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.