Health Reform

Members of the PA program at Georgia Regents University, including Timber Wages, wear blue to raise awareness of diabetes

Her 27 months at physician assistant school was an intense experience, says Timber Wages.

“It’s like trying to drink water from a fire hydrant,’’ says Wages, 31, who attended the PA program at Georgia Regents University in Augusta.

A fire hydrant?

“The volume of information is overwhelming,’’ she explains, adding with a chuckle, “but not impossible.’’

Timber Wages

Wages, originally from Calhoun in northwest Georgia, weighed several job opportunities when she graduated about a year ago. She joined an Augusta urgent care center as a PA in primary care, and also works at a Columbia County detention center.

Over the past decade, both Georgia and the nation have seen a surge of PAs. The higher demand comes from several factors: the growth in outpatient clinics; the shortage of primary care physicians; and the added emphasis on cost-effective, team-based medical care.

A physician assistant is a health care professional who has the training to perform many of the duties that doctors routinely handle. PAs must be licensed and each must work under the direction of a physician.

About 95,000 PAs are practicing across the country, up from 43, 500 in 2003.

The number of PAs in Georgia has increased by 67 percent over the past 10 years, now surpassing 3,000. Still, experts say there’s a shortage of them in the state.

Though she and other PAs are not allowed to prescribe certain medications, Wages says she can do most things a primary care physician can do. That’s why PAs are so valuable in primary care: They can relieve much of the workload of doctors.

A large majority of Georgia PAs, more than 75 percent, are currently practicing in metropolitan areas, according to a state workforce survey.

Wages says an attractive feature of being a PA is lateral career mobility, where she can work in primary care for a while, then transfer into a specialty, such as dermatology or orthopedics.

Most physician assistants end up going into a specialty, says James Cannon, board chairman for the National Commission on Certification of Physician Assistants.

All are trained in primary care, which can help a PA who moves into specialty medicine, says Cannon. He’s a PA who works in psychiatry, and while he treats substance abuse patients, he also can address their primary care needs.

The NCCPA organization, based in Johns Creek in the northern Atlanta suburbs, is the only certification and licensing exam entity for the PA profession. NCCPA certification (passing a PANCE exam) is required for initial licensure in every state.

A calling that’s relatively new

The PA profession arose in the 1960s, when physicians and educators recognized there was a shortage of primary care physicians.

To help address the need, Dr. Eugene A. Stead Jr. of the Duke Medical Center, formed the first class of physician assistants in 1965. He selected four Navy corpsmen – military medics who treat sailors and Marines – to be the first students.

Now, PAs and nurse practitioners (who also can handle many of the duties frequently left up to doctors), are considered part of the solution to primary care shortages, especially with the coverage expansions from the Affordable Care Act.

Chris Parker, associate project director at the Georgia Health Policy Center, adds that under the ACA, “as more individuals find coverage, an even greater demand will be placed on our primary care system, especially in rural and underserved communities.

A Rand Corp. study published in November said new roles for PAs and nurse practitioners may cut a predicted shortage of physicians by about 50 percent.

“Growing use of new models of care that depend more on non-physicians as primary care providers could do much to reduce the nation’s looming physician shortage,” said David Auerbach, the study’s lead author. “But achieving this goal may require changes in policy, such as laws to expand the scope of practice for nurse practitioners and physician assistants, and changes in acceptance, on the part of providers and patients, of new models of care.”

Using PAs and nurse practitioners in “medical homes” – teams of health professionals working together to coordinate care – can relieve the doctor shortage by serving larger numbers of patients than a single physician can treat, experts say.

Georgia now has four PA schools – at Emory in Atlanta, Mercer in Atlanta, Georgia Regents University in Augusta and South University in Savannah.

USA Today reported last year that according to the American Academy of Physician Assistants, 60 new physician assistant programs were waiting then for accreditation, and 10,000 new PAs were expected by 2020.

Jeff Chambers is one of five PAs on an Air National Guard special medical team.

Many schools that already teach people to be physicians are branching out into teaching people to be physician assistants. For instance, the Georgia campus of Philadelphia College of Osteopathic Medicine (GA-PCOM), located in Suwanee, said recently that it plans to add a PA program, pending accreditation.

