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Patient transportation is crucial issue affected by ConnectCare's decision to reduce services

This article first appeared in the St. Louis Beacon: The reduction of health programs at ConnectCare will go beyond important specialty medical services and will extend to the crucial transportation network that has made it possible for some patients to get treatment at the site at 5535 Delmar Blvd.

Health planners said they will be scrambling to figure out which medical systems can provide specialty care to the more than 10,000 patients being displaced by ConnectCare’s decision. The planners promise to find transportation to alternative facilities.

Primary care services at ConnectCare will continue without interruption.That’s one message ConnectCare wants to send to patients, says Melody Eskridge, the facility’s president and CEO.

“Over the years, any time there has been a change in services or if money is an issue or funding is being cut, people hear different things out of that,” she says. “They tended to stop accessing services because they thought we were closed. We are still open; we are not closing. We are here to serve the needs that we are able to serve.”

ConnectCare is a relatively small but crucial part of the region’s network for treating the needy. The two largest providers of Medicaid specialty services for this population are Washington University School of Medicine and SLUCare, treating 53,864 and 28,035 patients, respectively, in 2011. Barnes-Jewish Hospital treated another 17,349 and the JFK Clinic at Mercy treated 2,485 that same year.

The public might be surprised how crucial transportation is to the region’s health care network for the poor, even when general public transportation is available. Eskridge says the facility operates 11 wheelchair lift vans and two minivans. That service ends Oct. 1, she says, but could be extended a week or two if an extension is needed while an effort is made to find a vendor.

She said the facility had spent down $12 million in reserves because it had assumed that Medicaid would be expanded in Missouri. As Missouri moved toward expansion, more patients would access the new care model model, called Gateway to Better Health. That system provides the needy with a card that allows them to access health care at various sites, with the federal government reimbursing the institutions for provided services.

One problem, she said, was the complexity of getting patients signed up for Gateway. Plenty of patients were interested, but she says the enrollment process took time, might have required more than one visit, and/or required more identification than some were able or willing to provide. In addition, she said some prospective enrollees failed to complete the process out of fear that signing up might affect other benefits they were receiving.

But she said the biggest issue contributing to ConnectCare’s decision to reduce services was the refusal of state lawmakers to expand Medicaid. Doing so would mean extending health services to more of the needy at the bottom and bringing in more revenue from Medicaid services provided by ConnectCare and other providers.

She says, “Lots of medical folk are saying expansion is a good idea, but that gets drowned out in the noise,” such as the argument that health care is costing too much and politicians expressing “philosophical” opposition to Missouri’s program.

The absence of additional Medicaid funding has led ConnectCare to eliminate jobs. Another 88 of ConnectCare’s 160 workers will be laid off on Oct. 26. The workers will get severance pay and job placement assistance, Eskridge says.

Transportation to health services

“I do not know of a study on barriers to health care that does not include transportation as a major barrier,” Eskridge says.

She adds that patients have many reasons they are unable to use Call-A-Ride or other public transportation. She cites a “few reasons off the top of my head” that might account for the challenge:

• They do not qualify for Call-A Ride or can't afford it

• They can't purchase a Metro pass because they don't have sufficient cash at one time

• They might have bus fare today to get to work and home, but not the fare to get to work, get to a medical appointment and get home

• The medical appointment is on a work day and using public transportation would require missing too many hours off work or missing work entirely

• They live in a neighborhood where they are afraid to walk to the bus stop

• Their physical limitations prevent them from walking to the bus stop

“We know that we have a problem that we need to solve,” she says.

“Medicaid expansion is a must. If you are an adult in Missouri, your income has to be below 19 percent of poverty to qualify for Medicaid.”

Under expansion, any person earning up to 138 percent of poverty would qualify in Missouri and across the nation. In addition, the insurance exchange system is supposed to help others earning between 100 percent, or $23,050 for family of four, and 400 percent of poverty or $88,000 for a family of four.

Revisiting Medicaid expansion

State GOP lawmakers, who control both the House and Senate, have promised to revisit the Medicaid issue in the next legislative session, but they have not promised to expand the program. Opponents point to voter support of Prop E, which forbade the governor or state workers from doing anything to speed up Medicaid expansion in Missouri without approval of state lawmakers or voters.

Some respond that it’s possible many voters didn’t know much about the federal law when they cast ballots on Prop E. Opponents of the proposition point to the latest tracking poll by the Kaiser Foundation, showing that a large share of voters remains confused about the law’s status. It shows that 44 percent either think the law has been repealed (8 percent), overturned by the Supreme Court (5 percent), or unsure whether it remains the law or not (31 percent).

Robert Fruend, CEO at the Regional Health Commission, called ConnectCare a crucial piece of the puzzle for assuring that poor people have access to medical services. He also says it’s troubling that workers are being laid off.

“I don’t want to diminish this day,” Fruend says. “It’s a sad day when we lose an access point because we didn’t extend Medicaid.”

He regards the refusal to expand Medicaid as a major blow to health care access for the region’s needy. He says creating the Affordable Care Act without expanding Medicaid is like “having a new car without an engine. It looks good, but it won’t go anywhere.”

He says the commission is taking the lead, at ConnectCare’s request, to find other providers to fill the gap. Fruend says his group is asking existing providers as well as other hospital systems, such as SSM, to help.

Meanwhile, he points out that ConnectCare isn’t the first in the region to announce job cuts in relation to changes in government health care policies. The first, he notes, was BJC HealthCare. These reductions are just the beginning of similar cuts in health systems across Missouri due to some provisions of the Affordable Care Act and particularly the decision not to expand Medicaid, Fruend says.

ConnectCare opened in 1997 following the shutdown of Regional Medical Center. It initially was funded from disproportionate share payments that normally went to hospitals. Fruend and others sought a federal waiver to allow that money to go to ConnectCare and other clinics. Last year, the funding model changed when St. Louis got a grant through Gateway to Better Health. It was charged with enrolling poor people who were ineligible for Medicaid.

Under the plan, those enrolled were supposed to be moved into an expanded Medicaid system. But that plan is in limbo because state lawmakers didn’t expand Medicaid. The region is now seeking a waiver to extend the Gateway program. That idea has support from U.S. Sens. Claire McCaskill, a Democrat, and Roy Blunt, a Republican; and from the area’s two U.S. House members, William Lacy Clay, a Democrat, and Ann Wagner, a Republican.

Federal officials have yet to say whether they will grant the waiver.

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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