Addressing Medicaid Reforms—the Athens Health Assurance Program

Athens Clarke County has a large number of residents that would qualify for the benefits added under the Affordable Care Act, but Georgia’s decision to limit the expansion of these benefits may require Athens to come up with local solutions to the widespread healthcare needs.

As far as how a local Athens Health Assurance plan will address those who will not gain Medicaid under Gov. Deal’s denial of expansion, Alexandria Chambers of the Athens Health Network calls this “the million dollar question.”

According to the U.S. Census Bureau, 22.8 percent of Athens-Clarke county residents are uninsured this is higher than Georgia’s average and the national average.

The Affordable Care Act passed in the summer of 2012, sought to address the access disparity of healthcare to the poor. “The law put in motion the creation of a nationwide insurance system that would sharply reduce the number of Americans without coverage,” reported the New York Times.

Before the Affordable Care Act, Medicaid requirements designated certain categories of need that had to be met in order to receive Medicaid. Though requirements varied by state, common categories included people living with certain physical disabilities or pregnant women and children living below a designated poverty level.  Many low-income adults without children and some low-income parents whose children received benefits did not qualify for Medicaid coverage under previous Medicaid legislation.

New legislation from the Affordable Care Act provides Medicaid to all adults who earn up to 133 percent of the federal poverty level, but allows for states to decide whether or not to expand Medicaid coverage to include this entire new population of Medicaid recipients.

Georgia Governor Nathan Deal chose last summer not to expand Medicaid in Georgia. “I think that [Medicad expansion] is something our state cannot afford,” said Deal in an interview with the Atlanta Journal Constitution.

Deal’s decision reflected the beliefs of many other Republican governors at the time who did not believe the federal government would be able to fully provide the funds required for Medicaid expansion in each state.

“If Georgia expanded its Medicaid program according the the ACA, an additional 646,557 Georgians would be eligible for Medicaid by 2019,” said Monica Guaghan an assistance professor in the Health Policy and Management Department at the University of Georgia’s College of Public Health.

“I think that Georgia will continue to have a population that is unhealthier than other parts of the country,” said Guaghan. “The primary reason for this is a lack of political will within the state of Georgia to address social problems related to poverty.”

Some communities are looking to develop local healthcare programs to address the large number of people who will remain uninsured because of Deal’s decision to not expand Medicaid.

In Athens-Clarke County the Athens Health Network was created to provide services for the health needs of the uninsured and under-insured by bringing together multiple healthcare stakeholders in the Athens community.

Under their 2008 proposed recommendations, the Athens Health Network stated a need to “Create the OneAthens Healthcare Plan to serve the primary health care needs of the estimated 14,250 uninsured in Athens.”

Today the Athens Health Assurance program is being developed by executive director of the Athens Health Network Alexandria Chambers.

Chambers calls the Athens Health Networks Health Assurance program a “navigation system,” for those without insurance seeking healthcare services.

This program is not an insurance plan, said Chambers, and patients will still have to pay for the cost of services. What this program is providing is a facilitator between healthcare providers and the uninsured. “We are essentially acting as that broker for services, negotiating a discounted rate for people to pay.”

The Assurance program would provide patients with access to information and guidance on where to get primary care, how much it is going to cost, and how to go about making payments and filling out paperwork.

The Athens Health Assurance program is currently in the early stages of development and funding. The program has filed for nonprofit status and requested grants from partners, including Kaiser Permanente.

Once the program receives the funding it needs, there are three major pieces that must be developed in order to see the Health Assurance program come to term, said Chambers. Developing a network “of [healthcare] providers that would be willing to see our members at a discounted rate,” developing the resources needed to provide member services and implementing operations.

Currently in Athens there are three clinics that provide primary care to the uninsured. One of these clinics is the Mercy Health Center. Executive director at Mercy Health Center, Tracy Thompson sits on the board of the Athens Health Network and fully supports the creation of a health assurance program in Athens.

Thompson explained that the program would best serve the fairly healthy in the working poor population of Athens—to help them get the primary care that they otherwise could not afford. In order to implement a health assurance program in Athens the health network needs, “a few key physicians to buy into the program and good hospitals to buy-in,” said Thompson.

The program will work with people and help them plan for their health needs. People will have a better understanding of cost up front and they will be able to take the necessary steps to financially prepare to address these needs before they develop into debilitating problems that could prevent them from working and being able to afford the healthcare they need, said Thompson.

“Because Governor Deal at this time is choosing not to expand Medicaid coverage here in Georgia we will still have that number of people who would have been eligible [Under the Affordable Care Act] for Medicaid, but will not become eligible because there is not an expansion,” said Chambers. That is the target population the Athens Health Assurance program hopes to help.

If funded and put into action, the Athens Health Assurance plan would also provide a healthcare option for those receiving minimum government subsidies, those choosing to pay the 1 pecent tax and not purchase insurance, and undocumented immigrants who do not receive any benefits.

Just as the development of a local health assurance program is still in development the implementation of the Affordable Care Act is still under debate.

In recent weeks Republican Governors who previously choose to opt out of Medicaid expansions for their state changed their minds.

Most recently New Jersey’s Governor Chris Christie, previously an adversary to the Affordable Care Act, chose to accept the expansion of Medicaid in his state.

This raises the question as to the permanence of Deal’s decision on Medicaid expansion in Georgia and what Medicaid reforms will mean for local healthcare programs—particularly in communities like Athens where health accesses and disparity are prominent issues.

