Safety Net

If you add Medicaid and PeachCare beneficiaries to the members of the state employees’ health plan, it comes to more than 2 million Georgians.

The Department of Community Health, in charge of those three health programs, oversees the health care of more than 20 percent of the state’s population.

David Cook has presided over DCH as commissioner for more than a year. Formerly the executive director of the Medical Association of Georgia, he has had to tackle several fiscal problems from the start of his state job.

The agency is now pursuing a high-profile restructuring of Medicaid and PeachCare. And if the Affordable Care Act, the wide-ranging federal health reform law, is upheld by the U.S. Supreme Court, Georgia’s Medicaid program for people with low incomes and for the disabled will add more than 600,000 people to its rolls.

Cook discussed the issues involved with the health programs – and what keeps him up at night – in a wide-ranging GHN interview in March.

Q : Is the State Health Benefit Plan, which covers state employees, teachers, school personnel and retirees, now on a more stable financial footing?

A: Absolutely. We had some really tough decisions to make. We had an $815 million deficit we were looking at over a two-year period  –  fiscal years 2012 and 2013. Through a series of plan design changes, and premium increases by both employers and employees, we were able to reduce it to $62 million. . . .

We made the structural changes that we needed to make. In the near term, we created the largest wellness plan in the country.

Q: In terms of numbers of members?

A: Right. It’s a pretty traditional wellness plan. . . . About 40 percent of members, about 360,000, voluntarily signed up for the wellness plan.

We also increased [employer contributions for non-certificated public school system personnel]. We have a phased-in approach now for the non-certificated employer premiums. It increases $150 per member per month for the next three years. That really catches them up pretty close to the full employer contribution of about 75 percent that we try to achieve.

So we’re on a path to a much stronger, more fiscally sustainable health plan.

The longer-term structural changes were phased-in subsidies, beginning five years from now, that deal with the long-term liabilities [for retiree health costs] of the plan. That was reduced from $62 billion to $51 billion.

I’m very proud of the fact that we’ve taken some really challenging situations, and we’ve taken some significant steps to address them. I feel really good about the future of the plan.

Q: Teachers and other state employees this year faced premium increases of 11 percent or 17 percent. Do you expect that type of increase this coming year and in years to come?

A: I certainly hope not. I think the state employees, teachers and [other members] all have faced, over the last several years,  a number of significant plan design changes and some significant increases in premiums. It’s my goal to minimize those to the greatest extent possible . . .

We’ve got that $62 million deficit to deal with. We will deal with that, in one form or fashion. We’re seeing some positive results in structural changes we’ve made. . . .

We have begun an audit [of employer contributions – from public school systems –  for the state plan]. I was concerned it was more on an honor system. Our audits have shown we in some instances have not been paid the full amount [owed for the coverage provided]. . . .

We’re in a new age. There’s a new normal . . .  We have new 21st-century challenges we have to deal with. This is part of bringing in a more transparent, accountable method of doing it. It’s more administratively simple for everybody. . . .

We have done some audits. We’re auditing all payroll locations…. Once I learned about how this was working, I became concerned about it. As a result of our audits, we are seeing improved collections, which actually [could be as much as] $25 million. …

 Q : Is there enough competition among health plans in the state health plan? We have only two insurers, and one of them, UnitedHealthcare, has an overwhelming majority of members.

A: The short answer is yes. I think those two health plans compete for members. It’s a good thing to allow them to compete for members without the state directing them to one plan or another. It’s good to have that competition and choice. As I understand the history of the State Health Benefit Plan, there used to be a wide variety of plans, and the constant complaint was that it was too confusing . . . [with] too many options.

 Q:  There has been pushback on eliminating bariatric surgery as a benefit in the state health plan. Has that surprised you? [Editor’s note: The Legislature has since put $1.75 million into the budget to continue this benefit.]

