Working from Within, in Partnership

While statewide organizations like UHCAN Ohio and national networks like UHCAN! work for change in the U.S. health care system, there is concurrent action within the present system to increase access to health care, to provide more equitable care, to achieve better health outcomes. In isolated regions and dense urban areas, public health departments and private, nonprofit community health centers reach and serve people who are uninsured or whose coverage is inadequate and/or too costly. In this issue of Update, C.William Keck, M.D., M.P.H., Director of Health for the Akron Department of Public Health, and Katherine Kuck, Deputy Director of Ohio Primary Care Association, describe the opportunities and challenges they face.

Public Health

Among other responsibilities, local public health departments are expected to assure that all persons in a community have access to the services they need, both preventive and clinical. This social justice expectation is often one of the most difficult challenges faced by public health professionals.

The particulars vary community by community, but in almost every jurisdiction one can find examples of local health department efforts to "plug holes" in the availability of health care for individuals. Common examples include so-called well baby clinics and prenatal clinics. Generally these services are narrowly targeted to respond to specific deficits, or categories, of need. Occasionally, however, health departments have offered full service primary care. In either case, these programs have usually been heavily reliant on Medicaid reimbursement to subsidize basic costs and allow services to be extended to those with no third party payment mechanism.

The recent trend to privatize Medicaid has greatly diminished fee-for-service revenue in many health departments. At the same time the number of uninsured individuals has continued to climb steadily with the result that a weakened health department illness care safety net has been faced in many communities with a growing number of uninsured.

In the absence of a national system of universal access, the only viable approach left for poorly funded public health agencies anxious to improve access is to broker existing resources by engaging a wide range of partners in a collaborative effort locally to fill existing gaps. Thus, a recent initiative of the Health Resources and Services Administration's Bureau for Primary Health Care, "100 Percent Access, O Disparities" seems promising. This ongoing campaign seeks to provide regular health care and a medical home for as many Americans as possible, while addressing ways in which states and their individual communities can help equalize health care outcomes regardless of race, ethnicity, or income.

In Akron, the health department catalogues about 30,000 visits annually for a variety of categorical child and adult health services. To expand access to care, the health department is partnering with the three major hospitals in town to develop and support Akron's new federally qualified health center. The department also participates in a large community collaborative called "Healthy Connections" which has just decided to explore the possibility of developing a "100 Percent Access, 0 Disparities" program in Summit County.

It is likely that local health department effectiveness will be judged in the future on both how well local partnerships have evolved to provide access to the broad range of needed services, and whether health status has measurably improved.

Federally Qualified Health Centers

Although grounded in the local community, each federally qualified community health center is a part of a 30 year-old nationwide system of over 900 organizations serving nearly 10 million children and adults in medically underserved areas. Ohio's 22 health center organizations in nearly 70 sites provides primary health care to about 220,000 patients.

Federally qualified community health centers throughout the country are actively engaged in "100 Percent Access, O Disparities." In Ohio, the effort is focused on Cleveland and the 29 counties of Appalachia, and is organized by the Ohio Primary Care Association (OPCA), representing community health centers and the Ohio Department of Health. The health centers are inviting community health care related groups to participate in these comprehensive projects. Cleveland has already held one meeting with the Assistant Surgeon General, Dr. Marilyn Gaston, in attendance. In that meeting, various public and private groups discussed their individual and collective efforts to address parts of the health care needs spectrum in the Cleveland area, from enrollment of children in SCHIP (Healthy Start), to a 6-county HIV/AIDS initiative, to a diabetes project in the churches.

In a related initiative called the Ohio Primary Care Campaign, the Ohio Primary Care Association is trying to encourage all Ohioans, regardless of income, to have a medical home, to adopt a health care provider whom they can trust and can visit regularly. Adults in Ohio rank very poorly in health status, and the state is beset with high rates of cardiopulmonary disease, diabetes, and cancer.

As communities collaborate to address the needs of the uninsured, there should be fewer health disparities or differences in measures, such as life expectancy, and more equivalent health care outcomes. Collaboration will mean better care for everyone and more efficient use of the total health care dollars available to a community.

(For more information, contact the Ohio primary Care Association at 614/224-1440.)