“There are a lot of jobs available, especially in emergency medicine,’’ says Jeff Chambers, a physician assistant who works in orthopedics in Athens. “More primary care jobs are opening in rural areas.’’

As a PA in orthopedics, he says, “I can put bones and joints back in place,’’ plus assist in surgery.

It’s cheaper and quicker to train a PA than a doctor, says Chambers, a past president of the PA association.

Nationally, the median salary for a PA is about $97,000.

Wages says she wanted to practice in Georgia because it’s her home state.

“I’m very proud to be a PA,’’ she says. “And I enjoy general practice much more than I anticipated.”

The owners of this Braselton antiques and home decor business say they aren’t interested in the small business insurance exchange.

The health insurance marketplace for small businesses is now open.

But Mom and Pop aren’t buying.

Many small employers do not even appear interested in checking out this feature of the Affordable Care Act, which is different from the better-known individual exchange where people buy coverage for themselves.

Jackie Stowe is a small business owner trying to settle into a new location.  She and her husband, Mike, recently moved their antiques and home decor store from Hoschton to Braselton.

Stowe plans to add a couple more people to the JarFly Station payroll, but she’s been so busy with the move that she admits health insurance hasn’t been on her agenda.

Meanwhile, everyone in the store’s small workforce already has insurance. Mike is also employed with Keller-Williams Realty, and he and his wife are covered through that company. And the couple’s two employees get health insurance through their spouses.

Stowe says she needs to do more research, but she hopes that she does not have to get a plan through the Small Business Health Options Program (SHOP), the government’s health insurance marketplace for small businesses.

“I don’t really want to go through it,” she said.

And she’s not alone.

An option, not a mandate

“I think it’s become so complicated that the reaction for people is just to shut down,” said Ann Murray, head of the employee benefits practice at the law firm McKenna Long and Aldridge.

Unlike with some other programs of the ACA, this is an option, not a mandate. The health law does not require businesses with fewer than 50 employees to offer health insurance to their workers.

But SHOP is meant to help small business owners find affordable coverage. As incentives, the government offers certain tax credits and deductions to employers with fewer than 25 employees who set up coverage through SHOP and help pay for it.

Currently in Georgia, the only way to sign up for a SHOP plan is to go see an agent, broker or insurance company and fill out the paperwork.

Interested employers can view SHOP plans and prices through an online premium estimation tool.  However, to enroll in SHOP coverage, employers need to enroll directly with insurance companies and pay them the first month’s premium.

Online enrollment won’t be available till later this year.

To get the tax credit, employers need to submit an application to determine their SHOP eligibility. Interested employers can download the application online and send it by mail; apply by phone; or work with an agent, broker or insurance company.

‘Not our most popular offering’

While some companies enroll in the small business exchange because of the tax breaks, some employers prefer to skip SHOP’s “intensive” paperwork and just advise workers to seek their own coverage through the individual exchange, said Bert Kelly, director of communications for Blue Cross and Blue Shield of Georgia,

Blue Cross is one of the companies that offer SHOP plans in Georgia, but Kelly said, “It’s not our most popular offering.”

The goal of SHOP is to provide a variety of health insurance options to both employers and employees of small businesses.

Under the original ACA design, workers from different small businesses could enter the SHOP exchange and be able to pick a health plan from several options, similar to what large employers offer.

But currently in states that have federally run insurance exchanges, such as Georgia, only employers can choose the plan they will provide. Employees will not be able to choose their plans until late 2015 or even 2016.

On top of delayed and only partial implementation, eligibility requirements are complex.

“A lot of the people are confused,” said F.J. Fenn, president of the Jackson County Area Chamber of Commerce.

The Jackson County Area Chamber of Commerce says local businesses are confused about their ACA options.

Fenn says the law’s new policies could have been introduced and explained a lot better. He encourages business owners to talk to their current insurance provider to make sure they really understand how the law is going to affect them as individuals and as business owners.

But mom-and-pop owners have little time to wrestle with new rules about health insurance because they’re juggling payrolls, books and inventories, legal expert Murray said.

Enrollment barriers and launch delays for the online exchange have discouraged a lot of people, she said.

In February, to help with the transition to the ACA’s requirements, the Obama administration delayed the mandate for employers that have to provide insurance to full-time employees. Businesses with 100 or more employees will not be fined for failing to provide health coverage till 2015, and businesses with 50 to 99 employees will not face fines until 2016.

