March 12, 2006
The Post and Courier
Jonathan Maze

Laurie Martin was riding her bike to the store on New Year's Eve 2003 when she slipped on landscape gravel at her Isle of Palms apartment. She didn't have a chance to brace herself.

"I lay on the pavement in excruciating pain and I knew I did something really bad," Martin said.

She did: She broke her left hip.

Worse, the 53-year-old divorced mother of two started herself on a path that ultimately would leave her homeless for more than a year.

Martin fell into a wide chasm in the nation's health care system. She became one of many people whose health problems render them unable to work but who don't have the health insurance or savings to pay for the treatment they need to get back on their feet.

Catches and obstacles abound for anyone caught in that situation.

Big gaps exist in government programs such as Social Security, Medicare and Medicaid, leaving some people homeless for a year or more before they can receive any aid. And charitable programs designed to help the uninsured often come with a restriction that the patient must be working.

Many move in with family or friends while they return to normal. Those who can't do that may end up in places such as Crisis Ministries' downtown shelter, where Martin lives.

"It's a really serious problem," said.

Harriet Johnson, a Charleston disability law attorney. "Most of the people I represent don't have any type of private disability, they don't have any money in the bank and they don't have gold bricks under their bed. So when they become too disabled to work, it's catastrophic."

An estimated 3,000 Charleston County residents are homeless. Health problems long have been associated with that population. Studies vary, but at least a third of the homeless have one or more chronic physical problems. Many others have mental health problems. How many are homeless because of those issues is uncertain.

Growing problem

With more and more people lacking health insurance, there's widespread concern that even more people will lose their homes because of medical problems.

The number of uninsured in South Carolina grew by about 100,000 between 2002 and 2004 to a total of 609,000, according to U.S. Census Bureau figures.

One big health problem can destroy a person's finances. In fact, one major academic study found that half of all bankruptcies nationally are caused by health problems (although a recent insurance industry-funded study questioned that earlier study's results).

At Crisis Ministries, more residents are reporting complex health problems, said Stacey Denaux, the agency's executive director. She said it's uncertain how many of the residents' homelessness was caused by health problems.

Nevertheless, the agency increasingly is becoming a health provider of last resort. It is seeking funds to expand its health care offerings to provide more treatment.

"These people aren't being seen anywhere else," Denaux said. "They continue to come here."

Most of the problems among Crisis Ministries residents are mental health related. Many at the shelter have chronic problems such as hypertension or diabetes. Some have bad knees or bad hips. One has asbestos poisoning.

In each case, being homeless exacerbates the problem because the patients don't get regular or timely treatment. Their conditions worsen and they frequently end up in the emergency room.

Martin does not fit the stereotypical image of a homeless person. She worked for 24 years at the Medical University of South Carolina, where she was a lab technician who conducted tests on cancer patients. She left her job in 2000 to work for her now-ex-husband's business.

By late 2003, she was divorced, looking for work and uninsured. That's when she fell on her bike.

Martin had a hairline fracture of her hip. "How could anything that tiny cause so much pain?" she wondered.

She had surgery at East Cooper Regional Medical Center, where the hip was fixed with three screws.

She was able to get some financial assistance to pay the hospital bill, but she burned through her savings to pay for the physical therapy and doctor bills. She said she still owes her surgeons about $3,000.

Because her apartment was on the second floor and she couldn't pay the rent, Martin went to live with a friend.

Complications

Martin's hip improved until it was about "95 percent," and she was able to look for work. She spent two months working for a downtown convenience store. Then her hip began to deteriorate and grew painful.

A doctor said she had avascular necrosis, a condition in which part of the bone loses blood supply and dies, causing the bone to collapse. In Martin's case, the top part of her femur, or thigh bone, wore away. A doctor said she needed the hip replaced.

Martin couldn't work again without a new hip. By August 2004, she was out of money. On Dec. 7 that year, she moved into Crisis Ministries.

"I was rock bottom," she said. "I lived for 16 years in an upper-middle-class neighborhood. I had a Volvo, an SUV. I was a soccer mom. Never in a million years did I think I would end up here."

Martin acknowledged she had made a number of mistakes that contributed to her downfall, but after she got over her initial shock, she determined to get herself out of that situation.

Doing so proved easier said than done.

Martin had no money to see a doctor. And she didn't qualify for Medicaid because she wasn't old or blind. She learned she could qualify if she was declared disabled by the Social Security Administration, a condition that many advocates believe increases the number of people with disabilities because many people can't get health insurance without it.

In South Carolina, 151,828 people get Social Security payments because they are disabled, about 21 percent of the population who receive the benefit, according to the National Organization of Social Security Claimants' Representatives.

How many of those people could work is uncertain, but Johnson said 75 percent of people on disability want to work.

"I know some could work, on good days, if they have a flexible situation," said Johnson, who has a degenerative muscle disease. "They could do something to better their standard of living and be productive. But when they take the risk, they risk not only losing their monthly check, but they risk losing medical benefits they need to stay alive."

Getting Social Security benefits can be an agonizing process, especially for someone waiting to have surgery. Johnson said she tells clients to expect their disability payment requests to be turned down twice before they're approval. Waits of longer than a year are common, and Johnson said she had one client who took a decade to get approval.

Compared with that client, Martin was lucky. Her disability application was turned down once, but she was approved the second time, after 11 months. She received her first check last month.

Another barrier

Armed with the approval, she applied for Medicaid again. This time she ran into another barrier: Her income was too high.

To get Medicaid, a disabled person's income cannot be above the federal poverty line. That means a single person like Martin can't make any more than $9,310 a year, or $776 a month.

"It's the good news-bad news scenario," said Sue Berkowitz, executive director of the South Carolina Appleseed Legal Justice Center and one of the state's most prominent advocates for the poor. "Only the ones who are very low-wage workers will ultimately qualify for Medicaid.

"People with means can often find themselves on a downward spiral," Berkowitz added. "It can happen very quickly. Here you are someone who is healthy, working, with health insurance, and just one serious health crisis and you're homeless."

That leaves one option: Medicare. And there's yet another catch here: A person must be disabled for 29 months before Medicare will start covering health bills.

Such a delay can be fatal. Patients who need a heart transplant, for instance, can't get one unless they have health insurance or enough cash to pay the hefty bill themselves.

Martin doesn't plan to wait for Medicare. Her work history earned her disability payments of more than $1,600 a month, more than twice the poverty level. She expects to be out of the shelter within a month, making her 15th month at Crisis Ministries her last.

She also is working on a deal with MUSC to get the hip replacement she needs. With some help from the university, Martin hopes to pay for the surgery herself, making payments over the next couple of years.

"I can't go on like this," she said. "I'm in constant pain. I want to get back into work, back into life."