Uninsured

Betting on Reno
Sara Schopper was doubled over with pain from gallstones when she arrived last May at St. Mary’s Regional Medical Center in Reno, Nev. To make things even worse, she had no health insurance.

Once doctors had removed her gallbladder, Schopper faced thousands of dollars in hospital bills as an uninsured worker. Before she left the hospital, however, she heard about a local reduced-rate insurance program that would keep the bills for this procedure under $2,000, and that she could even join retroactively.

When Schopper signed up for the plan, she did not expect to have to use it very soon. But just three months later, she found out she was pregnant. She then added an additional maternity care package that covers doctor visits, an ultrasound, an epidural and a hospital stay. The total cost was $2,000, which she is paying in installments.

“My baby will be paid for when the due date comes, and that’s a relief,” said Schopper, 33, a single mother who runs a plant nursery and landscape company. “This makes the process easier because paying bills makes pregnancy not as fun.”

The pregnancy package is one feature of Nevada’s Access to Healthcare program, a network of doctors, specialists and hospitals that offer reduced rates to members who don’t already have health care insurance.

On the other side of the country, in Georgia, doctors are mimicking the program to bring better care to patients who do without insurance. Athens health leaders, who have investigated the 7-year-old Reno network, hope to start their own reduced-rate program by the end of the year.

The typical participant in the Nevada program is a working adult who earns too much for Medicaid eligibility. Members pay about $40 monthly for membership in the program, and they then pay set fees for doctor visits, medical procedures and hospital stays. For Schopper, that means $300 for epidural pain relief during her delivery and $400 for each day in the hospital.

“For a single mom who works hard, insurance is so expensive, and this is a nice option. I don’t know what I would have done otherwise with this pregnancy,” she said. “Hardworking people can’t get the best health care coverage with the economy the way it is, especially when they don’t want to turn to welfare or Medicaid.”

The Reno prototype

Doctors and community members in Reno created the Access to Healthcare Network (AHN) in 2007 to help an increasing number of locals who were not covered through employer-sponsored insurance.

“The network has been more successful than any of us thought it would be,” said Christine Caulfield, director of eligibility and enrollment. “We’ve been able to give structure to a structureless system.”

The goal is to accomplish several things at once: to focus on preventive care; to give individual Reno residents a primary care home [a central practice that handles a patient’s various health needs], to reduce paperwork for insurance claims; and to help doctors collect cash at the time of appointments, Caulfield said.

“It helps to get the ball rolling because people look at cost as a barrier to care.” said Jeff Snyder, administrator of Reno’s OB-GYN Associates. “Though we’ve always extended discounts to those with a financial need, patients didn’t approach us because they perceived a barrier.”

The private practice he manages accepts 10 to 15 Access to Healthcare members at a time who are pregnant or need gynecological care.

“The reimbursement from AHN is less than Medicaid reimbursement, so we must limit the available slots,” Snyder said. “But I think the community as a whole recognizes this problem, and other practices participate as well.”

To be eligible, a Nevada resident must earn between 100 percent and 250 percent of the federal poverty level, which is $11,000 to $27,900 for a single person or $15,000 to $37,800 for two people.

When members sign up for the program, a care coordinator helps them find a primary care provider. If the member needs additional services, the care coordinator arranges appointments with specialists as well.

When it comes to women’s health, OB-GYNs in the network offer reduced fees for annual exams, surgeries, and tests for gonorrhea and chlamydia. State grant programs also provide for breast and cervical screenings.

Dr. Ricardo Garcia, an OB/GYN, delivers care as part of  the Access to Healthcare Network in Reno, Nev.

“The system is ideal because of the focus on providing care for patients who otherwise wouldn’t get it,” said Ricardo Garcia, an OB-GYN at Women’s Health Specialists of Nevada. “And even though the rates aren’t the greatest, this is cash. The federal reimbursements take forever.”

The maternity care plan includes prenatal care, delivery and one postpartum visit for less than $2,500.

Depending on the mother’s income and which hospital she chooses, this includes $1,000 to $1,230 for a regular delivery or $1,650 to $2,400 for a Caesarean section.

