Karen Goroncy, a home health aide in Washington, Pa., has taken care of people for 25 years but can't afford health insurance to take care of herself.
A reader has promised to buy Goroncy insurance after she was profiled this fall in The Inquirer, and she hopes to have hernia surgery in the New Year.
But short of the generosity of readers - not a good national solution - Goroncy and millions like her are awaiting the sweeping health reform now being considered by President-elect Barack Obama.
Obama's plan, which has not been formally announced, could mark the biggest change in health care in 40 years. A central goal will be to cover 50 million Americans who don't have insurance. It is conceivable that all Americans will be required by law to have health insurance.
A principal architect of Obama's reform - Tom Daschle, nominated to become secretary of the Health and Human Services Department - has written at length about creating a powerful new board that would control health-care spending much like the Federal Reserve Board influences the nation's monetary policy.
Experts say for any plan to pass, it must contain soaring medical costs.
Obama's reform will almost certainly attract criticism that it overly expands the role of government in health care. And American history is littered with failures to revamp the system - recently Hillary Clinton's effort in 1993.
Less in dispute are the inadequacies of the current system. More than 45 million Americans had no health insurance in 2007, according to the U.S. Census Bureau, and that was before the current recession.
In Pennsylvania, for example, 145,800 working adults - an all-time high - were on a waiting list for state-subsidized health insurance in December, an increase of 15,000 since November, the Insurance Department reported.
The uninsured often struggle harder for care; they face longer waits for treatment and on average die sooner than those with insurance, studies show. And in at least two examples in this series, a lack of access to care earlier has led to more expensive treatment later.
Spending on health care, 17 percent of the nation's gross domestic product in 2009, will reach 20 percent by 2017 and "poses a serious threat" to the nation's fiscal health, said a report last week by the Congressional Budget Office.
What's more, said the report, much of that spending is of questionable benefit.
"Up to one-third of that spending - more than $700 billion - does not improve Americans' health outcomes," wrote Sen. Max Baucus (D., Mont.), chairman of the Senate Finance Committee, in a recent 89-page health policy paper that many see as an important Democratic blueprint for health reform.
Baucus added that "in addition to the uninsured, another 25 million Americans are underinsured, without enough coverage to keep their medical bills manageable."
The health-care system is often ridiculed as no system at all. "Kafka could not have designed a more bizarre system," said Robert Field, head of health policy at the University of the Sciences.
Field, among many others, says he is optimistic that some reform will be passed by Congress, helped along by the recession and huge bailouts of the financial and auto industries.
"Our frame of reference has changed," said Field. "Programs in the billions of dollars seemed like a lot of money . . . that's beginning to look like pocket change."
"I do think in a funny way, the economy's demise has forced people to think about what's really important," said Len Nichols, director of the health policy program at the New America Foundation, a centrist group in Washington. "So when people began to realize we're going to have to restructure a whole lot of our economy, how can you do that and ignore health care?"
The Inquirer in the last few months has chronicled the stories of people whose situations highlight a number of problems:
Too many young Americans - 30 percent between 18 and 24, and nearly that many between 24 and 30 - don't buy insurance. They feel that they don't need it or can't afford it.
On any given day, at least 300,000 Americans are caught in a Medicare gap. Too sick or injured to work, they qualify for federal disability income but must wait two years by law before they are eligible for Medicare. And they have no resources to purchase health insurance on their own.
Many are denied coverage because they have preexisting conditions or can't afford the high premiums they are quoted because of a preexisting condition.
Some have insurance but get so sick that they reach the lifetime cap on their plan - and promptly find themselves uninsured.
Some experts predict that next year's reform - whatever its final shape - could fill many of the cracks described in The Inquirer series.
Consider the case of Goroncy, the uninsured home health aide. Her employer could be mandated by law to give her health insurance or to make a contribution to new government-sponsored insurance plan that would cover her.
Goroncy herself might be required to purchase insurance - either through her employer, an individual plan, or a new government-sponsored insurance plan. And if she can't afford insurance, she might receive a government subsidy or a tax incentive.
Buying insurance might remain voluntary, not mandatory, supported by subsidies. The theory is that Goroncy would not be required to buy insurance, but a subsidy would make it affordable for her so naturally she'd purchase it.
