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Because of Prop E, some county health departments may not help educate consumers

This article first appeared in the St. Louis Beacon, June 24, 2013 -  Some health providers, administrators and volunteers got a glimpse Thursday at how they and others could help the working poor reap the benefits of medical care through an insurance exchange system that will open for business in the fall.

They learned how focus groups and one-on-one counseling, federal grants and private funding, social media and traditional advertising are all being harnessed to try to make it as easy as possible for people to gain access to this new health insurance.

The attendees -- and similar health-care professionals and advocates across Missouri -- may not be able to rely on state government for any help, however, because of Proposition E. This is the ballot measure passed last year that said state workers and agencies could be sued if they took any action on federal health reform matters without the approval of the legislature or a vote by Missouri residents.

That fact was a given among those at the Maternal, Child and Family Health Coalition’s quarterly meeting, which was devoted to a discussion of how to help women and families access the new exchange.

But what seemed to surprise some at the session in Richmond Heights was news that the proposition’s reach also extended to county health departments.

Out of fear of lawsuits, health departments across Missouri were reported to be reluctant to host meetings, distribute information or educate uninsured clients who might need help in wading through the exchange enrollment process.

Ryan Barker, vice president of health policy at the Missouri Foundation for Health, says some county health departments might be sympathetic to educating the public about the law, but he says the potential of being sued is a real concern to all of them.

News of this policy surfaced after the the Northeast Missouri Rural Health Network proposed a partnership with 11 county health departments in the Kirksville area to educate residents about the insurance exchange. The network’s office is in Kirksville, and the agency wanted to use space in county health departments to make it more convenient for residents to get access to information, says the group’s executive director, Glenna Daniels-Young.

Much to her surprise, the health departments were cool to the idea. She soon discovered that the response wasn’t isolated but was part of a policy among lawsuit-conscious local health departments across Missouri.

“The health departments want people to have access to care, but they still felt like it was too much of a risk. Even if there were a lawsuit and the health departments weren’t doing anything wrong, they’d be out the legal cost.”

Audrey Gough, a member of MOALPHA (Missouri Association of Local Public Health Agencies) said the group had sent information to all of its members, warning that Proposition E could affect whether a local health agency should get involved in insurance exchange issues.

"MOALPHA's official position is that we are making members aware" of the wording of Proposition E and Senate Bill 464 "to make sure that they look at it and get an interpretation from their lawyer before they accept any kind of grant or help anyone with health exchange information or provide education on information about health exchanges."

She said she was unsure how many health departments across Missouri are choosing not to participate.

Timetable for an exchange

The issue was only one of many exchange-related topics taken up at the local meeting. It included presentations by three health care experts – Barker, Stephene Moore, regional director of the Department of Health and Human Services; and Susan Kendig, a health policy consultant who is also a lawyer and nurse practitioner.

Moore rolled out the timeline for implementing the exchange. The steps include launching a call center this month, online training for consumer assistance navigators next month, testing in August of the exchange Web portal, an Orbitz-like system through which consumers will buy health insurance; opening the exchange for enrollment on Oct. 1, and going live with insurance on Jan. 1.

“It’s going to start on time; folks will have coverage starting Jan. 1,” she said. “The navigators will be out in the community and different areas to help enroll people.”

The system in Missouri will be what’s known as a federally facilitated market place, she says, meaning it’s set up by the federal government rather than the state. Missouri had two other options, one being to set up a system jointly with the federal government, the route taken by Illinois, or setting up its own exchange. Gov. Jay Nixon favored the state setting up its own exchange, but abandoned the idea after state lawmakers decided against the idea.

Barker noted that the policy involving county health departments didn’t mean they couldn’t continue to serve patients who happen to obtain insurance through the exchange, but that the agencies couldn’t educate people about the availability of the insurance.

“Many of us really didn’t understand how much this (Prop E) is going to impact  us,” Barker said. He noted that the policy didn’t apply to activities of about two dozen federally qualified health centers across Missouri. He says these centers will have access to about $2.8 million to pay for "navigators": people who help and educate consumers on their health insurance options in the exchange.

He added that Missouri is getting a relatively small amount of federal money, $1.3 million, for navigation and education and said the Missouri Foundation for Health was setting aside $5 million for competitive grants for people to offer consumer assistance to those enrolling in the exchange.

Work remains

Many of the participants at Thursday’s session seemed upbeat about the value of the exchange program, though they conceded a lot of work remains to be done to reach out to those needing health insurance.

Kendra Copanas, executive director of the Maternal, Child and Family Health Coalition, noted there is still a great need to convince people of the value of an exchange.

“It’s a change, it’s new and it’s complex,” she says. “I don’t think it’s well understood. We need to help make sure people understand how to access this new resource.”

She says the exchange will assist a family that might be headed by a single mom “who has a job but may not earn enough to afford the health insurance offered by her company or may work for a small employer that doesn’t offer health insurance.”

The exchange is expected to put insurance within reach of tens of thousands of consumers, along with businesses having fewer than 100 workers. The workers can earn between 100 percent and 400 percent of the poverty level. That means a family of four with an income of $94,000 would be eligible for subsidies -- that are set up on a sliding scale -- to buy insurance.

Joan Bray, a former state senator who is now head of the Consumers Council of Missouri, says she’s excited because the health law is now in place. “We don’t have to dream about it. It can have an impact on people’s lives. What we have to do now is implement it. People’s lives will be measurably better.”

But Robert Fruend, CEO of the Regional Health Commission, acknowledges the challenges ahead.

“It will take a lot of community groups pulling together, getting the message out that coverage is available to people through the exchanges,” he says. “We have a lot of work to do in six months to get 200,000 people enrolled in this state.”

The second challenge, he says, involves expanding Medicaid. “That’s a huge piece of the puzzle, too, and we shouldn’t forget that. We can talk about the exchange all we want. That’s important, but it’s less than half the story. If we don’t get Medicaid expansion, we aren’t providing full access to coverage that we could provide. Not only that, we are denying our health care providers an important stream of revenue that they need.”

Kendig, the health policy consultant, attended the session to talk about wellness and other issues affecting the health and well-being of women. But she couldn’t resist opening her comments by mentioning the issue involving county health department workers.

“When I teach my ethics courses, I tell students what’s legal is not always ethical and what’s ethical isn’t always legal.” She asks what one of her nurse practitioners is to do if she’s providing women’s health care at a county health deparment “as I have done in my life” and is caring for someone who needs services and isn't insured.

“You are telling me I’m not allowed in Missouri to facilitate their getting insurance to get the care they need.”

She paused and said, “I want all of you to think about how we can fix that.”

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.

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