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Health Care for the Uninsured

Mulling changes for uninsured care, Palm Beach County studies South Florida neighbors
By Phil Galewitz, Palm Beach Post Staff Writer
Sunday, July 24, 2005

As state and federal efforts to reduce the number of Americans without health insurance lag, the burden has fallen to cities and counties to tackle the growing problem that prevents millions of people from getting timely medical care.

No Health Insurance

South Florida has the largest concentration of people under 65 without health insurance in the state.

Miami-Dade 28.7%
Broward 18.4%
Palm Beach 18.9%
Treasure Coast 18.4%
Duval 13.7%
Hillsborough 14.1%
Alachua 17.1%
Polk 17.8%
Florida 19.2%

Source: Florida Health Insurance Study

In Florida, as in most states, communities typically take care of the uninsured at hospital emergency rooms and a mishmash of free clinics. But a handful of Florida counties, including Palm Beach, have programs and funding dedicated to health care for the uninsured.

Palm Beach County health leaders have been working for more than a year to devise a more coordinated health system for the uninsured, including studying how other communities address the dilemma. Two of the more interesting strategies are being used in Miami-Dade and Broward counties.

Residents in Palm Beach, Broward and Miami-Dade all pay taxes to help fund medical services for the uninsured. By contrast, most Florida counties don't have a sustainable funding source for those without health insurance. Using money collected from a portion of its property tax, Palm Beach County provides health coverage to about 22,000 of its more than 150,000 uninsured residents.

How the three South Florida counties — which account for about one-third of the state's population — use their local tax dollars for the uninsured varies significantly. Miami-Dade targets all its public dollars to county-owned Jackson Health System, while the North Broward Hospital District spreads its property tax dollars to four public hospitals and numerous outpatient clinics.

The Palm Beach County Health Care District has the least centralized program, using property-tax dollars to run a managed-care program in which uninsured residents can choose from any of 13 hospitals in the county and more than 150 doctors.

No program is a silver bullet. Miami-Dade County has long had the highest uninsured rate in the state. Last year, nearly 29 percent of Miami-Dade residents were uninsured, compared with about 18 percent in Broward County, nearly 19 percent in Palm Beach County and 19.2 percent statewide.

But R. Paul Duncan, a health policy expert at the University of Florida, said if not for the community efforts, the problem of the uninsured would be worse. "These local initiatives have helped to suppress at least slightly the growth in the uninsured," he said.

Miami-Dade

OPA-LOCKA — Just off a busy road in northern Miami-Dade County, the Jackson Health System's North Dade Health Center is nearly hidden under a canopy of oak and banyan trees.

The parking lot is jammed on a recent morning, as it is most days. Inside, the hallways are filled with people waiting to see doctors, refill prescriptions and visit the dentist.

Karen Malcom, 49, who lives up the street, is here to meet with a dietitian and learn how to use the new blood-glucose meter the center gave her to monitor her diabetes. A part-time limousine driver, she has no health benefits.

Patients who qualify for Jackson's charity care program, which is supported by a half-cent sales tax and property-tax dollars, pay on a sliding scale. Malcom is poor enough that she pays nothing.

"This is the only place I can go," she said.

Opened in 1918, Jackson is the main hospital in the county for the uninsured and the only to receive local tax dollars.

The hospital gave away about $471 million in medical care last year to uninsured patients. Jackson received $277 million from local taxes. The shortfall was partly offset by money Jackson makes caring for insured patients. As a result, Jackson lost about $120 million in 2004. It subsequently had to lay off more than 100 workers and cut hundreds more positions through attrition.

Jackson doesn't give a detailed accounting of how it spends its tax dollars, which are lumped in with the hospital system's $1.5 billion budget. That troubles critics, who argue Jackson isn't accountable enough.

With 1,567 beds, Jackson Memorial Hospital is one of the largest hospitals in the country. But on any given day, patients are still stacked up in the downtown Miami hospital's large emergency room. To help improve patients' access to primary care, Jackson has 13 primary-care clinics across Miami-Dade County that treated an estimated 170,000 patients last year. Half the patients are uninsured.

