Access denied

Worrying has become a way of life for Tracey Grable. Today, it won't allow her to relax into the soft couch in the lounge of the Ruopp and Ruopp dental office in Cape Girardeau. Hands wringing in her lap, the Oak Ridge mother constantly shifting her posture to get a better view of her 8-year-old son Tristen, who's having the roots of two broken teeth extracted in the adjoining room.

Born blind, blue-eyed and albino, Tristen has undergone five surgeries to correct his vision and two other procedures for his tonsils, adenoids and sinuses. Compared to that, a simple tooth-pulling may seem like a professional flossing, but still, Tracey worries. She worries foremost about her son, his pain and well-being. But in the back of her mind, she can't help but worry about the bill.

Since Tristen's birth, Tracey has lived with the worry that many parents and people in her situation know: Without insurance, affordable and adequate health, dental and mental health care is hard to find.

In Cape Girardeau County and Scott City, 62 percent of the population is either uninsured, on Medicare or on Medicaid. That is why the Community Assessment Partnership -- formed in 2001 through the United Way of Southeast Missouri and the Community Caring Council -- has rated this problem the second most critical issue facing the people of this area, behind only inadequate transportation.

That may be news for some, but for people like the Grables, it's like the steel needle of Septocaine staring Tristen in the face. Tristen is one of nearly 13,000 children in Cape Girardeau County and Scott City on Medicaid. But being on Medicaid is no guarantee of getting treatment.

"There aren't many dentists that take Medicaid," Tracey says, seeing the needle and wincing in vicarious fear. That is why it had been five years since Tristen's last checkup. A couple of months ago, Tristen brought home a flier from school saying that the Ruopps' dental office was offering one day of free care to children nobody else would see -- mostly Medicaid children -- as part of the national Give Kids a Smile program. Tracey anxiously made an appointment. Today, Tristen is here for follow-up work from that initial examination. Tracey hopes the Ruopps will take Medicaid to cover this visit.

Solutions already available

This is hardly a local problem. But locally there are people who are trying to help.

When the Community Assessment Partnership identified this issue in January, they called the problem "affordable medical care." But since then, the issue has been changed to "accessible" care.

"We realized there was not a lot we can do about affordable care," said Vicki Smith, CEO of Cross Trails Medical Center in Cape Girardeau. "We have no control over the price of care or insurance. With access we can make a difference."

When the issue was changed, the partnership decided to expand it to include two smaller questions that didn't make the final cut but could be related to the core problem of access. Improving access to dental care and mental health care were then included in the plan. Representatives from local schools, city government, health and social services, and community organizations have been meeting to formulate a plan of action to engage the access problem.

Nancy Jernigan, executive director of the United Way of Southeast Missouri, said the plan begins with public awareness.

"We have to make people in need aware of programs that already exist to help them," she said.

Although the Grables learned about their temporary dental solution from a flier, Jernigan said this campaign will have to be more far-reaching than just running newspaper ads and television spots.

"We really don't know exactly how we're going to go about it yet," she said. She suggested it might be accomplished through disseminating literature through different agencies to their clients. "I think we'll want more one-on-one contact," she said.

Two existing resources the partnership wants to better publicize are Cross Trails and the Cape Girardeau County Public Health Center.

Both provide primary health care services -- generally those found in a general practitioner's office -- to individuals regardless of their ability to pay, and they do so through government funding. Both accept Medicare and Medicaid.

Through state, county and some federal funding, the county health center offers immunizations, nutritional supplement programs, asthma case management and HIV/AIDs case management and provides screenings for breast and cervical cancer and family planning. Director Charlotte Craig said the center emphasizes preventive and primary care for the young, middle-aged and elderly.

Cross Trails is a federally funded health center with clinics in Cape Girardeau, Marble Hill and Advance. In addition to taking Medicaid and Medicare, Cross Trails also offers a sliding fee scale to patients who qualify. That scale reduces charges for patients based on the number in the family and the average monthly income.

Cross Trails also offers dental care in its Marble Hill clinic, mental health care by referral and patient prescription assistance.

Contact

Clara Southerland found out about Cross Trails in the one-on-one fashion Jernigan talked about. She heard about the clinic through Christ Church of the Heartland. It may have saved her life.

Southerland, 42, was a licensed practical nurse before her legs were injured in an automobile accident in 2000, forcing her to go on disability. But Southerland said she had to wait two years without medical insurance until Medicare kicked in to help with the medical bills. Medicare doesn't fully pay for the medicine she needed to control her diabetes and high blood pressure.

