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Threat Of Obamacare Repeal Leaves Community Health Centers In Limbo

Treating people for free or for very little money has been the role of community health centers across the U.S. for decades. In 2015, 1 in 12 Americans sought care at one of these clinics; nearly 6 in 10 were women, and hundreds of thousands were veterans.

The community clinics — now roughly 1,300-strong — have also expanded in recent years to serve people who gained insurance under the Affordable Care Act. In 2015, community health centers served 24.3 million people — up from 19.5 million in 2010. Most of the centers are nonprofits with deep roots in their communities and they meet the criteria to be a federally qualified health center. That means they can qualify for federal grants and a higher payment rate from Medicaid and Medicare.

The ACA was a game changer for these clinics — it has enabled them to get reimbursement for much more of the care they provided, because more of their patients now had private insurance or were on Medicaid. Revenue at many clinics went up overall, and many of the health centers used federal funding available under the law to expand their physical facilities and add more services, such as dentistry, urgent care or mental health care.

With repeal of the ACA looming, clinic directors said they stay up at night wondering what’s next. We spoke with four, who all say their clinics are in a holding pattern as Congress debates the health law’s future.

Saban Community Clinic, Los Angeles

Julie Hudman, the CEO of Saban Community Clinic in Los Angeles, Calif., said there’s a lot at stake for her patients.

“A lot of the folks that we see are single adults,” she explained. “They’re maybe more transitional. They’re homeless patients. They have behavioral health challenges. They’re really, to be honest, some of the most vulnerable and poorest patients of all.”

Before the ACA went into effect, eligibility for Medi-Cal, as Medicaid is known in California, depended on a variety of factors, including income, household size, family status, disability and others. Under Obamacare, according to the California Department of Health Care Services, people can now qualify for Medi-Cal on the basis of income alone if their household makes less than 138 percent of the federal poverty level — that’s $16,395 for an individual and $33,534 for a family of four.

Prior the ACA, about half of the Saban clinic’s 18,000 patients were uninsured, Hudman said. They paid little for treatment — maybe a copay of $5 or $10. Almost all of those patients qualified for Medi-Cal after the health law expanded eligibility, she said, and that’s made a big difference for the clinic’s bottom line: Medi-Cal pays the clinic around $200 per patient visit.

These days, more than half of Saban’s revenue comes from health insurance. The possibility of losing some of that money, Hudman said, is forcing some hard decisions. She had been looking to lease or buy a fourth facility, she said, but now that plan is on hold; as are her hopes of expanding free help for the homeless.

“I’m not willing to move forward and take some of those risks,” she said. “I need to make sure that we’re able to pay our bills and pay our staff.”

Before the last election, Hudman said, “we had a lot of momentum moving forward. And now we’ve just sort of stalled.” — Rebecca Plevin, KPCC, Los Angeles

Jordan Health, Rochester, N.Y.

In the last few years, funding has been on the rise at Jordan Health, in Rochester, N.Y., and so has the extent of the clinic’s services.

The boost in funding has partly come from higher reimbursement rates the ACA authorizes, and from the increased number of patients at the clinic who have insurance. But Jordan Health, which has 10 locations in the area, has also benefited from the federal government’s pumping of more money into what are known as section 330 grants that enable expansion of services and facilities.

Janice Harbin, CEO of Jordan Health in Rochester, N.Y. says section 330 grants have allowed Jordan Health to hire more health practitioners. (Karen Shakerdge/WXXI)

Janice Harbin, CEO of Jordan Health in Rochester, N.Y. says section 330 grants have allowed Jordan Health to hire more health practitioners. (Karen Shakerdge/WXXI)

The 330 grant money gives qualified clinics the option of offering services that aren’t billable to insurance plans. At Jordan Health, the funds enabled the hiring of some different types of health practitioners who were not previously part of the team — dietitians, behavioral health specialists and care coordinators. And that, in turn, said Janice Harbin, president and CEO of Jordan Health, means patients can increasingly get the different kinds of care they need in one place.

Almost 90 percent of Jordan’s patients are considered a racial or ethnic minority, and over 97 percent live at or below 200 percent of the federal poverty line, according to data gathered by the federal Health Resources & Services Administration.

“When you’re dealing with a situation of concentrated poverty,” Harbin said, “your patient needs more than just ‘OK, let me give you a checkup, and pat you on the back and say now go out and do all these things I told you to do.’”

Jordan Health received an increase of about $1 million since 2013, according to its grant coordinator, Deborah Tschappat.

Tschappat said she expects Jordan will get about the same annual award in 2017, assuming federal funding for the 330 program stays about the same. If federal funding is cut significantly, they would potentially lose some services.

For now, Jordan Health plans to “expand services judiciously, while increasing efficiency and productivity,” Tschappat said.