From the Director, Larry Bresler

Residents throughout the state of Ohio are facing wide ranging obstacles accessing necessary health care, many of which violate the letter or the spirit of federal law. The range of the issues and problems facing Ohioans are illustrated by the following:

• In violation of federal welfare laws, Mercer, Wood, Clermont and Lake county hospitals have turned away migrant pregnant women who are in labor. At a hospital in Lake County, a woman in labor was told as she was turned away, "You can hold on long enough to swim back."
• Some Department of Human Services caseworkers in Lucas County have told applicants seeking to apply for the Children's Health Insurance program (CHIP) that Lucas County does not have that program. (CHIP is available throughout the state and country).
• Meigs County's only hospital will close its emergency room and acute care facilities unless a four mil levy is passed. The emergency room serves predominately low income and uninsured residents.
• Across the state, patients seeking hospital care who are non-English speaking are receiving inadequate translation services in violation of federal civil rights laws.
• Families are entitled to transitional Medicaid for up to a year after leaving welfare. However, many eligible families are not remaining in the program because they have not been informed of their eligibility.
• Despite the availability of the CHIP Program, the number of children enrolled in a Medicaid Program has declined by almost 80,000. Efforts to make enrollment easier have met resistance. "making it (CHIP enrollment) too easy could also make it too expensive," explains Barbara Edwards, Medicaid director for the Ohio Department of Human Services (Plain Dealer 1/3/2000).

Many health care access issues can be successfully resolved with universal health care. However, universal health care remains a long- term goal, and even with universal health care, some of the access issues illustrated above will not be addressed.

UHCAN Ohio has been providing organizing support, giving technical assistance, and/or participating in coalitions to address health access issues. Through our Cleveland and Columbus offices we are available to support and assist other community health care access efforts. Feel free to contact us.

Work in Progress

A report on organizational activities

CLEVELAND

Cleveland Coalition works locally, statewide

In December 1998 UHCAN Ohio organized and convened a Cleveland coalition to press for a state Medicaid expansion for working poor families. The Family Health Care Coalition (at that time a counterpart to the Ohio Family Coverage Coalition in Columbus) coalesced members from labor, county government, health care providers, community, and church. The proposed expansion did not win inclusion in the 1999 biennial budget. Its defeat in the legislature pointed sharply to the need to develop sympathetic constituencies in other key areas of the state.

The coalition is now taking its first steps in building sister coalitions in targeted cities to better advocate for an inclusion of a state Medicaid expansion in the next biennial budget. At the county level, the coalition agreed to cooperate with the county commissioners in their plan to increase health care access to families up to 300 percent of poverty.

Join in the Day of Action

Following the U2K kick-off event in November, UHCAN Ohio, along with several other endorsing organizations, have been hard at work planning a Day of Action for October 15, 2000. The Sunday event will open with churches throughout the city incorporating universal health care into prayer and sermon (this on Saturday for synagogue and mosque) and will culminate with a massive rally downtown. During the rally, candidates for Congress and other political offices will be invited to commit to working for universal coverage. The hope is to develop this model into a National Day of Action, with participation from diverse coalitions in cities across the country.

If your organization or coalition would like to get involved in the Day of Action, call UHCAN Ohio at 216/241-8422 or send an e-mail to uhcanoh@apk.net.

COLUMBUS

UHCAN Ohio Tackles Lack of Dental Care

Dental care is often cited as one of the biggest unmet health needs in Columbus. And no wonder: although Franklin County, as a whole, has a patient to dentist ratio of 1,500 to 1, the Near East Side has a ratio of 20, 564 to 1, according to Ohio Health Department records cited recently in the Columbus Dispatch. Some examples of the problem:

• When tooth pain becomes unbearable, many people go to a hospital emergency room. Lacking dentists, the ER staff provides temporary pain relief, not treatment. Dental patients rack up an estimated $700-800,000 in ER charges per year.
• When screenings identify children with tooth decay, school nurses notify parents, but many children do not get treated. Two reasons: the dental clinic at Children's Hospital, a large Medicaid provider, has a three-month wait for appointments; many working parents cannot take a day off from work.
• Recently, a 15-year-old student with a broken tooth sat crying in the school nurse's office. Children's Hospital doesn't take children that old; OSU's dental clinic - listed as a safety net provider - wanted $50 cash to do an extraction, and the boy's mother only had $10. It took the nurse 2 1/2 hours on the telephone to find a dentist for the boy.

