Modern Healthcare - - NEWS - By Har­ris Meyer

CEDAR RAPIDS, Iowa—The spa­cious wait­ing room at the Com­mu­nity Health Free Clinic is two-thirds full, and CEO Dar­lene Sch­midt and her team of vol­un­teer and staff providers have a lot of pa­tient prob­lems to solve be­fore noon, when the clinic closes.

Sch­midt, a nurse who co-founded this clinic in 2002 in Iowa’s sec­ond­largest city, scur­ries from one hall­way hud­dle to an­other with the doc­tors, nurses and phar­macy staff.

Even with the Af­ford­able Care Act’s pri­vate in­sur­ance and Med­i­caid ex­pan­sions in Iowa—which she calls “an ab­so­lute bless­ing”—she is con­stantly schem­ing to get pa­tients ac­cess to af­ford­able treat­ment and pre­scrip­tion drugs. She works closely with the city’s two hospi­tals, Mercy Med­i­cal Cen­ter and St. Luke’s Hos­pi­tal, and with the East­ern Iowa Health Cen­ter, a fed­er­ally qual­i­fied com­mu­nity health cen­ter, to ar­range ser­vices for her pa­tients, most of whom are unin­sured, wait­ing to be in­sured, or un­der­in­sured.

While the clinic was scram­bling to fill th­ese gaps, a non­stop pro­ces­sion of pres­i­den­tial can­di­dates trooped



Dar­lene Sch­midt, CEO Com­mu­nity Health Free Clinic

through Cedar Rapids this month try­ing to win over vot­ers ahead of the Feb. 1 Iowa cau­cuses, the first-in-the-na­tion pri­mary con­test. But there has been a big dis­con­nect be­tween this city’s—and the na­tion’s—com­plex health­care re­al­i­ties and the can­di­dates’ rhetoric.

The Repub­li­can hope­fuls who came here, in­clud­ing Florida Sen. Marco Ru­bio, men­tioned health­care just long enough to call for re­peal of the ACA. In con­trast, the Democrats, in­clud­ing Hil­lary Clin­ton and her hus­band, Bill, warned that elect­ing a Repub­li­can pres­i­dent would kill af­ford­able health­care. Hil­lary Clin­ton promised to “fix” the ACA with mea­sures to make care and drugs more af­ford­able, while at­tack­ing the govern­ment sin­gle-payer pro­posal by her ri­val, Ver­mont Sen. Bernie San­ders, who has surged in the polls here.

The Repub­li­cans “have no clue what they’ll re­place the Af­ford­able Care Act with,” said for­mer Pres­i­dent Clin­ton, cam­paign­ing for his wife at a lo­cal mu­seum. “Do we need to do more work on it? Yeah. But should we scrap it? No.”

Repub­li­cans are less spe­cific be­cause “right now, health­care is more of a sym­bolic is­sue—be­ing against Oba­macare and ril­ing up the base,” said Dou­glas Gross, a Des Moines at­tor­ney who headed Repub­li­can Mitt Rom­ney’s Iowa pres­i­den­tial cam­paign in 2008. “One of the lessons they learned from Rom­ney is don’t of­fer your own plan be­cause it may come back to bite you. But in the gen­eral elec­tion, you’ll have to have a cred­i­ble al­ter­na­tive to Oba­macare if you want to re­peal it.”

Political ob­servers say health­care won’t be the top is­sue for most Iowa cau­cus­go­ers when they gather to pick their re­spec­tive party nom­i­nees. But sharply clash­ing views about Oba­macare are help­ing shape the cli­mate, con­ver­sa­tions with health­care providers and vot­ers in Cedar Rapids sug­gest.

Providers say more de­tailed dis­cus­sion of health­care is­sues is badly needed, in­clud­ing how to fill the ACA cov­er­age gaps, re­duce drug costs and boost ac­cess to men­tal health ser­vices. One health­care leader shrugged off the politi­cians’ light­weight health­care talk. “We’ll hear in­ter­est­ing con­ver­sa­tions when the pri­maries are over,” pre­dicted Tim Charles, CEO of Mer­cyCare Ser­vice Corp., which op­er­ates the in­de­pen­dent Mercy Med­i­cal Cen­ter.

Other health­care ex­ec­u­tives are more anx­ious about the re­peal pledges. “There are pieces of the ACA that we know aren’t per­fect, and we’d like to see some mod­i­fi­ca­tions,” said Sabra Rosener, vice pres­i­dent of govern­ment re­la­tions at Uni­tyPoint Health, which op­er­ates St. Luke’s and 16 other hospi­tals in Iowa, Illinois and Wis­con­sin. “But full-scale re­peal? We have made so many changes in how we de­liver care and our IT sys­tem, I don’t know how it would even be pos­si­ble to un­roll it and not have com­plete chaos.” One health­care is­sue that has gained political trac­tion in Iowa is Repub­li­can Gov. Terry Branstad’s push to rapidly move 560,000 Med­i­caid ben­e­fi­cia­ries, in­clud­ing those with se­vere dis­abil­i­ties, into pri­vate man­aged­care plans. The Obama ad­min­is­tra­tion re­cently de­layed that con­tro­ver­sial con­ver­sion from Jan. 1 to March 1. Branstad prom­ises the new pro­gram will im­prove care and save money, though many say Iowa al­ready has one of the best-run Med­i­caid pro­grams in the coun­try.

