BY K. MCSTAY

HERALD DEMOCRAT

Susan Hooper was diagnosed with stage four breast cancer. Her prognosis was guarded; the treatment was expensive. Hooper was uninsured.

Her response to the diagnosis, after the fear faded, was wondering how she would pay for it. She had gone to a Grayson County Health Department screening, and the technicians detected a problem. Wilson N. Jones provided a follow-up screening.

Each beginning chemotherapy treatment would cost $8,000, and four later treatments would cost $12,000. Later radiation therapy and surgery would add to that cost. As a self-employed business owner, Hooper said she couldn't afford insurance.

A growing problem

Lack of insurance is unfortunately common among the population of Grayson County: According to statistics from the Greater Texoma Health Clinic, 27,063 persons are estimated to be uninsured, and many more are underinsured. For women in this position, it can mean lack of consistent gynecological check ups, and skipping anything from mammograms to pap smears. A recent study, conducted by the National Women's Health Resource Center and Harris Interactive, showed that almost half the women in the poll failed to seek medical care in the year before the survey, citing cost.

"Definitely there is a downturn in routine care," said Dr. Jeffrey Hermann, a Sherman obstetrician and gynecologist. Hermann said that his office frequently receives calls from patients who need to renew prescriptions, but first need a check up to ensure those medications are still accurate. Hermann said the problem is ongoing, but is noticeably, if not largely, worse than in past years.

Depending on the age of the woman in question as well as other specific life circumstances, certain screenings and tests are more or less necessary, he said. "The basics, such as checking weight, blood pressure and other vital signs is very important: We call them vital signs for a reason," Hermann said. Breast exams for women older than 20 are also important, and screening for sexually transmitted diseases is key. Pap tests, also known as pap smears, can be minimized to once every three years, with a doctor's permission, but Hermann said some sort of basic exam is necessary. "That allows us to do other things we have to do, though a Pap doesn't necessarily have to be done," he said.

A personal relationship with a doctor, Hermann said, allows a personalized screening, meaning that some (potentially expensive) services can be skipped. "If you have a doctor that knows your history, they can say, 'That would normally apply, but because of (some reason), it doesn't," Hermann said.

Community help -- Greater Texoma Health Clinic

All of this, of course, is assuming that the woman has insurance, or the ability to go to a regular doctor. Failing that, the county and state have several programs to help out. The Greater Texoma Health Clinic, the Grayson County Health Department, Planned Parenthood and the Texoma Health Foundation each cover specific areas of women's health, and focus on the uninsured of the area.

"We have seen more people that used to have insurance and lost their jobs," said Susan Rawlings, a women's health nurse practitioner from Greater Texoma Health Clinic, though she added that there's always been a big unmet need in the county. The clinic provides well-woman exams, including a pap smear and a mammogram if necessary, as well as contraception and infection checks. The fee, Rawlings said, is based upon how the individual compares to the federal poverty level.

The Grayson County Health Department offers immunizations and other general health care, as well as family planning services, the GEMS (Gynecologic Exam and Medical Screening) program, which offers gynecological services, as well as lost-cost pregnancy and STD screenings.

The Health Depatment

The Health Department also refers out to the Texoma Health Foundation, which offers financial assistance to those needing financial assistance with breast cancer.

"Those are just wonderful programs, they serve the community very well," said Steve Devore, the director of the Grayson County Health Department. Programs offered by the Health Department are for those who meet a certain income level, Devore said. "Usually we don't ask them for the insurance, we ask them about their income," he said. "The majority don't have health insurance, or have limited insurance." For those individuals, the cost is minimal. Because of the downturn in the economy, said Wellness Nurse Denise Wardell, the clinic is seeing "more middle income that have fallen into downsizing," she said.

The GEMS program, Wardell said, is specifically for women between 45 and 64 years old, or women who have had a tubal ligation. "We're targeting the older ladies who are uninsured, and don't have a way to access other services," she said. The family planning services of the health department is dedicated to younger women, she said.

The Family Planning Clinic, on Tuesday by appointment, is located in the Sherman office, and includes a pap smear, breast exam, medical screening, birth control counseling and prescriptions. The GEMS clinic, also located at the Sherman office, is opened on the first Tuesday of the month, also by appointment, and includes a pap smear, breast exam and mammorgram, blood pressure check, diabetes and cholesterol screening.

Planned Parenthood

Planned Parenthood's Sherman clinic had approximately 800 patients in 2,200 visits during 2008, according to Holly Morgan, the director of media and communications for Planned Parenthood of North Texas. "Our average patient is women ages 20-29 years old in their first job who are either uninsured or underinsured," she said.