Larger paychecks rather than benefits

Meanwhile, many Jackson County business owners are not even thinking about providing health insurance for their workers, much less using the government marketplace as a way to do it. Some of these owners have very small businesses and don’t employ anyone but themselves, while some hire people who already have coverage through parents or spouses.

Shawn Watson, owner of Legacy Landscape Management in Jefferson, has given the matter some thought. And he says that his employees would rather have larger paychecks than benefits.

“In the past, most employees were not interested in insurance,” he said in an email.

Watson has personal health insurance coverage, and said he knows that six of his eight employees are covered either through their spouses or through an individual health plan. He does not know about the other two.

According to an analysis done by the Kaiser Family Foundation, workers at businesses with fewer than 50 employees are 25 percent of the workforce, but they account for 40 percent of all uninsured workers.

Ultimately, suggests Murray, what happens with small business health insurance will be up to individual workers, not employers. The business owners will have to worry about providing such coverage only when – and if – their workers start calling for it.

But uninsured workers will probably not take that step until they face their other options under the ACA: either to buy insurance themselves or pay a penalty.

“Until it hurts the individual, [they’re] not going to start complaining” about small businesses’ lack of coverage, she said.

Hyacinth Empinado is a freelance science writer. She is currently a first-year graduate student in the health and medical journalism program at the University of Georgia.

Cecelia Smaha (seated) and Sr. Joan Serda at a Get Covered America event in Atlanta

The volunteer army in the Affordable Care Act enrollment effort included two older women stationed regularly at a Macon Kmart.

Sister Joan Serda and Cecelia Smaha, a layperson associate of the Sisters of Mercy, talked to hundreds of local residents about the health care law in the months leading up to Monday’s enrollment deadline.

The two say they volunteered for the Get Covered America campaign because their organization’s mission includes helping people living in poverty who lack education and health care.

“I feel terrible that so many people don’t get health care,’’ said Serda, 76, who has been a nun since 1956. She’s a retired educator, so the role of informing people about their insurance choices was a natural fit.

She and Smaha set up a table at Kmart, answering questions about the ACA and talking about coverage, and gathering names of people who wanted further help. They also did education sessions at local Catholic parishes.

James Ramirez, the Get Covered America official who oversees Macon, says Serda and Smaha made a huge impact in the education effort.

“They are probably the most passionate, dedicated people I have seen in my experience, willing to sacrifice their time and energy to make the world a better place,’’ he says. “There is no way we could have made this much impact in Macon without their help.”

Hours after the midnight Monday deadline for sign-ups, the White House announced Tuesday that more than 7 million Americans were enrolled in the health insurance exchanges.

The two Macon women didn’t help people sign up directly. They were not “navigators,’’ specially trained counselors hired to help people enroll in the insurance exchange.

Divisions among Catholics

Still, they say, there was a lot of education to be done about the complicated law, which has many critics and is not well understood by many Americans. The state’s Republican political leadership remains united against the Affordable Care Act, also known as Obamacare.

Sr. Joan Serda at Kmart in Macon

The hardest thing to explain to opponents of the law was that the ACA helped the working poor, Smaha says.

“This is not a freebie,’’ says Smaha, 71, who has been a lay associate of the religious order since 2000. “Some people [signing up] had two or three part-time jobs.’’

None of the ACA opponents who talked to them were “really rude,’’ Serda says.

“We had a few people who came to us and discussed their opinions,’’ she adds. The two say they acknowledged to the skeptics that the ACA isn’t perfect, that it could be improved. “No one was ugly’’ in the way they disagreed, Serda says.

Some of the law’s provisions have been opposed by the U.S. Conference of Catholic Bishops. The group set out a position that supported the expanding of insurance coverage to millions of Americans. But the bishops also opposed final passage of the ACA because of concern that it would expand the role of the federal government in funding and facilitating abortion and plans that cover abortion.

The bishops also oppose the ACA requirement to offer insurance coverage for contraceptives. A Catholic religious order, the Little Sisters of the Poor, has fought in court against a contraception coverage mandate for people it employs.