Many providers, in­clud­ing Mercy Med­i­cal Cen­ter, have not yet signed con­tracts with any of the three con­tract­ing Med­i­caid plans. Ben­e­fi­cia­ries have had a hard time get­ting in­for­ma­tion on what providers are in the plan net­works. “It’s just been a mess,” said Demo­cratic state Sen. Rob Hogg of Cedar Rapids, who’s seek­ing to chal­lenge Repub­li­can U.S. Sen. Chuck Grass­ley in the Novem­ber elec­tion. The plans did not re­spond to re­quests for com­ment by dead­line.

Hil­lary Clin­ton has sought to make the gov­er­nor’s Med­i­caid pri­va­ti­za­tion a cam­paign is­sue, warn­ing that it could mean a cut in ser­vices. “She’s us­ing the is­sue quite ef­fec­tively with the Demo­cratic base to drive a wedge,” said Repub­li­can at­tor­ney Gross.

Iowa, which voted for Obama in 2008 and 2012, has a mixed ACA track record. Branstad pushed through a cus­tom­ized Med­i­caid ex­pan­sion with ben­e­fi­ciary pre­mium con­tri­bu­tions, which started in 2014. The state’s unin­sured rate, which was a rel­a­tively low 9.7% in 2013, dropped to 5% in the first half of 2013, ac­cord­ing to Gallup. Both Cedar Rapids hospi­tals say the ACA cov­er­age ex­pan­sions have im­proved their bot­tom lines by re­duc­ing un­com­pen­sated-care costs.

But nearly 200,000 Iowans re­main unin­sured, with 47% el­i­gi­ble for Med­i­caid and 16% el­i­gi­ble for ex­change sub­si­dies, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion. One fac­tor that may have lim­ited the law’s im­pact was the de­ci­sion by Well­mark Blue Cross and Blue Shield, the state’s dom­i­nant in­di­vid­ual-mar­ket in­surer, not to par­tic­i­pate in the fed­er­ally run in­sur­ance ex­change dur­ing its first three years, though Well­mark has agreed to sell on the ex­change in 2017. An­other is­sue is that the state let in­sur­ers keep sell­ing plans that don’t com­ply with the ACA, though that ends this com­ing fall.

Then there was the fi­nan­cial col­lapse in late 2014 of CoOp­por­tu­nity Health, an ACA-funded not-for-profit in­surer, which forced thou­sands of Iowans to switch plans. More re­cently, av­er­age pre­mi­ums for Iowa


Tim Charles CEO Mer­cyCare Ser­vice Corp.

ex­change plans for 2016 jumped by dou­ble-digit per­cent­ages. All this strength­ened the ar­gu­ments of Oba­macare op­po­nents that the re­formed mar­ket is un­sus­tain­able.

At the Com­mu­nity Health Free Clinic, Sch­midt and her team deal with the ACA’s im­per­fec­tions ev­ery day. They of­ten have to help in­sured pa­tients with their high de­ductibles and other cost-shar­ing and fi­na­gle to get Med­i­caid pa­tients into pri­vate providers for tests, spe­cialty care and pro­ce­dures. On the day Mod­ern Health­care vis­ited the clinic, Sch­midt au­tho­rized an $80 pay­ment to cover a pa­tient’s co­pay so she could see a rheuma­tol­o­gist.

For unin­sured pa­tients, the goal is to get them signed up for an ACA ex­change plan or Med­i­caid. The clinic’s en­roll­ment coun­selors helped Jack Fligor of nearby Hi­awatha ap­ply for Med­i­caid last month. While he waits for an el­i­gi­bil­ity de­ci­sion, he’s vis­it­ing the clinic to pick up in­sulin for his di­a­betes, with no charge. “If I won the lot­tery, I’d do­nate a ton of money to this place,” he said.

But other pa­tients fall into the law’s cracks. Dr. David Rater, a re­tired car­di­ol­o­gist who vol­un­teers ev­ery Wed­nes­day at the clinic, walks into Sch­midt’s of­fice to dis­cuss how to ar­range surgery for a young Su­danese woman with a pos­si­ble ma­lig­nancy on her neck. She’s a le­gal im­mi­grant but has to wait five years to qual­ify for Med­i­caid. Sch­midt will have to pull strings at the hospi­tals to get the woman in for an op­er­a­tion. Rater says he wishes the U.S. had a na­tional health sys­tem like Canada’s that guar­an­tees care for ev­ery­one.

