.
To opponents of Obama's health-care reform effort, however, it would lead to health care "rationing" for the disabled and elderly -- a charge made by Betsy McCaughey, New York's former lieutenant governor.
McCaughey made a media splash this spring when she claimed in a widely read article that the Obama reform plan would create "death panels" to deny life-saving treatment based on cost-effectiveness. That claim has since been debunked by all sides of the debate.
In any event, health-care rationing already exists in America, and it has for many years, said Weil, of Sarah Lawrence College.
"We use rationing just as much as a very restrictive system in another country," she said. "We just use a different criterion for rationing: If you can afford to buy health insurance and pay out of pocket for health care, then you can have it. If you can't, you can't."