Busy safety net clinics eye possible Medicaid expansion
On a recent Thursday, Matt Willis sat in the lobby of Health Care Access in Lawrence waiting for treatment for an upper respiratory illness.
It wasn’t so long ago that a much more serious condition wouldn’t have moved the Eudora man to seek medical attention. Just three years ago, he ended up in the Lawrence Memorial Hospital emergency room with a mild stroke after ignoring symptoms of high blood pressure.
After immediate treatment at the hospital, Willis — who was working for an employer who didn’t offer health insurance — was referred to Health Care Access, a safety net clinic providing healthcare to uninsured Douglas County residents.
“They probably saved my life,” Willis said, who now has regular checkups at Health Care Access to track how prescription drugs are controlling his hypertension. “I’m pretty sure I would have died. I can’t say enough good about them.”
Willis’ story is all too familiar to administrators and healthcare providers at area safety net healthcare clinics.
“I’ve seen people come through those doors with conditions so advanced all we could offer was palliative care,” said Diane Hill, a nurse practitioner at Health Partnership Clinic of Johnson County’s Overland Park clinic. “What were operable malignancies grew to something much more serious. That’s very frustrating.
“Those extreme cases are rare. Much more common are people coming in with out-of-control diabetes or extreme hypertension.”
Karole Bradford, development director for St. Vincent Clinic in Leavenworth and Duchesne Clinic in Kansas City, Kan., said the two clinics routinely see very sick people who have deferred health care to put food on the table or pay the rent.
“If you’re in that position and only have a cold, you’re not going to come to us,” she said. “You come to see us when you have a headache for 19 months and you think you’re dying and find you have hypertension.”
Of course not all those seeking medical attention have life-threatening medical conditions. Some already aware of the clinics’ existence use them for primary care, and others, like Carlos Portillo of Shawnee, visit seeking treatment for unexpected medical problems.
On Friday, Portillo visited Health Partnership Clinic’s Overland Park site for treatment of an eye infection. A seminary student in his early 20s, Portillo said he was “never sick” and didn’t think he needed health insurance.
Clinic numbers increasing
Whether they are very sick, walk-ins or visiting for scheduled primary care appointments, the number of patients are increasing at area safety net clinics. Bradford said the increase reflected the continued economic difficulties that have left many out of work or underemployed with jobs offering no health insurance.
Data the U.S. Census Bureau released in September show 13.1 percent of Kansans, or 365,000 people, did not have health insurance during the study’s survey period of 2010-2011, said Suzanne Schrandt, senior analyst and health reform team leader for the Kansas Health Institute.
That was “not a significant change” from the 12.8 percent rate in the 2008-2009 study, she said. But as a report on the Kansas Health Institute website notes, it is in line with a trend that has seen the percentage of uninsured in the state rise from 9.7 percent in 2000-2001.
Heath Care Access executive director Nikki White said the Lawrence clinic had 6,937 patient visits in 2011, a 116 percent increase from 2010. The clinic is on pace to have 10,795 visits this year.
Duchesne and St. Vincent had a 32 percent increase in visits this year and the two clinics will see more than 3,000 patients for more than 9,000 medical visits.
“I can’t overstate the increase we are seeing and also the increase we have seen in the last 18 months,” Bradford said.
Health Partnership Clinic’s sites in Overland Park and Olathe are also busier. But Health Partnership Clinic CEO Jason Wesco said there was an added reason that made a comparison to past numbers meaningless. In July of this year, Health Partnership Clinic changed its mission from seeing only uninsured patients to also accepting patients on Medicaid.
Safety net clinics provide service to uninsured patients on sliding scales based on income. Those payments don’t cover the clinics’ costs, and they stay open because of federal, state and private-sector grants and individual donations.
However, Health Partnership Clinic gets cost-based payments for its Medicaid patients, meaning it doesn’t lose money for providing those patients treatment.
Wesco said there are many Medicaid eligible, low-income residents living in Johnson County, despite its affluence. The county has 36,000 residents living at or below the federal poverty level ($11,170 of annual income for an individual and increasing by $3,690 for each additional household family member) and 103,000 residents living at or below 200 percent of that level, he said.
“The demographics are changing,” he said. “Wyandotte County has the highest percentage, but that’s the highest number in Kansas outside of Sedgwick County. “We’re very far behind in providing health care to low-income patients. I’d venture more than anybody.”
Health Partnership Clinic is trying to catch up through a series of expansions that will add more medical exam rooms to its Overland Park site, medical and dental exam rooms at its Olathe clinic and a new clinic in Paola, Wesco said.
Even as safety net clinics deal with increasing demand, they face an uncertain future because of state and federal reforms.
Kansas is currently waiting for the federal government’s approval of its KanCare reform, which would have three private-sector providers administer state Medicaid dollars.
KanCare could mean an increase in Health Partnership Clinic’s caseload, Wesco speculated.
“Right now, the state provides quick reimbursement,” he said. “With KanCare, there will be three different companies to deal with different compensation schedules and three different documentation requirements. We’re prepared to deal with it, but there may be some private-sector providers who stop seeing Medicaid patients because they don’t want to go to that extra trouble.”
Affordable Care Act
But the real potential game changer is the Affordable Care Act and its provision to expand Medicaid benefits to people with income at or less than 133 percent of the federal poverty level. That would have major consequences in Kansas because Medicaid in the state is tailored for low-income children and their adult providers. Childless adults do not qualify unless elderly or disabled. The proposed expansion would make 143,000 adult Kansans eligible for the program.
The U.S. Supreme Court ruling of June found the ACA constitutional but said the federal government couldn’t penalize states opting out of Medicaid expansion, leaving that decision to individual states.
ACA still has a carrot to entice states to expand Medicaid, Schrandt said. Under the law, the federal government will reimburse states 100 percent of expanding Medicaid in 2014. The reimbursement level drops to 90 percent by 2020, and those states expanding later will be reimbursed at whatever percentage is applicable the year they expand, Schrandt said.
Brownback, who voted against the ACA while in the U.S. Senate, said he would wait until after the election to decide whether to expand Medicaid. Republican presidential candidate Mitt Romney has promised to repeal the legislation if elected.
Wesco, who is already suggesting Health Partnership Clinic look for an empty big-box building as a future clinic, said the state’s opting to full affordable care act Medicaid expansion would require a large Health Partnership Clinic capital commitment to meet demand.
“Instead of needing 30 exam rooms we would need to have 100,” he said. “We would have to think as big as possible.”
Bradford said Duchesne and St. Vincent would change their missions with an expansion to include care of Medicaid patients. Administrators were already starting to plan for such a change with the expectation the clinics would be the healthcare gateway to many new patients, she said.
“If Medicaid expands in Kansas, you’re going to give a lot of very sick people access to coverage but without more doctors to take those patients,” Bradford said. “Many physicians’ offices will only take so many Medicaid patients, and we already are in medically underserved communities.”
Health Care Access is taking a different approach, White said. It will continue to provide healthcare only to the uninsured, who will still be there no matter what happens with the Medicaid expansion, she said.
“For the foreseeable future, our mission and target audience would remain the same,” she said.