Walking back from the post office one day in May, Toni Taylor excitedly fingered a sealed envelope from the state government, feeling for the health insurance card inside.

On the Edge One in a series on the medically uninsured

VWH Campbell, Post-Gazette Toni Taylor is one of 96,000 Pennsylvanians waiting for AdultBasic health insurance program for the working poor. Click photo for larger image. Previous articles How those with least are charged most (3/25/04) Forgoing health insurance can be a costly gamble (2/22/04) Looking for health care in all the free places (10/31/03) Health-care cutoffs leave many here out of luck (10/17/03)

Taylor thought her yearlong wait for coverage had finally ended, but when she opened the letter, she found a bitter pill instead: She likely would have to wait another 11 months for the health insurance to kick in.

That's a problem for Taylor, 25, of North Apollo, because she suffers from a neurological problem that threatens her eyesight.

It's also a problem for another 96,000 people on the waiting list for coverage in the state's adultBasic program, which is funded by revenue from Pennsylvania's share of the national settlement with tobacco companies.

With settlement dollars shrinking each year, the Legislature had to find $12 million in the budget passed earlier this month to subsidize adultBasic just to ensure that the program didn't have to close some existing slots.

The state has applied for more than $1 million in federal money to develop a more stable approach to providing coverage for people like Taylor. But the task is daunting, because while tobacco dollars dwindle, the cost of adultBasic coverage -- like coverage for everyone else -- keeps going up.

"Rather than facing cost increase after cost increase, which either causes us to reduce the number of people who can be covered or substantially increase the amount of money we put in to cover the same amount of people, we're trying to develop a more systematic approach," said Ann Torregrossa, senior policy manager for the governor's office of health care reform. "It's just symptomatic of the untenable situation that I think anyone who's trying to provide health care coverage to people is facing."

Taylor, her husband and two children have an annual income that's less than $37,700, the limit for a family of four applying for adultBasic. Her husband, Nathan, has health insurance through his job in asbestos remediation, but his company doesn't subsidize costs for dependents.

Taylor's children are covered by the state/federal Children's Health Insurance Program.

Last month, 39,440 people were covered by adultBasic, which is available to Pennsylvania residents 19 to 64 years old who don't have other coverage. Had the Legislature not found money to subsidize the program, about 8,000 slots would have been lost this year from attrition. The program is already down about 10,000 slots from its high point of enrollment in February 2003 of 50,258.

To Taylor, the blizzard of numbers simply means a long wait for coverage.

Taylor was covered through her job at a nursing home, but lost the insurance a few months after she quit in October 2002. She had just given birth to her second daughter, and she couldn't rely on her family to care for her children while she worked.

She knew this was a risky move, considering her December 2001 diagnosis with a condition called pseudotumor cerebri. The name literally means "false brain tumor," but that's not to suggest it isn't a real problem.

Causing headaches, nausea and the risk of vision loss, the condition requires treatment to monitor and relieve the buildup of cerebrospinal fluid in the space surrounding the brain.

When Taylor had insurance, she received regular spinal taps to gauge the pressure. She also received medicines to reduce the fluid buildup.

But she stopped the regular treatments after she lost insurance -- her symptoms largely went away at that point, too.

In June 2003, she applied for the adultBasic coverage, but it wasn't there for her when symptoms returned early this year. She didn't seek care immediately because of the costs, but the headaches and nausea finally drove her to an emergency room in May.

Now, she has about $1,200 in bills for the emergency room visit. A bill collector sent her a letter about the matter this week. Thankfully, that letter was quickly followed by notice of a charity care policy from the Alle-Kiski Medical Center.

Hospital charity care is just one of many policy issues swirling around public debate about the uninsured in the United States. The issue was raised indirectly this week when four Allegheny County residents sued the University of Pittsburgh Medical Center, saying the hospital wrongly charges full prices for care provided to the uninsured. Similar lawsuits have been filed against hospitals across the country.

But providing insurance to the uninsured is the solution being pursued by the state through its grant application to the federal government. If the U.S. Department of Health and Human Services funds Pennsylvania's request, the state will spend more than $1 million to plan a strategy for expanding coverage.

One possibility, said Torregrossa, is to let employers buy coverage for workers through the state's Medical Assistance program. That would enable companies to provide more comprehensive coverage at a better price, because it would generate a match in funding from the federal government, she said. Maine is exploring this possibility.

"A very strong component of this will be trying to do something about the cost, and another important and related component is quality," she said. "We know that we're spending billions of dollars on health care that, if we had better patient safety and hospital infection control measures, we wouldn't have to spend."

That sort of change, though, would be slow in coming.

In the meantime, Taylor is getting free samples of medicine from her neurologist and has applied to pharmaceutical assistance programs for free and reduced-price drugs. She's also getting primary care at a discount from a family health center operated by UPMC St. Margaret in New Kensington.

These measures don't eliminate the need for insurance, Taylor said, because they wouldn't help her pay for surgical treatments that are sometimes called for with pseudotumor cerebri.

"Insurance would mean a lot," she said. "It would assure me that I would have a better chance of seeing my kids walk across the stage at graduation."