The group conducts screenings for general health care, such as blood pressure testing and diabetes screening, as well as female-specific medical care, such as well-woman visits and pap smears. "We even do flu shots," Morgan said. Because of the reduction in cost for those who are qualified, she said, many women repeatedly visit the clinic, and with the economic downturn, that number is increasing. "All of our clinic managers are seeing an uptick," Morgan said, though it's too early in the year to have any firm data. "(The new patients) lost a job or they've lost their health care insurance; they've lost the amount of money they used to make," she said.

Planned Parenthood receives federal and state funding and individual donations, each used for a different purpose. "If we get money for breast and cervical cancer, it goes to cancer screenings only," she said. "Everything is earmarked." Still, the majority of patients pay for their own care. "We work out ways for patients to pay for it," Morgan said. "We have all kinds of patients: It's not just young people or college people," she said. "Its all the people you interact with ... people in all walks of life...They need a way to take care of themselves; they don't have basic health care coverage."

Texoma Health Foundation

Mammograms are offered by all of the groups, and for those women who need further treatment, based upon the results of that test, the Texoma Health Foundation, through the Susan G. Koman foundation, provides funding. Susan Hooper was referred to the foundation by a family friend after her diagnosis, and the group paid for her cancer treatment. "It's an unbelievable organization," she said. All donations from the Komen foundation are put back into the community, she said.

The Koman donations are 100 percent for uninsured women, said Michelle Lemming, the director of the program, though some smaller, private donations can be earmarked for use for underinsured women.

At a recent screening, the THF conducted 36 mammograms, and two of those needed follow ups. "A small percentage from the mammograms go into treatment," she said, but "the cost of the services are incredibly high. It's very difficult for the uninsured." More than 75 percent of those that receive funds are working uninsured, and the treatments themselves are provided by local doctors and hospitals.

Funding issues

With the exception of Texoma Health Foundation, government assistance provides a significant part of funding. Problems occur, however, when the funding is enough to cover tests, but not treatment, particularly when the lab work is unusual or expensive. "If the person has an abnormal pap smear ... how are they going to follow up?" Hermann said. "If they can't pay for the test, what makes anyone think that they can pay for the more costly diagnostic?"

"We depend on the generosity of the hospitals for providing things like that," Rawlings said. Even with a discount, tests like an MRI can cost more than $500, and are necessary for ruling out symptom causes. "I had a woman with cervical cancer who had no insurance, and she could not find a way to get health care," she said. "Even though I can volunteer my services, getting those diagnostic tests is more than the patient can afford."

Prescription costs can also be prohibitive. "If they want (hormonal) contraception, its pretty limited to what they can afford," Rawlings said. Many of the local pharmacies that offer discounted prescriptions have limited selections, she said, so occasionally, the clinic will go through the companies directly, or through a prescription assistance program. The latter, however, can take quite a while. "If we have to go through the assistance program, if you want birth control, that's a long time," she said. The wait is even more costly for diabetes, or those with other chronic illnesses.

Hooper said that she feels like women frequently don't get screened or tested if they don't think they can afford possible negative results from the tests. "They'd prefer not to know," she said. In addition, she said, women are unaware of the services that the community offers. "Unless you're touched with something, you don't notice the advertisements," she said. "People don't look for the services."

Some services, however, come to the residents. The Reba Mobile Mammography Bus goes out nearly three times a month to Madill and Bonham and does screenings for women around the community. Becky Sewell, an RT registered in mammography, has participated in the program on and off for ten years, she said. "There are a lot of women that if it weren't for that truck ... I don't know," she said. "They just don't want to come to the hospital." The early part of the year is often light, she said, as women haven't met their insurance deductibles. Towards the end of the year, however, the flow of women pick up.

Many of the truck's clients are elderly women from Oklahoma. "They don't want to drive that highway, and that truck is so convenient," she said. Sewell said that she doesn't see the economy affecting the number of women going to the screenings. "I don't feel like that its hit here," she said. "If people start getting laid off, and we get a lot of people ... lose their insurance, that will impact it."

Putting off routine tests, however, is not an option. "People's capacity for denial and delay is mind boggling," Hermann said. The only way to change he trend, he said, is if more funding frees up. There are challenges, however. "If you don't have a job, it's difficult to pay for gas and cars; if you don't have a good public transportation system, it's difficult to make it to a doctor that's further away," he said. "If the country doesn't support the programs locally, people won't travel to a program that's far away."