A spokeswoman for the bishops noted Wednesday that while they have opposed certain provisions of the ACA, they have not joined in efforts to repeal the law.

Serda and Smaha do not appear overly concerned about these stands by the bishops and some other Catholics. Their order, the Sisters of Mercy, on their website said they supported the passage of the ACA out of a conviction that people have a right to health care.

Two outspoken women

Serda and Smaha say their biggest challenge was not having a navigator at Kmart to help people apply for coverage. Kmart didn’t allow it, they say. “We would have gotten a lot more people,’’ Serda says.

A spokeswoman for the company said in an email to GHN that the role of the insurance navigator is to help consumers prepare electronic and paper applications and enroll in coverage.

“This may have been why the navigator was not able to assist,’’ the spokeswoman said. “No computers were on site nor were any enrollments being processed.’’

The two women say they’re unhappy with the decision by Gov. Nathan Deal not to expand Georgia’s Medicaid program. Expansion of Medicaid is outlined under the ACA but is optional for states, and several are not doing it. Deal, backed by fellow Republicans who control the General Assembly, says Georgia can’t afford to do it.

If Medicaid expansion were carried out, it would extend coverage to hundreds of thousands of uninsured Georgians, who are making below 100 percent of the federal poverty level but don’t qualify for subsidies in the insurance exchange.

“So many people have been caught in the gap,’’ with neither Medicaid nor subsidies, Smaha says.

The two women don’t know how many of the people they talked to eventually enrolled in coverage.

“I think it was worthwhile because we helped some people,’’ Serda says.

Ramirez of Get Covered America has a stronger view. He says Serda and Smaha “have been central to our success statewide, but definitely in Macon.”

Gov. Nathan Deal visits WellStar Cobb Hospital last year. Photo courtesy of Andrea Briscoe

Nathan Deal has been involved in many high-profile decisions on health care while serving as Georgia’s governor.

Deal, who is running for re-election this year, has staked out his opposition to the Affordable Care Act (often called Obamacare) and to expanding the state’s Medicaid program. He has also supported changes to the health plan covering state employees and educators, following a wave of criticism that occurred after a new benefits framework debuted Jan. 1.

Georgia Health News recently emailed questions to Deal on a wide range of  major health care issues in the state. We received his reply Monday,  shortly before the scheduled close of the 2014 General Assembly.

In his answers, he discusses pending legislation, the federal law on ER care, the financial struggles of rural hospitals, and what he sees as ways the state can improve its health care system.

Here are GHN’s questions and Gov. Deal’s responses:

Q: What is your biggest accomplishment as governor in the field of health care?

A: When Washington tried to levy the huge taxpayer burden that is the Affordable Care Act on Georgians, I could not allow for billions of dollars of our state budget to be diverted from our schools and our citizens. By mitigating that disastrous impact on our state — an additional 620,000 people on Medicaid rolls and billions of dollars — we are keeping our budget balanced and protecting the people of Georgia.

Q:  As governor, you have blocked Medicaid expansion in Georgia. House Bill 990 would require legislative approval for any such expansion in the state. Do you support this legislation?

A: Yes, just the expansion of Medicaid would cost Georgia an additional $2.5 billion over 10 years. This will have major budgetary impacts so it only makes sense to have our state legislature play a part in the decision making process.

Q:  Do you foresee any circumstances under which you would support an expansion of Medicaid?

Gov. Nathan Deal

A: No, not under current conditions. I am doing everything in my power to rebuild our school funding as we come out of the Great Recession. We simply cannot afford the $2.5 billion in new spending that the expansion would require without a severe impact on public education. The federal administration needs to start acknowledging the Supreme Court ruling and look at other alternatives that don’t force new spending by the state. I have often discussed the advantages of a block grant. States need more flexibility in order to make their program work for their unique population rather than a one-size-fits-all Washington mandate. When I was a congressman, I served as chairman of the health subcommittee of Energy and Commerce. The need for flexibility is not new to me, but serving in my role as governor has only reinforced the notion that states can operate more efficiently with flexibility.
Q: HB 707 would prohibit employees of any state unit from spending state funds to advocate for Medicaid expansion. It would also bar the University of Georgia from operating its current navigator program, which hires and trains people to help consumers use the health care exchange. Do you support this legislation?