A:  A little bit, but not really. It’s about a $3.5 million expenditure per year, which translates to less than a 1 percent premium increase for every member in the State Health Benefit Plan. The more benefits are mandated, the more expensive the plan will be. One of the reasons we looked at bariatric surgery was because it was a very high-cost benefit – well over $20,000 per surgery – for a very few number of people that needed the benefit.

Our short-term review of the cost savings associated with that showed we were not actually saving costs. And that’s been the big argument for bariatric surgery – that  it reduces cost .Our experience has been the cost has been relatively flat, or the costs have increased just slightly. . . .

The bottom line was we had an $815 million deficit to deal with. I charged my team with looking at everything. That was one of the options we came up with in terms of plan design changes . . . A lot of these are tough decisions.

Q: This year’s budget is the first one in a while that contains no major cutbacks in Medicaid or PeachCare. That must be a pleasing thing to you.

A: It is. I think we’ve got some serious challenges with Medicaid. That’s an understatement. One of the issues is provider payment rates. I’m concerned about the provider workforce issues we have and access issues.

We have to do what we can to make Medicaid a product that providers are willing to take. I think providers are willing to take it, [but] they want to be paid a reasonable amount. And I think they want a program that’s administratively simpler to deal with.

Providers are willing to take a little less than cost to provide care to the underserved population. They just don’t want to be hassled in doing that. There’s a great altruistic nature to the provider community. But that can’t be abused or taken advantage of.

The goal would be: How do we, with a workforce shortage, make the Medicaid program an attractive product for providers to participate in?

Q:  Has there been a decrease in the number of doctors taking new Medicaid patients?

A: The last data I saw showed a slight decline in the number of doctors taking Medicaid patients. . . .

Q: That’s a concern?

A: Absolutely.

Q:  Talk about reducing administration burdens for medical providers.

A:   We have done a number of things that have made the program easier for providers to deal with. One of the bigger things we did was the credentialing issue. It [formerly] took months to get a Medicaid provider credentialed. . . .

 Q:   How long does it take now?

A:  It’s 15 days. And I tell people if you don’t get it in 15 days, I want to hear about it. The real number is about 12. Our goal is seven.

[In the past] you could submit your credentialing application online, but the affidavit had to be on paper. Now you can submit everything electronically. That was a big help. I believe there are all kinds of solutions like that out there. We need to be willing to listen to people. We need to hear what the problems are in order to deal with them.

Q:  Where does the process of redesigning Medicaid stand now?

A:  After the [consulting firm Navigant} report was out, it was very important to us to have stakeholders take a look at it, read it, digest it, and get their comments back. . . . We have been very actively encouraging feedback and discussion. I believe the best solutions are going to come from people on the ground delivering care. We’ve gone to great lengths – I’m told more than any other state that has done this – to solicit that kind of feedback and input.

We have three task forces that are assembled [and] each has about 20 to 30 people on it – a provider task force, an ABD [aged, blind and disabled] task force, and a family and children task force. They have met several times. We are pushing people to challenge us, and to challenge themselves, and to offer ideas on what we can do to design a program [to be able to meet] the 21st-century challenges.

 Q:  Has the care management organization program been a success, a failure, or a mixed bag, in the CMOs’ management of Medicaid patients?

A: I’ve been impressed with the CMO process, to be honest with you. It’s an evolution. I don’t see us so much as moving from Point A to Point B, but to making sure we’re on the right track for a sustainable future. It’s not so much a major shift, but continuing an evolutionary process.

In 2004 and 2005, the leadership of the state said Medicaid was on an unsustainable fiscal path. . . . Medicaid was going to consume, by projections, 40 percent to 60 percent of all new revenues. That was before the Great Recession.

So the CMOs were brought in . . . There were several things included in provider protections. That’s a good thing about the state being able to contract. The state can control through a contract how managed care is delivered.

Those contracts have to be renewed and renegotiated. Every year it’s redone. . . Problems arise, and there’s an attempt to address those problems through contracting. Access issues, payment issues, as well as goals related to quality.

This year, we have a goal of reducing by 2 percent our low-birthweight and very low-birthweight babies. And there are metrics, and the CMOs are pushing forward on that.

