Carmen Gray is a married mother of four and a self-employed contractor who works mostly short-term jobs. In recent years, she's had private insurance, Medicaid, no insurance and then Medicaid again. As a result, in 2008, she received widely varying levels of care at three different Northeast Ohio facilities for problems related to vertigo. She believes one doctor dismissed her problems as no big deal because of the low reimbursement rate Medicaid coverage provided. That doctor told her that as long as she didn't drive, she didn't need treatment.
Then, last summer, after she again had temporary employment and was off Medicaid, she came down with a bladder infection, a relatively minor and very treatable ailment. Her infection ultimately resulted in an emergency hospital admission because she had not yet been approved for a primary-care visit to a doctor — during which she probably would have received a simple prescription for antibiotics.
Gray's problem? A delay in getting "rated," or proving that her low income qualified her for a charity-care program.
Getting rated is a term heard often among the uninsured. You're categorized according to income and put on a sliding scale of ability to pay. The scale varies depending on the hospital. The county is often involved because a prerequisite for qualifying for the sliding scale is being denied Medicaid.
"It was a three-month process while I waited for all the documents I needed," says Gray. While she was waiting, her infection spread, and the pain was excruciating.
Jackie Peterson, 67, of Berea, is on Medicare now, so her bills for stress tests and other cardiac care at Southwest Hospital are covered. But she and her husband, who get by on Social Security, are still paying hundreds of dollars each month on bills from heart attacks they both suffered in their pre-Medicare days. At the time, she knew nothing about how to obtain charity care.
"It's a deep, dark secret," she says.
Gray and Peterson are just two of the estimated 250,000 in Northeast Ohio (130,000 in Cuyahoga County) who lack health insurance. Many of them have struggled to navigate the fragmented and cumbersome local charity-care system. Many others don't even know where to begin. Gray's situation is particularly ironic: She works for the Ohio Benefits Bank as an advocate for low-income people. She knew what to do, but couldn't get the system to work fast enough for her.
"I have a bad vision of things — I'm pessimistic," she says. Her experiences have led her to conclude that the poor are left hanging — sometimes to die — by an indifferent system, perhaps as a warning to the middle class: Don't expect a safety net.
Despite the mergers and expansions that have created monstrous regional, national and sometimes global empires, most hospitals have retained their legal status as nonprofit charitable institutions.
Legislators sometimes take issue with that. In 2007, U.S. Senator Charles Grassley of Iowa put the fear of taxes into health-care institutions nationwide. Grassley charged that the nonprofit tax status hospitals enjoyed was a sham. They were operating like for-profit entities, he said, making mega-bucks from insurance revenues, spending lavishly on expansion, advertising and marketing, and rewarding their executives handsomely. At the same time, they paid no taxes and benefited from other perks, like access to tax-exempt bonds for construction projects. Grassley argued that the longstanding deal that hospitals would put the needs of their communities ahead of their profit goals had been broken.
Local studies conducted by the Service Employees International Union of Ohio around that time confirmed Grassley's thesis. The SEIU found that in Ohio, nonprofits spent less then 25 percent of the value of their tax-free status on care for the uninsured.
Such findings prompted Grassley to threaten legislation that would revoke hospitals' nonprofit status — unless they increased assistance to the uninsured.
Local hospitals heeded the call and created more formalized programs, now commonly known as charitable-care programs, community benefits programs, discount programs or "the ratings system" by those who have used them. The Cleveland Clinic Foundation offers free care for the uninsured whose incomes don't exceed the federal poverty level and discounted care for those earning up to 400 percent of the poverty level. University Hospitals and St. Vincent Charity have similar policies for up to 400 and 200 percent of the poverty level, respectively.
The Cleveland Clinic reported that it spent $99 million in charity care in 2008, the last year for which figures were available, and $436 million in total community giving, which includes things like community health fairs, education, funding to other providers and other outreach programs. The Clinic also provides free lab work to the Free Clinic, and donates time and similar services to Care Alliance Health Center. In 2008, its revenues were $4.9 billion.
University Hospital reported a total of $39 million in uncompensated medical care and $210 million in overall contributions to the community. (Neither the Clinic nor UH responded to requests for interviews.)
Local advocates say that charity-care programs and the ratings system are making strides, but still fall short of the community's needs. At most hospitals, coverage does not include prescription drugs, dental care or mental-health care.
The ratings system, according to those who have experienced it, is often not just frustrating, but humiliating. "You have to prove that you're worthy, not that you're sick," says Tim Walters, a longtime advocate for the poor who now directs the Community Partners for Affordable Accessible Healthcare.
The documentation required to get rated, say patients and advocates, is daunting. To prove that you have no income, you might be asked to provide a recent tax return — even though many people with little to no income aren't required to file with the IRS. So too can obtaining birth certificates for those who have no driver's license, which is sometimes required. And patients often have to go through the ratings process more than once if they're sent to specialists or different facilities.
"You lose all dignity, the things you have to do to prove you're poor," says Heather Ives, an emergency room nurse at Allen Memorial Hospital in Oberlin who previously worked at Metro Health. Ives is active in Ohio's Single Payer Action Network.
Carmen Gray says that she works with ex-cons leaving the justice system who can be totally overwhelmed by the paperwork. "They get over a few humps, and then they quit trying," she says.
And some people who would qualify never start, because they don't know that help is available.