Jackson Health System offers free or discounted care to people with incomes below 200 percent of the federal poverty level, or $37,000 for a family of four. Those with incomes under the poverty level pay $5 per drug, nothing for a clinicvisit and nothing for routine lab tests and X-rays. Those making twice the poverty level pay $15 per drug and up to $55 for an office visit or medical tests.

Dr. Cheryl Holder, medical director of the North Dade Health Center, said most of the uninsured have multiple health conditions.

"They are living with the long-term complications of chronic illnesses that have not been well-managed," Holder said.

But Jackson Memorial is a magnet for criticism from other hospitals who say it's unfair that all local tax dollars go to one hospital to treat the uninsured although the uninsured go to all the hospitals in the county — albeit mostly to Jackson.

James Pelton, South Florida's top executive for HCA Inc., which runs six hospitals in Miami-Dade County, said the problem with redistributing tax dollars away from Jackson to other area hospitals is that it would probably cause Jackson to go bankrupt.

"The tax dollars should follow the patient, but in Miami-Dade there's just not enough dollars to go around," he said.

Joe Rogers, a Jackson spokesman, says having all the county's uninsured residents in one health system is cost-effective because Jackson can better reduce costs and reduce duplication of health services. With its ties to University of Miami Medical School and its many specialists, Jackson attempts to attract enough insured patients to subsidize care to the uninsured.

But that hasn't been enough. Jackson Health System expects to lose $25 million this year.

Broward

FORT LAUDERDALE — On the outskirts of downtown Fort Lauderdale sits the Seventh Avenue Family Health Center. It's a modern three-story building where Broward County's uninsured flock for medical care each weekday.

On most mornings, the parking lot is full and food vendors set up shop outside to feed the visitors. The center is open 15 hours a day to provide primary and specialty medical care to about 125 adults and 50 children, as well as fill about 800 prescriptions a day from its pharmacy.

The Seventh Avenue center is one of eight primary-care centers along with 25 outpatient centers run by the North Broward Hospital District. The district runs four hospitals in Broward County and provides health care to poor people living between Hollywood and the Palm Beach County line.

Supported by a portion of the county's property tax, the hospital district provides free or discounted care to county residents with incomes below 200 percent of the poverty level.

Last year, the district took in $175 million in tax revenue and treated about 93,600 uninsured patients, including 33,000 at its outpatient clinics. In the fiscal year ended last June, the district made a $19.7 million profit on $736 million in revenue.

On a recent morning at the Seventh Avenue center, Gregory Clarke, 58, waited to see a doctor in the crowded clinic. It was his second visit in six months. He enrolled in the health district's charity care program after suffering a heart attack a year ago.

"This program is a godsend," said Clarke, who lost his insurance when he quit his job as a telecommunications analyst. Through the district, he pays nothing to see a cardiologist, get a checkup from a family doctor and obtain five prescriptions a month. Without the district's help, he would have to pay $400 a month just for the drugs.

Monica McCullars, 47, of Lauderhill said she was disqualified from Medicaid two years ago and has used the district's health program since. Despite having to wait three weeks for an appointment and another hour once she arrived at the Seventh Avenue center, she still praises the program that enables her to get treatment for her heart condition and lets her get nine different medications for $67 a month.

"You have nothing to complain about," she said. "This is just as good as insurance."

Jasmin Shirley, a vice president with the health district, said the district's health centers provide more preventive services, such as smoking-cessation classes, than offered in most private physician offices. "We want people to establish a medical home here," she said.

The district also offers patients with chronic diseases a case manager to help them schedule doctor appointments and teach them how to stay healthy.

"Our patients have so many obstacles; they are usually uneducated, have difficulty with transportation, and many don't understand the health-care system," said Dr. Anna Hayden, a family doctor at a district clinic.

North Broward's hospital district gets complaints about patients having to wait too long to get doctors' appointments, forcing some to go to local hospital emergency rooms for care.

By expanding their clinics, North Broward officials say they are succeeding in keeping uninsured people from making unnecessary visits to hospitals.

"Our system is working as designed," said Mark Knight, the hospital district's chief financial officer.

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