A con­stant chal­lenge is that the hospi­tals and doc­tors’ of­fices in town are putting Med­i­caid pa­tients on wait­ing lists. At the East­ern Iowa Health Cen­ter, which can’t turn any­one away, CEO Joe Lock said his per­cent­age of pa­tients on Med­i­caid has soared to nearly 80% be­cause pri­vate providers are cap­ping the num­ber of new Med­i­caid pa­tients they’ll take.

Uni­tyPoint’s pri­mary-care clinic in Cedar Rapids gets up to 20 calls a day from Med­i­caid ben­e­fi­cia­ries seek­ing ap­point­ments. Dr. Clete Younger said two of the doc­tors there are “com­pletely full” while he and an­other doc­tor are ac­cept­ing new Med­i­caid pa­tients only on a lim­ited ba­sis.

Lo­cals have dif­fer­ent re­ac­tions to the ACA’s im­per­fec­tions and to the vis­it­ing can­di­dates’ rhetoric about Oba­macare. Shel­ley Sul­lens, a bed-and-break­fast op­er­a­tor who lost her in­sur­ance two years ago when her hus­band was laid off, hates the law. She and her hus­band bought an ex­change plan with a sub­sidy in 2014. But she thought the pre­mium was too high and didn’t like tak­ing govern­ment help. They switched to a faith-based, health­care cost-shar­ing plan.

Sul­lens says she’s glad to be out of Oba­macare be­cause her pre­mium dol­lars are no longer be­ing used to pay for abor­tions or “prison in­mates’ sex-change op­er­a­tions.” She plans to at­tend a GOP cau­cus, though she doesn’t yet know which can­di­date she will sup­port, and the ACA will play a role in her think­ing.

In con­trast, Roger Hen­ley, a re­tired cor­po­rate pur­chas­ing di­rec­tor who vol­un­teers at the free clinic as a Med­i­caid en­roll­ment coun­selor, said the law helped many peo­ple he sees who lost jobs, work at low-wage jobs with­out in­sur­ance, or have a se­ri­ous med­i­cal con­di­tion and can’t work. And it’s helped him per­son­ally.

Though he’s on Medi­care, his wife, who is younger, pre­vi­ously couldn’t get in­sur­ance be­cause of a se­ri­ous med­i­cal con­di­tion and had to go into the state’s high-risk pool, where the cov­er­age was ex­pen­sive and not very good. Un­der the ACA, she was able to buy com­pre­hen­sive, high-qual­ity pri­vate cov­er­age. “That’s made a huge dif­fer­ence, and it’s made a dif­fer­ence for me po­lit­i­cally,” he said. “The ACA isn’t per­fect, but it’s a real good start.”

Some of the grass-roots hos­til­ity to­ward the ACA is be­ing stoked by em­ploy­ers, said Tom Hoff­mann, ex­ec­u­tive vice pres­i­dent of Ben­e­fit So­lu­tions, an em­ployee-ben­e­fits con­sult­ing firm in Cedar Rapids. “Em­ploy­ers are us­ing stri­dent rhetoric and telling their em­ploy­ees, ‘Your pre­mi­ums are go­ing up be­cause of Oba­macare, which you voted for in the last elec­tion,’ ” he said.

Sch­midt, who keeps a pic­ture of Mother Teresa on her of­fice wall, sup­ports the law be­cause it has helped her pa­tients es­tab­lish a med­i­cal home for man­ag­ing their chronic con­di­tions. It’s also re­duced her clinic’s an­nual pa­tient vol­ume from 15,000 to 7,000. To her cha­grin, some of her pa­tients say they hate Oba­macare and refuse to sign up for cov­er­age, and then they seek free care at her clinic. “It’s frus­trat­ing to get a few of those pa­tients, but it’s not our place to judge,” she said.

She de­clines to dis­cuss how the out­come of the pres­i­den­tial elec­tion could af­fect health­care, say­ing she never talks pol­i­tics be­cause it could alien­ate her more con­ser­va­tive med­i­cal vol­un­teers. She did, how­ever, at­tend that week’s Hil­lary Clin­ton speech and praised the can­di­date’s warmth and knowl­edge on the is­sues.

Sch­midt is in­ter­rupted by a col­league seek­ing help in ob­tain­ing a de­pres­sion med­i­ca­tion for a pa­tient who’s sched­uled for surgery in a few days and got bumped off Med­i­caid. Re­turn­ing to the elec­tion ques­tion, she won­ders how her com­mu­nity could deal with all the health­care ac­cess prob­lems if the ACA were re­pealed. Still, she says, no mat­ter who’s elected, “There will al­ways be a need for a free clinic, be­cause the poor will al­ways be with us.”


Jack Fligor, pa­tient at the Com­mu­nity Health Free Clinic




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