As the program enters its seventh year, it is signing up more and more patients from the Las Vegas area and from Nevada’s remote rural counties, where there are few doctors or hospitals. The network received 40 calls inquiring about maternity care in February alone, Caulfield said.

“There aren’t many options in Nevada other than Medicaid or private insurance,” Caulfield said. “Even then, some insurances don’t cover anything related to maternity care, and that becomes very expensive out-of-pocket.”

The Athens program

In Georgia, doctors and community members are creating a similar health care plan for the roughly 5,000 people in Athens who went without insurance in 2010. This is the first time the Nevada approach to a health safety net has been adopted outside the state, though the two programs are not affiliated.

“This is for our small businesses and nonprofits that don’t have a large enough risk pool for insurance, our part-time artistic workers, our students whose parents don’t have insurance, and others,” said Allie Chambers, director of the Athens Health Network, the organization that hopes to start the program.

The Athens Health Assurance Program is not an insurance plan. It’s a way of buying discounted care through a club membership (like buying discounted groceries through a warehouse club). As the Affordable Care Act moves forward, many Athens-area residents will still be in need of this nonprofit medical discount network, especially if Georgia does not expand its Medicaid program.

When Chambers was earning her master’s degree in public health at UGA, she scoured the nation for a “capstone project,’’ a way to make health care affordable for low-wage workers. That’s when she discovered and studied the Reno plan, and AHN’s board members were so enthusiastic about it that they agreed to bring it to Georgia.

Chambers is now the point person for obtaining grant support, gathering donations, and recruiting doctors and hospitals for the provider pool, which they plan to have in place by the end of the year.

Chambers and others are conducting focus groups and a community survey to estimate how many Athens residents will sign up, how much they would be willing to pay for services and which services are needed.

The group will start by enlisting primary care doctors and then go after specialists, including OB-GYNs.

A maternity care package probably won’t be offered at the start.

Three Athens clinics — Mercy Health Center, Athens Nurses Clinic, and Athens Neighborhood Health Center — offer reduced-price Pap smears, pelvic exams, and testing for sexually transmitted diseases if patients fall under 150 percent of the federal poverty guidelines. But these clinics are not equipped to care for pregnant women or deliver babies.

Right now, the only option for uninsured low-income women who need obstetric care is the midwifery clinic at Athens Regional Medical Center, which has been delivering babies for more than two decades.

The hospital primarily serves Athens and the five counties in its immediate area, but the midwifery clinic pulls in patients from the entire northeastern region of the state.

“A maternity package is probably not going to happen when we pilot the program, but I think partnering with Athens Regional and being able to use their midwifery clinic will be a huge help,” said Tracy Thompson, executive director of Mercy Health Center and chairwoman of the Athens Health Network executive committee. “Obstetric care is very lacking in this area, especially for the working poor, who must pay everything up front.”

Carolyn Crist is pursuing her master’s degree in Health and Medical Journalism from the University of Georgia. She graduated from UGA in 2010 with degrees in newspapers and English and worked at The Times in Gainesville  as an education and political reporter.

Jayme Robinson, shown with one of her daughters, was hurting and apprehensive late last year, hoping to get surgery for a strangulated hernia.

Tammie Cox of Calhoun needed a cervical polyp removed. She had to wait several weeks for surgery, while dealing with cramping and bleeding.

S. Rita Wilson, a Rome woman, had a dangerous problem with a large uterine fibroid, which was finally removed after four months and three emergency room visits.

Jayme Robinson of Lithia Springs also waited months for surgery, all the while suffering pain from a strangulated hernia.

These three Georgia women were all in essentially the same financial predicament: No health insurance, and no ability to pay out of pocket for surgery and doctors’ fees.

Getting specialty care, such as surgery, can be difficult, if not impossible, for an uninsured adult with little financial means.

Primary care is cheaper and can be obtained at a retail clinic, a doctor’s office, a charity clinic or a community health center. But when an expensive specialized procedure such as surgery is needed, experts say, patients who lack coverage can have trouble getting it.