After researching the problem, UHCAN Ohio's dental committee pushed successfully for the formation of the Columbus Dental Task Force, which began meeting in spring of 1999. The task force is presently supporting two proposals to improve access to care:

1. OSU's College of Dentistry wants to establish a dental emergency room for Columbus, but they need operating funds. Two obvious sources: the hospital CEOs, whose ERs cannot heal dental patients; and OSU, which keeps the College on a tight budget that does not include funds for community dentistry.
2. A subcommittee of the task force is developing a funding proposal to buy and operate a mobile dental van which would park at elementary schools and Head Starts where screenings have identified children needing treatment. Staff would obtain informed consent from parents to treat children during the school day. After school, the van could treat families.

Together, these proposals could help many uninsured people. In the long run, however, the state and municipalities will need to spend real money increasing access to dental care for uninsured Ohioans.

Ohio Legislation Highlights

UHCAN OHIO KEEPS AN EYE ON OHIO HEALTH LEGISLATION. For more information on pending bills, either check our website or call the policy director, Cathy Levine, in our Columbus office,
(614) 253-4340. Full texts and summaries of bills are available on the state's website:
www. legislature.state.oh.us.

House Bill 53, The Mental Parity Bill, remains stuck in House Insurance Committee, by will of the Chair. The recently issued Mental Health: A Report of the Surgeon General recognizes, on the one hand, tremendous progress in treating mental illness and, on the other hand, the gaping disparities in availability of and access to mental health services. The report recommends, in part, the need to eradicate financial barriers to seeking treatment, including through enacting mental health parity in insurance coverage. Supporters of HB 53 plan to use the Surgeon General's report to educate legislators and the public. Action: contact Ohio House members about mental health parity.

SB 183, "Safety Needles" (Sen. Brady, D-Cleveland), would require the use of safe needle technology for all public employees performing procedures involving potential exposure to blood borne pathogens. Needles would either be retractable, like a pen, or self-sheathing (pulling into a sleeve to cover the needle). The bill would also create a single reporting system throughout the state.
Each year, more than 1 million needlesticks occur nationally. Over 1,000 will contract some blood borne pathogen disease such as HIV, hepatitis B, or hepatitis C. More than 100 will die.
District 1199/SEIU, which represents many health care workers, has championed this important safety legislation. The difference in the cost of safe needles and regular needles is less than the cost of a postage stamp. Bill Borwegen, Director of Safety and Health for SEIU, asked, while testifying, "Why is it that hospital CEOs can have retractable pens so that they won't get ink stains on their pockets, but health care workers can't have retractable needles to save their lives?"
Status: passed the Ohio Senate; will go to the House Health, Retirement and Aging Committee. Action: Call and write members of the House Health Committee to express views.

U2K Builds Momentum

As reported in the last issue of Update, a grassroots campaign has been initiated to place universal health care back on America's agenda, to make it a central issue in the 2000 elections and beyond.

Since its launching, U2K has drawn almost 150 national, state and local organizations endorsements. Endorsers come from 23 states and a broad spectrum of constituencies organizing to address America's health care crisis. In Ohio, 5 state and 17 local organizations have signed on to the campaign.

State and local health care justice organizations are beginning to see U2K as a way to strengthen and build the work they are already doing, to foster more durable and diverse coalitions, and to renew the national movement for universal health care. Missourians for Single-Payer Health Care featured U2K at their statewide conference. Health Care for All California are organizing around U2K to strengthen their advocacy work for State Bill 480, which requires the state to investigate alternative methods of achieving universal health care. Illinois Campaign for Better Health Care are organizing "IU2K," a statewide effort, using the U2K model as a jumping-off point.

For more information, to sign up for Health Care Justice NOW: U2K Update, a free bi-monthly fax/email newsletter, or to get involved, contact Lee Chilcote, Field Organizer, at 216/902-5577, or send an email to info@u2kcampaign.org. Visit the campaign web site at www.u2kcampaign.org -- endorsement forms are available for downloading.

Some Good News on Medicaid Coverage

The Ohio Department of Human Services announced several changes that will expand health coverage to more working families. As of July 1, 2000:

• Uninsured Children at 151% -200% federal poverty level (FPL) are eligible for Medicaid. Coverage lasts for 12 months regardless of income changes.
• Parents at or slightly above FPL can get Medicaid.
• Applying for family and children's Medicaid is easier. It can be done by mail and most information, except income and pregnancy, requires no documentation.

Much advocacy led to this victory which brings health coverage to more working families.