DENVER - Bankrupted by crippling medical bills, for a year Cindy Ramer could not afford to put a headstone over her husband's final resting place.

Truth is, she hasn't been able to afford a tombstone since Jim Ramer died from a heart attack in 2005.

She eventually asked her bank to tack on the expense to a larger loan. The bank agreed.

The Ramers had filed for bankruptcy two years before Jim's death because of mounting medical expenses from his diabetes. They scraped together just enough money to save their home.

Even freed from mounting medical bills, Ramer lives every day knowing she is a heartbeat from another financial disaster.

The Denver woman works long hours and weekends as a certified nursing assistant. She has dedicated her life to caring for others, yet fears another bankruptcy if she ever falls ill herself.

"I worry about it. I hope my health doesn't get bad," she said.

She lives a precarious existence for one simple reason: For more than 20 years she has not been able to afford quality health care.

Still uninsured, Ramer is a familiar face to anyone who attended Democratic Party caucus events in 2007. She has dedicated the years since her husband's death to advocating for health care reform.

"Losing Jim just has made me more determined. It's driven me to do the talking that I've done," she said.

Ramer spreads her message with the help of Iowa CareGivers Association. Di Finley, the group's president, said the widow is not alone in living without insurance.

"It's really a very, very sad commentary on our society when the very people that are providing care don't have access to care themselves," she said.

Recent polls and surveys show the number of uninsured Iowans are rising every year. Last month, the Census bureau released a report based on 2006 figures. It found 10.8 percent, or about 272,000, Iowans were uninsured.

A Gallup poll released a few weeks ago estimated those numbers had risen to 11.6 percent in 2008 and 13.5 percent through June 2009.

The numbers are even higher for certified nursing assistants in Iowa's nursing homes. Iowa CareGivers Association's last survey was in 2004. It found 25 percent of workers have no health care coverage.

Finley said uninsured workers often have access to employee-based health insurance. But it is simply too expensive.

"I think many employers do their best to provide coverage. They're finding it challenging to find coverage that is affordable for their employees," she said.

Coverage too expensive

It's not that Ramer and her husband did not want health insurance. Both worked for small businesses, so coverage had always been expensive.

After Jim got sick, they looked into buying coverage. It cost more than $400 a month. The cheapest plan required them to pay any bills from pre-existing conditions for one year.

Ramer works for ABCM Corp., a Hampton-based nursing home company. She paid for a supplemental insurance plan until about a year ago.

That's when she smashed her head against a car trunk lid, opening a gash that needed stitches. The emergency room trip cost her $1,076, she said, and her insurance paid for $160.

Shortly thereafter, she decided it would be cheaper to go without insurance.

Becky Lohrbach, ABCM Corp.'s benefits manager, said the company is limited in the health insurance it can afford. To purchase major medical coverage - in which companies and employees split the costs of premiums - 75 percent of eligible workers must participate, she said.

With a 2,500-person work force that is 95 percent female, the company already begins with a smaller pool, she said. Many workers opt for a spouse's insurance, while others choose government coverage through Medicaid or Medicare.

"It becomes very difficult to be able to meet the participation requirements that the insurance companies have set up to even have a group plan," she said.