The first question a doctor's office asks any new patient: "What kind of insurance do you have?" Shaneera Smith's answer, like that of millions of Americans, is: "I don't have any."
Smith and her husband, Omar, both had pretty good jobs - she as a hairstylist and part-owner of a salon, he as a mortgage broker - though they were without health benefits. But they figured they were young and healthy enough that they could skip the added expense of monthly insurance premiums, especially as they struggled to pay the rest of their bills.
Until November, when Smith felt a lump the size of a dime in her right breast.
So began an odyssey through a system where the words "self-pay" are near-anathema, where the health worries of a 32-year-old are not always heard and where lack of insurance can ultimately be the difference between life and death.
For Smith, proper diagnosis and treatment of what turned out to be very aggressive breast cancer would take months of begging doctors to see her and worrying about how to pay them, thousands of dollars on an overextended American Express card and energy that could better have been spent fighting the disease.
An estimated 47 million Americans, including 800,000 Marylanders, are without health insurance, a number that could grow with the downturn of the economy. They are not poor or elderly - government programs provide care for those groups - but often earn too much to qualify for subsidized insurance, too little to find affordable care.
Studies estimate that as many as 80 percent of them have jobs, some like Smith from dual-income families. The Smiths earned about $45,000 last year while taking care of a baby and Smith's 16-year-old adopted son.
"We should have looked into other options," Smith says now. "We were, like, we'll get it [insurance] eventually. We just never did it."
A complicated illness like cancer, which often requires batteries of tests, hospitalization and long-term care, is hard enough to navigate through with solid private insurance. But those without, or those who are covered but not as well as they need to be, are left to cobble together health care through a mix of government programs (if they are eligible), hospital emergency rooms, charity and luck, if they can land in the office of a doctor willing to take them on.
"I have heard this so many times," said Dr. Peter L. Beilenson, who runs the Howard County Health Department, which is establishing a program that will eventually cover all county residents who lack insurance. "It's maddening and sickening at the same time. Someone in the midst of a health crisis should not have to search around looking for someone to see them."
A recent report in a journal published by the American Cancer Society showed that women without private insurance were less likely than those with insurance to be diagnosed with breast cancer at an early stage, when the disease is more curable. Breast cancer patients without insurance, the report states, don't survive as long as those with private insurance or government-provided insurance like Medicaid.
"If you don't have insurance, you're not going to get your annual mammogram. If you find a lump, you'll put off going to the doctor because of the money," said Rebecca McCoy, grants and education program manager for Susan G. Komen for the Cure's Maryland affiliate.
Aid programs are scattershot, depending on what body part is affected. While breast and cervical care can often be found, programs for lung and skin cancer are virtually nonexistent.
Shaneera Smith's story begins two months after she gave birth to Tatyana. Smith had always gotten her yearly gynecologist check-ups - paying in cash and paying doctors out of pocket to deliver her daughter.
But she found the lump and needed to be seen. The doctor told her it was likely a clogged milk duct or mastitis, an infection typically caused by breast-feeding.
Whatever it was, it wasn't going away. In mid-January, she was back at the doctor, this time with a mass the size of a quarter. The doctor suggested she see a breast specialist.
Easier said than done. With Smith and her mother in his office, he called three doctors. Each refused to see her because she had no insurance. "She has no balances with me," he vouched for her.
On the fourth try, a doctor was found. The next day, Smith saw her. She dismissed Smith's concerns, pointing to her age. Smith explained that her aunt had been diagnosed with breast cancer at 32 and "she's no longer with us."
Still, Smith got an ultrasound - paying hundreds up front - and was again told it was most likely mastitis. Smith knows she should have pushed harder and would have under different circumstances, but couldn't really afford to. Every time she saw a doctor, it cost money she didn't have. "I was scared of what the bill might be," she said.
Six weeks later, with a mass the size of a lemon in her right breast and a new pain under her arm, Smith went to the emergency room at Greater Baltimore Medical Center in Towson on a Saturday night in March. She got no treatment and was told to call a doctor Monday.
She did and somehow got an appointment that day with a doctor at St. Joseph Medical Center. The nurses quickly sized up the situation. Before the week was out, she had a biopsy, a diagnosis of cancer and a promise they would help, despite her financial situation.
Still, the money issue didn't go away. Handed a half-dozen prescriptions for diagnostic tests needed to determine the course of treatment and the extent of the cancer, she kept running into snags. She kept breaking out the American Express card. Hundreds here, $1,700 there. When it came time to get an MRI, she waited for an hour and a half and was told they didn't take AMEX.
"If you don't have medical insurance, you get bounced around," she said. Smith said she is certain she would have a much better prognosis if only she had health insurance. Her cancer might have spread too far.
Smith's medical needs are now being handled. She got care through the state Department of Health and Mental Hygeine's Breast and Cervical Cancer Diagnostic and Treatment Program. Because she and her husband are separated after nine years of marriage, she qualified for that program and for Medicaid, the state-federal health insurance plan for the poor.
"What's sad is that if my husband and I weren't separated, I wouldn't have qualified," she said. "I probably would have just been in limbo."
The state-funded program has a budget of $14 million and sees 4,200 low-income women a year. "We never turn people away" who qualify, said Donna Gugel, director of DHMH's center for cancer surveillance and control.
But the program isn't known to everybody. Gugel said it has a Web site and providers know about it, but acknowledges that a woman having access problems might never hear about it. "Her case illustrates that it's hard," she said.
A bill that would have established a program to provide a year of coverage to any Maryland resident newly diagnosed with cancer earning less than 300 percent of the federal poverty level ($63,000 a year for a family of four) failed to get out of a committee in the Maryland House of Delegates this year.
Come July 1, however, Maryland will expand access to Medicaid by an estimated 40,000 to 45,000 people. It will add more parents, children and workers to the rolls by allowing a family of three making $20,500, for example, to enroll. The limit is now $7,000 a year.
In Maryland, the law requires that hospitals be reimbursed for uncompensated care. But doctors are still running businesses and can't always take on cases like Smith's. Her St. Joseph's surgeon, Dr. Maen Farha, takes that into account but feels a duty to find a way to treat patients like Smith who come to him without options.
"When it comes to somebody who's sick or has a serious condition ... we just treat them," Farha said. "It's not an elective situation. This is a serious situation that has to be taken care of."
Smith can no longer work. She has lost her stake in her Gwynn Oak hair salon. But she has the support of her friends and even her estranged husband, who has accompanied her to appointments and is the actual holder of that American Express card. Smith's only credit is at Macy's.
The medical journey for Smith, who is also an aspiring actress who appeared on The Wire as an exotic dancer who died of an overdose, didn't end when doctors agreed to treat her. Her tumor now encompasses nearly all of her breast, and two different courses of chemotherapy failed to significantly shrink it.
On Monday, Farha will perform a mastectomy and remove Smith's lymph nodes. He hopes he won't have to take out muscles, too. It will depend on how large the tumor has grown. The surgery will be followed by more chemo and radiation. It will be months before doctors will know whether Smith will be cured.
She almost didn't get this far. She almost gave up, until her husband reminded her that their daughter needs two parents.
Smith and her 10-month-old daughter have moved out of the family's Pikesville home and now live with Smith's mother in Columbia, sleeping each night cuddled up on a pullout couch. "I tell myself every morning when I wake up, I'm going to pull through this," she said. "But you never know."
stephanie.desmon@baltsun.com