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Jo Christie has been with Kaiser for 35 years, but longevity, she has discovered, does not breed loyalty from the Kaiser executives who have been taking her money for decades. They have inched her rates up over the past several years until this year she has finally decided she may not be able to afford it anymore. Her premiums shot up to $490 a month, and after all these years she is looking for some other way to take care of her health care needs.

That, she believes, is exactly the outcome Kaiser and other insurers are looking for among their aging patients.

Jo, 58, is a San Francisco native who lives in Cupertino and is self-employed. Her husband, whom she divorced six years ago, had their family covered through Kaiser as a Lockheed employee. They raised three children in Woodside. The Lockheed coverage ended six years ago, and Jo went on COBRA for three years. Then began the upward spiral.

Now, she says, "I don't know what I'm going to do. I cannot obtain affordable coverage from Kaiser, and I have not found other coverage. I am ready to drop health insurance and take my chances on staying healthy, but I know that is quite risky."

Her travails are aggravated by the fact that she has a pre-existing condition, which, along with age, makes insurers leery of taking on a patient. She has the condition under control. She has not seen a health care provider for 20 months, nor has she taken any medication for a condition Kaiser labels "incurable. I have totally changed my lifestyle. That means nothing to them."

Jo is bothered by more than the disloyalty and cost. She feels she is not getting her money's worth in this buyer-seller relationship. While costs have gone up, service has declined. One example: Kaiser tries to dissuade patients from using the services they've paid for.

"I have to convince them I need to come in," Jo says. "Their attitude is, 'it's too bad you're dying, it's too bad you're sick."

"For this I pay $5,000? I'm paying more money for less service."

Jo has thoughts about health care reform. First, she says, there should be some way for the self-employed to get a group rate. The safety net is yanked away when you leave the safety of a large employer.

Kaiser and others also have to control costs. "That's a big thing that has to happen." The health care industry is spending far too much on advertising, to cite just one excess, she says, especially on prescription drug advertising.

Drugs are playing too much of a part in health care, she adds. "There's way too much emphasis on medication. It's an easy out now," with doctors prescribing them excessively to both children and adults.

Jo adds that the health care system should place more emphasis on preventive medicine.

Should the government get involved? Jo is wary about that. She doesn't trust the government to be more efficient. She would, however, like to see a government panel regulate premium and other costs. Insurers should not be able to arbitrarily raise rates outrageously, dismissing the act with a glib "our costs have gone up," she says. They need to prove it.

As the population ages, Jo points out, the situation is going to grow more acute. And it is not only patients who will suffer. "The country can't really afford it."