In the coming months Harbin and her colleagues will be lobbying lawmakers in Albany and Washington, D.C., to renew Jordan’s funding — including the 330 grant, which is set to end in September.

“We’re used to doing a lot with a little, but we increasingly know that we do need to have financial support,” Harban said. “And that’s keeping us up at night.” — Karen Shakerdge, WXXI, Rochester

Adelante Healthcare, Phoenix

Adelante Healthcare has been part of the health safety net in Phoenix for nearly four decades — when its doctors began helping farm workers in the city’s surrounding fields. But the Affordable Care Act enabled Adelante to expand like a brand new business.

“Adelante has grown by 35 percent in the last 12 months,” said Dr. Robert Babyar, Adelante’s assistant chief medical officer. “We’ve increased our provider staffing — almost doubled our providers. And the number of services we provide has doubled.”

Adelante operates nine clinics throughout the Phoenix metro area. The one where Babyar met with me includes play areas for children and a dental office.

Most of their 70,000 patients are low-income and about half are covered by either Medicaid or KidsCare — Arizona’s version of the Children Health Insurance Program. In 2014, Arizona became one of the Republican-led states that expanded Medicaid under the ACA. That brought more than 400,000 people onto the state’s Medicaid rolls and created big demand for Adelante. Low-income patients who did not have insurance before the expansion had relied on Adelante’s sliding fee schedule. Much of that population now has health coverage, either through the ACA marketplace or the state.

“That opened up more options for our patients, more specialists they could see, procedures they could have done,” Babyar said.

As Congress moves to repeal and replace the health care law, Adelante is in a holding pattern. It has delayed the groundbreaking of a new site until later this year because of the uncertainty. A full repeal of the ACA — without a replacement that keeps its patients covered — would limit any future growth, and strain the new staff and resources it has added. It wouldn’t be the first time Adelante had to scale back its services because of changes to Medicaid. In 2010 and 2011, Arizona lawmakers froze enrollment for its CHIP program and for childless adults in Medicaid. Then, in 2012, Adelante lost more than a million dollars.

Babyar said it has taken several years to get their new patients into the system and working with doctors consistently to manage their conditions.

“All the progress we made with those patients to stay and be healthy — that can fall apart really quick,” said Babyar. — Will Stone, KJZZ, Phoenix

Denver Health, Denver

Denver’s Federico F. Peña Southwest Family Health Center is part of Denver Health — the safety-net system that takes care of low-income people.

“Definitely this clinic has benefited from Obamacare,” said Dr. Michael Russum, who practices family medicine for Denver Health and helps lead the clinic. “And this population has benefited from Obamacare by the expansion of Medicaid.”

That’s what helped make the economics work as Denver Health put a new $26 million clinic in a high poverty neighborhood in 2016, said Dr. Simon Hambidge, Denver Health’s CEO of Community Health Services. With the ACA in place, he said, the health system was able to count on the new clinic having a population of paying patients with insurance that could help support it.

Hambidge predicted the hospital will weather the storm if Obamacare is repealed and there are serious cuts to safety-net programs, like Medicaid and Medicare, as some Republicans have suggested. But it will probably be harder to open new clinics in other high-need neighborhoods, he conceded.

“We’ll survive,” Hambidge said. “We may not be able to be as expansive, because we would be back to less secure times.” — John Daley, Colorado Public Radio

This story is part of NPR’s reporting partnership with local member stations and Kaiser Health News.

Categories: Medicaid, Public Radio Partnership, Repeal And Replace Watch, States, Syndicate, The Health Law

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Veteran Teaches Therapists How To Talk About Gun Safety When Suicide’s A Risk

Jay Zimmerman got his first BB gun when he was 7, and his first shotgun when he was 10.

“Growing up in Appalachia, you look forward to getting your first firearm,” he said, “probably more so than your first car.”

His grandfather taught him to hunt squirrels and quail. Zimmerman, who lives in Elizabethton, Tenn., said pretty much everyone he knows has a gun. It’s just part of the culture.

“When I went into the military, that culture was reinforced,” he said. “Your weapon is almost another appendage. It’s part of who you are.”

Zimmerman served as a medic in the Army in the late 1990s and early 2000s, with stints in Bosnia, Africa and the Middle East. Since he came home, he’s struggled with PTSD and depression. It reached a crisis point a few years ago, when his best friend — the guy who had saved his life in a combat zone — killed himself. Zimmerman decided his time was up, too.

“I decided that I would have one more birthday with my daughter, one more Christmas with my daughter,” he said. “I had devised my own exit strategy for 16 February 2013.”

But then he bumped into a woman who used to ride the same school bus when they were kids. His exit date came and went. They’re married now.

Zimmerman still gets depressed, but now he’s a peer counselor at the Mountain Home VA Medical Center in Johnson City, Tenn. He also travels to conferences all over the country, sharing his story with therapists and with other vets, encouraging them to ask for help when they need it.

