 Nurse Angie Diaz attends to client Nubia Rivera at Rosewood-Zaragosa Clinic photograph by Jana Birchum |
Salvation Army downtown on Eighth Street and found work in home care, those
were only temporary solutions, because Linda also arrived in Austin eight
months pregnant. She says she doesn’t have a partner or friends to help share
costs, and no health insurance. She uses South Austin Health Center, a city
public clinic, for her maternity care, and will probably have her baby at
Brackenridge Hospital. All at the taxpayers’ expense. Local taxpayers, that is.
Linda is not on welfare and not on Medicaid, she says, but she also can’t
afford to pay for her own medical care. The bulk of Linda’s costs, and the
costs of others like her, will be absorbed by the city and county 13-clinic
system under the Austin/Travis County Health & Human Services Department
(HHS). Although Linda may eventually qualify for welfare and Medicaid, since
she plans to quit work for a while and stay home with her child, she currently
falls in the “unfunded” category of the medically indigent.
She’s not alone — not even close. Almost 40% of Austin/Travis County
residents are defined as the “working poor” who are between 100%-200% of the
poverty level, and therefore do not qualify for federal assistance, yet cannot
afford health insurance. (Do you qualify? Get out your calculator. In 1996, the
feds set the poverty level at $15,600 in yearly income for a family of four.
Double that to $31,200 and you’re at 200% of poverty.) Statewide,
that portion of the population known as the working poor is growing very fast,
much faster than the categories who are eligible for federal assistance:
those over 65 years of age, or below 100% of poverty.
One former state Medicaid specialist, now a private consultant, attributes the
growth of the working poor to the state’s non-unionized work system and a
low-paying, service-based economy. Four years ago, the projected percentage of
Travis County’s unfunded clinic patients was expected to continue at 8-12%, a
normal range for “safety net” clinics and hospitals receiving Medicaid and
Medicare funds. That figure has been far exceeded. As of September this year,
more than 62% of clinic patients are designated “working poor” and don’t
qualify for federal aid.
Only a third of those, about 9,500 people, are registered under the city and
county Medical Assistance Program (MAP). With consistent primary care at the
clinics, the MAP patients can stay healthy and out of the hospital. The other
two-thirds are not so fortunate; they’re the ones who “fall through the cracks”
if funds are cut, as they are not registered with any program. Although all the
city’s services are open to them, the non-MAP clients who are not covered by
Medicare usually only come in for acute illnesses, and pay what they can at the
time of service. Normally, that’s not much — they are on a sliding scale and
only about 4% actually contribute to their medical bills; the other 96% can’t
afford to pay a dime.
Financially, there is little difference between MAP clients and the unfunded;
both groups are paid for with local tax dollars, but the non-MAP patients are
the most volatile, at-risk group, who tend to use the emergency room more than
other categories of patients. “Most of the working poor are more concerned
about putting food on the table than about taking care of their personal
illnesses,” explains Angie Diaz, a Registered Nurse who works out of the
Rosewood-Zaragosa public clinic. “Health is not their number one priority, so
they come in with a laundry list of problems, far too late to do preventive
care, and they usually end up in the hospital.”
The growth of the working poor in the Austin area, and how to continue to pay
for their health services, is at the center of the current debate over what to
do with the local public clinic system. Blame it on changes in the health care
industry toward managed care, a reformist Congress looking to cut welfare and
Medicaid funds, or on state economics, but the issue remains: Traditional
public health care practices are under the gun. The pressure on public clinics
to compete in a leaner, faster, private, managed care environment is
threatening the basic philosophy behind them — preventive, holistic health
care.
It’s true: Public clinics take too long to see patients; they’re heavy on
costly social services; patient registration is bureaucratic; there is no
follow-up in billing the self-pay (unfunded) patients; leadership in the
clinics is scattered, and what little there is, nurse-oriented and tied to the
status quo — the list goes on. As one former clinic worker noted, the clinics
just seem to run themselves — seemingly without any guidance at all. Clinic
administrators blame these problems on lack of funding; city staff and
politicians blame it on the stagnant and outmoded philosophy of public health
care. Major clinic improvements in recent years, such as time limits on patient
visits to encourage more efficiency, and the installation of a computer system
to speed up administration, have done little to alleviate the concerns of
clinic detractors who say it’s time to shake things up. The best way to do
that, according to Mayor Bruce Todd, may be to privatize, a move that
some public health care advocates say could mean the demise of services that
Austin’s working poor desperately need.