We’ve been recognized nationally for the quality metrics and quality achievements that we’ve made. Some have criticized us because we fall below in the national [quality] standards. If you look at us in the region, we’re probably one of the best in the region. . . . Nationally, the South, just does poorly in commercial plans as well as Medicaid.

In terms of softening the hard edges of managed care and pushing quality forward, it’s been successful. I would again characterize that as an evolution.

Q: Have CMOs been able to reduce unnecessary ER visits to your satisfaction?

A:  No. That’s an area we all have to work at. . . . The care management organizations are performing much better, but we’re not where we should be. Frankly, there are federal rules that don’t help. [It would be preferable] if we had a little bit more flexibility . . . applying some incentives…

There’s really no disincentive for Medicaid patients to use the emergency room [unnecessarily]. There is no consequence for the patient . . . We also need to look at innovation. We’ve had grants, in rural areas, that have showed some promise…with co-locating primary care clinics near the emergency room, to work with patients who have gone to emergency rooms with a non-emergent condition and link them up with a primary care physician.

Q:  You are saying everything’s on the table in redesigning Medicaid. Are you narrowing things down?

A:  We’re letting the task force process work . . . I’ve stayed out of it personally, so as not to chill any discussion. From what I’ve heard, we’ve been getting very, very good participation and feedback. We’re currently waiting for some additional assessment on financial [issues] regarding the impact of the Affordable Care Act and the [Medicaid] expansion [under that law]. . . . We’re refining ideas in terms of what might be possible. Learning a lot. Waiting for some of this financial modeling to come back, which takes a long time to get done.

I think it’s important to take the time to do it right. I’m not so much feeling bound by time constraints . . . as being bound by doing the best we can, designing a good system going forward. We’ve got some serious time issues, with the January 1, 2014, deadline with the Affordable Care Act. Not only the eligibility and expansion population — we’ve got the mandated electronic eligibility system, which is a huge effort.

Q:  Are you already game planning for that?

A: Absolutely. You’ve got to plan for it now.

Q:  Advocates and providers for the aged, blind and disabled populations are obviously concerned about managed care. As you hear their concerns, what are your thoughts?

A: I appreciate their concerns. There are a lot of separate and distinct groups within that population that need different approaches to how you might manage care. One of the interesting things is that everybody agrees that it’s a good thing to manage the care. So the question becomes what is the best way to manage care that is going to be different for [the] aged population, different for the developmentally disabled, different for foster children, etc. I’m very aware and cognizant of the fact that these are really different populations.

Low-income Medicaid is the easier population to manage. We have to have a more refined approach for the ABD population.

Q: Is there a state that gives a blueprint for what to do with aged, blind and disabled?

A: It is the clear trend that states are moving ABD into managed care. Texas has had some demonstration projects that have now gone statewide, the entire ABD population. Other states have taken portions of it. Washington state, Oklahoma, Indiana.

Q: The state’s goals in the Medicaid redesign are financial sustainability, quality, and access to care. Is any more important than the others?

A: Without the finances, you don’t have anything. Obviously you have to build within that. Getting a handle on the [Medicaid] expansion population, and just the growth in general of the Medicaid population. We’ve had a history over the last several years of not funding what we currently have in Medicaid.

This year, we’re one payment behind in [the] care management organization contract. That’s $82 million. Growth projections are low in the budget. Being able to finance populations that we have is going to be a very important piece.

I think having good, accurate projections  –  both growth we already have, as well as the new expansion population  –  is going to be crucial… For the expansion population, from 2014 through 2018, [it will cost the state] an average of $300 million a year. We’ve underfunded Medicaid $100 million to $200 million a year for the past several years. . . .

We actually had a seven-year projection, done in August 2010. That’s what we’re updating now.

It’s about $150 million in 2014. By the time you got to 2020, it was $2.5 billion over 7 years to the state. The further you go out, the more the state gets hit. . . . We’re going to begin planning for the 2014 budget this next year. You have other interesting issues, too, like the hospital tax. That’s a couple hundred million dollars.

