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Rural Health Care:
A
Commitment Shattered
St. Louis Post-Dispatch
THE BRUTAL ECONOMICS of health
care may not be obvious under the capitol dome in Jefferson City. But they
are difficult to deny down in Howell County, hard by the Arkansas border,
where state Sen. Chuck Purgason was born and raised.
In Howell County, Mr. Purgason is both hero and villain of the Medicaid
morality play that is testing the character of Missourians and their
government. He is a hero for what he did six years ago, helping to start a
health clinic in West Plains. He is a villain because he is sponsoring Gov.
Matt Blunt's Medicaid cuts that would take health coverage from 4,554 of his
constituents.
A toothache and a nurse
It was hardly the first toothache that school nurse Cathey Amyx had
encountered. Kids at the elementary school often stopped by to complain
about their teeth. Their problem wasn't a lack of health insurance; many
were covered by Medicaid. What they lacked was a dentist willing to work on
their teeth for what Medicaid was willing to pay. But one day in 1999, Ms.
Amyx decided she had seen one toothache too many.
Soon she was talking to anyone she thought could help—a
local bank
executive, the mayor and, eventually, Mr. Purgason, who was then a member of
the Missouri House.
He set in motion a chain of events that culminated two years ago with the
opening of the Southern Missouri Community Health Center in a small strip
mall just off Porter Wagoner Boulevard. "We wouldn't be here today if it
weren't for Chuck," said Scott Corman, a bank president who heads the
clinic's Board of Trustees.
About nine months ago, the clinic began offering dental care. The demand was
overwhelming—about
3,000 visits during the first six months alone, enough to keep two full-time
dentists busy. The clinic draws from an area that includes four of the
nation's poorest counties (Oregon, Texas, Ripley and part of Shannon
counties), and it was obvious from the dozen or so parents and kids in the
waiting room one day recently that it fills a deep need.
Better make that past tense—filled.
Mr. Purgason sponsored a bill, approved this month by the state Senate,
which would slash Medicaid rolls and end a host of "optional" benefits.
Among them are wheelchairs, crutches, prosthetic limbs and adult dental
care.
Folks at the clinic are trying to remain cautiously optimistic. They deeply
appreciate all that Mr. Purgason has done for them and look forward to
offering suggestions to a committee that would be created to reshape
Medicaid.
But there is real concern about what the cuts would mean. A staggering 87
percent of the health center's dental patients are covered by Medicaid;
another 12 percent are uninsured and unable to pay even a token fee. The
rest—1
percent—are
mostly clinic employees.
Dentists can, and do, turn away Medicaid patients. But community health
centers have to serve everyone who comes through the door. It's not clear
how many of the clinic's dental patients would lose coverage, but it's a
safe bet that many would. Even so, they'll likely keep coming just as they
have for the last nine months. Only the clinic will have to treat many of
them for free.
Eating it
Up the street at Ozarks Medical Center, the 114-bed hospital that serves
West Plains and the surrounding counties, the prognosis is even grimmer.
More than one third of the patients admitted last year were paid for by
Medicaid. The program also pays for about a third of outpatients using
hospital-owned clinics. It covered 41 percent of emergency room visits.
"It will cost us at least $1.1 million, and that's only one piece of it,"
said
Phil Bagby, the hospital's CEO. "They'll continue to come to the ER. A lot
of that care is going to have to be written off. We're going to have to eat
it."
Because Medicaid covers so many people—52
million across the country, more even than Medicare—it
helps hospitals and clinics offset the cost of caring for the 45 million
Americans without health insurance. The cuts in Mr. Purgason's bill would
increase the number of uninsured Missourians by 19 percent.
Without Medicaid and the state Children's Health Insurance Program, most
children in south central Missouri would never see a doctor. More than half
the kids in Texas County and about 60 percent of those in Howell County have
their health care paid for by those two programs. In neighboring Shannon
County, the programs cover about three-quarters of the children; in Ripley
County, they pay for more than 81 percent.
Mr. Blunt avoided cutting most programs for kids, but a budget proposal in
the House would result in about 15,000 families being forced to drop out of
the children's health insurance program. State officials estimate that
23,400 kids would lose coverage.
Shifting costs, shifting blame
Just outside of West Plains, in a tan metal building a half-mile or so down
a dirt road, Mr. Purgason was taking a short break in a long work day.
Across the floor of his small business, Ozark Awards, lay boxes of trophies
and plaques awaiting engraving.
"The Medicaid system does a poor job of caring for poor people," he said,
leaning back in a worn chair. "There's no avenue for preventive care, and
it's very hard for people to get any kind of specialty care."
The crux of the problem, as he sees it, is that legislators added coverage
for too many people during the 1990s. Yet they failed to increase the rates
paid to doctors, dentists and hospitals. The result is that while more than
1 million people in Missouri have Medicaid cards, they often can't find a
dentist or medical specialist willing to accept them.
Because hospitals are underpaid for treating Medicaid patients, they shift a
portion of their costs onto privately insured patients, or those who pay for
their own care, he continued. Mr. Purgason didn't mention that the shift
would be even greater if they no longer are paid for those Medicaid
patients.
During the 1990s, legislators extended benefits to about 90,000 children
under the children's health insurance program. As a result, the number of
uninsured kids in Missouri is below the national average.
But in recent years, enrollment has continued to grow even as eligibility
requirements were tightened. In most cases, parents can earn no more than 75
percent of the federal poverty limit and remain eligible. Under Mr.
Purgason's bill, that would drop to 30 percent of poverty.
Mr. Purgason said no one is more aware than he of the impact of those cuts.
More Medicaid patients would lose coverage in his Senate district than any
other in the state. "I'm sure over the next few months, we'll have problems.
But over the long term, we can come up with a better system."
Besides, he knows what it's like to go without health insurance. "I didn't
have any the whole time my wife and I were having our children," he said. "I
paid $50 a month to the doctor and $100 a month to the hospital until the
bills were paid off."
Paid off at 136
That was more than a decade ago, a decade during which health care costs
rose at double-digit rates. Just ask Jeri Winchester, a 63-year-old
grandmother from West Plains who lives on $355 a month.
"When I had my heart attack five years ago, the hospital in Springfield
charged me $22,000," she said. "I'm paying it off $25 a month."
At that rate, she'll be out of debt when she's 136.
She said she depends on her Medicaid prescription drug coverage the most.
"For people like me—the
elderly, the mentally and physically handicapped—it
truly is a godsend."
But God doesn't pay the bills, the taxpayers do, and for years, Republicans
have run for office promising not to raise taxes. It has been an effective
strategy, but it has painted the party into a corner. Having been elected to
office on an antitax platform, how can they possibly go back to voters and
argue for more revenue?
Even if they did, Mr. Purgason claims, voters wouldn't buy the argument. And
under the state's Constitution, raising more than $70 million in revenue
would require a vote of the people.
So Republicans like Mr. Purgason are left with only hard choices. Do they
keep their commitment not to raise taxes, or their commitment to look out
for the health care needs of their constituents? Are they repairing a system
that is broken, or breaking a system that—with
all its faults—is
far better than the alternatives?
Over at the Ozarks Medical Center, Phil Bagby, the hospital CEO, offered one
answer: "If you're really committed to your constituents, you can either cut
expenses elsewhere or raise revenues. We made a commitment to these people.
We have to find a way to fulfill it."
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