Who’s Minding the Clinics?
Because they were open to the working poor, in 1992, all 13 clinics thatHealth and Human Services (HHS) oversees in the Austin/Travis county area won
classification as Federally Qualified Health Centers (FQHCs). That designation
ensures them 100% “cost-based” Medicaid reimbursement and 60-80% “fee for
service” Medicare reimbursement. HHS actually performs over and above the
federal requirement, overseeing an additional non-FQHC site — the David Powell
AIDS clinic. The MAP program exceeds federal requirements as well. “We’re one
of the only cities with an insurance program for people under 200% poverty
level,” says Dr. Eduardo Sanchez, health authority for HHS. “We’re
looked upon not just as progressive, but as downright benevolent.”
Of the 13 FQHC sites, the city is responsible for four main clinics — East,
Northeast, Rosewood-Zaragosa, and South Austin — plus two smaller satellites
in Montopolis and far South Austin, as well as a dental clinic and a Salvation
Army clinic. The city clinics normally operate on a $15 million annual budget;
$7 million of that is self-generating revenue from Medicaid and Medicare. The
city’s general fund subsidizes the rest with an additional $5 million for the
FQHC operation, plus $3 million for MAP patient care reimbursement. The county
administers the remaining five FQHCs in the rural areas of Manor,
Pflugerville, Jonestown, Oak Hill, and Del Valle, for a total cost of about
$2.25 million annually. Federal reimbursements equal $850,000, and county
taxpayers throw in $1 million for operations and $400,000 for rural MAP patient
care. How come the county clinics cost so little? As of September, they had
just 12,209 visits, about one tenth as many as the inner-city clinics.
With so many being served in Austin, privatizing, and what may be the fallout
of such a move, has been a topic of conversation not only at city hall but also
among non-profit organizations like Family Eldercare, Inc., which networks
services for the elderly. Family Eldercare executive director Karen Langley
sponsored an emotionally-charged forum September 30 on the future of the
clinics and the privatization issue.
Asked about her main concerns should the structure or ownership of the clinics
change, Langley said she, like most of those in her organization, was
“concerned about the erosion of public health care services for Austin’s
population. The bottom line is accountability — it’s a lot easier to keep the
city council accountable than it will be a corporation.”
Currently, the four main clinics that the city oversees provide adult, dental,
pediatrics, maternity, and women’s health care, plus access to a social worker
who will refer clients to social services all over town. Most clients are seen
by nurses, but two or three resident-level doctors are available on any given
day, courtesy of the Central Texas Medical Foundation. Most clinics have an
adjacent pharmacy, a full-service lab, a WIC center (the Women with Infant
Children federal program), space for community meetings, and sometimes a
satellite office for city utilities. Since the 1970s, the focus for public
clinics has always been — not just in Austin, but nationwide — to provide the
basics of preventive care: Disease control; family planning; nutritional
education; child wellness programs and immunizations; teen pregnancy programs;
and short-term mental health counseling. Providing acute primary care developed
later over several years, as rising hospital costs forced the health department
to look at ways to prevent the flood of medically indigent patients into
Brackenridge Hospital.
Extra Services
For Those With Less
The majority of Austin/Travis County clinic users are Hispanic (50%), with thesecond highest ethnic group being African-American (20%). Almost all live in
lower-income, or severely disadvantaged, areas. With the high number of
Hispanic clients, bilingual clinic workers are a must. As important is a
commitment from all to work under sometimes difficult conditions with patients
who don’t fit into the “normal” category of managed care clients. To put it
bluntly, health care needs for people below or close to poverty are different
— and for the most part, concomitant with, their socio-economic needs.
“Working with someone with diabetes over 50 who has a career, is college
educated, and well-off, is different from caring for someone with diabetes
forcibly retired after 50, who doesn’t have marketable skills, and who has a
hard time getting food on the table,” explains HHS health authority Dr.
Sanchez. In other words, social services that may not be so important at a
private primary care outlet such as Austin Regional Clinic, are imperative at
the Rosewood-Zaragosa public clinic.
