Paying Doctor

Federal Insurance Program Could Aid Texas' Youth

Dr. Celia Neavel, director of adolescent health services at the People's Health Clinic

photograph by Jana Birchum

It's the first day of Thanksgiving vacation, and Travis High School students Matthew and Cheryl are going browsing at the mall -- at least, that's what they've told Cheryl's family. In fact, they have a less carefree morning planned. They catch a bus in South Austin and arrive at the People's Community Clinic, where they register Cheryl at the desk. Five weeks ago, 16-year-old Cheryl noticed that her period was overdue. When it finally came, she was still worried and talked to her friends about it. A close relative of hers had died of uterine cancer. Matthew, 18, whose father spent a career in nursing, suggested Cheryl get an examination. But Cheryl's mother, who works in a fast-food restaurant, didn't want to pay for a doctor.

So today they've taken matters into their own hands, choosing the clinic because Matthew learned from a school nurse that Cheryl could be admitted there without money up front. "At least she's seeing a doctor," Matthew says after Cheryl is called by the nurse. "At least we've done this much."

Thankfully, Cheryl is in no immediate danger and is released by the clinic physician. But the difficulty she has accessing medical attention is a serious problem shared by 1.3 million minors in Texas. Many, like Cheryl, are teenagers of working parents, ineligible for Medicaid coverage but too expensive for their parents to insure. A family must typically earn around 25% of the federal poverty level, or less than $200 per month, for children over 14 to qualify for Medicaid.

As Jane Rider, a San Angelo pediatrician, puts it: "You'd have to be eating out of a garbage can to qualify at that age."

And private health insurance for dependents, if not offered through an employer, can easily cost $250-350 per month, nearly one third of a $1,000 monthly income.

The result is that Texas has a large population of kids whose health needs are generally neglected -- who don't see a doctor regularly, have incomplete immunizations, and suffer from treatable chronic ailments which disrupt their lives.

In Austin, more than 1,600 of these teens seek help each year from the People's Community Clinic, a nonprofit provider that is a vital part of the medical safety net for the 150,000 Travis County residents who have no insurance. The People's Clinic scrapes together federal grants, physician volunteers, and sample-sized medications from drug companies to treat its 12,000 annual patients, who are typically working parents and their children.

Dr. Celia Neavel, director of adolescent health services at the clinic, says many of these parents are alienated from the medical system; they never establish a connection with a primary physician and seek only "episodic" care from emergency rooms or clinics when their kids fall ill or are injured. They tumble on and off the Medicaid rolls as they change jobs, often confused about who their provider is or for what they are eligible. Given the confusion, Neavel says, it's not surprising that teenagers, who tend to be generally healthy, are medically neglected.

"They're young, healthy people," observes Dr. Pat Crocker, director of emergency medicine at Brackenridge Hospital, "but young, healthy people do get acute minor illnesses." Crocker says teens suffering from ailments ranging from throat infections and bronchitis to common colds pass daily through the Brackenridge children's emergency room -- about one in four, he estimates, could be treated by a primary care physician, but wind up in E.R. because their families have no "medical home." According to figures provided by a hospital spokesperson, about 25% of its yearly 27,000 E.R. patients aged infant to 18 are uninsured, contributing to a total cost of $23.9 million the hospital expends each year on charity care.

"If you're poor enough to qualify for Medicaid, or wealthy enough for private insurance, every opportunity is open to you," says Crocker, "but the people in the gap are a major problem.

"One of the greatest advances in children's medicine was the expansion of Medicaid coverage to that group [infants-12] -- getting that expanded into the teenage population would reap similar benefits."

Getting teens insured has been the goal of Texas state health care officials and legislators for several years. Medically uninsured populations cost everybody money, through higher health care premiums, and through local tax dollars, as hospitals write off hundreds of millions annually providing charity care through their emergency rooms. But the Legislature has never had the willpower to appropriate matching funds that would bring in the necessary Medicaid dollars. Instead, initiatives have come from those local health care providers, often public hospital districts, who absorb the costs of indigent care. In 1995, these providers offered to fund a Medicaid waiver program which would have extended Medicaid coverage to children up to 18 in families earning up to 133% of the federal poverty level (about $1,800 a month for a family of four). The state legislature approved the plan, but the federal Health Care Financing Administration (HCFA) nixed it. The reason? The system did not give clients a choice of health care plan options: The local hospital districts who were fronting the money wanted to make sure it came back to them as sole administrators of the insurance program.