A: It is my policy to not comment on pending legislation that is not part of my legislative agenda.

Q: You recently commented that changes to the federal EMTALA law (requiring hospitals to treat arriving ER patients) can help reduce health care costs. Can you expand on those comments?

A: I have always been a supporter of promoting primary care and preventative care as opposed to emergency room visits for non-emergency circumstances. In the case of a true medical emergency, people should always have access to emergency rooms. However, for non-emergency situations, we should encourage those people to seek treatment in a more cost-effective setting, thus opening beds and reserving resources for those in most critical need. Because there is some confusion on this issue, let me be clear: No one’s going to be denied service. None. This isn’t about blocking doors to health services. It’s about opening new doors that yield better health outcomes at a fraction of the price of emergency rooms. The onus is on us to make sure these non-emergency resources are available and convenient to the populations in need of service.
Q: Four rural hospitals have closed in Georgia over the past two years. Can the state of Georgia do anything to prevent more from closing?

A: I recognize the critical need for hospital infrastructure in rural Georgia, as they save lives and maintain our communities. Hospitals large and small have all felt the impact of the recent economic downturn. While support that these hospitals received has diminished, I am hopeful that as the economy improves, so does the flow of funding and contributions that keep our rural areas thriving. We will continue to monitor the situation with the Department of Community Health.

Q: The changes to the State Health Benefit Plan that began in January have sparked a wave of criticism from educators, state employees and retirees. Will the pending switch to a co-pay system alleviate the members’ concerns?

A: The intention of those changes was to lower out-of-pocket health care costs for state employees. The SHBP already covered 100 percent of preventative care visits, and these improvements give employees an additional layer of security so they can do the right things to stay healthy. I believe the changes address the core concerns of our employees, but the Department of Community Health will continue to monitor and evaluate the situation.

Q: Medical marijuana has suddenly become a high-profile topic in the General Assembly. Do you support this legislation that would create a mechanism to help children with seizure disorders?

A: As I said previously, it is my policy to not comment on pending legislation that is not part of my legislative agenda.

Q: What can be done to improve the health care system in Georgia?

A:  Since taking office, I have focused on the need for additional health professionals in Georgia. We have been increasing the number of residency slots in hospitals across the state. Georgia taxpayers help fund a promising young Georgian’s pre-K, K-12, post-secondary and graduate-level medical education only to see them perform their residency outside of our state and not return. That doesn’t provide value for Georgians paying taxes. It doesn’t make sense for Georgians needing care and it isn’t fair to young Georgians looking to begin medical careers. We must ensure that no doctor trained in Georgia is forced to leave the state to complete his or her medical education. There is still work to be done, but we are making strides on this front. Individuals in Georgia can also play a major role in improving their own health by being active in their healthcare decisions. This means taking advantage of all the preventative care opportunities to improve the well-being of themselves and their families.

Protesters in Coweta County rally against the UGA navigator program in November. Photo courtesy of  the Newnan Times-Herald.

Back in December, with the deadline approaching for people to enroll for Jan. 1 coverage in the new insurance exchange, an event was scheduled to inform Greene County residents about the program.

The event was to feature a health insurance “navigator,” a person trained and licensed to inform people about the Affordable Care Act and guide them through exchange enrollment. This particular navigator, Kimberly Jenkins, was one of a dozen working under a federal grant to the University of Georgia.

Greene County would seem to be a promising venue for such an information session, since 19 percent of its residents have no health insurance. “A lot of people could benefit in this community,” said David Daniel Jr., the county’s extension agent for agriculture and natural resources.

But this particular gathering did not work out as planned.

Daniel said he tried to distribute flyers for the event in many locations — including a hospital, a drugstore and many medical offices — but the only place that agreed to put one up was the Greene County Public Library.

“I left them with a couple of doctors’ offices, but no one put them out,” Daniel said. “It’s kind of understandable. It’s still one of those issues that no one wants to touch. With things being the way they are now, everybody’s got to be politically correct. No one wants to go out on a limb to make it work or to help it work.”

And if that lack of response was not annoying enough, the session had to be called off at the last minute because Jenkins became ill. It has not been rescheduled so far.

