The Crested Butte News Serving the Gunnison Valley since 1999
More work ahead for getting everyone insured, containing costs
When it comes to health care, Gunnison County is actually well-insured compared to other communities in Colorado. But there are still cracks to fill and a steep learning curve to climb when it comes to getting everyone covered and comfortable with how it all works. Many residents remain uncovered, or underinsured, and many who are newly insured struggle to navigate what is still a cumbersome, complicated health care system.
In 2010, about 80 percent of Gunnison County residents had some form of health insurance. That was the year the Patient Protection and Affordable Care Act (PPACA) was passed. Looking closely at the numbers, Gunnison County Public Health (GPH) found that seniors on Medicare were major contributors to that statistic, while many younger residents went uninsured. So Public Health trained its sights on the 18-64 year age demographic, with a goal of getting 80 percent of those residents insured by 2015.
Patient facts and figures…
“We’re now already at 85 percent,” said Renee Brown, director of Public Health. A chunk of that increase comes from the PPACA’s expansion of Medicaid for those with low incomes. In April 2013, there were 539 adults in the county covered by Medicaid.
By April 2014, that number had nearly tripled, to 1,418. “There’s also a sizable increase in children covered,” Brown said. Add that to a high rate of enrollment in PPACA subsidized policies through Connect for Health Colorado (CHC), and overall coverage for local residents shot up dramatically, from 76 percent covered last winter to 85 percent today.
“We were seventh highest of all 64 counties in Colorado in enrollment,” said Brown, “and second highest for counties of our size.”
Some folks logged onto or called Connect for Health Colorado (CHC). That’s the state organization charged with signing people up for health insurance under the new PPACA program. Others went through a local insurance broker, who specializes in the new health coverage plans. “Gary Schondeck enrolled about 700 people,” said Brown. “About 40 of those were previously uninsured.”
Prospective enrollees were directed first to a questionnaire that solicits income information to determine whether the applicant is eligible for Medicaid. Those disqualified from Medicaid were assigned a subsidy based on income and sent to shop the CHC marketplace. The more comprehensive the coverage provided by a given policy, the higher the out-of-pocket premium. “The Affordable Care Act requires insurance companies to provide a minimum standard of coverage,” said Brown, “and there is a catastrophic option.”
The breakdown goes as follows: Catastrophic care is cheapest, a viable choice for the young and healthy who need insurance only in case of major accident. Bronze plans offer 60/40 coverage. That’s 60 percent covered by insurance, 40 percent covered by the patient. Silver plans are 70/30, Gold are 80/20 and Platinum are 90/10.
Additional variables include deductibles and required co-pays. In general, more coverage with a lower deductible means a higher monthly premium. The Affordable Care Act also limits out-of-pocket costs to maximum $6,350 for an individual plan and $12,700 for a family plan. That maximum includes deductibles and co-pays. The idea is to prevent people from losing their homes to pay for health care.
The new target for GPH is to have 90 percent of Gunnison County residents insured with some sort of coverage by 2016.
More citizens with health insurance is generally viewed as a good thing, but there are caveats.
“One concern is, ‘Do they know how to use it?’” said Aging Adult Services manager Karin Stewart. Many of the newly insured have never had health insurance before, so are unfamiliar with the lingo. “Deductibles, co-pays, etcetera. There’s some education to be done there,” she said.
More people covered by insurance means more people are likely to go to the doctor when they’re sick. That’s nice, provided they can get an appointment. “The good news is that a practice like Gunnison Valley Health now has expanded hours, and they’ve added a nurse practitioner,” said Brown. “I think they’re seeing 100 patients a week. The Town Clinic of Crested Butte also has expanded hours, to include weekends.”
“Now we also have more people with a mental health benefit too, so they can seek treatment,” said Stewart.
“The big piece that remains,” said Brown, “is ‘How do we work to contain the rising cost of healthcare, and, is the system efficient?” Brown sees Public Health’s role as not merely helping people find an insurance plan and navigate that system, but recognizing their options in obtaining services and getting the most of their health care. “It’s an opportunity for enhanced personal responsibility,” she said, not only for learning to make healthy choices in life, but for “shopping around.”
“And to know they’re allowed to do that,” said Stewart. Too often, she said, patients simply accept the price they’re being charged for a given service or medication. Teaching people to compare costs not only gets them the best price, but sparks competition. Brown and Stewart want locals to become savvy health care consumers.
“Outreach includes connecting directly with Medicaid patients, helping to provide a continuity of care for those clients,” said Brown. “You have preventive options with Medicaid. We look at high utilizers of emergency rooms.”
Things have improved on the healthcare front, but Brown sees room for improvement. “It’s good,” she said, “but I think we have to ask ourselves, ‘Is this really the best we can do?’”
Seniors on fixed incomes worry Brown most. “If your income is $1,000 per month,” she said, “and you’re paying $200 to $300 for supplemental insurance to your Medicare—health care costs should not be 30 percent of your income.”
Many small businesses cannot afford to provide health care coverage for their employees, but the PPACA subsidies provide some affordable options not available before. “Some employers have opted to provide a stipend, so the employee can go and shop on the exchange,” said Stewart.
From the doctor’s perspective…
“We have been affected,” said Marsha Thorson, office manager for the Crested Butte Town Clinic. “There’s definitely been an influx. The biggest is related to the Medicaid expansion. We accept Medicaid, but some physicians don’t see those patients, and some put a cap on the number of Medicaid patients they see.” Medicaid, she said, “pays about 50 cents on the dollar,” and only for the doctor’s visit. It doesn’t cover peripheral support or paperwork.
