Approaching Health Care Reform with Imagination and Realism

by Ken Frisof, UHCAN Board Chair

The 2000 campaign is over. The status quo won. The big winner was big money. In most races, including the Presidential, the winner was the candidate who received the most money. Even when money doesn't determine the winner, it usually frames the issues that the candidates debate.

In 2000, health care justice was not one of those issues. The unnecessary illness and suffering of those with inadequate or transient or no health insurance received little attention from the candidates. The most hotly debated health issue of the campaign ­ prescription drugs ­ was framed as my plan vs your plan. Drug companies spent millions in campaign contributions and issue ads to prevent the debate from focusing on their profiteering excesses. When it appeared that Bush had won, their stock prices soared.

Nationally, a partisan stalemate is likely to stall meaningful legislation to expand coverage for at least the next four years.

So what are activists for health care justice to do? Just as in the era of Bush the elder, we need to focus at the state level.

We need to do so with both imagination and realism.

The majority of Ohioans, along with the majority of Americans, believe that everyone deserves access to quality care. Most patients, as well as a growing number of businesses, realize that managed care is not living up to its hype. It is neither effectively controlling costs nor improving access. The combination of health care inflation and a weakening economy will lead to renewed calls for change.

Activists have to respond to that call with imagination. We must realize that there are a number of ways to achieve justice in health care. We have to consider the pathways of change. We have to find the right small steps to take, steps that create momentum to go further, not steps that lead into dead ends.

We also have to respond with realism. With billions of dollars at stake in health care reform, the voice of the grassroots, the voice of faith, the voice of justice will not create change alone. To make meaningful change, we will have to find allies with resources, resources that will join our voices to theirs in a call for change. The health care system is crumbling, a slow crumble, not a loud crash. An increasing number of those working within it are recognizing that it meets neither their needs nor the needs of their patients. These are our potential allies. The vision of change we create has to be a joint vision, one that meets their vision of effectiveness, alongside our vision of justice.

We cannot achieve all our goals in the next four years, but if we proceed with both imagination and realism, we can be confident that health care justice will be part of the national debate in 2004.

From the Director, Larry Bresler

During the summer of 2000, UHCAN Ohio conducted two different surveys of those who are uninsured and their use of hospitals in Columbus and Cleveland. Two other articles in this issue give details on each. Full reports on both of these surveys are being issued in December. (Check the UHCAN Ohio website for a copy of the reports.)

The Columbus survey explored to what extent hospitals provide information to individuals about their free care services. It found that information about free care services was difficult to obtain.

The Cleveland survey explored the experiences of uninsured residents when using one of four Cleveland hospitals in the past year. It was part of a national survey conducted through the Access Project in Boston. The survey found that many respondents experienced problems with access and went without medications because of their inability to pay.

The survey results from both cities are consistent with national studies that have shown that one third of uninsured U.S. residents reported problems accessing care, and about two thirds had delayed care due to problems paying for health care.

In Ohio, where almost all of the hospitals are non-profit, formed for charitable purposes, there is an obligation both from statutory requirements and the hospitals' non-profit status to provide community services and benefits, including free care. Hospitals are fulfilling these obligations to varying degrees.

By and large most hospitals are strictly meeting their requirements to provide free care. However, as both the Columbus and Cleveland reports indicate, the hospitals are providing minimal information on their free care policies and are frequently providing minimal assistance.

As the hospitals are charitable institutions serving our communities, we must insist that they establish close collaborative relationships with representatives of the communities they serve. These relationships should be centered on working with the communities to do outreach to identify the unmet health care needs; to identify and provide necessary community benefits and services including free care to meet these needs; to establish collaborative appropriate community outreach so that residents are aware of the services available to them, and to develop a vehicle that provides consistent community feedback.

Our medical institutions must be held accountable to the communities they serve.

UHCAN Ohio Issues Report on Free Care in Columbus

In the summer of 2000, UHCAN Ohio's free care committee conducted a survey of the ten non-profit acute-care hospitals in Columbus. The group wanted to find out how easy it is for individuals to get information about free care. The concern was not that the hospitals aren't providing free care, but rather that hospitals do not take steps necessary to inform patients and the public that free care is available to those in need.

Free care is care provided by a hospital to low-income, uninsured people for which the hospital does not expect to be paid. Hospitals have an obligation to provide free care to low-income, uninsured people. That obligation comes from several sources, a major one being Ohio's statutory Hospital Care Assurance Program (HCAP).

Among the report's findings:

• Information about the availability of HCAP and other hospital free care programs is difficult to obtain.
• Written information about free care programs and hospital policies is not readily available or prominently displayed.
• Although all of the hospitals had at least some of the required signs describing HCAP, the signs were in English only, and they were often difficult to find, read, or understand.
• Callers were generally discouraged from applying for free care in advance of receiving services.

The report contains a set of recommendations, including:

1. Hospitals should reach out and actively seek to qualify individuals for Medicaid, HCAP, and their own free care programs.
2. Hospitals should collaborate with each other and with community members to improve access.
3. Hospitals should collect and report HCAP and free care data in a standard format.
4. The Ohio Department of Job and Family Services should expand its monitoring of the HCAP program and collect and report data on free care, by patient income, excluding hospital bad debt.

UHCAN Ohio has already met with administrators of several hospitals, all of whom indicated a willingness to collaborate with the community group on instituting improvements recommended in the report.