In the campaign, Obama said he favored only making insurance mandatory for children, but voluntary for adults, sweetened by subsidies that would make it possible for the uninsured to afford it.
Hillary Clinton during the campaign favored mandatory participation.
Several experts say that the economic downturn, with so many people losing jobs and insurance, could give Obama and Congress the political cover they need to make participation mandatory. "I think the environment may have changed," said USP's Field. "We're in much more of a crisis setting."
The health-insurance industry last month came out in support of universal coverage and an end to a primary means of denying coverage to sick people - the preexisting-condition clause - but only if participation is mandatory.
"That's great political cover for Obama," said health economist Tom Getzen of Temple University's Fox School of Business. "It's what Hillary wanted to begin with. You need everybody in one system. If you're going to control costs, you can't have some people in the system and some people out of it."
The very simple theory of insurance is this: It only works with very broad participation. You can best afford to cover the sickest if the healthiest are also paying in.
Conservatives are leery of many of the proposals being discussed, in particular a new government-funded program intended to provide insurance to people who can't buy it anywhere else.
"The creation of a new public plan would result in millions of Americans losing their employment-based coverage coupled with a massive expansion of government coverage and financial control," writes Robert E. Moffit, director of the Center for Health Policy Studies at the Heritage Foundation.
Some experts say Obama must bring enough Republicans on board, and build a consensus, if he is to succeed. The new president will have his work cut out.
"I am concerned that some proposals will make your health insurance more expensive, not less, and do nothing to protect your current coverage," Jon Kyl, a Republican senator from Arizona, wrote to his constituents last week.
"A government-run plan and an employer mandate, I believe, would exacerbate, not fix, the problem of growing health care costs and would erode employer-sponsored health coverage," Kyl added. "I believe Congress must build upon, not completely dismantle, our current health care system."
Millions of Americans who can't afford the health care they desperately need are waiting to find out what that change will be.
Some who lacked coverage
As the year ends, The Inquirer wanted to take a moment and update readers on some of the people whose stories have been told in this series.
Karen Goroncy, the home health worker without insurance in Washington, Pa., was promised insurance by a reader. She expects to have surgery to repair her painful hernia after the New Year.
Ruby Spencer, the uninsured 61-year-old widow from Logan, had surgery in November to remove a massive tumor in her abdomen, which turned out to be benign.
The Inquirer had chronicled how Spencer was bounced from welfare office to emergency room to city clinic, without getting any help.
A reporter referred her to health-law advocates and started asking local officials about her situation, which led to her getting Medicaid and surgery.
"I'll never be able to thank you enough," Spencer wrote in a note recently. "I'm doing very well and I owe it all to you. Thank you. Thank you. Thank you."
Jean Hawk of Tower City, Pa., who cut back on drugs for her kidney transplant after she lost her insurance, was contacted by Social Security after the Inquirer story, and told she likely is eligible for Medicare. (She had been told the opposite before the story.) She was encouraged to apply again, and did so on December 3. She's waiting to hear back.
"I cannot thank you enough for what you did for me," she wrote.
Iyasu Habtemicael - Izzy - was driving a flower truck and working in a parking garage, both part time, and had no health insurance. He nearly died when his diabetes soared out of control. He's now working full time at a University of Pennsylvania garage - with health insurance - and feeling better.
Others received incredible support from readers - notes of encouragement, small cash contributions, and, in a few cases, even worldwide attention.
"I've had some wonderful people write me and wished me well plus a few gifts also," said Dan Daskus, 41, of Minersville, Pa., who got cancer, lost his job and health insurance, and went into debt from medical bills. "I also did an interview with Danish television."
And even the unexpected happened.
Richard Hershman, divorced four times, a former drug addict now receiving methadone, had suffered without health insurance. But he also had lost touch with nearly everyone in his life. His only friend was his dog, Blue.
After the Inquirer story, a group of friends he had known as a boy in West Philadelphia contacted him, and now he goes to their houses for Sunday dinners and watches the Eagles with them. He went over to one rediscovered old friend's house for a Christmas meal.
"Now I have REAL FRIENDS again," he e-mailed. Maybe that's the best medicine of all.
- Michael Vitez
For Michael Vitez's blog and previous stories in this series, go to http://go.philly.