"The community has to know about [charity-care services]," says Gail Long, recently retired director of Tremont's Merrick House, who has often lobbied for better health-care policies for the poor. Hospitals, she says, "have to figure out a way to make them more accessible."
Tim Walters agrees. "I'd like to get to the day when the Clinic has a big billboard on the Shoreway saying, 'We take people with no money.'"
The Metro Health System also has a ratings policy for charity care, but as the county-funded public safety-net hospital, it is required by law to take care of those who cannot pay. That is both an asset to the poor and a problem.
Despite the implementation of the ratings system at other hospitals, many of the uninsured still assume that if they're sick, there's no choice but Metro. Advocates and patients also say that other hospitals will refer patients to Metro if they are on Medicaid or uninsured, despite their own charity-care policies and regardless of whether the patient lives near Metro.
Sometimes the referrals to the county hospitals are simply the most expedient way to get much-needed treatment for patients quickly. The Free Clinic doctors send patients to Metro for specialty care because they know the patients will be guaranteed treatment in a timely manner.
Metro Health revamped its charity-care program in 2009 to respond to the exploding numbers of uninsured in Cuyahoga County and to make its own program easier to access. Eileen Korey, a spokesperson for Metro, says eligibility for the Community Discount program has been expanded to up to 400 percent of poverty level and free care to 200 percent.
The qualifying process has been streamlined so that once a patient at Metro is in the system, he or she has a "medical home" where ongoing and specialty care can be provided without additional paperwork. Metro has also instituted a team approach to care, so that once in the system, nurse practitioners and others besides the primary- care doctor can make sure the patient is receiving followup care. That's particularly important for patients with diabetes, hypertension and other chronic conditions.
Gwyn Hartman, Metro's director of managed care for the uninsured, says that in 2009, Metro handled about 181,000 inpatient, outpatient and emergency visits from uninsured patients. Korey adds that those patients came from all over Northeast Ohio, not just Cleveland and the inner-ring suburbs. Uninsured from Solon, Westlake, Rocky River, Chagrin Falls and elsewhere are treated at Metro — an indication of not only of how widespread the uninsured patient problem is, but of how much care the safety-net hospital must provide.
"It's important that the load is spread more evenly, so that the burden is not all on Metro," says Gail Long.
Ken Frisof, a Metro physician, cites estimates that 12 percent of the county's population is now uninsured. That could drop to five percent if one element of the recently passed Patient Protection Act of 2010, the individual mandate, does what it's supposed to: compel people to carry insurance, regardless of whether it's offered through their employers.
Will it work? A study published in May 2009 by Jonathon Ross, a Toledo physician and single-payer advocate, said in American Journal of Public Health that when Massachusetts instituted a similar insurance-mandate program, some individuals still couldn't or wouldn't buy insurance. The state did not penalize them. Ross says that the new federal law also does little to reduce the amount of administrative overhead — now figured to make up about 30 cents of every healthcare dollar — and there's no telling what kind of deductibles or co-pays people will be required to pay.
Also, that portion of the law won't take effect until 2014, and demand for care by the uninsured is rising now.
Care Alliance provides medical care to the homeless. CEO Francis Afram-Gyening says its patient load has almost doubled, from 5,000 in 2008 to 9,000 last year. That's just one indication of the rising demand for medical care faced by community clinics — some of which receive federal subsidies and charge minimal fees — and by free clinics, which receive no federal funds.
The Patient Protection Act will increase funding to qualified health clinics that offer care to the poor and impose tougher charity-care standards on hospitals. Every three years, hospitals will be required to complete a community- needs assessment and submit to an IRS review of their tax-exempt status. Hospitals also will be prohibited from billing those who qualify for assistance at top rates and from taking extraordinary collection actions if the hospitals have not made "reasonable efforts" to notify patients about the financial-assistance policy. (The amendments were introduced by Senator Grassley, who still voted against the bill.)
Locally, Afram-Gyening and others are hoping that a new a countywide initiative — the Cuyahoga Health Access Partnership (CHAP) — "is the right medicine" for the ailing charity-care system in Cuyahoga County. The program is orchestrated by a consortium of nearly all the health-care providers in the county, including all the hospitals, community and free clinics, and some in private practice.
Frisof, who is vice-chair of the CHAP project, says it will provide a central number to call for people who "don't know where to turn to for help."
"Our primary objective is to have people know that whether or not you're insured, you're taken care of," he says. The current system, he adds, is "full of holes."
Frisof says a patient will be able to enter the CHAP system at any provider site, receive an access card that will allow treatment at that site and others in the system. Patients won't have to bring verifying documents from one institution to the next; hospitals and clinics participating in CHAP will be able to access the same electronic medical records. CHAP is being funded by local foundations and providers.
Frisof hopes to start enrolling the first patients within three months and will be "ramping up" staffing and publicity by the end of the year. CHAP could serve up to 80,000 people.
Afram-Gyening and others are optimistic that CHAP will allow for a "continuum of care," so that the uninsured can receive ongoing primary and specialty care with relative ease. This will relieve the burden on emergency rooms, which often treat those who waited too long to get treatment or don't know where else to go for primary care.
And CHAP theoretically could spread out the geographic distribution of patients, allowing them to access more facilities throughout the county.
Carmen Gray says she's heard, particularly from patients at Metro, that once an uninsured patient is in the health-care system, continuing care is "going a little more smoothly." But it's still a challenge to get in, and that's a problem that may persist, at least for now, as the ranks of the uninsured continue to grow. "It's hard for newcomers," says Gray.