As cash dries up in the current recession, people are resorting to bartering their skills in exchange for health care in the US. Ads offering services such as cooking or repair work in exchange for dental and eye exams are becoming more common. A woman in New Mexico, for example, hopes to get an urgently needed filling in exchange for an exquisite evening meal, while a California man is offering his services as a repairman in exchange for an eye examination. A physiotherapist in Maryland is offering massages for violin lessons.

Offers such as these have been booming in the US where health insurance coverage is not universal. Millions of people don't have health insurance or the coverage they have is not sufficient to cover all their needs. Patients are seeking ways to pay their doctor bills at websites, barter exchanges and a variety of agencies. They also are going to see their doctors without any money in their pockets and offering payment in goods such as vegetables and firewood and in services such as Spanish lessons.

More than Money is the name of an initiative run out of the health centre in Goshen, Indiana. Small jobs are arranged for patients in need so that they can be treated. Rising unemployment over the last year resulted in a doubling of the number of people who couldn't pay their medical bills, said James Gingerich, the centre's founder and medical director. It gives people the possibility to go to the doctor without feeling shame, he said, adding that patients feel better about the arrangement because they are not taking charity.

There are 400 registered barter exchanges in the US. One of the most professional is ITEX based in Bellevue, Washington and is used by 24,000 companies to trade without using cash. Steve White, chief

executive of ITEX, said in the last year the number of medical services providers has increased by about 50 per cent.

The amount of trade conducted monthly through ITEX would equal about 1 million dollars, White said on Fox News. The providers in greatest demand are dentists and eye doctors, but chiropractors also are highly sought after. All who engage in trade at the site are required to report the transaction to the tax authorities.

Every transaction is noted in the books - at least at recognized operations like the Barter Clinic in Floyd, Virginia. Ten per cent of the clinic's patients pay for their services using "alternative means," said a doctor there. Whether firewood, cabbage or baby-sitting is on offer, the office calculates its value in dollars. Other clinics have established a special bonus point system for bartered transactions.

The principle is not new. Ron Nelson, co-founder of a US association of rural clinics, said that in the 30 years he's worked in such clinics, providing treatment in exchange for goods or services has been a matter of course. In a television interview Nelson said he's received everything imaginable - from chickens to

greens - in exchange for his medical services.

This is a situation that President Barack Obama would like to change with the introduction of a health insurance reform proposal now being debated in Congress. In the US, the only industrial country without universal health insurance, the number of people who must pay their doctor bills out of their own pocket is estimated at 47 million. Others are uninsured or have insurance only through their employers and if they lose their job, they also eventually lose their insurance if they don't find a new job that offers a group policy.

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