For example, nurse Diaz of Rosewood-Zaragosa tells the story of a young mother
who came in with her newborn son suffering from an earache. A typical childhood
illness, but no one could escape noticing bruises on the young mother’s face,
unmistakable signs of domestic abuse. In the examining room, the mother was
counseled by the resident social worker and referred to the Battered Women’s
Shelter. In another case, a nine-year-old was recently shot in the projects
near the clinic, and his mother, Diaz, and an APD neighborhood liaison managed
to get the family transferred to a safer home in South Austin. Then there’s the
elderly client who suffers from hypertension because his grandson is heavily
involved in gang activity; and yet another, like so many, who is illiterate and
cannot speak English. These are everyday occurrences for Diaz and the other
nurses. Certainly they are not the typical patients seen by private
organizations.
 Director of the HHS Primary Care Division, Shirley Brown photograph by Jana Birchum |
Brown, Acting Director of the Primary Care Division of HHS. And she questions
whether private providers would provide the same level of care. “We have
clients that have low literacy levels, they’re not vocal, not responsive,
living in areas with poverty and crime. Knowing those clients, we provide the
extra services. You’re not going to find somebody in the private sector — not
Seton, not St. David’s — who’s going to deal with that kind of patient. The
ones who may need STD [sexually transmitted disease] testing, counseling, and
many other services — private organizations are not going to have the network
we have. I question whether they can do it faster and cheaper. And what do we
call faster and cheaper?” she asks rhetorically.
But if the city transfers management to a private health organization, can’t
the city council demand, as a condition of the agreement, that the basics of
care now provided be maintained? “How do you define basic primary care?” asks
HHS spokesperson Dan Pickens. “The private agency will define it as narrowly as
possible to not do too much, and the city will try to define it as broadly as
possible since there are so many socio-economic issues tied up in clinic care.
We’re caught up in the health care industry changes — what we practice is
different from the medicine practiced elsewhere. If PCA says they can provide
care for 70,000 people at the clinics, for the same amount of money that the
city does for 45,000 people, I’ll go with that. But the question is, are you
making them well in terms of curing their earaches, or are you making them well
in terms of their lives? And what will happen to the unfunded in a
privatization scenario?” Pickens queries further. “Private organizations aren’t
going to want them if they can’t pay.”
“Having patients fall through the cracks has a lot to do with who owns us,”
adds HHS primary care director Brown. “We have maternal and child health, STD
programs, birth control — even if the city provides these services, they would
have to take it out and separate it, particularly if Seton takes over,” since
Seton is run by a Catholic organization. “I don’t know if I would be content
with that. My concern is that if you narrow your focus of services — if you
don’t take care of the high-risk clients — how do you keep down your rate of
pregnancies and STDs? Where would we be with the quality of care? There’s an
accountability problem.”
While it was commonly known that Brown’s predecessor, Sue Milam, who was also
the director of the entire HHS department, was an advocate for privatizing,
Brown says she is not. “I’m a patient advocate. That’s all.”
Some in the community have accused Brown and Milam (who was recruited by the
city from a private managed care organization seven years ago) of benchmarking
the clinics only with private health care organizations to make the public
clinic system appear outmoded, inefficient, and in need of privatization. Brown
admits that the department has not performed sufficient benchmarking,
explaining only that she visited several private doctors’ offices and private
clinics in the area, including Seton East and People’s Clinic. “Nothing has
been formally prepared,” she says. But she and Pickens both say that it’s
impossible to compare the Austin/Travis County clinics with other systems.
“It’s like comparing apples and oranges. First you have to look at all the
services we provide, and ask whether they do — well, they don’t,” says
Brown.
Then the question is: What is Brown, as the head of the city and county
clinics, prepared to do to keep the clinics public? “What we’re prepared to
present is: Here are the services we’re providing — this is how much it costs,
and that you can’t compare us to the private sector because they don’t have all
these services,” Brown answers. “I am prepared to do that — to separate out a
cost comparison by talking about the nutritionists and the social workers.
Under privatization, we may have a fragmented system. In order to be
comprehensive about public health care, you have to look at all the components
we offer. For example: If you don’t work with our type of clientele on their
diet regime, and a multitude of other factors in their lives, they end up in
the hospital at a higher cost to the city. We need to paint a picture of
inclusion of the services they get now — that the patients we serve are
high-risk, and that receiving the services they get will put them in better
health. How do we do that? I don’t know, we have to come up with a strategy.
That’s how we’ll sell [the idea of keeping the clinics public].”