It’s a national problem, says Mark Rukavina of the Access Project, a Massachusetts-based research and advocacy organization that works to improve health and health care access.

Rukavina says the Buncombe County Project Access model in North Carolina, though limited, has helped many uninsured patients obtain specialized care.

Georgia Watch, a consumer advocacy organization, says that for many uninsured Georgia adults, specialty care services are virtually non-existent, because these people usually don’t have the cash to pay upfront.

The organization says it’s fielding more calls from uninsured adults seeking help in getting specialty care. Liz Coyle, a spokeswoman for Georgia Watch, notes that many of these patients wind up in a hospital ER, the most expensive place to deliver care.

The organization wants to see a streamlined process for uninsured patients to get the advanced care they need.

These patients generally have to find a willing physician — and often a hospital or outpatient center — to discount their fees or to count them as pure charity care.

Charity care eases the burden

The Georgia Hospital Association says uninsured people, if they have to go to hospital ERs, are getting the specialty care they need there.

Kevin Bloye, a GHA vice president, says he has heard nothing specific about patients actually having to do without surgery or other specialty care if it’s necessary.

“Every hospital has a charitable care program,’’ Bloye says.

In 2010, Georgia hospitals provided $1.5 billion in uncompensated care, mostly for patients without insurance. One third of all hospitals in the state finished 2010 losing money, Bloye added.

Yet Georgia’s Charitable Care Network, which provides hundreds of millions of dollars’ worth of primary care annually through more than 90 clinics, has seen a longstanding gap in patients getting specialty care. These clinics try to connect patients with hospitals or specialists to receive advanced care when needed.

For a patient at Good Shepherd Clinic in Morrow, it’s very difficult to get a referral to see a specialist, Lisa Page, the clinic administrator, told GHN last year. She told the story of a patient with leukemia whom the clinic finally had to send to a hospital emergency room, along with his medical paperwork.

Orthopedists are hard to find to set broken bones for uninsured patients, Page said last year.

Donna Looper, executive director of the Charitable Care Network, says Northeast Georgia Medical Center in Gainesville, as well as some smaller community hospitals, has helped patients get the care they need.

And in metro Atlanta, Northside Hospital “has really stepped up to the plate’’ with surgeries, colonoscopies and endoscopies, Looper says, adding that Piedmont Hospital is helping as well.

Atlanta’s Grady Memorial Hospital also provides a large amount of specialty care.

The Medical Association of Georgia says that charity care is commonplace among physicians in the state.

A national 2008 survey by the Center for Studying Health System Change found that 59 percent of physicians reported providing charity care—defined as free or reduced-cost care—to patients in financial need.

The specialized care gap shows no signs of fading, though, because of an increasing number of uninsured people and a lack of affordable health insurance. Georgia has about 2 million uninsured people, 20 percent of the state’s total population.

Surgery made all the difference

After reaching out for help with their plight, Cox, Wilson and Robinson were able to get the medical treatment they needed.

Cox, 45, who is unemployed, was first seen by a public health department. “I’m in a world of mess,’’ she told Georgia Health News, saying she couldn’t afford a local physician’s fee to remove the polyp.

Certified nurse midwife Marilyn Ringstaff of Rome referred Cox to a Chattanooga hospital, Erlanger. Cox recently had the outpatient surgery there as charity care.

Wilson, 40, says she made three trips to two local emergency rooms because of the fibroid. It was so big it made her look pregnant, and it was causing pain and bleeding. The ERs stabilized her each time.

Finally, a local hospital did the surgery, a major hysterectomy, in February. Wilson is now back at work at a day care center. “Hers was a really dangerous condition,’’ Ringstaff says, adding that Wilson had to receive blood transfusions twice in the months leading up to her surgery.

Robinson, 29, a single mother, was told she would have to pay thousands of dollars out of pocket for surgery, including anesthesia. “I’m not trying to leave here before my time,’’ she told GHN in December. “I have two little girls.’’