Q : That expires this year, correct?

A:  Yes. You could be looking at [shortfall] numbers like $300 million to $700 million. That’s what keeps me up at night.

Q: On the redesign, who will be making the ultimate call on what option to pick? You? The governor’s staff?

A: We’ll be in close consultation with the governor himself about where he would like to go and what he’d like to see. We are very focused on driving input, being very collaborative, in terms of the governor, the governor’s office, the Legislature. We had two briefings this week with legislative leadership on it. We’ll continue to do that. We’ve received a lot of input. Hopefully, what we roll out will have some broad-based support. It’s not going to be what everybody wants… Hopefully it will be something that we for the most part can get behind.

 Q: You’ve been in this job a little bit over a year. Has it been what you expected?

A:  It’s been a great experience for me and a great opportunity to serve. I’m very thankful to have this opportunity. I’m learning a lot. I’ve been impressed right from the start by the dedicated and talented staff that we have. We’ve got obviously big issues, which are exciting to work on. It’s just been a pleasure to me to have an opportunity to see if I can make a positive difference for Georgia.

Tiffany Miller, 37, uses Good News Clinic services to manage symptoms of her chronic nervous system disorder.

Tiffany Miller was supposed to drive her 15-year-old daughter to a birthday party. But before the mother of five even made it out the door, she suddenly collapsed and lost all muscle control.

Panicked, Miller’s daughter tried to give her mother her medicine, but Miller was unable to swallow the pills and began to choke. At that point, Miller’s teenage son called 911.

Though she had stopped choking before the ambulance arrived, Miller still couldn’t move and needed medical attention. But even in such dire circumstances, her children knew she wouldn’t be relieved to see the paramedics.

“Mama’s going to kill you now,” Miller’s daughter said to her brother, scolding him for making the call.

Miller is all too familiar with the emergency room, and she already owes Northeast Georgia Medical Center in Gainesville  more money than she can spare. She’s been to the ER “countless times” for sudden fainting spells due to an unidentified central nervous system condition that has plagued her for the last four years.

Her worsening symptoms, which mimic MS, fibromyalgia and chronic fatigue, make day-to-day tasks like driving and grocery shopping increasingly difficult.

Visiting the ER has become “pointless,” Miller said. “I just lay there, sometimes in a hallway, until I’ve regained full mobility and can leave.”

But to stay out of the ER, Miller would need to see a primary care doctor monthly and take five different medications daily.

Uninsured and unable to work for the past two years, Miller couldn’t afford any of those preventive measures until she turned to Gainesville’s Good News Clinics.

It’s Georgia’s largest free clinic, funded by United Way and private charitable donations, and it’s keeping uninsured Hall County residents such as Miller out of emergency rooms.

It also has a benefit that may be less obvious: It significantly lowers health care costs for the county.

Besides allowing Miller to see a primary care doctor monthly, the clinic provides her with two of her five medications free of charge.

At first, Miller admits, she was ashamed to use a free clinic, but now she says she would be lost without it.

“Every month, the worry of how I’m going to pay my doctor is gone,” Miller said. “I have another primary care physician, but it’s $50 to see her. That’s $50 that could go towards our light bill or groceries.”

Cheryl Christian, executive director of Good News Clinics, said many patients have been served there during the economic downturn.

“We’re seeing people who have lost their jobs and their health insurance, and for the first time in their lives are having to reach out to a free clinic,” said Christian.

The economic factor

She said free clinics like Good News are especially important right now. With the high number of uninsured people these days, the free care that these clinics are able to offer reduces unnecessary hospital visits and overall health care costs for Hall County.

A recent University of Georgia study showed that health care for patients at the Good News Clinics costs considerably less than care for uninsured residents who use the local hospital.

Researchers followed 207 new patients at the Good News Clinics for a year and found that annual non-urgent ER and inpatient costs fell from $223,095 to $187,948 a year, saving the county $35,147 in health care costs. This equates to a savings of roughly $170 per patient after enrollment.

