Healthcare Safety Net

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As Arizona contemplates removing 280,000 people from its Medicaid rolls, we’ll take a look at the state’s health care safety net and whether or not it’s prepared for the additional caseload.

Ted Simons: Record-setting job losses in recent years have placed a tremendous strain on Arizona's healthcare safety net, which is a loosely connected web of public and private health centers, clinics and hospitals that care for uninsured and under-insured Arizonans. That safety net will be tested once again if 250,000 people lose their Medicaid eligibility due to state budget cuts. More on that in a moment, but first, David Majure shows us one piece of Arizona's healthcare puzzle.

Narrator: Mountain park health center is a community health center with five valley locations serving about 54,000 people. This location near baseline road in south Phoenix is its largest. Caring for about 25,000 patients. As a federally funded health center, Mountain Park provides health coverage for those with private insurance, government insurance or no insurance whatever.

>> Actually this is generic medication.

Narrator: Uninsured patients pay what they can afford on a sliding scale based on their income. There are more than 120 community health centers throughout Arizona, most located in poor and under-served communities. They're all a vital part of Arizona's healthcare safety net.

Ted Simons: Here now to talk about Arizona's healthcare safety net is Dr. John Swagert, CEO of mountain park health center. Which we just saw in the last video. Janice Ertl, director of St. Vincent de Paul's Virginia G. Piper Medical and dental clinic. And Dr. Nicholas Vasquez from the Arizona college of Emergency Physicians. Good to see you all here, thanks for joining us.

Nicholas Vasquez: Thank you.

Ted Simons: John we'll start with you. We just saw what your operation deals with. Give a cursory definition of a healthcare safety net.

John Swagert: We try at mountain park to provide a primary care home that patients can get all of their medical needs met in one place. Without having to bounce in and out of emergency rooms because that's really the only other available healthcare for people who don't have insurance.

Ted Simons: How coordinated is the healthcare safety net here in Maricopa County and in Arizona in general?

Janice Ertl: Well, I think that's what we were kind of talking about. We think there's really no true safety net here in Arizona or maybe in the whole United States, I'm not sure.

Nicholas Vasquez: Yeah.

Janice Ertl: Yeah

Nicholas Vasquez: We were discussing it before, when you say safety net or healthcare system, it implies a level of coordination or a level of oversight. Or even a level of information sharing. And that just doesn't exist. Really, healthcare is really a mall of independent businesses that all select which market they want to play in. The people you have around this table are some businesses that get support either from public entities or private charities to take care of people who can't pay for the products otherwise. But really, it's much more like independent businesses than a coordinated safety net or healthcare system.

Ted Simons: Is it a lack of coordination that there are possible ways to fix this? Is it just the wild west out there? How do you survive? What kind of cooperation do you get?

Janice Ertl: Well, you know, we're a charity, and we're very fortunate because we -- there's a number of people in this community who volunteer their services. Physicians and clinicians who volunteer their services so we're able to get people in quicker, but yet as a charity, we can't take care of people for their whole lives. So we try and educate and stabilize them and keep them on for nine to 12 months and then move them to a community health center at some point in time.

Ted Simons: Talk about what you see on a day-to-day basis. Again, what I'm hearing now seems to be a lack of coordination in the safety net.

John Swagert: I disagree there's no safety net. I think Mountain Park provides a safety net. The problem is it's not scaled to the level of the problem. Maricopa County has something like 600,000 uninsured people and we can take care of 50,000 and coordinate their care. We just don't have resources to expand that to all 600,000 people.

Ted Simons: What are you seeing on a day-to-basis, from the underinsured and uninsured?

Nicholas Vasquez: Mostly what we see are insured. Most of the patients who come to emergency rooms are people who have insurance and have a doctor but couldn't get in. It's really much more people are voting with their feet and looking for convenient, accessible care rather than waiting to go elsewhere. Many times, specialists are three months out or six weeks out. And if you get a cold or backache or toothache, whatever, the normal randomness of life, you want someone to take care of you now. If it's get it now versus waiting six weeks, most are choosing now.

