Almost one in five Georgians under the age of 65 has no health insurance, despite the fact that more than two-thirds of these are either full-time employees or dependents of these employees. This costs the uninsured dearly: an Institute of Medicine study found that they become sicker and die sooner than those with coverage for basic health care. Lack of coverage also costs the health care institution to which the uninsured eventually turn. As the number of uninsured and underinsured Georgians continues to grow, almost every hospital in the state bears some of that cost, but a disproportionate share of those with the most catastrophic and expensive medical problems in Georgia arrive at or are referred to Emory Healthcare. In the 2005–2006 fiscal year, Emory Healthcare physicians provided $70.7 million in charity care, a 7% increase over totals for the previous year.

What is "charity care"?
Under Emory Healthcare policies, charity care encompasses indigent and catastrophic care, terms used in the parlance of federal poverty guidelines. Indigent care is provided to patients with no health insurance, not even Medicaid or Medicare, and with no resources. Catastrophic care is given to patients who may have some coverage but whose health care bills are so huge that to pay them would be a life-shattering hardship, if even possible. These terms are illustrated in very real case studies throughout this book, with names altered to protect patients' identity.
     Of course, there are many other instances of unreimbursed care, such as the difference between what some procedures or treatments actually cost to provide and the amount an insurer is willing to pay. If such treatment is in the best interest of the patient, then Emory Healthcare provides it, even when doing so costs the institution money. Losses from unreimbursed care are not included in the charity care figures listed to the left.

(Still) on the way to a good life
Trish Thomas had it all: a new college degree, plans for graduate school, and a summer job. What she didn't have was health insurance. When an uninsured driver plowed into her car, she was taken, unconscious and barely breathing, to the closest community hospital, where doctors began to tend her multiple broken bones and other points of damage—except for one, a tear in her aorta. In a patient so badly injured, only Emory had the expertise to make the delicate repair needed.
     When she arrived at Emory University Hospital, it was clear that stabilizing her condition enough to operate was not going to be quick. And very likely, it was never going to be paid for. Her car insurance had not covered even the medical costs at the community ER, and her application for Medicaid was still under review. After weeks in rehab—at a cost of more than $300,000—Trish now is ready for her heart operation. Emory may never receive payment for this either, but Trish's physicians believe the surgery will put her back on the road to the life toward which she was headed before the accident.

Who will be there for my wife?
In the Gainesville church where he serves as pastor, Alejandro Miguez offers thanks, even though his family has been hard hit in recent years. The first blow was the return of his wife's lupus, a disease in which a person's immune system attacks the body's own organs. The second was when Juanita's form of lupus did not fit the guidelines for a clinical trial she had hoped to enter at the NIH. And the third blow—the one that sent Alejandro into a panic—was when a recent change in Georgia's Medicaid legislation meant his wife's care would not be covered except in emergency situations, as defined by the state. (The Miguezes are legal residents—they have worked and paid federal and state taxes for almost a decade—but they are not U.S. citizens.) Such an emergency seems inevitable, when the lupus will have completely destroyed Juanita's kidneys, making her eligible for a transplant. But until that day of crisis, cried her husband, who will be there for my wife? Emory Healthcare will, said Dr. Antonio Guasch, the Emory Clinic nephrologist to whom she had been referred by her local hospital as her condition worsened. Pastor Miguez's prayers of thanks are for Guasch and the team of other Emory clinicians and social workers. The unreimbused costs of care to Emory so far in the past year: $15,000.

On the road to recovery
For years, 58-year-old Hank Beeson had driven a truck hauling peaches and apples. It was hard work, without fancy benefits like health insurance, but it was one of the few jobs available in his part of South Georgia. And besides, he liked watching the sun rise over the horizon while the miles slipped by and coming home tired but satisfied with tales of the open road for his grandchildren. But one day his travels ended abruptly. When the chest pain hit, he was rushed, stunned, to the closest regional medical center. Because his heart attack was complicated by irregular heartbeats, he was transferred to Emory Crawford Long Hospital.
     After performing bypass surgery and implanting a pacemaker, his Emory Healthcare clinicians struggled to stabilize his condition and to care for a surgical incision that resisted healing. A team of clinicians and social workers met weekly to look for possible long-range solutions for Mr. Beeson, helping his family apply for Medicaid and disability benefits. Medicaid paid only $8,000 of the more than $300,000 that Emory Crawford Long expended on Mr. Beeson's surgery and care. Nevertheless, this care made it possible for him to be transferred to a long-term acute care facility near his home and eventually to a local rehab facility where the care team there hopes to get him back on his feet.

When medical "coverage" doesn't reach
When he awoke at Emory Crawford Long Hospital and found himself with a tracheostomy and on a respirator, 85-year-old Bill Jenkins wanted to die. He already had gone through debilitating treatment for throat cancer. This was too much. His son was ready to honor his father's wishes. But when his daughter arrived from Indiana, she convinced her father to reconsider and to reverse his living will. When Mr. Jenkins had first arrived at the hospital, the care teams had pulled him from death's door. Now, honoring his new decision, they readied him to continue to live. It was not easy, but slowly, steadily, he grew more stable while the Emory social services team began an exhaustive search for a nursing home close to his daughter's home that would be able to manage his tracheostomy. Six months after he arrived at Emory, he was transferred by air ambulance to a facility in Indiana.
     Mr. Jenkins was never counted among the 19% of Georgians with no health insurance, since he had Medicare. But he had no other resources, and his children had no legal responsibility to pay anything. For the six months of care he received at Emory, Medicare paid less than $50,000. The remaining costs, well over $900,000, were simply "eaten" by Emory Healthcare. Thanks to superb care, Mr. Jenkins left Emory alert and comfortable, ready to make the most of the rest of his life.

An unexpected part of the curriculum
When 24-year-old Megan Sharp was diagnosed with a particularly invasive type of breast cancer, she was stunned, understandably. Halfway through her studies to become a physician's assistant, she had expected to be providing care, not dealing with a complex chemotherapy regimen of her own. The fact that she had health insurance provided some comfort, but the next shock was when she realized her policy covered only 80% of charges, with a $1,500 annual cap. After her first month of surgery and treatment, she already owed more than $2,000 that would have to come out of her pocket. Furthermore, her aggressive cancer meant she would be receiving care—and bills—for at least a year. Emory's Winship Cancer Institute helped her apply for charity care through Emory's own program, and Emory began to forgive the medical costs not covered by insurance. During the first six months, the institution lost approximately $15,000 in unrecovered costs, with more losses to come. Megan did well with her treatment, however, and has been able to resume her studies. She knows she could never have afforded such good care without Emory's willingness to forgive the uncovered charges and says that Emory's empathy and generosity at this difficult time are going to make her the most compassionate health care provider imaginable. "I learned it from the best," she says.