“The ER is the most expensive place to get care, and when more uninsured people resort to the ER, it raises health care costs for everyone,” said Angela Fertig, a health economist and researcher on the study.

“Then it’s this vicious cycle — employers [stop] covering their employees, people become uninsured and use resources inefficiently, raising the costs for everyone, and then employers drop even more employees,” Fertig said.

Though non-urgent ER costs fell significantly, providing primary care for a patient who hasn’t seen a doctor in a long while can be very costly at first.

The cost of delivering primary care at Good News in the first year was almost three times greater than the savings — a staggering $505 per patient — but these costs are expected to fall.

“Whenever you have an uninsured person who finally gets access to primary care, you’re going to have high initial costs,” said Fertig. “They are going to have a lot of undiagnosed problems, and are going to need costly diagnostic tests.”

Over time, she said, those initial costs should be recouped, because offering preventive care for the uninsured will eliminate frequent trips to the ER.

Fertig and fellow researchers estimate that three years after a patient enrolls at Good News, the economic benefits of receiving free care will far outweigh the preliminary costs.

“The power of the Good News Clinics partnership is evident in our community,” said Christy Moore, community health improvement manager at the Northeast Georgia Medical Center in Gainesville. “Keeping people well and in the workforce definitely makes a sizeable impact on our local economy.”

Health departments have their limits

Unfortunately for uninsured people in neighboring counties, Good News Clinics offers care only to residents of Hall.

While most Georgia counties have health departments that provide care for the needy, state-funded services pale in comparison to those offered by free clinics, said Dr. David Westfall, director of the Gainesville-based North Public Health District and a co-founder of Good News Clinics.

In addition to primary care, Good News offers dental, pharmaceutical and optometry services.

Health departments focus almost totally on routine preventive services such as cancer and vision screenings and blood tests. “It’s great for preventive services, but the health department can’t really offer anything beyond that,” said Westfall.

He also pointed out that the health department, though equipped with knowledgeable nurse practitioners, has only one licensed physician to oversee daily protocol. This makes prescribing medicine and managing chronic diseases much more difficult.

Westfall knows this dilemma all too well, since he’s his district’s health director and the only physician in charge of its 13 counties.

Now, with an increase in uninsured patrons, Westfall said having one free clinic in the area may not be enough.

“When we started the Good News Clinics, it was our goal to be able to provide care for everyone in need,” he recalled. But due to the recent influx, he said, the clinic now has to focus on “the neediest of the needy.”

Unfortunately for Tiffany Miller, that rather grim description now applies to her. But at least she has somewhere to turn.

“There would be nowhere else to go if this wasn’t here,” she said. “It’s just as personable as any other primary care clinic and it’s invaluable.”

This article is the latest in a series developed by the Public Health News Bureau, a project funded by Healthcare Georgia Foundation. The bureau is staffed by graduate students from the Health and Medical Journalism Graduate Program at the University of Georgia’s Grady College of Journalism and Mass Communication.

Robyn Abree is a second-year master’s student studying health and medical journalism at the University of Georgia. She’s mainly interested in covering nutrition, fitness, and other forms of prevention and recently worked at GivingPoint, an Atlanta-based nonprofit that educates youth about health and public service.

After Joe Sellers was diagnosed with leukemia, he was able to get decent health insurance for his wife and children, but not for himself.

Joe Sellers sees himself as a square peg fitting into a round hole of health insurance.

A real estate agent in the northern Atlanta suburbs, Sellers was diagnosed with leukemia in 2009. The next year, his health insurance company said it was going bankrupt, and he lost that policy.

So Sellers, middle-aged and self-employed, had to scramble.

He was able to buy an adequate plan for his wife and children. But with his pre-existing condition, he was basically uninsurable. All he could get for himself was a barebones policy, called ‘‘limited benefit.’’ (Here’s a USA Today article about these plans.)

Sellers went looking for what he calls ‘‘a regular job, so I could get group coverage.’’ But in a very difficult economy, there were few opportunities.