But though Robinson was originally told she didn’t qualify for Medicaid, she was later approved for the government program, and had her surgery in January. She spent a week in the hospital.

Today she’s still sore, but sufficiently recovered to start looking for work again. She is thankful. “The pain was getting worse. It was rough. I was barely able to stand straight up.’’

Robinson is feeling relief not just from the pain, but from the fear. She knew that if the hernia remained untreated, it could have forced a major complication. “I could have had to have a colostomy bag,’’ she says.

Dr. Charles Johnson meets with uninsured patient Caron Anderson at the Good Shepherd Clinic in Morrow.

The clinic’s waiting room filled up quickly Wednesday morning, and there were still more patients waiting outside, sitting on the porch of the converted home.

Good Shepherd Clinic, which provides free medical services to the uninsured of Clayton County, is a busy place every Monday and Wednesday, the only days when it’s open.

Patients and staff squeeze past each other in the narrow hallways, and there’s a steady flow of people in and out of the exam rooms.

The Morrow clinic draws people such as Lois Joiner, 63, of Forest Park. Joiner is unemployed and hasn’t had health insurance in five years. She has high blood pressure and high cholesterol, and has a regular appointment at Good Shepherd every three months.

When asked where she would be without the clinic, Joiner promptly answered: “The emergency room.’’

The day after the U.S. Census Bureau reported that nearly 50 million Americans had no health insurance in 2010 – a record high – Good Shepherd staff and patients said they weren’t surprised that the number is increasing.

“Nobody is working,’’ said Gary Shelton, 49, of Forest Park, who has diabetes and high cholesterol. He’s a refinisher of hardwood floors, but he hasn’t gotten many jobs in the past few years.

“There’s hardly any way to pay’’ for care, he said as his blood pressure was being taken.

Good Shepherd, like other free and charitable clinics in the state, is seeing greater demand for services.

Unemployment in Clayton County, just south of Atlanta, hovers at 13 percent, higher than the state and metro Atlanta rates. About 20 percent of county residents have no health insurance, roughly the state average.

Georgia’s uninsured rate ranked sixth among states in a three-year average in the Census report.

Many patients at Good Shepherd are the working poor, who either are not able to afford insurance or are not offered such coverage by their employers, said Jim Phillips, a former Delta Air Lines employee who’s chairman of the board of the clinic. “We have about a four-month waiting list.’’

Faith and generosity keep effort going

Georgia has 96 free and charitable clinics, the highest total of any state, said Donna Looper, executive director of the Georgia Free Clinic Network.

Much of the spread of these clinics in Georgia comes thanks to churches and other faith-based organizations, she said, with about 70 percent of the clinics having such affiliations.

“They’ve stepped up to the plate and filled the void in their communities,’’ Looper said of the religious groups.

The state’s clinics served 320,000 patients last year, and the persistent economic slump keeps pushing demand higher. Waiting lists for appointments run from six weeks to six months, Looper said. “Some clinics can’t even keep up with a waiting list.’’

The patients generally have chronic disease such as diabetes and hypertension, and part of Good Shepherd’s $280,000 annual budget goes to purchase medications. The clinic also gets drug samples and links patients to free medication programs run by pharmaceutical manufacturers.

Individual donations supply much of the money that the clinics run on.

The medical care is donated, too. One of the volunteers at Good Shepherd is Dr. Charles Johnson.

A primary care physician for more than 50 years, Johnson, in his 80s, joked that the volunteer work “keeps me off the streets.’’

“I love the practice of medicine,’’ he said. But he added that he can’t see all the patients who need help. “We don’t have enough physicians,’’ Johnson said.

Another volunteer is medical assistant Elaine Saperstein, who along with her husband, Jay, is unemployed. Her husband has diabetes, she said. “If it wasn’t for this place, my husband couldn’t get his medications, his insulin,’’ she said.

‘A never-ending battle’

But even this valuable safety net has some large holes.

If a Good Shepherd patient needs to see a physician specialist, it’s very difficult to get a referral, said Lisa Page, the clinic administrator. She told the story of a patient with leukemia whom the clinic finally had to send to a hospital emergency room, along with his medical paperwork.