Many people skeptical of Obamacare

The misfired effort in Greene County was partly a matter of bad luck, of course. But the whole incident seems to sum up the roadblocks that navigators face in Georgia. The ACA, also known as Obamacare, is complex and controversial. People who are trying to raise awareness about it are in an uphill battle.

The problems for the navigators began early, with the bungled October 2013 debut of healthcare.gov, the federal exchange website. Navigators were supposed to help people use the exchange, but most Americans could not get access to it. Repairs on the site took weeks.

At the same time, a controversy over policy cancellations led to a nationwide wave of bad publicity about the ACA in general. Many people became wary of having anything to do with Obamacare.

And in Georgia, members of the Republican-led political establishment have remained firmly opposed to the ACA. They fought the health law before it was passed, tried unsuccessfully to repeal it and supported legal challenges to it. In the General Assembly, GOP lawmakers are now seeking to bar the public state universities or colleges from helping to implement it. (That would appear to eliminate the UGA navigator program.)

Health and Human Services Secretary Kathleen Sebelius, visiting Atlanta on Monday, defended the navigator work, saying of the UGA program: “I can’t imagine a more important job than letting people know what the law says, and what their rights and benefits are.’’

Navigators themselves have become a focus of ACA opponents. Late last year, an ACA information session in Coweta County was the target of a protest by Georgians for Healthcare Freedom and the Coweta Tea Party. Some protesters carried signs reading “Navigators get out.”

Though the Coweta demonstrators were few in number and peaceful, the safety of navigators is a top concern, said Sheri Worthy, the principal investigator for the grant that funds the UGA navigator program. Since the protest, the UGA faculty members who supervise the navigators posted in rural areas have decided to cut back on big, open events and concentrate on individual enrollment.

“We really refocused our efforts to work with individuals and doing small, focused events in trusted venues,” Worthy said last month during a presentation on the UGA campus.

All told, UGA’s 12 navigators have held 365 educational activities in communities throughout Georgia.

Enthusiasm for the mission

Jenkins, the navigator whose illness forced the cancellation of the Greene County public information session, said she is trying to reschedule it, and hopes to work next time with St. Mary’s Good Samaritan Hospital in Greensboro.

County official Daniel, who distributed flyers the last time, said he is still trying to determine the “most efficient way to get information out in a timely manner.” A newcomer who has been on the job for only seven months, he acknowledged that printed notices may not be the way to go.

Greene County resident Mary Miller said she gets most of her news from local newspapers such as The Breeze and Lake Oconee News. She said she did not hear any talk about the planned event in December and did not see any advertisements for it.

But she’s familiar with the ACA effort. “I’ve heard talk about it at work,” said Miller, a real estate agent who has insurance. “There’s certainly word around that they are trying to get people to sign up for it.”

Jenkins is responsible for disseminating health care information to about 100,000 people living in 12 of Georgia’s 159 counties. She tries to visit a county once or twice a week and devotes the rest of her time with to individual appointments with people trying to get insurance through healthcare.gov. An appointment typically lasts one hour as she walks the person through the application and answers any questions.

It’s a slow process, but Jenkins said she is making it work by visiting several counties in one day and spreading the word wherever people gather. She regularly attends churches in the community and enrolls people after services.

“I’ve enjoyed it,” Jenkins said. “Just being able to help and meet different people.”

Becoming part of the existing “community system” is crucial to reaching rural people, according to Sharon Gibson, the cultural trainer for the navigators. She instructs navigators to work with the leaders in the community and the popular groups that already operate there.

The hostile response to the ACA, made worse by the implementation problems last fall, has been a hurdle for Jenkins. She said people are often skeptical until they see the premiums for health coverage.

“Once they see the prices associated with the claims, they are generally happier, so I urge them to do the application,” she said.

Georgians can sign up for health insurance until March 31, when 2014 enrollment closes. The navigators and extension agents are working to sign people up by the deadline. After that, they will continue to educate people about health insurance in general.

“It doesn’t matter who they are — white, black, Latino — people in rural communities are wary of change,” said Gibson. “There’s a lot of TV and radio and that’s confusing. A lot of what our navigators do is address misconceptions.”

Lindsey Cook is a senior at the University of Georgia,  studying journalism, computer science and new media. She is an AP-Google scholar and her work has appeared in The Washington Post, The Atlanta Journal-Constitution and Online Athens.