Ted Simons: Is that what you're seeing as well as far as a day-to-day basis?

Janice Ertl: We've been taking care of the uninsured working poor and new we're seeing the lost my job, lost my insurance folks. $240 a week in unemployment doesn't go far. And we're seeing the kids who are no longer eligible for kids care and poor kids without insurance. And there's been a mental health cut and we're seeing those folks too. But we're seeing much sicker patients now than we saw three or four years ago. Much sicker. People are waiting way too long sometimes to get healthcare.

Ted Simons: Is that what you're seeing as well?

John Swagert: Certainly we are. It's a -- it's a problem that -- that, especially exacerbated by the economy where so many people have had to slide into sliding fee scale and our clinics and they wait too long and go in and out of emergency rooms.

Nicholas Vasquez: It's not just the uninsured. I don't want to sound cynical but really a lot of insurance companies, who I'm not going to vilify, but they've offered lower priced policies that include a high deductible, 2,000, 5,000, 10,000, something where people get to pay that deductible at the beginning of the year. You have to choose whether you want to spend that money on your medical care and it definitely decreases demand and makes people choose to wait. Sometimes they choose wisely and sometimes they don't.

Ted Simons: If that's the present scenario, what do you see, what are your thoughts on proposed Medicaid cuts here in Arizona?

Janice Ertl: I think we're doing what we can. I mean, we all understand the fact that the budget needs to be cut. It's just that we don't always -- we're not always sure that our elected officials are not just targeting the weak target, such as the poor.
John Swagert: I think in many ways, we're offered a false choice. People don't stop getting sick because we decide to stop covering their healthcare costs. We still see people getting sick they just go to the emergency room instead of going to a doctor's office where the cost would be less so the cost of these illnesses is just transferred instead of through Medicaid or AHCCCS, it's transferred through the rest of us through higher insurance premiums.

Ted Simons: Where will these people go?

Nicholas Vasquez: The only place that they're guaranteed access to care is an emergency room. There are a lot of well intentioned altruistic people who work hard to take care of people. They're just overwhelmed. The emergency rooms aren't an endless supply of care. They have to maintain profitability. I hate to use the word profitability, but that's what a hospital looks at and if a hospital starts being exposed to a lot of uncompensated care, they have and will close emergency departments.

Ted Simons: From the other angle here and what we hear on this show, when we have lawmakers here and what they'll say that there are lots of ways for these folks who wind up getting reduced -- cut off from the Medicaid rolls. Lots of ways for them to receive healthcare. Is that valid?

Janice Ertl: You're talking about people on AHCCCS and very low income and oftentimes there isn't a lot of health literacy that goes along with it. These are people who oftentimes get on AHCCCS because they're sick too. These are generally sick people losing their insurance. So it's -- it's a little bit tougher, I think a lot of them are just going to do without until they can't.

John Swagert: Mountain Park is a big part of the safety net and we do get federal funding that helps us take care of these patients and I think we have a big part of the answer and we can grow. But our federal grant is fixed and it doesn't grow with the number of patients we see so eventually our resources run out.

Nicholas Vasquez: Don't you think if it was a coordinated system or a system responsive to the demand that your grant would grow? There would be a response by the safety net to respond to increasing demands and instead it shrinks or pales into the challenge?

John Swagert: Well, I just -- this is why I'm a doctor and not a politician.

Nicholas Vasquez: Me too.

John Swagert:I think it would grow and we believe we can do more if we had more resources.

Nicholas Vasquez: And I believe you can do a lot. We've talked about how many patients I refer to you. I have a lot of faith in your system. I guess what I'm worried about, the idea there's a healthcare safety system and I don't think there's a coordinated system to respond to the challenge we have and as soon as we do away that, and get to the reality, the better off we will to handle this difficult time.