Orthopedists are hard to find to set a broken bone, Page said.

Good Shepherd is open just a few hours a week. It would need to be open 40 hours-plus to meet the demand, Page said.

“It’s a never-ending battle,’’ she said, adding that the clinic is trying to hire a part-time nurse practitioner.

The patients are grateful to be there. “I don’t have the out-of-pocket money to pay for doctor visits and prescriptions,’’ said Hazel Moore, 62.

And Caron Anderson, 59, had a stark answer when she was asked what would happen if she didn’t have access to Good Shepherd. “Without it, I’d just be suffering,’’ she said.

Lauren O'Brien (left) helps an unidentified family through her nonprofit Embraced organization.

Lauren O’Brien’s career path changed when she fell off a horse.

She suffered orthopedic injuries in a riding accident three years ago. O’Brien, who had plans of becoming a physician, wanted to donate her orthopedic equipment to someone else after her recovery. Yet when she tried to give away the braces and crutches, she found it wasn’t a simple process.

“I felt there should be an easy way to recycle this equipment,’’ recalls O’Brien, 27.

So, in 2009, O’Brien decided to form an Atlanta nonprofit, Embraced (www.embracedatlanta.org), that would do just that. The organization takes used crutches, walkers, canes, wheelchairs, braces and prosthetics, then donates them to individuals and other nonprofits, such as free clinics and organizations serving the uninsured.

“That way they don’t end up in a closet,’’ O’Brien says. “If the equipment makes it to a landfill, it’s a liability. This way they can become usable assets.’’

Embraced picks up used equipment from doctors’ offices and orthopedic clinics. People also can arrange to drop off the equipment.

Anthony Baskett of St. Joseph’s Mercy Care, which helps medically needy people, says it has received wheelchairs, walking canes and shoe inserts from Embraced. The partnership works well, he says. “I think this is a wonderful opportunity, and a good marriage with Embraced, to deliver more services to our patients.’’

Patients get a chance to be donors

Embraced has posted collection bins at metro Atlanta offices of Resurgens Orthopaedics, which donates the braces, crutches, walkers and other equipment that ‘’typically ends up in a person’s closet or gets thrown away,’’ says Jeff Goldberg of Resurgens.

“We tell patients they have the opportunity to recycle,’’ Goldberg says, adding, “Our employees love the fact they’re involved with something that gives back to the community.’’

A set of crutches has great value to an uninsured person who can’t afford them, O’Brien notes.

Some donated equipment winds up overseas. Embraced works with MedShare, a Decatur nonprofit that has collected, recycled and distributed more than $90 million worth of  medical supplies and equipment to developing countries.

Another local nonprofit that recycles and donates equipment is the Friends of Disabled Adults & Children (www.fodac.org), which is part of a network of  organizations in the state.

The goal for Embraced, O’Brien says, is for the 2-year-old organization to recycle 5,000 items per year, which she estimates would equate to $500,000 in health care savings.

“I know I’m doing the right thing,’’ O’Brien says.

Melba Kida, nurse practitioner at the Hall County Health Department, screens patient samples for cervical cancer.

Gainesville — The recent battle over federal funding for Planned Parenthood is still echoing here.

The attempt by congressional Republicans to stop all $327 million of federal Title X money — while targeting Planned Parenthood as an abortion provider — endangered funding for women’s health services at clinics in Hall County, public health workers say. Those clinics are partly funded by Title X money.

Signed by President Richard Nixon in 1970, Title X was established to provide free reproductive health care, including birth control, to women living at or below the poverty level. Although it has never underwritten abortion, some conservatives want to end Title X as a way of cutting federal funds to agencies involved in abortion.

Referring to Planned Parenthood, U.S. Rep. Mike Pence (R-Ind.) recently said, “The largest abortion provider in America should not also be the largest recipient of federal funding under Title X.” He sponsored a bill to end federal funding to the organization.

While the GOP efforts against Title X failed this year, the brouhaha about cutting the money is far from over.