Later, he looked into the government’s Pre-Existing Condition Insurance Plan, designed for people, like himself, with health problems. But Sellers had insurance — albeit threadbare –- and thus was told he did not qualify. PCIP requires a person to be uninsured for at least six months to be eligible for enrollment.

Enrollment, and costs, picking up

PCIP, launched under the 2010 health reform law, got off to a very slow start in Georgia and elsewhere.

But last week, the federal government announced that nearly 50,000 Americans have now enrolled in  PCIP. And the number of Georgians in the state’s ‘‘high-risk’’ pool for people with pre-existing health conditions has nearly tripled in less than a year, to 1,476.

As of March 31, 2011, Georgia had just 515.

Georgia’s current number in PCIP is similar to enrollment in other states’ high-risk plans that were set up prior to the health care reform law, says Bill Custer, a health insurance expert at Georgia State University.

Reasons for the increase in enrollment include the feds’ lowering the monthly premiums for  PCIP in Georgia and showing more flexibility on how a person demonstrates a pre-existing condition, says Cindy Zeldin, executive director of the consumer advocacy group Georgians for a Healthy Future.

Another factor, she says, is more publicity about PCIP. ‘‘The word has gotten out a little more,’’ she says.

Twenty-seven states are operating their own PCIP program, often linked with existing ‘‘high-risk’’ insurance pools. Georgia, 22 other states and the District of Columbia have federally operated program.

Many of the enrollees are 45 years of age and older, but still are not old enough to be eligible for Medicare.

And many, like Sellers, now 46, have cancer.

In covering such serious medical conditions, PCIP’s health care costs for enrollees are expected to be more than double the amounts initially predicted for the program, the Washington Post reported.

Some don’t have time to wait

PCIP’s coverage would be a definite upgrade from Sellers’ current policy, which would pay just $30,000 for a hospital stay and $5,000 for an injury.

He does not have the practical option of dropping his current policy and then waiting six months. His doctor told him in December that he needed to start treatment immediately, Sellers says.

The six-month waiting period is a barrier for people such as Sellers, notes Custer.

The health reform law, which will be fully implemented in 2014 unless derailed by the Supreme Court or Congress, would resolve Sellers’ problem by allowing him to enter an insurance exchange.

‘‘The law is intended to prevent situations like his,’’ Custer says.

Sellers, a Republican who lives in Kennesaw, says he’s not exactly enamored of the health care law, known officially as the Affordable Care Act. He sees it as too rigid. But he says government should be able to help ‘‘square pegs’’ such as himself.

“When a person has exhausted all other means, our government should step up and take care of those people who can’t take care of themselves.’’

He recently received a big break when a drug company agreed to give him a chemotherapy drug free of charge. Normally it would have cost $30,000 over six months, he says. “It was a gift from God,’’ he says. Sellers adds that family and friends have offered to help, too.

But he worries about the possibility of getting an infection and being hospitalized –- and the resulting out-of-pocket costs.

PCIP is ‘‘a great idea,’’ Sellers says, but it needs to be more flexible. “This is not a Republican or a Democrat thing,’’ he says. “I’m the guy with cancer in the middle.’’

Jamie Cook has been living in 'supported housing' in Gainesville for the past seven months.

Jamie Cook has come a long way in the past two years.

For much of her life, she suffered from drug addiction and from bipolar disorder, along with depression and anxiety.

She endured periods of homelessness. She generally acted ‘‘full of bitterness and rage,’’ alienating her family. She lost custody of her two children. And she frequently attempted suicide and had to be hospitalized.

But Cook, 43, has now been sober for more than two years, and for the past seven months has lived in an apartment in Gainesville. Her rent is being paid by the state of Georgia, and she has received help with medication for her mental illness and with living skills.

Cook actually feels well enough now to help other troubled people. She’s a volunteer at an alcohol/drug rehab program.

“My life has been turned around,’’ she says. “I’m just a completely different person.’’