Ted Simons: Others see a reality of folks taking advantage of the system. Of the healthcare system as it stands. We've had lawmakers even say, I think the quote was, "I'm tired of coddling these people." This sort of attitude. How much of a problem is that?

Janice Ertl: You know, we're a charity clinic and you would think there'd be a lot of people abusing us. It's not what you think it would be. There's always a few but it's not the vast majority, I don't think.

John Swagert: The typical Mountain Park patient is a working poor person who either lost a job or has a job that they couldn't afford to continue paying for health insurance coverage and these are people that come and see us in after-hours clinics and trying to get by. I just don't see very much abuse of that system in our clinics.

Ted Simons: What do you think?

Nicholas Vasquez: You know, this is a difficult question for me. Because there are people that sometimes you would say, all right, these folks don't need to be here, but where else are they going to go? When you ask why do people go to the emergency rooms, it's out of convenience or they need something that they can't access otherwise. You have few choices and don't know your options and not exactly worldly when it comes to the options for your condition. You're going to go to the first place that you think of and that's the closest location you can find and I ask people to think about that. If you empower emergency departments to start being judges and jury, you better on the other end have a place for them to go.

Ted Simons: I got to get to more criticisms here. I want your responses. The idea that we cut Medicaid rolls, that this would put us in line with most other states. They seem to manage, shouldn't we be able to manage as well?

Janice Ertl: I don't know what other states are doing. I thought other states were a little bit higher in their Medicaid programs than we were until I read that in the paper.

John Swagert: I think if it's purely a cost thing you're looking at, trying to save the state money, I think -- again, I say this is a little bit of a false choice. If these people, without -- without Medicaid coverages, these people don't get vaccinations and take care of the things that if you leave untreated get much worse and you roll the clock forward five years and suddenly, the population is sicker and people who are more expensive to take care of and there's a lot of suffering we might have been able to avoid. From a cost-effectiveness standpoint, I think the voters of Arizona were pretty smart when they realized we could save money if we invest in this group and get them healthy enough to get them back to work.

Ted Simons: What do you think about the idea, states seem to have one level and all we're doing is going to the level they're at.

Nicholas Vasquez: I don't think that's a good choice. It's an argument that's made to reach the idea we're going to cut off Medicaid funding. But our state is really not -- not -- not a state that has a diverse economy enough to really handle these cuts. It's not like there's a lot of people out there who are getting their insurance through private employers. In fact, most employers are pulling back that insurance coverage. Most of our state is a service economy. You pull the rug out from underneath them you have a lot of people who hold on as long as they possibly can until they can't anymore and then it's very expensive to fix them. We'll allow them to suffer with the disease but won't allow them to die. We allow them to get sick enough until we go, man, I really want to take care of this. I'll spend the money then.

Janice Ertl: There's couple of patients we had to send to the emergency room in one day and I bet their total hospital bills were over $100,000. People just present way too sick.

Nicholas Vasquez: When you ask the question, how much can people go without when it comes to healthcare, how much pain, illness, from what I have seen, it's a lot.

Ted Simons: Is there any - last question we got about 30 seconds, don't mean to put oyu on the spot. Is there anything we can learn from other states, other municipality, counties, what are -- can we do something? Can we learn?

John Swagert: The sad part of this argument is we're forgetting that Arizona's Medicaid system, AHCCCS, we should be teaching other states. It's one of the cost effective medical systems in the country and instead, we're looking at ways to cut it when we should be learning and teaching other states.

Ted Simons: Alright, we have to stop it right there. Thank you for joining us. We appreciate it.

Janice Ertl: Thank you.

Dr. John Swagert:CEO, Mountain Park Health Center;Janice Eertl:Director of St. Vincent de Paul's Virginia G. Piper Medical and Dental Clinic;Dr. Nicholas Vasquez:Arizona College of Emergency Physicians;

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