If Title X is abolished, there could be “tragic” consequences for low-income women and for the health care system in Hall County, said Jennifer Parker, the women’s health coordinator for the county. Women with no other resources rely on Title X for overall physical exams as well as screenings for breast cancer and cervical cancer, preventive immunizations, and screenings for sexually transmitted infections, she said.

“We are the only health providers some women see,’’ Parker said. “If we cut Title X, repercussions would be critical for these women.”

Title X cutbacks would affect the wave of new Health Department clients who have flocked there since the economic downturn left them without jobs and health insurance. Every day, more women in this predicament call the Health Department, Parker said.

‘We may have . . . to close our doors’

Some of these women may have early, treatable cancers. “If a woman comes to the Health Department because she can’t afford birth control, she’s probably not getting Pap smears or mammograms on a regular basis from a private-practice gynecologist,” said Melba Kida, a nurse practitioner at Hall County’s Health Department. “It makes sense that the majority of low-income women depend on the Health Department for cancer screenings.”

Although local health departments aren’t equipped to treat cancer, they can refer patients to physicians participating in the Health Access Initiative, a Hall County Medical Society program that provides inexpensive care to uninsured adults. The Health Department staff also helps women apply for Medicaid if needed.

“We rely very heavily on Title X to keep our program and the department alive,” said Kida. “Even if a woman cannot afford to pay, the Health Department is still mandated to provide services. If we continue to see many people that are unable to pay for care, and we don’t have federal funding, we may have no other choice but to close our doors.”

The state’s Public Health District 2, which includes Hall and 12 other counties, received more than $500,000 in federal funding for fiscal year 2011 to cover staff salaries, supplies and equipment to run reproductive health care programs.  All federal money is funneled through the state, and since the recent economic downturn, Parker said, the state has diverted $93,141 from family planning clinics to other programs. Normally, she said, all Title X funds would be depleted by the end of the fiscal year, June 30.

If all federal funds stopped, that would drive more patients to the Good News Clinics, which is Hall County’s only privately run, nonprofit clinic and a major source of free care in the area.

Good News receives no Title X money, but staff member Jean Peeples predicts that its patient load will increase if services are cut at the Health Department. The clinic, which has two volunteer gynecologists who see patients once a week, already handles about 800 monthly visits from uninsured women. Waiting times will increase if cutbacks occur at the county Health Department, Peeples said.

Good News screens for cervical and breast cancer but does not provide birth control assistance.

Title X is a bargain, backers say

Kida disagrees with the conservative rationale for cuts in funding. “Title X doesn’t pay for abortions and never has. It stands to reason that when you have more people pregnant who didn’t want to be, your rates of abortion may very well go up. Do they think that just because there is no family planning, people are going to stop having sex? To me, that just seems shortsighted.”

Small clinics like Good News obviously can’t shoulder the whole burden of family planning, and any decrease in federal support will have to be made up elsewhere — most likely in state taxes, defenders of Title X say. “I think that taking away money from our clinics is just going to result in an even larger burden on our taxpayers,” Parker said.

There is evidence that Title X saves health care dollars in the long run because it provides so many preventive services, including breast exams, Pap smears and screenings for sexually transmitted diseases. The Guttmacher Institute, a research and advocacy group on sexual and reproductive health, estimates the program saves U.S. taxpayers at least $3.4 billion each year.

U.S. Rep. Tom Graves, a Republican whose district includes Hall County, supported the Pence-sponsored bill. A Graves spokesman said the congressman sought “to protect millions of pro-life taxpayers from subsidizing Planned Parenthood, the largest abortion provider in America.”

“This bill is not about health services; it’s about protecting innocent, unborn life,’’ said spokesman John Donnelly.

Meanwhile, on general Title X funding, Parker said it all comes down to the welfare of children born into low-income families.

“Our mission [at the Health Department] is to help families plan for children they can provide and care for, so that when they grow up, they’ll be good citizens of Georgia,” Parker said. And with or without Title X, Parker said, the department “will do everything in [its] power to support that effort.”