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Gary Younge
Who wants to be a Carilionaire?

David Crimmins sits on a chair outside his house, holding his youngest son and smoking a cigarette. With no phone and no car, he would be the first to admit he doesn't own much.

But what little he does have, he nearly lost earlier this year after he fell of a ladder while he was painting and went to the local hospital to get a herniated disc treated. Crimmins was left with a $5,000 bill; he earns $15,000.

When he was taken to court for the money, he didn't bother showing up. "I didn't see the point," he says. "They're going to do whatever they want anyhow."

So Carilion, a nonprofit private clinic that gets tax breaks in return for a commitment to provide healthcare to the poor, garnished his wages. They are also garnishing his sister's wages for money she owes them and extracting money from his mother's pay packet for care she received. "Carilion have been trying to take me to court since I was 18," says Crimmins.

Indeed, since 2003 Carilion has accounted for 40% of all the judgments at Roanoke district court. Such is the volume of its collections that the courts set aside one day a week just to deal with healthcare. They call it Carilion day.

"While the numbers seem large, they represent a small fraction of the 2 million patient visits to Carilion facilities each year," says Eric Earnhart, a spokesman for Carilion."

"But we are working hard to reduce the number of people who qualify for charity care but do not pursue it. Last year we provided approximately $43m in free care to patients who couldn't afford to pay."

A local group, the Citizens Coalition for Responsible Healthcare, has been set up to challenge Carilion and raise the issue of affordable healthcare in the town.

Ken King, the coalition president, says that if you cannot afford health insurance, "your doctor of choice becomes the emergency room".

"At that point you are probably walking into a room that has the highest cost of operation of any medical facility, any kind of care available ... If you can't pay it, you get sued. Thirty-three thousand people in Roanoke general district court in the last five years have been sued for that bill."

Once a railroad town, Roanoke is now dominated by Carilion, which merged with another local hospital in the late 1980s. At the time, the justice department tried and failed to prevent the merger, warning that it would create a monopoly.

According to the Wall Street Journal, health insurance rates in the area have risen since then from the lowest to the highest in Virginia.

Carilion disputes this: "A comparison of Carilion's prices with hospitals that have comparable volume, and with the state average, shows that in many if not most cases, our prices are lower," it says.

Today, a colonoscopy at Carilion costs between four and 10 times what you would pay at a local endoscopy centre, while a neck CT scan is just under three times as much. Hospital care, Carilion says, is always more expensive than that provided at outpatient facilities.

The hospital has a charity care programme through which anyone who earns twice the federal poverty level or less should pay less, or nothing. A single person earning less than $20,800 or a family of four with an income below $42,400 should qualify. Clearly, however, many fall between the cracks.
So Crimmins, it turned out, was eligible for assistance, and Carilion has stopped pursuing him.

Healthcare has emerged as a huge issue in this election. With the provision of care here often tied to jobs, the failing economy means anyone worried about their job security is, almost by definition, worried about their health.

And this isn't just a concern for the very poor. One small business owner and cancer survivor I spoke to says she has not been for her check-ups for three years because she has no health insurance. She simply makes it a priority not to get sick.

With 16% of the country uninsured, and 50% of bankruptcies linked to non-payment of medical bills, the issue is central to the economy.

The numbers are staggering. "Forty-seven million [people] - which is 35% of the population - don't have healthcare insurance in the United States right now," says King. "$143bn is the administrative cost of the healthcare system, and that's simply the paperwork cost; $2tn is the annual healthcare cost in the United States ... and $7,000 per person is what it costs us.

"One of the things that is really a problem is that employers are beginning to say: 'We can no longer do this. We can't provide healthcare for you as an employee.' And that number is going to go way up."

For the most part, that is good news for the Democratic presidential nominee, Barack Obama, who is regarded as better on health than his Republican rival, John McCain.

"Me, personally, I think I would put a poor man in, somebody who knows how to budget, knows how it feels to struggle," Crimmins says. "[I've worked] pretty much since I was 12 years old. My mom, she was raising nine of us by herself, so she didn't have the money to get what we wanted - or what we needed, most of the time. So I always had to pitch in and help out."

He has never voted, and he is not registered. But he is rooting for McCain because, he says, the Republican is more experienced.

If she were registered, his partner, Melissa Hicks, would vote the same way. "I don't know why I don't like Obama," she says. "But it's not because he's black."

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