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Safety Net Clinics At Forefront Of Debates On Controversial Issues

Jim McLean
Heartland Health Monitor

Kansas hospitals are leading the push for Medicaid expansion.

But they’re not the only providers for which expansion is a critical financial issue. It’s also a priority for the safety net clinics that exist to provide free and reduced-cost care to low-income Kansans.

Two-thirds of the people who rely on the clinics live under the federal poverty line: annual income of $11,670 for an individual and $23,850 for a family of four. Virtually all of them would qualify for KanCare — the state’s privatized Medicaid program — under expansion.

“KanCare expansion is a big issue for us,” says Denise Cyzman, the still relatively new executive director of the Kansas Association for the Medically Underserved.

Cyzman was hired last fall to succeed Cathy Harding, who left to become chief executive of the Wyandotte Health Foundation. Prior to taking the KAMU job, Cyzman was a vice president for the National Kidney Foundation of Michigan.

The KAMU clinics provided care to more than 250,000 people in 2014. However, because many patients couldn’t afford to pay their bills, the clinics ended the year with $44 million in uncompensated care on their books.

Expanding KanCare eligibility to low-income adults would greatly reduce that financial burden, Cyzman says.

“It could generate all the way up to the $44 million,” she says. “But even if we get only a portion of that covered through KanCare, it would be a tremendous economic boost for our clinics.”

The clinics have estimated that expansion would lower their uncompensated costs by at least $25 million, Cyzman says.

Jason Wescoe, chief executive of the Health Partnership Clinic, says KanCare expansion would generate another $1.5 million in revenue for his Olathe-based clinic, which has an annual operating budget of about $5 million.

“Putting $1.5 million into this organization means I hire more doctors, hire more nurses and open more clinics,” Wescoe says. “It seems so simple from where I sit.”

But the politics of the issue is anything but simple. 

The connection between Medicaid expansion and President Barack Obama’s Affordable Care Act has created widespread opposition to it among Republican governors. Some have negotiated alternative plans  that use federal Medicaid dollars to expand access to private coverage and require recipients to share in the cost of their care. But several of those proposals have run into opposition from GOP legislators.

In Kansas, Gov. Sam Brownback and Republican legislative leaders have so far refused to consider expansion. The Kansas Hospital Association is crafting a proposal that it hopes will appeal to the governor and his fellow conservatives.

The safety net clinics are ready to help lobby for the KHA plan, Cyzman says. But based on preliminary conversations with legislators, she doesn’t expect it to be an easy sell.

“There are more and more (legislators) who say, ‘Well, we’re interested in thinking about it, but we’re really concerned about how the state is going to pay for it,’” Cyzman says. “Until we can figure that out, it’s going to be really challenging to get it through the Legislature.”

The federal government has promised to pay the full cost of a state’s Medicaid expansion through 2016 and at least 90 percent after that. A study commissioned by the Kansas Hospital Association estimated expansion would cost the state an additional $312 million through 2020.

An expansion bill, House Bill 2270, introduced by a committee controlled by moderate Republicans would give the secretary of the Kansas Department of Health and Environment the authority to levy fees on hospitals and other providers to offset the state’s portion of the expansion cost.

It’s not known what financing mechanism, if any, will be included in the hospital association’s bill, which could be introduced as soon as this week.

Fending off budget cuts

The same budget issues that have legislators concerned about the cost of Medicaid expansion are threatening the approximately $8.2 million in funding that safety net clinics receive from the state.

A bill signed Tuesday to plug a $344 million hold in the state’s current budget included a cut of $254,000 for the clinics. 

But lawmakers are resisting Brownback’s plan to reduce funding to the clinics by another $378,000 in the next budget cycle.

Members of the House Social Services Budget Committee recently voted to restore the proposed cuts and instead take the money out of the Kansas Department of Health and Environment’s administrative budget.

“They (the clinics) do exceptionally well with the limited funding that they have,” said Rep. Kristey Williams, a Republican from Augusta, as she made the motion to restore the funding.

The bipartisan legislative support the clinics historically have enjoyed is due to the “great work” they do, Cyzman says. But she says she isn’t taking it for granted that support will be enough to spare the clinics as lawmakers struggle to balance the budget in the face of plummeting tax revenues.

“We don’t feel like we’re out of the woods at all,” she says.

Filling the oral health gap

As if Medicaid expansion and the budget crisis weren’t enough, Cyzman stepped into another long-simmering debate when she accepted the KAMU job. The association is a leading member of a coalition pushing for a change in state law to allow for the licensure of a new kind of mid-level dental provider.

Opposition from the Kansas Dental Association has effectively blocked consideration of the mid-level proposal for several years.

Kevin Robertson, KDA executive director, has said repeatedly that the training that dental hygienists would be required to complete to become mid-level practitioners “is simply not adequate” to master the restorative and surgical procedures the proposed changes would allow them to perform.

But Cyzman is among those who maintain that licensing mid-level providers and requiring them to work under the general supervision of dentists is no different from what the state allows doctor-supervised advanced practice registered nurses to do: diagnose and treat patients.

“Nurse practitioners have freed up doctors,” she says. “We can do the same for dentists. We can increase access to care and give our dentists the opportunity to provide the higher-level, complex care they are trained to do.”

Several safety net clinics offer dental services. But recruiting dentists is difficult. Licensing mid-level practitioners would expand the recruiting pool, Cyzman says, and help to alleviate a documented shortage of dental providers in 95 of the state’s 105 counties.

Editor’s note: The coalition advocating for licensure of mid-level dental providers is supported by the Kansas Health Foundation, which also provides most of the funding for the Kansas Health Institute, the parent organization of the editorially independent KHI News Service.

Jim McLean is executive editor of KHI News Service in Topeka, a partner in the Heartland Health Monitor team.

Jim McLean is a political correspondent for the Kansas News Service, a collaboration based at KCUR with other public media stations across Kansas. You can email him at jim@kcur.org.
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