For more information, or for help in doing a similar survey in another community,
contact Cathy Levine, in the Columbus office.

Ohio Restoring Medicaid Coverage to 160,000 People

Following a year's work by legal services attorneys, UHCAN Ohio, and other advocates, Ohio is reinstating Medicaid for 160,000 people who lost ADC -- or cash related Medicaid during welfare reform. But the state needs help in locating many of them.

The 160,000 people include everyone who lost Medicaid between November 1, 1997, and April 30, 2000. Each person will receive 3 months of free coverage, with no strings attached, along with a short application for continuing Medicaid coverage. Those reinstated may also ask the state to pay any medical bills incurred when Medicaid stopped covering them. The temporary Medicaid cards will go out in mid-December and will be effective Jan. 1, 2001 to March 31, 2001.

The state sent out notices in late October, informing people about reinstatement. Unfortunately, nearly 40,000 have been returned, mostly for bad addresses. A large outreach effort will try to locate people eligible for reinstatement and encourage them to take advantage of this opportunity.

"This is a great opportunity to re-enroll people who lost Medicaid when they left welfare," said UHCAN Ohio policy director Cathy Levine. Good outreach will be doubly important, she noted, because many of those affected were turned off to Medicaid by welfare reform and now qualify for continued Medicaid under Ohio's new, higher eligibility levels. "It will take a grassroots effort, by community organizations and social service agencies, to find and enroll eligible people."

For more information on reinstatement, or for assistance in doing outreach, call Cathy Levine, at (614) 253-4340.

Uninsured Surveyed on Hospital Care

UHCAN Ohio, along with the Access Project of the Robert Wood Johnson Foundation, has completed a survey and issued a report on the experiences of uninsured patients who have received services at four Cleveland area hospitals over the past year. This was part of a twenty-four-site project carried out across the country to document the experiences of the uninsured in seeking care at hospitals and health clinics. UHCAN Ohio staff members are meeting with administrators at Huron, MetroHealth, Cleveland Clinic and University Hospitals to discuss the results and means by which services for the uninsured can be improved. We plan to release the results publicly by the end of the year. In the meantime, here are some highlights from the report:

-- Almost all of the 680 uninsured patients we surveyed had used an emergency room at least once in the past year. This suggests that uninsured Clevelanders may not be using other service settings (such as outpatient clinics) at these hospitals for receiving care.

-- Overall, the majority of respondents from all hospitals were either satisfied or very satisfied with providers at their facilities.

-- Most respondents experienced high levels of financial stress when trying to pay for their medical care, and many did not receive assistance from staff at their facilities in dealing with their financial issues.

-- At three of the four hospitals, substantial proportions of respondents reported that they did not obtain any -- or filled only some -- of their prescribed medications because they could not afford them.

-- Sixty to 70 percent of respondents from each hospital said they owed money to the hospital.

Other major problems reported by respondents included waiting times to get appointments, waiting times to see a doctor on the day of their visit, and transportation issues.

Event Launches Legislative Action

In mid-October, some 300 people rallied for universal health care during the Day of Action held at Pilgrim United Church of Christ in Cleveland. The event, coordinated by UHCAN Ohio, and part of the national Universal Health Care 2000 Campaign, drew several candidates for congressional and state office and sizeable representation from labor, faith and community groups. The candidates declared the need for universal health care and publicly pledged to work for it if elected. Members of various constituencies also signed a community pledge, committing themselves and their members to ongoing work for comprehensive, quality, affordable, and publicly accountable health care for all, at both the national and state level.

Of those candidates who pledged to work for health care for all, the following were elected: To Congress - - Ted Strictland (D, 6th District), Dennis Kucinich (D, 10th District), Stephanie Tubbs Jones (D, 11th District), Sherrod Brown (D, 13th District), Deborah Pryce (R, 15th District), James Traficant, Jr. (D, 17th District); to the Ohio State Legislature -- Claudette Woodard (D, 9th District), Peter Lawson Jones (D, 11th District), Mary Rose Oakar (D, 13th District), Erin Sullivan (D, 18th District), Dale Miller (D, 19th District).

UHCAN Ohio is following up with a post-election strategy that includes expanding the base of legislative support for universal health care as well as working with those legislators already on board around targeted issues.

Doctor's Input Sought

In Cleveland, UHCAN Ohio provides staffing support to Project HEAL, a council of Medicaid managed care consumers. Project HEAL is preparing a survey of primary care physicians on the panels of QualChoice and Renaissance (formerly Emerald), both Medicaid HMOs. Doctors will be asked to rate these local Medicaid HMOs on such factors as adequate and timely reimbursements, support of quality care and administration of benefits.

Project HEAL previously designed and administered a survey to Medicaid consumers and is using the findings to negotiate with the HMOs as well as sharing the information with state and county governments. This new survey will give doctors an opportunity to weigh in with their experiences and concerns and to influence the outcome of the request for waiver Ohio has requested from the U.S. Department of Health and Human Services to continue to mandate managed care for most Medicaid consumers in Ohio's urban counties.

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 578 (Rep. Dale Miller) would extend time limits for welfare recipients from three years to five years. Current time limits are sending people out into the workforce before completing education and job training necessary to support a family. Especially devastated are new immigrants, who face cultural, language and educational barriers to employment.

Status: Sponsor testimony took place on November 28, 2000. Direct correspondence on the bill to members of the Finance and Appropriations committee, especially vice-chair, Rep. E.J. Thomas.