there are now serious conversations about lowering the MEDICARE age to 50.

My mother (who has medicare and a really good supplemental) could not handle a normal physical therapy regimen.  In order for insurance to cover PT, she has to make a certain amount of "progress."  If she does not, PT is cancelled.

This regimen, which we tried for 3 separate sets of treatment with 2 different therapists, caused my mother so much anxiety that she would have an A-fib episode within 24 hours of a PT visit, like clockwork.

We could not make it work.  We tried to get her private PT "on demand" without the accompanying pressure to improve.  They wouldn't do it, explaining that if they take private pay patients, the insurance companies consider that to be "competition" and they risk losing the huge business from patients who are insured.

For a resident of limited means and mobility, having to travel a long distance to get to a doctor or dentist can be highly problematic. And so, many tend to forgo such care, until the situation reaches a point where they're finally compelled to present themselves in an emergency room, sometimes under very critical and dire circumstances.

In Hawaii, which is over 90% rural, the problem is particularly acute because most all specialized care is localized on the urbanized island of Oahu. This means that those residents on the neighbor islands in need of such care have to fly to Honolulu to receive it.

That's a minimum out-of-pocket expense for the patient of $150 in round-trip air fare. If you're a parent of a minor child who's the patient in need, you can double that air fare cost. And if such care requires you to stay overnight for a day or more and you're not being hospitalized, you can throw in a minimum of $100 per night for a hotel room, as well. Good luck collecting on those incidental expenses from your insurance carrier.

Those of us who live (or have lived, in my case) in major urban areas aren't necessarily aware of the sometimes significant barriers and hurdles which our fellow Americans in rural communities must often overcome, in order to access the sort of quality health care which many of us otherwise take for granted.

And I have to admit that as a former cancer patient myself, that prospect crossed my mind when we made the decision to relocate from Honolulu, population of one million people, to Hilo, a town of only 45,000 that's considered "the big city" by those who live in the smaller coastal communities which dot the East Hawaii landscape.

There are only three hospitals on this island of nearly 200,000 residents -- Hilo Medical Center (just down the road from home), North Hawaii Community Hospital in Waimea, and Kona Community Hospital in Kealakekua on the southern Kona coast.

The State of Hawaii pioneered the concept of universal health insurance coverage in this country with its landmark Pre-Paid Health Care Act of 1974, which was enacted 32 years before Massachusetts undertook a similar endeavor. So, 95% of Hawaii residents have long had health insurance, and the remainder are covered under Medicaid.

For many of us on the Big Island, it's not a matter of how we're going to pay. Instead, we worry about where are we going to go in the event we need specialized care, the type which is above and beyond the call of our friendly neighborhood general practitioner or pediatrician.