Athens community confused about healthcare reform

 by Chari Sutherland

Sean Bokelman, a local restaurant manager, doesn’t have health insurance.  The last time he had insurance was three years ago when he was still covered under his parents’ plan.  Patricia Porterfield, a hairdresser in the Athens area, buys a personal plan. 

“I’m self employed and it’s the only way I can get insurance,” she said.  “Either I pay or I have no insurance.” 

With the recent passing of the healthcare bill, many questions still linger for those in positions like Bokelman and Porterfield.  The most pressing questions are: will insurance costs be lower?  Will self-employed persons be positively affected by this reform? With the national mandate that every American must have insurance, who will monitor this? 

White has devoted several pages on their website to answering the public’s questions about this reform.  The site states that insurance premiums will not go up, nor will co-pays or deductibles.  Also, those who are self-employed will have access to cheaper insurance through insurance exchanges. 

An opinion poll by CNN/Opinion Research Corporation conducted in December, 2009 found that 39 percent felt the health reform bill would not make any real changes at all, 37 percent felt there would be changes for the worse and 22 percent felt there would be change for the better.  An ABC News/Washington Post Poll conducted in November, 2009 found that 55 percent of persons polled considered themselves to have a “good basic understanding” of the changes being proposed for the health care system.  Another 44 percent felt the changes proposed were too complicated to understand.  However, a Gallup poll in that same month found that 36 percent of those polled felt changes in the healthcare system would make their personal healthcare situation worse.  Only 26 percent felt it would improve. 

On top of this, many in the insurance industry remain in the dark about what the reform will really mean for the self-employed or anyone else for that matter. 

“I feel just about as clueless as everyone else,” said Dustin Rector, an insurance agent at Baumwald Insurance.  “The bill is very vague.  Seems like (its) impact will be very delayed.”  Some of the proposals in the bill will not take effect until 2014.   

Debbie Kinard, of Blue Cross Blue Shield was unsure of the effectiveness of the healthcare reform.  She said no one is addressing the basic problem: increasing costs.  “We have to stop the runaway freight train of costs going up.”   She said there is a common misconception that health insurance companies get rich from premiums they offer.  In fact, she said, health insurance companies only make about three percent profit.  Pharmaceutical companies make ten to 15 percent. 

There’s a domino effect driving costs, she said.  For example, if the cost of needles increase, then bed sheets increase, then doctors’ leases increase, and thus hospital costs increase.  “The general public doesn’t understand that.” 

Windy Manders, an insurance agent with Chastain and Associates, said her company is selling more individual policies due to consumers losing coverage at work or losing jobs.  She pointed out that the cost of doctors and hospitals serving the uninsured drives up medical costs.  “The hospitals and doctors are going to make up cost of seeing the uninsured somewhere.” 

Dustin Rector of  Baumwald Insurance agreed.  “It’s not uncommon for a premium to go up at least ten percent every year.”  His company has sold less individual policies this year because of the shear cost of them.

Manders said people have to remember insurance companies are a business, too.  “If they’re paying out more money than you’re paying in, they can’t make a profit.”  If they can’t stay in business, they can’t provide insurance to the public.

 One proposal of the reform bill is the use of insurance exchanges for the self-employed to find good rates on insurance by being grouped with other self-employed persons buying insurance.  Neither Manders, Rector or Kinard could elaborate on how the exchange system might work.  Rector offered an explanation of why they could be beneficial.  The theory, he said, is if the healthy are combined in a group with the unhealthy, it will bring down the premiums of the unhealthy and everyone’s cost will meet in the middle.  “If the healthy are paying $100 a month on insurance and the unhealthy are paying $600 a month, when you group them all together, they might all pay $300.”  He said this lessens the risk for the insurance companies.   

“I don’t see the healthcare bill lowering costs for us,” said Brandt Halbach, Executive Director of Georgia Neurological Surgery, a practice located on Old W. Broad Street in downtown Athens.  This practice’s patients include 30 percent on Medicaid or Medicare.  Another nine percent are self paying or privately insured.

Halbach said the economy of healthcare is different than any other business.  When you go to a store and buy a basket of goods, the store gets their payment on the spot.  It’s not that way in healthcare, he said.  After the provider collects the co-payment from the patient, the bulk of the expenses are sought from the insurance company.  It can take up to 60 to 100 days to get payment.  If the insurance company denies payment, doctors often appeal.  “We need personnel to follow up on these things,” he said.  “Those costs are in the system.”

As far as the mandate that all Americans must have insurance or be fined, that concerns many. 

Manders questioned, “If a person without insurance couldn’t afford it to begin with, how are they going to afford it after a mandate?” 

Kinard and Bokelman were concerned about citizen rights. 

“If you take over health insurance and it is now run by the government, that’s the beginning of losing freedom of choice and self regulation,” Kinard said.  She also wondered how a mandate will be enforced.  However it is enforced will likely result in loss of some privacy she said.  “Are we going to have a national database so the ‘health police’ can come out and knock on your door?”

Bokelman said the idea of levying fines on those who remain uninsured “seems like a violation of my rights.  I get the point—if everyone’s covered it will be cheaper for everyone.  But to make it mandated…it blows my mind.  Especially considering the foundation of this country.”

In any case, Rector said his understanding of the new reform is that the changes will come about in several years.  “I really don’t know what’s wrong or what’s right with the bill,” he said.  “But what we have now isn’t working well either.”