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Delta residents deal with lack of insurance

- The Washington Times - Sunday, September 6, 2009

MOUND BAYOU, Miss. | The segregated Mississippi Delta was no place for a black person to get sick in the 1940s.

Black doctors, and even some white ones, would treat black patients, but hospital beds were few and far between. Into that gap stepped the Taborian Hospital, built by a black fraternal order in Mound Bayou, a town incorporated in 1887 by former slaves, to provide care the farmhands, entrepreneurs and professionals couldn't get elsewhere.

The hospital was an early adopter of prepaid services — annual dues of $8.40 entitled an adult to hospital care and burial benefits, while the fee for a child was $1.20 per year. It was the precursor to what eventually became the modern system of health insurance.

Taborian Hospital shut its doors more than two decades ago, and Mound Bayou now sits in the heart of an area with some of the nation's lowest rates of health insurance coverage. In fact, Nielsen Claritas, a demographic research firm, says fewer households are insured in the Greenville metropolitan area, right next door to Mound Bayou along the state's western border with Arkansas, than anywhere else in the country.

The root causes of the shortfall are simple: Bad economic times, coupled with the traditional agriculture-based economy, mean many businesses here simply don't offer coverage to their workers.

The solutions, however, are not as easy to pinpoint.

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It's the new segregation, though one that this time breaks down along the lines of health care coverage, not race. But the tradition of Taborian Hospital also lives on in the doctors who reach out to uninsured patients, and in the clinics that have sprung up here and throughout the country tailored specifically to those who don't have health coverage.

As Congress and the country grapple with how to overhaul the nation's medical care system and extend health insurance coverage to everyone, that same debate is taking place in the Mississippi Delta, where its effects are most acute.

DELTA WOES

It's a running joke that Mississippi ranks near the lowest of all the states on just about every bad list — from education to obesity to quality of life. But people here say the untold story is that if you took the Delta population out of those calculations, the rest of Mississippi would probably jump up to middle of the national pack.

To illustrate that point, Delta doctors tick off some of the health problems where their region is among the nation's worst-off, including high infant mortality rates; low birth weight; soaring rates for diabetes, hypertension and stroke; and high incidence of stage three and four breast cancer in women.

Dr. Aaron Shirley, a doctor who has pioneered trying to extend health coverage to the uninsured, says some of those problems are a direct result of lack of insurance.

For example, low-income women generally can't sign up for Medicaid until they are actually pregnant. That delay means prenatal care starts later, which translates into lower birth weights and a higher chance of medical complications early in life.

Sitting in a cluttered office at the Jackson Medical Mall, an innovative project Dr. Shirley started to help make health care more accessible, he said the government was to blame for failing to sign up those who are eligible for Medicaid, even though Mississippi gets more federal matching money for each of its own Medicaid dollars spent than any other state.

Under a recent change, Mississippi also requires Medicaid recipients to have an annual face-to-face meeting with a program employee, often at a tough-to-reach location. It was designed to cut down on fraud and has cut the state's Medicaid rolls, but doctors say it has kept eligible people from getting coverage they're entitled to.

"Historically, policymakers in Mississippi have resisted Medicaid-like programs, and it's linked to the notion that in the early days it was perceived as a handout to black people," Dr. Shirley said.

LOCAL EFFORTS

The doctor has taken matters into his own hands. He arranged to have a satellite Medicaid office opened in the medical mall, one easier for applicants to get to. And he's pushing for innovative reimbursement plans to get folks under a doctor's care earlier in the process, and then have government-sponsored health care kick in when it can.

Dr. Shirley has been through the health care fights before. He was part of President Clinton's health care task force in the 1990s, and was part of the Citizens Health Care Working Group that Congress created a decade later to re-examine the issue.

He's a fan of a single-payer system, in which the government guaranteed health care coverage for all. But he acknowledged that that is not politically realistic right now, so he supports what President Obama is trying to do. Mr. Obama has proposed pushing companies to either cover employees or pay higher taxes to help pay for government subsidies, and has proposed a taxpayer-financed "public" plan that would guarantee a basic level of coverage.

"The status quo doesn't work. The status quo will only make things worse over time," the doctor said.

PUBLIC DOUBTS

That's not the way the doctors and nurses at the Good Samaritan Health Center in Greenville, a couple hours' drive northwest of Jackson, see it.

Sitting around a table on an August afternoon, with stethoscopes still slung around their necks from their patients' visits, they have dedicated their practice to caring for the "working uninsured," and say they fear the pressures from a government-sponsored optional health plan will change care for the worse.

"I think you'd have to ration [health care] eventually," said Dr. John Estes, a doctor at the clinic.

Susan Prather, a family nurse practitioner, says she fears a public option plan would drive down payment rates for specialists, creating both a shortage of doctors and waiting lists for patients to get care.

But the clinic staff does highly praise proposals to digitize electronic records, predicting it will both cut costs and improve overall care.

Doctors here know the problems of the uninsured: Greenville ranks as the metropolitan area with the highest rate of uninsured households of anywhere in the country, according to Nielsen Claritas. The firm estimated that 34 percent of local households lack coverage.

The doctors tick off a list of ailments common to the region, with Dr. Estes estimating that 70 percent of his patients are diabetic or have hypertension.

The explanations for lack of insurance that apply in other places — healthy 20-something workers who elect not to buy insurance, or noncitizens ineligible for government programs — don't explain the numbers here.

The immigrant population is small, and it is farmers and small business owners who generally decide they can't afford to offer insurance, not workers who refuse it.