Hung Out To Dry
But it may be that the cards are stacked against staying public. It seems theclinics have been left to weakly flounder into deep waters, perhaps
deliberately. Rose Lancaster, a member of the clinics’ oversight board, told a
Family Eldercare audience in September that she believes privatizing the
clinics has long been in the works. The evidence, she said, lies in what has
taken place under clinic administrative leadership, or lack of it.
“The clinics have suffered in the last year from an attitude on the part of
the city administration and the mayor that the clinics would be privatized,”
said Lancaster. “The administrative coordinator position [for the clinics] was
eliminated, the current director position is still filled by an acting
director, and the administration sat on that vacancy for a long time. The
medical director resigned in the spring, and that position has only been posted
this month. There’s low morale among the staff. Their ideas have been ignored
— mainly, in my opinion, because of a lack of leadership.” In the end, such
actions lead to only one conclusion, which Lancaster summed up with this
analogy: “It’s like having a rental house. You do some things to rent it, but a
whole lot more things you don’t do because you aren’t going to have it in a
while.”
If Lancaster is correct about the lack of leadership at the clinics, how much
weight do Brown and her anti-privatization rhetoric have with the council? To
quote Jack Kemp from the recent vice presidential debates, “Weakness is
provocative,” and the clinics’ weakness is a condition which has invited Seton
Medical Center, and perhaps several other health care organizations, to look at
obtaining the public clinic system as a way to improve their own competitive
positions. At least two years ago, during its negotiations with the city over
management of Brackenridge Hospital, Seton’s president, Charles Barnett,
expressed an interest in taking over the clinics — a prospect that the council
didn’t pursue at the time, given citizen acrimony over losing the public
hospital.
But Seton’s interest has not waned. In fact, if Seton doesn’t obtain the city
and county clinic system, their future in Austin’s tight market could be
extremely tenuous. Seton’s main competitor, St. David’s Hospital, gained
enormous financial strength last year, by merging with the biggest for-profit
health care chain in the nation, Columbia/HCA. Two years ago, St. David’s
purchased four primary care/urgent care cinics in Austin. “Seton needs the
clinics,” observes HHS spokesperson Dan Pickens somewhat caustically. “They
have to have them to survive. The money’s not in hospitals any more, it’s in
primary care. The insurance companies are squeezing the belt so tight on
hospital reimbursements, it’s imperative that Seton and St. David’s have a
primary care system to keep patients out of the hospital and get reimbursement
for minor acute care.”
It came as no surprise to anyone that it was Mayor Todd — the one accused of
masterminding the Brack/Seton merger — who pushed the debate to the forefront
of council business this summer. Many saw it as a further move by the mayor and
city staff to unload fiscal responsibility of public health care and hand over
the clinics to Seton, as they did Brackenridge. The mayor and city staff
publicly stress that privatizing the clinics is not the point of their efforts,
and that the city is not negotiating with Seton at this time. “Some have
predetermined that we will privatize,” says Assistant City Manager Marcia
Conner, who oversees HHS’s city operations. “That’s not necessarily how it will
end up. The options are open.”
 Assistant City Manager Marcia Conner oversees HHS’s city operations photograph by Jana Birchum |
he is not against privatization, believes that city staff is leaning heavily
towards it. “I really believe the focus has been on privatizing at the highest
levels, and the clinics have been left to hang out there with no support,” he
says. As evidence, Slusher points to Conner’s original idea of the ideal task
force to consider, among other things, selling the clinics. Conner’s version of
the task force, as presented to the council in September, included no clinic
workers, doctors, or public health care advocates. Opposition from Slusher and
others on the council forced Conner to enlarge the group to 17 members, with
more health care and community representation. (Councilmember Ronney Reynolds
preferred Conner’s original staff-heavy committee, complaining that a
citizen-led group would “run amok,” as so many of them do, he further
admonished.)
Notwithstanding Reynolds’ objections, the new formation passed. Conner has
since toed the line, and now even she says she supports the new line-up. “From
the city’s perspective, it is not a privatization task force, and I’m happy
with the proposed members,” she says. The task force will “identify systems
providing health care, examine the Medicaid and Medicare environment, the
financial impact, and the concerns about whether the county is sharing their
fair portion of the burden,” explains Conner. “They’ll be looking at several
financing options: a health authority; dedicated monies; outside management;
leasing clinics; selling clinics; and at how other systems are paying for
it.”