Her apartment comes as a result of a housing initiative agreed to by the state of Georgia in a 2010 settlement with the U.S. Justice Department.

According to that five-year pact, 2,000 individuals with serious and persistent mental illness will be placed in state-funded ‘‘supported housing’’ by 2015, as part of a broader commitment to establish community services for about 9,000 Georgians with mental illness.

Such housing programs are designed for people with disabilities, mental illness or addictive disease. They feature ‘‘supports’’ such as counseling and offer help with everyday needs, including medication and transportation. They also help teach basic skills such as cooking, keeping a checkbook or applying for a job.

Such arrangements can stabilize people who are homeless or at risk of institutionalization, experts say.

A landmark agreement

The housing component is a linchpin of the DOJ settlement. The agreement also has moved people with development disabilities out of state hospitals to community settings through ‘‘waiver’’ programs.

Supported housing can take many forms, from group homes to rental apartments, and can be funded by various sources, from federal and state government to nonprofit and for-profit organizations.

The deal Georgia made with the feds is unprecedented, and what the state does to fulfill its housing pledge will be a focus of national attention. “How it happens in Georgia will be watched very carefully,’’ says Curt Decker, executive director of the National Disability Rights Network.

“This is the right thing to do,’’ Decker says. “We’re just really hopeful that Georgia will be a model.’’

But Decker admits he’s uneasy because of the state’s generally weak track record on caring for people in need.

“I’m a little concerned about a state that doesn’t have a lot of experience in this area,’’ he says. “I’m nervous about the state’s ability to ramp up.’’

Decker says that there must be strong monitoring of the housing arrangements at the local level. “There will probably be some bad actors [looking] to make some quick bucks,’’ he says.

Other supported housing programs, though, have established a solid reputation in the state.

In Brunswick, a housing complex serves women battling addiction, along with their children. In the Atlanta area, Project Interconnections operates permanent residences for formerly homeless adults struggling with mental illness.

As a result of the Justice accord, more than 250 people with ‘‘serious and persistent’’ mental illness have been placed in supported apartments across the state, says Doug Scott, supported housing director for the state Department of Behavioral Health and Developmental Disabilities.

The state’s target is to double that number by July 1. It’s spending $2.5 million on the housing alone, Scott says.

Successes, failures, challenges

The program is working well, Scott says. The state is using 130 different properties, in settings that are integrated into the community. “We’re in very rural areas and in urban areas.’’

But the record isn’t perfect. “Some individuals have gotten into housing but have violated their lease’’ and are now living in a more restrictive setting, or are in jail, Scott says. About 7 percent leave the program, he says.

Talley Wells, director of the Mental Health and Disability Rights Project for the Atlanta Legal Aid Society, says he’s concerned about the ability of the state to serve 9,000 people with housing help, as outlined in the DOJ pact.

“There’s an extraordinary amount of need for this housing,’’ Wells says. This year, he adds, “is the critical year for the Department of Justice settlement.’’

Cook, who is part of the housing voucher program, has had her apartment partly furnished with the help of special state funding.

She was placed there by Avita Community Partners, a service agency in the region that found residences for seven other people last year.

Avita residential supervisor Janice Modisett says the people are assigned a community support person, and are linked with a counselor and psychiatrist. “You have to follow through with your treatment,’’ Modisett notes.

Cook has done that. She is now able to see her children again. They’re no longer worried about her, she says.

“I had to change my heart,’’ she says about her recovery. “I thank God for that heart change.’’

‘‘This has been the most peaceful year of my life.’’

Open two days a week, Marilyn Ringstaff's clinic has had hundreds of patient visits this year.

Jennifer Fuller was among 31 women who recently went to a Rome clinic for a free Pap screening.

Fourteen of the women had not had a Pap test in the past three years. Two had gone more than 10 years without the screening. (Two years is the generally recommended interval.)

It had been four years for Fuller, 30, of Rome. She has no health insurance and, as a nursing student with three children, has a low family income.

