State cuts to health care for Minnesota's poorest adults means a 28-year-old diabetic may go without insulin, or a 63-year-old diabetic alcoholic with cancer goes without treatment.
"You need to put a face to who this is going to impact," Margaret Demers, North Country Regional Hospital lead social worker, told a Minnesota House panel Thursday morning about the effect of eliminating the General Assistance Medical Care program.
The 28-year-old, she said, is on two different insulins which he can't afford without GAMC coverage. Not taking insulin will lead to more serious medical problems such as organ failure, foot wounds, amputations, and leading to losing the ability to work.
The 63-year-old is short of qualifying for Medicare. "In our area, we have a significant population of chemically dependent patients who fall into the GAMC category," Demers said. "They struggle with life, their addiction and serious health problems. By its nature, chemical dependency affects their ability to function normally and as their illnesses progress, so do their medical problems."
Gov. Tim Pawlenty, as part of an effort to bridge a $3 billion budget gap between the DFL-controlled Legislature's spending bills and expected revenues for the biennium that started Wednesday, line-item vetoed funding for the GAMC program.
The program, which provides health care coverage for the state's most destitute adults, would see funding cut as of March 1 and into the second year of the biennium. Pawlenty excised about $400 million, a figure that will be $888 million in the next biennium if it is not restored.
The House Health and Human Services Policy and Oversight Committee is traveling northern Minnesota to hear from local hospitals about the affect of losing GAMC, and was in Bemidji on Thursday.
Committee Chairman Rep. Paul Thissen, DFL-Minneapolis, and Rep. Erin Murphy, DFL-St. Paul, and panel staff met with about 25 local medical and social services officials.
Demers outlined six cases of real people on GAMC. "The person may choose to not even seek treatment or not even try because they can't pay for it. We see that a lot with populations that don't have coverage. They wait until its turned into a very, very huge medical problem. They don't come in for prevention or day-to-day management."
A survey of 10 percent of about 650 GAMC enrollees served by North Country Regional Hospital shows an average age of mid-30s, from 21 to 63, said Jim Hanko, president and CEO of the parent North Country Health Services.
Of the sample, 63 percent were self-designated as American Indians who live in Bemidji or on an area reservation. Seventy-two percent were self-designated as unemployed.
"The majority of the services -- 60 percent -- were provided in the emergency department," Hanko said. "And 20 percent were in the imaging department, which is an expensive modality."
Under a fee for service program, 652 individuals had 1,033 GAMC accounts last year, Hanko said, with gross charges of $3.2 million. State reimbursements were $1.1 million while the cost to provide services was $1.7 million.
And, under the state Pre-Paid Medical Assistance Program, only 55 percent of costs is reimbursed, he said.
"We have an estimate from the state that the total impact for GAMC in our particular locality is about $4.8 million to $4.9 million," Hanko said. "That includes clinic services received by people at MeritCare and other clinics and includes the emergency department and any in-patient services."
That amount will become the uncompensated care if all the GAMC patients became patients at NCRH, mostly likely through the emergency department, he said. The emergency room then becomes the safety net for all who can't afford medical care.
Thissen said the Legislature's focus will be on the "bigger health care reform that we need to do in this state. ... We really need to focus on how we're going to help this population -- folks who are going to be with us regardless whether we're paying for them or not."
Murphy is floating around some ideas that may help, she said.
"A lot of them are poor because they're sick," she said of GAMC patients. "We know they're poor because the income standards are so low. ... A lot of them are sick and probably not able to work."
Legislators need to understand the population in order to find solutions, Murphy said, listing off pretty sick, some mentally ill, suffering from chemical dependency, chronic diseases.
"A lot of states are looking at care coordination," she said. "We keep hearing from hospitals that this population looks at the hospital as their primary care source, to come here to the emergency room because that's what they know. Is it possible for us to figure out how to deliver care in an out-patient way where the patient is, get them healthier, keep them healthier so they're not coming to the hospital in their most chronic state, and then we're incurring these large costs."
The benefits of coordinated care is savings to the system, delivery of better care, and allowing a better life for the GAMC population, she said. "To do it means we'll have to work across the system - the health care system and the social services system ... to do that kind of intensive coordination."
It was suggested that the population could be served by more urgent care or "minute clinics," but there is a lack of primary care providers. It's tough to recruit new doctors to Bemidji, as rural salaries are lower and on-call hours greater than in the metro area, said NCRH Dr. Robert Rutka.
There were discussions of starting a "minute clinic" but there aren't enough primary care physicians to staff it, he said.
State changes in credentialing are needed to allow mid-level practitioners to perform some duties now delegated to physicians or physician assistants, said Bob Verchota, NCHS vice president of human resources and ancillary services.
"From a human resources perspective, there's one thing you could do," he said, "and that is to support some changes in the licensure requirements through either the credentialing, certifying licensure, etc., to increase the capacity.
"We don't have the capacity up here from an access standpoint to even get people in if we wanted to," Verchota added. "We're sending people ... to Park Rapids and Deer River for primary care."
Some positions are fully capable of providing primary care, such as in lab, rehab or imaging, and in mid-level area alternative to physicians, he said. The problem affects all who seek medical care, not just GAMC patients, he added.
"No supply, the price goes up," Verchota said.
"It doesn't make sense to pay lower reimbursement rates to rural communities that are having the hardest time attracting doctors," said Sen. Mary Olson, DFL-Bemidji.
"We're actually seeing an outflow of nurse practitioners," Rutka said. Another problem is while MeritCare has an urgent care office, it closes at 5 p.m., with center referring patients to the hospital emergency room after about 3:30 or 4 p.m.
?We've had a net outflow of nine primary care providers in this community in the last three years," Rutka said. "I, as a family doctor, can probably take care of 92 percent of the things that come through my door."
Another problem, participants said, with the high percentage of American Indians on GAMC, U.S. Indian Health Service is not always paying for services.
Georgia Downwind of Beltrami County Human Services at Red Lake, said IHS once paid for most services, but the number of those seeking services has grown while money to pay for services hasn't, forcing partial or no payment.
And, if an Indian who lives on the reservation gets a heart attack while in Bemidji, HIS won't pay for those services, she said.
"The misperception is that Indian people in this area in the treaties that were signed 100-plus years ago the federal government guaranteed health care services to them," said Rep. John Persell, DFL-Bemidji. "That's not being provided, obviously."
It's a shortcoming of the federal government, he said. "Indian people believe, and they know because it's written on paper, we are guaranteeing health care services. That adds to the overall complexity of the situation."
Indian people have to apply for some other medical service and get denied before using HIS, which Persell said "befuddles" him.
Participants also said transportation was a problem, as many poor adults have no means to seek medical care if they live outside of Bemidji. And, some are homeless and the system can't find them after they've sought initial care.
"In many ways it isn't a problem of having people finding people, it's having them stay found," said John Pugleasa of Beltrami County Health and Human Services. Continuity of care is hard, he added. "Having this population stay found, leading to any kind of continuity, is a real challenge."
That could be helped with more affordable housing and transitional housing, he said.