“We’re also seeing people who didn’t seek services before for nagging conditions they’ve been putting off for years because they couldn’t afford,” added Dr. Eric Thorson.
While Medicaid is considered public insurance, those covered via the exchange, even though subsidized, are a part of the private insurance provider system.
“Insurance, regardless of whether it’s pubic or private, is a bear,” said Marsha Thorson.
One thing people new to health insurance have trouble understanding is what portion of the bill is their responsibility versus what’s covered by their policy. “They now pay a premium and are also paying on a deductible, and they’re frustrated by that,” said Eric.
The maximum out-of-pocket provision is a big help, said Marsha. “In the past,” when faced with a mountain of medical bills, “people were filing for bankruptcy,” she said.
The Thorsons devote whatever time they can to education, helping patients understand the terminology, how deductibles and co-pays work, etc. That effort, said Marsha, is not restricted to the newly insured. Many who’ve had insurance for years also struggle to understand how it all works.
The Thorson’s agree that having more people covered is a positive step, but, “We still haven’t addressed the fundamental flaws in the system. It’s still broken,” said Marsha.
“The need for insurance coverage drives a wedge between doctor and patient,” said Eric. “At the end of the day, we’re focused on, ‘How much is this going to cost?’”
Insurance in general, public or private, is a bit of a crapshoot for doctors. “If you go to a restaurant,” explained Marsha, ”you pay for your meal right then. If you pay your doctor with insurance, he’s lucky to get paid within a month. More often it’s a minimum of three months before the insurance company decides if they’ll cover the treatment.” Sometimes it’s six months, she said, or as long as a year, with no guarantee a treatment is even covered. If coverage is denied, then clinics are faced with billing patients directly, and in many cases those patients cannot afford that cost.
Taking a bite out of dental care shortcomings…
“Oral health is also a priority,” said Brown. Medicaid offers dental care, so with the expansion, more people than ever have coverage. The trouble, said Brown, is that only one dentist in the county accepts Medicaid.
“We do it as a service to the community,” said Gunnison Family Dentistry’s Amanda Thiede. “We aren’t in it for the money.” Dr. Brady Bichon sees Medicaid patients the first two Wednesday afternoons each month. “Our focus is primarily on kids,” said Thiede. Bichon sees children as needed, but accepts only one new adult Medicaid patient per month. They’re currently booked solid with Medicaid patients through the end of the year.
“There are also two hygienists who accept Medicaid,” said Thiede. One is Tricia Kubisiak of Brighter Image Dental Hygiene in Crested Butteand Leslie Hearn of Healthy Smiles accepts Medicaid kids under age 21. Hygienists clean teeth, but are not equipped to do comprehensive exams. “If Tricia notices anything, there’s a dental clinic in Montrose where she can refer people,” said Thiede.
“It’s a flawed system,” said Jennifer Flynn of Gentle Dental in Gunnison. Dental insurance provided as a provision of the PPACA through Delta Dental, she explained, carries with it a restricted provider list. “So all those people got what they thought was a great plan [on the Connect for Colorado Exchange or through Medicaid] only to find out nobody in Gunnison is on that list.” By contrast, there is no restricted list for Delta Dental customers covered through an employer.
“The reimbursement methods through the third-party processor used by Medicaid creates accounting challenges,” Flynn added. When reimbursements aren’t denied, they’re low. “They only pay $70 for a filling. We can’t put in a filling for $70. It’s not sustainable.” Instead, Flynn said, Gentle Dental provides free dentistry once a week to kids, which they can do without incurring the additional costs associated with filing Medicaid claims.
On July 1, the reimbursement system and third-party administrator changed. “It’s a complete overhaul,” Thiede said, “and a big adjustment with a steep learning curve.” With a mix of skepticism and hope in her voice, she added, “It all looks good on paper.”
Going after the young ones…
One of the biggest challenges to the county in hitting that 90 percent target for health care coverage is convincing 20-somethings they need insurance. “I think the young, invincible population—they were somewhat resentful that they were being forced to pay for something they don’t use,” said Kelsey Vander Veen, certified health coverage guide.
That, added Stewart, is misguided thinking. “You have car insurance before you can drive a car. You ought to have health insurance before you need that.” Allowing parents to keep kids on their policies until age 26 has helped, and foster kids can remain on Medicaid until age 22.
Vander Veen gave the example of a 23-year-old diabetic with no health insurance. “He was low income, and had to pay out-of-pocket. With a subsidy, he was able to get a plan that would cover his care and supplies for about $65 per month.”
“Being covered under your parents’ plan is a huge benefit in a town like this,” said Dr. Thorson, but agreed that selling young people on the merits of buying a policy, even a cheap, high-deductable catastrophic plan, is tough. “The penalty is so low, many would rather just pay it rather than pay a monthly premium,” he said. In 2014, a single adult with household income below $19,650 would pay a penalty of $95 if uninsured. An individual making more than that would pay 1 percent of household income. That fee increases annually, up to 2 percent for a second year of non-compliance. (A single person with an income below $10,150 will pay no penalty at all.)
Brown encourages anyone apprehensive or confused about any aspect of the healthcare process to visit Public Health. “Between Kelsey and our technicians, we can help. Come in and talk to a real person—a friendly person,” Brown said. The number is 642-7301. The next open enrollment opportunity to sign up through Connect for Health Colorado is Nov. 15 through Feb. 15.