She came to the two-day Rome clinic, she says, ‘‘because they’re doing it free.’’ It costs $200 simply to be seen at a local physician practice, Fuller says.

The free testing at the Women of W.O.R.T.H. clinic provided a complete exam, including the Pap smear to find cell changes that can lead to cervical cancer. Five of the 31 women were found to have breast lumps and were referred for mammograms.

Two women, part of the area’s growing Hispanic community, were referred immediately to a local emergency room — one with anemia and an abdominal mass, and the other with apparent congestive heart failure.

Another woman, apparently the victim of a sexual assault, received a test for sexually transmitted diseases.

The clinic, run by certified nurse midwife Marilyn Ringstaff, is fairly unconventional for the Rome area.

It’s a city with modern hospital facilities and thriving physician practices, yet the clinic, in a modest rented house, fills a void for low-income uninsured women. Rome, like the rest of Georgia, is mainly a conservative area, while Ringstaff is firmly on the other side of the political spectrum.

The steady flow of patients into the waiting room illustrates a crucial gap in the health care system: Despite the array of free and low-cost clinics across the state, many financially strapped patients can’t get certain services they need.

Ringstaff is a fierce advocate for preventive care for women. And she’s a critic of a system that often fails to address the needs of poor, uninsured women.

The Georgia public health system has suffered from years of budget cuts. Ringstaff says Pap screening at public health clinics now is often unaffordable to many women, when they can get such screenings at all.

“We see patients who can’t afford public health,’’ Ringstaff says. ‘’I saw one woman who hadn’t had a Pap screen in 37 years. She had a lump on her breast.‘’ The woman is having surgery this week, says Ringstaff.

Most free clinics in the state do not perform Pap tests.

The Rome clinic is open on Fridays and Saturdays, plus some additional odd hours. There’s nothing fancy about the layout. The former kitchen serves as a lab area, and the vaccine-only refrigerator contains Gardasil, the vaccine for HPV, which causes cervical cancer.

The furniture is donated. Medical supplies are donated as well, or are bought at reduced prices. Volunteers run the office and help with patients.

The women’s clinic gets little funding. The grants that Ringstaff has received help pay for the free Pap screenings.

Besides Pap smears, Ringstaff offers a range of gynecological services on regular office days. She does complete physical exams, STD testing, birth control counseling and prescriptions, and other services, with fees ranging from $20 for an office visit to $45. Many patients who have no money ‘’don’t pay a dime,’’ says Ringstaff, who also works part time in the health law section of the Atlanta Legal Aid Society.

“We do everything a GYN office can do,’’ Ringstaff says. W.O.R.T.H. stands for Women’s Organization for Reproductive and Total Healthcare.

Cancer is a particular focus. Though cervical cancer is highly preventable, about 120 women in Georgia die from it each year — one of the highest rates in the nation.

Donna Maxwell (left) credits Marilyn Ringstaff with helping her get Medicaid after she lost her job and health insurance.

Among Ringstaff’s hundreds of patients is Christina England of Summerville, whose visit to the clinic led to the discovery of a high-grade lesion on her cervix. Georgia Medicaid has a program that covers low-income women with breast or cervical cancer, and England is trying to get qualified.

England, who until recently was homeless, says she faced problems getting seen at a local health department before she came to Ringstaff’s clinic. “I just wish they paid more attention to women who have these problems,’’ she says of the health department.

For Janie Morris, 60, who lives in a homeless shelter in Summerville, it had been roughly 12 years since her last Pap smear before she arrived at the clinic.

Morris says that during that time, she had no insurance and no money. “I had a job, but it was paycheck to paycheck.’’

A biopsy at the clinic found cancer of the vulva. The Medicaid program did not cover it, but Morris was accepted into a cancer aid plan, and will have laser surgery soon.

Ringstaff also helped Donna Maxwell, 50, of Rome get Medicaid after a Pap test found abnormal cells.  “I‘m just so thankful to Marilyn for giving me an inkling of what I had to do,’’ Maxwell says.

“I feel like she saved my life.’’