The task force members have not yet been appointed — the council is awaiting
approval of the group from the other governmental body in charge of the clinic
system, the Travis County Commissioners Court. Assuming county approval, the
task force will have 120 days to review clinic operations and future funding
options. This issue, and the recommendations of the task force, are almost
certain to become the battleground on which several political wars are fought
— from mayoral and council elections next year to possibly a citywide vote on
a taxing authority.
Hemorrhaging Money
HHS’s Pickens says that the question is “not whether to privatize, or not toprivatize — it’s… who’s going to pay?” Up to now, financing public health
care for the city and the county has simply been a matter of maintaining the
current level of commitment for the MAP patients out of local taxes, since
federal government programs take care of the poorest of the poor, and most of
the costs for the elderly. In fact, the city’s investment in its clinic system
has stayed flat for the last five years, despite over 20% growth in the
population and a 34% increase in clinic visits (for 1996, that’s an estimated
125,000 visits to all 13 clinics). The need is growing, but, as usual, the
monies are shrinking. HHS budget analyst Thomas Watson confirms what city staff
told the council at budget time: The health department is looking at losing $10
million over the next five years.
How did they get that figure? Watson and several top officials in the health
department point to Congress, which is likely to produce time limits and cuts
in welfare, which means that fewer people will be carried by Medicaid. Talk
about states’ rights — Texas will be responsible for the health care of
millions more of the working poor and indigent once they’re kicked off the
federal program. Anticipating this, there are bills being written this fall for
the 1997 Texas Legislative session to create a 10-district statewide health
care system. Each district — and Austin/Travis County is named as one — would
be responsible for approximately a 30-county area. Funding could come from a
variety of sources, including a district taxing authority.
Two more significant changes are in the works — the city has received about
$17 million in federal disproportionate funds annually for the past several
years because it treats a “disproportionate” share of the community’s indigent
population through Brackenridge and the clinics. City officials expect those
funds to be cut over the next year or two; Congress is also expected to
eliminate the FQHC designation that ensures Medicaid and Medicare funding, and
to cut Medicaid reimbursement from 100% to 80%, requiring recipients to produce
a co-pay for services given to them. It is unlikely, says Pickens, that
Medicaid patients, being the poorest in the community, will be able to
contribute anything for services. And since the city and county are committed
to serving patients “without regard to their ability to pay,” the losses will,
again, be absorbed by local taxpayers. In other words, he says, “the unfunded
patient population — given cuts in Medicaid, changes in welfare, and changes
in the current cost-based reimbursement system — could explode.”
“One has to ask if this is a contrived emergency or a real emergency,” he
adds. “We are losing money and sources for money. We lost $350,000 this year,
and that was with Medicaid” — which, as noted above, provides 100% cost
reimbursement. “In another three years, we’ll be on capitation [a new form of
insurance that caps reimbursement per individual, rather than per procedure, as
is currently practiced], and lose another $250,000 because of that.”
Keeping Accountability
As Mayor Todd said in a speech prior to the inauguration of new councilmembersthis June, the decision to privatize Brackenridge was “a business decision” and
the same should be considered for the clinics. In fact, when presented with the
comment that it may be in the city’s best interest — financially speaking —
to shift the burden of health care to private sector, Pickens agrees. “Yes, it
probably is in the city’s best interest to get out of the clinics.”
“But this shouldn’t come as a surprise to anyone,” Pickens adds. “We’re
finally coming full circle on a 20-year cycle. In the late Seventies, Brack was
losing money, so we transferred the MAP system to the health department because
no private doctors would see the poorest patients. We developed a series of
clinics and we took all those patients. Now the federal government has made it
possible to reimburse for those patients enough so that private companies are
interested in having them for themselves. But now with welfare reform, many of
those patients won’t be under Medicaid, and we’re back to a population of
non-paying patients who will turn to the city for help. We also have a growing
population who can’t afford insurance — the working poor.”
At the Family Eldercare meeting, Medicaid consultant DeAnn Friedholm also said
she believes the issue is far beyond privatization. “We should not get tripped
up in whether health care is private or public, but focus on what is our
commitment as a community to pay for health care for the indigent. Things are
changing too fast. You’re asking to be a dinosaur if you stick your head in the
sand and ignore what’s happening.”
“If we agree that health care is a right, our decisions will be right on,” she
said, adding that the key to success with any future public/private
partnership, or sale of the clinics, is that the city and the county stay
accountable. “As the caterpillar in Alice in Wonderland said to Alice:
What’s important is who decides.”
This article appears in November 22 • 1996 and November 22 • 1996 (Cover).