Texas might have remained at this impasse for years -- too miserly to commit to additional entitlement spending while prohibited from accepting the self-interested money of local providers -- but for a bailout through the 1997 federal Balanced Budget Act, which offers the state up to $2.5 billion to fund a new Children's Health Insurance Program (CHIP). State lawmakers were briefed on the program October 28. Through CHIP, the state can insure teens in families earning up to 200% of the poverty level, receiving nearly three federal dollars for every start-up dollar it fronts (the Medicaid match is closer to
2-1). However, the deadline for submitting a state plan could come as early as February, with lawmakers out of session.

So once again, independent funding entities are offering to foot the bill. Eight hospital districts, the University of Texas Medical Branch at Galveston, and the City of Austin have put $151 million on the table, arguing that the money saved on emergency room care will easily pay for the program. And state officials are virtually certain that HCFA will not interfere this time, because CHIP is not Medicaid spending.

The City of Austin, though not technically a hospital district, spends about $35 million on indigent health care. Through CHIP, the city believes it could reduce the costs of its medical assistance program (MAP) and the cost of sliding scale discounts offered through public clinics by transferring children onto the new, federally underwritten program. The direct savings would not be large, according to Assistant City Manager Marcia Conner, but the quality of health care for teens could dramatically improve.

Bastrop resident and People's Community Clinic employee Laura Langston is typical of the parent who could benefit from CHIP. Langston, who earns about $1,300 per month, has three children aged 11, 13, and 15, and the two youngest need regular treatment for attention deficit disorder. Langston's income is just high enough to disqualify her for Medicaid, but even if she did qualify, her oldest child would be ineligible and the other two not far away from ineligibility. Treatment for attention deficit disorder requires a series of three to four initial doctor's visits, at $70 per session, plus medicine costing $20 per child monthly, and behavioral therapy once or twice a week at $70-100 per hour. It's expensive, but critically important, Langston says. Her son, Brian, could not read at the kindergarten level when he was in second grade, but now that he gets treatment, his reading skills have risen to the eighth-grade level in only three years.

As a clinic employee, Langston has access to affordable health insurance for her children, but that's unusual for someone at her income level, she says. Friends of hers who are not so lucky rely on emergency room care, and struggle to afford routine check-ups and tests for their kids. Plus, waiting times for sliding-scale clients at the city's health clinics average about five weeks.

"In Bastrop, there's not a lot of community anything [to provide health services] -- I'm not sure what we would do without my job's insurance, truthfully. I guess [my children] wouldn't get the treatment they needed. And I think that happens a lot. People go so long with illnesses until, when they finally get to a place like this, they're really, I mean, really sick. It would be better to have preventative medicine than to wait until they're so sick."

"I think that's especially true with teenagers," adds the clinic's director of social services, Robin Rosell, "because they don't want to go in anyway, then if their families can't make it financially, they stay away."

Under CHIP, however, mothers such as Langston could enroll their teens in the insurance plan and not worry about them being taken off the rolls until age 18, even if, with a family of four, they earned up to $30,000 per year. A single parent with one child would still be able to insure that child with an income up to approximately $21,000 yearly. For the first time, family providers with solid jobs will be able to count on access to regular health care for their children until they become adults.

CHIP is a more flexible program than Medicaid, designed to let states build and manage their own systems of care. It is also a logical outgrowth of the recent federal initiative to control health care spending by delivering capitated payments -- per-patient insurance premiums -- rather than cost-based reimbursements, to Medicaid health care providers. But looser regulations equal more opportunity for large HMOs to control health care, and that's why CHIP could face opposition in Texas; it does, after all, place hundreds of thousands of clients on the service rolls of 10 major HMOs. Smaller providers who contract with those HMOs to treat CHIP enrollees may have little control over the reimbursements they receive.