Even today, he explains at these conferences, if he’s not doing well, he disassembles his guns and stores them separately from ammunition, so he can’t make any rash decisions. And if things get really bad, Zimmerman has a special arrangement with a few friends.

“I call them and say, ‘Look, I’m feeling like it’s not safe for me to have firearms in my home. Can you store them for me for a couple days till I feel like I’m OK to have them back?’ ”

Suicide is often an impulsive act. Nearly half the people who survive an attempt say the time between their first thought of suicide and the attempt itself was less than 10 minutes. But the method can mean the difference between life and death: People who take pills have time to change their minds, or may still be alive when discovered. That’s not the case with guns.

Almost 70 percent of veterans who commit suicide do so with a gun, which prompted President Barack Obama to order the VA to talk to vets about gun safety and storage options like the ones Zimmerman uses.

But here’s the trouble: Most therapists aren’t gun people. They don’t know how to talk about guns and so they don’t.

“One obvious reason for that is that no one has taught them how,” explained Megan McCarthy, a psychologist and National Deputy Director in the Office for Suicide Prevention in the U.S. Department of Veterans Affairs.

McCarthy was invited to speak recently at a suicide prevention conference in San Francisco, aimed at therapists who work with vets.

“How many of you would say you feel really comfortable having a conversation with any of the people you work with about limiting access to all lethal means?” she asked the roomful of therapists.

Hardly anyone raised their hand.

“OK, so that’s why we’re here today,” she said.

Researchers recommend starting with a field trip to a shooting range. There, therapists can learn about different kinds of firearms, as well as gun locks, and get an introduction to gun culture.

When counseling vets, therapists have to ask more questions and be less directive, McCarthy said.

“We often conceive of ourselves as experts — as people who impart information to clients,” she said. But with vets, “it may take time to build trust. Telling them what to do the first time you’ve met them is probably not going to be a very effective approach.”

McCarthy presented a case study at the conference: A 28-year old, unmarried Army veteran who fought in Iraq told his VA psychiatrist that he had an argument with his girlfriend last week. He drove to an empty parking lot and sat with his loaded handgun in his lap, intending to kill himself.

He didn’t do it. A week later, the man told his psychiatrist things were still tense with his girlfriend. But he didn’t want to talk about suicide or storing his gun.

McCarthy asked the clinicians in the audience what they would do next, if they were this man’s psychiatrist.

“Why did he not do it? That would be my question,” one therapist said.

“I would want to see this individual again, within the same week,” said another. “I believe in strong intervention.”

Jay Zimmerman, the former army medic and peer counselor, stood up and explained his different perspective.

“Chances are the reason he’s not talking to you is because he’s afraid he’s going to lose his gun that he carries pretty much all the time,” Zimmerman said. “My buddies are the same way. We all carry — all the time.”

A lot of veterans would sometimes rather confide in a fellow vet than someone in a white coat, Zimmerman said. And that was an unusual takeaway for the professional counselors: Sometimes their role is not to intervene at all, but to be a facilitator. To make sure vets have someone to talk to outside the therapy office.

This story is part of a partnership that includes KQED, NPR and Kaiser Health News.

Categories: Mental Health, Public Health, Public Radio Partnership, Syndicate

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Travel Ban Spotlights U.S. Dependence On Foreign-Born Doctors

Patients in Alexandria, La., were the friendliest people Dr. Muhammad Tauseef ever treated. They’d drive long distances to see him, and often brought gifts.

“It’s a small town, so they will sometimes bring you chickens, bring you eggs, bring you homemade cakes,” he said. One woman even gave him a puppy. “That was really nice.”

Tauseef was born and raised in Pakistan. After going to medical school there, he applied to come to the U.S. to train as a pediatrician.

It’s a path thousands of foreign-born medical students follow every year — a path that’s been around for more than half a century. And, like most foreign-born physicians, Tauseef came on a J1 visa. That meant after training he had two options: return to Pakistan or work for three years in an area the U.S. government has identified as having a provider shortage. He chose to work with mostly uninsured kids at a pediatric practice in Alexandria, La.

“That was a challenge,” he said, “but it was rewarding as well, because you are taking care of people who there aren’t many to take care for.”

The U.S. medical system depends on doctors like Tauseef, said Andrew Gurman, president of the American Medical Association. He worries that President Donald Trump’s executive order on immigration, which is now on hold after a federal appeals court ruling.

“International medical graduates have been a resource to provide medical care to areas that don’t otherwise have access to physicians,” he said. “With the current uncertainty about those physicians’ immigration status, we don’t know whether or not these areas are going to receive care.”

According to the AMA, about 280,000 international medical graduates practice in the U.S. today — that’s about one in four doctors. Some are U.S. citizens who’ve gone abroad for medical school, but most aren’t.