Kim Dowdy, the clinic coordinator, says they don't see a lot of people who "could afford [coverage], but don't."

INTO THE BREACH

The silver-bullet solution would be more economic development. But that's not coming any time soon, so like Taborian Hospital decades before, clinics like Good Samaritan have stepped into the breach.

Founded in 2006 as a ministry by local churches, business owners and health care workers, the clinic today has about 675 patients, and gets two or three new applications every day.

Less than 10 percent of the funding comes from patients' fees, which means the rest must be made up from partnerships, charitable donations or grants.

In the absence of a full government overhaul, Good Samaritan's staff has suggestions for how to improve things. They've pioneered something called the Delta Plan, a type of health cooperative that allows local small businesses to enroll their employees at the clinic for $100 a year per worker.

As for the shortage of medical workers, Mrs. Prather, the nurse, said a simple tweak of the rules would help. She said that while nurses who practice at clinics that take Medicare or Medicaid patients can get their student loans repaid, she can't — even though Good Samaritan sees the same kinds of challenging patients.

And the doctors here say the national debate in Washington has fallen short because the main reform plans are not looking at tort reform to control the lawsuits that drive up medical costs.

Dr. Estes said he figures costs are inflated between 10 percent and 15 percent because doctors run extra tests to protect themselves from lawsuits.

And his colleague John C. Sandefur, one of the volunteer physicians at the clinic, says race still plays a role in malpractice in the region.

"If you're a white doctor and you have a bad result with a black patient, and you get a bad jury, you lose, your rates go up," said Dr. Sandefur said. "We need a national tort [system]. That's been a bad situation."

MAKING THINGS WORSE

It's one of the ironies of health care here that government has contributed to the very problem it is desperately trying to solve.

With corn prices high — due in large part to government support and subsidies for corn-based ethanol fuel — farmers are switching to corn from cotton. But cotton is a more labor-intensive crop, which means farmhands are losing work in the switch — leaving more families without a job or the means to buy insurance.

Those are just some of the folks who show up at Tutwiler Clinic, founded in 1983 by Dr. Anne Brooks, a Catholic nun.

The poster on the back of Dr. Brooks' office door — "Early Management of Acute Agricultural Pesticide Exposure" — tells a lot about some of the patients the clinic sees. In addition to farmhands and those who work in the farmhouses, there are both a local jail and a state prison nearby.

But more than a third of Tutwiler's patients are not employable because of illnesses or other conditions, and a quarter of the rest of the patients could work, but have no job.

One of those is Nellie Martin, 59, who on a recent afternoon was sitting in an office while Sister Cora Lee Middleton, a registered nurse, explained her medications.

Ms. Martin lost her health care coverage about five years ago, when she was let go from her last job making between $9 and $10 an hour, which she called "pretty good money" for these parts.

She suffers from diabetes and hypothyroidism and takes four medications regularly — two of which are paid for out of her grandson's government aid check and the other two of which are subsidized by the drug companies themselves.

Ms. Martin hopes to make it to the age when she can apply for Medicare, but says in the meantime she would love to see a health care bill pass.

Sister Cora Lee Middleton, a nurse and the clinic coordinator for Tutwiler, said clinic officials see a number of heartbreaking ironies among their patients.

She said one patient had to stop working because of a shoulder injury, but could go back to work — if only the patient could get rotator-cuff surgery.

And the poverty is a self-defeating cycle here. Sister Cora Lee said folks can't afford dental care, so they end up with bad teeth or dentures, and have to eat soft foods. For poor folks, that means buying calorie-filled, non-fresh foods — which contributes to obesity, diabetes and other lifestyle ailments.

So once a week, a dentist from neighboring Clarksdale comes to see patients, and once a month an eye doctor comes.

Tutwiler asks patients to pay what they can, but that leaves a giant hole — about three-quarters of the clinic's planned 2008-09 budget — to be filled from charitable donations. In a down economy, the donations drop off and the clinic must scramble to make up the difference.

A DISTANT MIRROR

The debate in Mississippi mirrors the national debate, with advocates begging for help and worried taxpayers afraid that a new program will bust the government's budget — something Rep. Bennie Thompson, the nine-term Democratic congressman who represents the district that includes Greenville and Mound Bayou, found out in several town halls last week.

To an audience of at least 750 people packed into an Elks Lodge in Jackson, Mr. Thompson said he doesn't begrudge the "plantation owner" who takes government crop subsidies, but said it's time that person repay by supporting more government spending for health care.

"I'm not going to let that plantation owner tell me I'm not going to help 47 million people get health care," Mr. Thompson said.

The room was filled with supporters holding pre-printed signs, but some constituents bucked the trend and demanded the congressman promise to oppose any taxpayer funding for abortion or for illegal immigrants gaining access to government-sponsored health coverage.

"It's not in the bill," Mr. Thompson kept repeating, at one point dropping the 1,000-plus-page document with a thud on the stage behind him to emphasize its complexity.

He told his constituents he'll go back to Washington and support Democrats' efforts, calling it his Christian duty.

Across the state, however, another Democrat, Rep. Gene Taylor, takes the opposite stance, and is not shy about it.

Earlier in the summer, Mr. Taylor, one of the most conservative Democrats in the House, released a statement calling taxpayer advocacy group Americans for Tax Reform "lying sacks of scum" for suggesting he approved of the Democratic leaders' bill.

Mr. Taylor reiterated his opposition in several town halls during August, with local news reports saying he drew a standing ovation when he told one crowd he won't be casting a vote for the bill.

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