Anne Dunkelberg, senior policy analyst with the Center for Public Policy Priorities, says that contracts between the funding entities and other providers have not yet been drawn up, nor have the specific services CHIP enrollees will be entitled to been spelled out. Furthermore, Dunkelberg says, the University of Texas Medical Branch at Galveston will be responsible for establishing the requisite program networks across the state, an invasion of local turf which some areas are bound to resent.

Another question is the extent to which welfare-shy Texas will actually implement CHIP. The legislature has approved extending insurance to children in families at up to 133% of the poverty level, but as one legislative spokesperson points out, it's a "big discrepancy" between that level and the 200% cap allowed through CHIP. Actually, families earning above 133% of the poverty level would have to share the cost of their insurance, paying roughly half of the $75-per-child monthly premium, so extra cost is not the concern -- rather, it's the appearance of socialized medicine.

"Everybody wants to cover more children, but I don't know if the political will is there to cover families up to 200%" of the poverty level, says another source.

Health and Human Services Commissioner Michael McKinney, whose agency will ultimately write and submit the final plan, spoke out strongly for CHIP at the Oct. 28 legislative committee hearing, estimating that the program could reach about a half-million kids.

McKinney stated that while health care coverage for uninsured children would be a worthy general revenue expenditure, he doesn't consider the additional appropriation necessary when so many local tax dollars are already being spent on charity care. "I think it's fair to say Texas taxpayers already have paid for a Texas Children's Health Insurance Program," McKinney says.

The Health and Human Services Commission says that whatever final plan is adopted, it has no intention of letting the federal money get away.

"What we want to accomplish is to insure more children -- that's what everybody wants," says spokesperson Charles Stuart. Stuart also says he hopes the roster of services CHIP provides will be "similarly rich" to those currently listed through Medicaid.

Dunkelberg says that 90% of health care advocates would probably say it is better to insure children through a Medicaid expansion, but that the current CHIP plan is better than nothing.

"I think that the system of `sole sourcing' is not the best option for families, but it is damn sure better than not having insurance for those kids," says Dunkelberg.

McKinney agrees, saying he believes the large funding entities will bargain in good faith with other providers, and that the downsides of "sole source" coverage are minimal as long as enrollees can choose their doctors. "That is where choice really matters," McKinney testified. "Not among plans, but among providers."

Local physicians say that establishing a program with preventative coverage and access to medicine will be crucial to helping teens. Pediatrician Stephen Barnett, medical director of primary care at Austin's Health and Human Services Department, says sliding scale reductions at clinics don't adequately address teens' medical needs. They need to be seen by a physician regularly to control asthma, identify sexually-transmitted diseases, and note developing problems with drugs or alcohol.

Neavel, from the People's Clinic, says that one of the most frustrating parts of providing treatment to teens is finding them affordable medicine. Her clinic relies on samples from drug companies, but the supply is not guaranteed continuous and some commonly needed but expensive drugs are not available. Neavel says that children needing medication for chronic problems such as attention deficit disorder suffer the most when parents are too poor to afford the medicine, since the disorder, untreated, may cause them to do poorly at school.

When Neavel's clinic offered sports physicals at a local high school, only one teen had a primary care physician; and 15 out of the 40 students tested failed the vision test, but had no insurance for glasses. "These are the ones who are going to see their quality of life improve," says Neavel. "When you lack insurance to cover access to primary care, you miss a lot of stuff -- preventive counseling about nutrition and pre-natal care, for example," she says.

Rick Gastelum, a nurse with 15 years experience at the children's emergency room at Brackenridge, says that a new program won't, however, be an automatic cure for children's neglected health needs.

"Funding is not the only issue when people make a decision about where to go for health care," says Gastelum. "Changing people's habits, their mindsets -- educating folks about the most appropriate source of health care -- is part of what's going to be necessary to decrease the burden on the Emergency departments.... There has to be both the opportunity and the understanding that long-term, they're going to have better health if they establish a relationship with their primary provider."

Pediatrician Rider says she recently treated a teen with pneumonia who could have been treated through outpatient care but had to be hospitalized because his mother put off bringing him in. "She's a working mom, not a charity case," says Rider. "I told her, `I won't charge you my fee. I just want you to write your legislator.'"

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