Many local residents are falling through the health care gap

• Health care gap

Health care gap

Talk about it

After moving to Grand Forks in 2009, Myra Williams made the rounds, applying for the slew of local, state and federal programs designed to help uninsured people like her get access to basic medical care.

She last had health insurance in 1990, and said she relied on hospitals in Chicago and Atlanta when she used to live there that treated all patients, even if they could not afford to pay.

But Williams encountered a troubling reality in Grand Forks — she was both too young to be eligible for Medicare and too old to qualify for coverage through Medicaid programs, which North Dakota reserves for children and low-income adults who are pregnant or disabled.

“I’m only 53,” she said. “I need to wait.”

Her income is another problem. She said her two part-time jobs are “barely making ends meet,” yet she earns too much to qualify for other assistance programs in the region.

“I work, true enough, but I still have to live,” she said. “They figure you make too much, but are you taking into consideration that I have to pay rent and bills?”

Williams is part of the growing number of Grand Forks and East Grand Forks residents who are falling into a “big gap,” local United Way President Pat Berger said — they can’t afford basic medical care, but are deemed ineligible for the very programs that are meant to help people like them.

“If you have an income level that really puts you below the poverty line, there’s a lot of things that you qualify for, and health insurance assistance is one of them,” she said. “But if you are that working poor, if you are making just a little bit more money and can’t do this, oh, it’s a struggle.”

On their own

Berger said the health care gap “pulls everybody down,” even residents who have a good health insurance plan and are able to get the regular care and checkups they need.

Grand Forks-based Altru Health System has posted dramatic increases in its charity care, a program that forgives some or all of a patient’s medical bills if they show a clear financial need and cannot pay the full amount.

The cost of providing charity care climbed to $21.6 million in 2011, up from $19.5 million in 2010. Chief Financial Officer Dwight Thompson said the lost revenue is made up with higher bills that are passed along to insurance companies and Altru’s other patients.

“Really, it’s built into the whole pricing of the system here and nationally, too,” he said. “It’s an indirect way of supporting it.”

From 2008 to 2010, an estimated 10 percent of Grand Forks County residents lacked health insurance, according to the U.S. Census Bureau’s American Community Survey. Nearly half of the uninsured were unemployed, but 11.9 percent were working.

Berger said many small businesses and employers in the region simply cannot afford to offer insurance plans. Even if it is offered, she said some workers do not have the money to pick up “another big bill” for something they will not use as long as everyone in their family remains healthy.

The average employer-sponsored family plan cost $15,073 in 2011, with workers paying 28 percent of the bill, according to a 2011 Henry J. Kaiser Foundation study. Family plan premiums shot up 113 percent between 2001 and 2011, outpacing the 34-percent increase in workers’ wages during that time.

“When you’re looking at ways to cut back, everybody’s got to eat, you need a place to live and you need the car,” Berger said. “You cut back on the insurance and you play this kind of roulette game of, ‘Well, maybe I won’t get sick.’”

There’s another hitch: Just because someone is insured does not mean they actually have adequate coverage to afford their post-insurance expenses, said Stan Salwei, patient financial services manager for Altru.

“People are raising their deductibles to keep their premiums down, so it’s leaving more out-of-pocket for them to pay,” he said.

Helping the poorest

Altru employs social workers and financial counselors who help patients find medical assistance programs, including government options as well as Altru’s own community care program that provides eligible patients with six months of primary care from their doctor.

“We’re trying to find options from federal, state or local programs that are available to try and get those in need on those programs,” Salwei said.

Altru doctors and staff also volunteer their time to see patients of Third Street Clinic, a no-cost clinic in downtown Grand Forks that has seen “skyrocketing” demand for its prescription and medication program, according to Executive Director Corey Mock.

In 2009, the clinic spent between $20,000 and $30,000 on covering prescription costs for its clients.

“Now, it’s closer to $70,000, and that has come from more people that qualify for prescription assistance but it’s also because of the rising cost of medications,” he said.

The clinic filled about 1,700 prescriptions for more than 1,000 patients last year, and also had 1,459 office visits and many more referrals to physicians and staff at Altru and other health care facilities.

Even with these programs, the health care access gap is getting wider.

In North Dakota, Medicaid is mostly reserved for children younger than 19. Adults younger than 65 can qualify for Medicaid coverage only if they have young children, are pregnant or have disabilities.

Federal poverty guidelines are used to determine what other assistance a resident could get, but the low thresholds often mean only the very poorest in the community have a chance of getting help.

Current guidelines consider an individual as living in poverty if their yearly income is at or below $11,170, and that threshold goes up to $23,050 for a family of four. About 20 percent of Grand Forks and East Grand Forks residents now live in poverty.

Third Street Clinic and Altru’s community care are reserved for patients who earn less than 150 percent of the poverty line — $16,755 for one person or $34,575 for a family of four.

Bridging the gap

But an ongoing effort by 20 local agencies could give local residents one more chance for getting access to health care, even if they earn too much for other programs.

The Alliance for Healthcare Access is now working to build a community health center, a model of health care that gives low-income, uninsured and under-insured residents a place to get primary care, dental care and mental health services that they otherwise could not afford.

Project coordinator Mara Jiran said these centers offer a way of covering the gap because they are open to any patient — insured or not, regardless of income level. All patients are expected to pay something, but those who earn less than 200 percent of the poverty line would see their bills reduced on a sliding scale to make their medical care more affordable.

The group will apply for a federal grant later this year. If successful, a community health center could open here as soon as next year.

North Dakota already has several community health centers, including a dental clinic in downtown Grand Forks and clinics in Larimore and Northwood. All together, the state’s centers are projected to save nearly $22 million annually through more efficient care and preventative care.

For Williams, these health centers have filled the gap.

After being turned down for everything else, she finally gained access to basic health care in 2010 as a patient of Valley Community Health Centers. She now visits the agency’s Grand Forks Dental Clinic and goes to the Larimore clinic for blood pressure checkups.

Jiran said this health care model cannot “fill in every gap,” but it is a way of getting more residents into the doctor and would complement the other medical care options for residents in need.

“It will be one very stable piece of the whole health system,” she said. “For the people who are just kind of floating from system to system, it provides a really stable medical home.”

Healthcare and how it works

• Current federal guidelines consider a person as living in poverty if a single person earns as much or less than $11,170 annually or $23,050 for a family of four. The guidelines are important because they often are used to determine eligibility for government and private programs that help low-income and uninsured people gain access to health care.

• 150 percent of federal poverty guideline ($16,755 for one person, $34,575 for family of four): People under this income level qualify for no-cost health care at Third Street Clinic in downtown Grand Forks and also could qualify for Altru Health System’s community care program, which provides patients with six months of primary care from their doctor.

• 200 percent of federal poverty guideline ($22,340 for one person, $46,100 for family of four): Residents who earn less than this income level would qualify for reduced-cost medical, dental and mental health services at federally sanctioned community health centers, such as the Grand Forks Dental Clinic.

• Between government programs like Medicaid and Medicare and other assistance options, the vast majority of children under 19 and seniors over 65 qualify for some form of health care coverage. Many adults between these ages earn enough wages and have adequate health insurance that gets them the medical care they need.

• An estimated 10 percent of Grand Forks County residents were uninsured from 2008 to 2010, and 11.9 percent of those without insurance had a job, according to the U.S. Census Bureau. Even more residents have limited health insurance that leaves them with unaffordable medical bills if they do go in for a checkup or surgery. Despite a wide variety of programs designed to help fill this health care gap, most assistance options are reserved for children, the elderly and those with severe disabilities — leaving many adults without any affordable health care options.

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