For most of her adult life, Debra Dieterich has lived without health insurance.
She doesn't remember a time when she didn't worry about developing a serious illness, having to have surgery or spending an extended amount of time in a hospital.
It's been a roll of the dice.
Not because she's a risk taker. She would love to have health insurance, she said. But the Hagerstown woman always has been employed by companies where health insurance wasn't offered or has worked part time and wasn't eligible for coverage.
The cost of obtaining private insurance, she said, is out of her reach.
It's an issue millions of Americans wrestle with every day — a fact of life that crosses geographic, economic and racial boundaries.
And every day, they have to make hard choices. Do you buy food or buy medicine? Do you spend money to go to a doctor or use the money so your child can go?
Dieterich said she never wanted to be in a position of asking for help. But with mounting health problems, including rheumatoid arthritis, high cholesterol and acid reflux, she needed medical attention.
So she turned to the Community Free Clinic, where she has been a patient for about five years.
At one time, she was visiting the clinic every three months. Now, she said, she has appointments about once a month.
"If I didn't have the clinic, I wouldn't have anything," she said. "I don't know what I would do without the clinic. I know I wouldn't be getting the care I need because I couldn't afford to go to a regular physician. I'm very grateful."
Dieterich, 55, has been married for 18 years and has two sons.
Her husband, 56, once worked for Verizon, but now is on disability because of Parkinson's disease and Lyme disease.
"He gets Medicare because of his disability," Dieterich said. "But he still has to pay toward some of his medical bills."
He also takes a lot of prescription medications, she said.
So does Dieterich.
"With my health issues, medication is part of the treatment," she said. "And everything is expensive. The Lipitor I take for my cholesterol is about $100 a month. Plus, I have other medications, especially for the arthritis. The Community Free Clinic takes care of my prescriptions. Otherwise, I couldn't afford them."
Even with assistance from the clinic, Dieterich said that with today's economy, the couple only can stretch their budget so far.
"We can't do anything or go anywhere," she said. "It takes money, and our money has to go for other things, like paying for fuel oil."
Last year, Dieterich said, it cost about $400 for 100 gallons of oil.
"This year, I'm sure it will be a lot more. And that's only for a month, maybe a month and a half," she said. "I don't want cold weather to come."
Dieterich said she has just started a part-time job at a grocery store. She previously worked at Sam's Club and was drawing unemployment until she landed her current job.
"I was in my fifth year at Sam's when I got laid off," she said.
Dieterich said the couple is more fortunate than others because their mobile home is paid for.
"We have utility bills and food. But I mainly buy what we need at the grocery store — like milk, bread and eggs," she said. "And I buy other things when they're on sale and try to stock up. I'm a smart buyer."
There is no such thing as an entertainment budget.
"Just television and DVDs," she said.
The couple doesn't have a clothes budget, either, Dieterich said. But when they do need articles of clothing, "I wait until they go on sale."
Dieterich said she and her husband, who have an income of more than $25,000, have learned to cut corners to survive.
"But all my life, I've lived paycheck to paycheck," she said. "It's impossible to save money or put money back for retirement. How can you when all your bills are taking it? And prices continue to go up for everything and paychecks haven't kept pace. You can't get ahead."
But she refuses to let herself get down about it.
"It's a struggle, but we make ends meet," she said. "And as long as we have food, a warm place to live and we're able to pay our bills, I feel we're very lucky — luckier than so many people."
She does, however, worry about what the future will hold for her three grandchildren.
"I'm hopeful things will get better," she said.
Debra Dieterich's monthly budget
Mortgage: Mobile home paid off
Food: About $220
Clothing: Buys clothes when needed and only when on sale.
Entertainment: No money budgeted; television and DVDs.
Utilities: $400 for 100 gallons of fuel oil last winter. Expects it to be higher this year. $60 for electric.
Medical: No health care insurance. Receives medical treatment and prescriptions from Community Free Clinic. Husband is on disability and Medicare.