“They don’t all have permanent visas and so a lot of them are concerned about what their status is going to be, whether they can stay, whether they can go home to visit family and still come back, and the communities they serve have similar questions,” he said.

And the care is top-notch. A study just published in the journal BMJ shows Medicare patients treated by doctors from foreign medical schools get just as good care — and sometimes better — than those treated by U.S. medical graduates.

The uncertainty is hitting medical schools at a tough time of the year. Dr. Salahuddin Kazi is in charge of recruiting top students from across the world for the University of Texas Southwestern residency program.

“Typically we have 3,000 people applying for our 61 positions — of those 3,000, at least half of them are international medical graduates,” he said.

Applicants find out their program match in March and usually start working in June. That gives them about 90 days to get a visa. Kazi worries this year that won’t be long enough, and that students from countries included in the travel ban won’t be let in.

“That would create hardship for the hospital, for us, and for our remaining residents,” he said. “They’ll have to pick up more shifts or give up vacation.”

Two-hundred and sixty people have applied for residency in the U.S. from the seven countries included in the travel ban, according to the Association of American Medical Colleges.

Tauseef left Louisiana two years ago but continues to care for low-income patients at Los Barrios Unidos Community Clinic in Dallas. Six of the 30 physicians who work at this clinic are from other countries. Tauseef said they’re all educated to do the same thing.

“As a physician, being a foreign medical graduate, U.S. medical graduate, a Muslim doctor, a non-Muslim, we are trained to look for signs and symptoms,” he said, “We do not look at anybody’s color, we are not trained to look at anybody’s religion or ethnicity.”

Tauseef, who has been in this country for 13 years, will apply for U.S. citizenship next month.

This story is part of a partnership that includes KERA, NPR and Kaiser Health News.

Categories: Health Industry, Public Radio Partnership, Syndicate

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Obamacare Came To Montana Indian Country And Brought Jobs

The Affordable Care Act created new health coverage opportunities more than half a million Native Americans and Alaska Natives — and jobs have followed on its coattails.

In Montana, this is playing out at the Blackfeet Community Hospital. It’s the only hospital on the Blackfeet reservation, and has been mostly funded — and chronically underfunded — by the Indian Health Service, which has been in charge of Native American health care since its founding in the 1950s. But now, many Native Americans have been able to afford health insurance on the Obamacare exchange, and last year, Montana expanded Medicaid. Now, about one in seven reservation residents gets Medicaid.

Blackfeet Community Hospital needed to build an infrastructure to deal with the byzantine bureaucracy that comes with taking Medicaid and private insurance. The tribe’s community college started a new curriculum to help meet the growing demand for people in Indian country to process insurance claims.

Blackfeet tribal member Gerald Murray took the courses. “I got a contract before I graduated in April, and then the day of graduation in May it became permanent so I applied for it,” he said.

Murray’s experience is an example of the health care law’s transformative power in Native American communities, said Montana’s director of American Indian Health, Mary Lynn Billy-Old Coyote.

“To me, there’s opportunity there to not only build health care, but to build your entire community and build jobs,” said Billy-Old Coyote.

Unemployment on most of Montana’s Indian reservations is at least double the rest of the state. And people who are working don’t always get health insurance with their jobs. So ACA subsidies that bring down the cost of insurance premiums are a big deal, Billy-Old Coyote said. Most Montanans, Native or not, can now get policies for about $75 a month. It is a big change for the reservation communities where people are accustomed to the underfunded IHS, which often didn’t pay for care unless someone was in immediate danger of losing life or limb.

(Courtesy of Mary Lynne Billy-Old Coyote)

(Courtesy of Mary Lynne Billy-Old Coyote)

“Now you’ve got an opportunity for American Indian people to truly have access to private insurance,” she said. “You have access to greater networks of providers and specialists, and all the things we generally don’t see you have access to.”

Medicaid expansion had a lot to do with the number of health care jobs in Montana growing by 3 percent last year, according to state statistics. And schools in Montana, including tribal colleges, are offering more classes in health care fields.

At Blackfeet Community College, 23-year-old Leroy Bearmedicine is working toward certification as an emergency medical technician.

“I’d like to become a registered nurse at some point, maybe even work my way up to flight nurse — something to get the adrenaline going,” he says.

Native American leaders have seen the Affordable Care Act as a means to remedy a series of broken promises by the federal government to care for them. They now fear that promise, too, will fade. One estimate suggests Montana will lose 3,000 health care jobs if the Affordable Care Act is repealed.

This story is part of a reporting partnership with NPR, Montana Public Radio and Kaiser Health News.

Categories: Medicaid, Public Radio Partnership, Repeal And Replace Watch, Reporting Consortium, Syndicate

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