To compound matters, Southerland's husband, Willie, was forced onto disability when arthritis in his back prevented him from performing his duties as a substance abuse counselor. In 2001, not long after Clara's accident, he suffered a pair of strokes, putting him in the hospital with only Medicare to help pay the bill.

"We still owe the hospital $11,200 on the 20 percent we had to pay for his stay and his tests," Clara said.

After he left the hospital, doctors had Willie on 17 different medications for residual stroke effects, diabetes and a number of other ailments. As the bills piled up, the Southerlands, who live in Fruitland, found themselves facing a grim choice.

With a prescription bill of almost $1,000 a month devouring their meager income from Social Security and disability, the Southerlands decided that since Willie's condition is more severe than hers -- he is 10 years her elder -- she would go off of her blood pressure and diabetes medication so the family could afford to live. For 14 months, Clara went without medication while she waited for her Medicare take effect.

"There was just no other way we could afford it," Clara said. "The spin down for Medicaid is more than Willie receives from disability. We felt that I could survive." Spin down is the patient's co-payment.

Looking back, Clara said she doesn't think she would've made it if they hadn't found out about Cross Trails' prescription assistance program. Through the program, patients receive free medication from pharmaceutical companies. Now the monthly medication bill for both of them totals $150.

The Southerlands think they can scrape by for now. They recently absorbed the cost of a faulty water heater and Clara's car breaking down. But they have to take it day by day. They know how quickly things can fall apart.

"It's just sad that we ever had to make that choice," Willie said of his wife having to go without medication. "There should be something that could be done. There has to be a better way."

Searching for a better way

There is a backlog of files like those of the Southerlands and the Grables. The Cape Girardeau County Public Health Center and Cross Trails can't even begin to address them all. Even though Cross Trails is planning to open another Cape Girardeau clinic that will offer dental care, Smith doesn't dream that the increasing need will be met.

"We could hire 10 more doctors and still be backed up for a year," she said.

Smith has tried to recruit help from the medical and dental community with little success. She addressed dentists at a regional conference, asking for someone who would help by taking Cross Trails' referrals. She said not one took her up on her offer.

Cape Girardeau dentist David Johnson said that simply isn't true. He said he was at that conference and said he knows of several dentists, including himself, who accepted referrals from Cross Trails. Johnson said that 40 to 50 percent of his practice consists of Medicaid patients, and that more than half the practices in Cape Girardeau can show a similar statistic.

Johnson said the truth is that dentists just aren't taking any new Medicaid patients.

"Most of us are already overwhelmed with Medicaid patients," Johnson said. "For anyone to ask us to do more is ludicrous."

Johnson believes the problem is that the state has taken a Medicaid payment model for general medicine and applied it to dentistry when the two are completely different animals.

"Most dentists would rather treat Medicaid patients for free than deal with Medicaid," dentist Dr. Janet Ruopp said.

She said that due to the inordinate amount of paperwork and the small reimbursement from Medicaid, it often makes more sense to do the work for free. With the high overhead of running a private dental practice -- 70 percent of gross income by Johnson's and dentist Pat Ruopp's estimation -- dentists can't find it feasible to do on a more regular basis.

"Medicaid pays at about 30 percent of the regular fee," said Pat Ruopp. "When you're taking Medicaid patients, you're basically operating at a loss. Most practitioners just can't afford to do that."

Craig, Smith and Jernigan all agree that for any progress to made in the battle for more accessible health care, the entire community has to buy into the effort. They need to know there is a problem and work to better understand that problem. They also agree that it will be gradual task. They'll just have to chip away.

The partnership is still ironing out the specific goals for its assessment. Beyond creating more awareness, Jernigan said they really aren't quite sure of how they're going to go about fixing the problem. They've discussed initiating preventive dental care programs and forming a youth mental health task force to explore and improve awareness of and access to existing mental health services.

But as they meet to ponder the how, they know the who, they know the what and they know the why. They know there is a shortage of doctors and dentists who will take uninsured patients and those on Medicaid and Medicare. They know there's an overall shortage of psychiatrists for the growing number of those seeking mental health care, and they know there are people in need like Tristen Grable.

Back at the Ruopps' office, Tristen lets out a shriek as the dentist injects the local anesthetic.

Tracey can hold back no longer. She bolts into the room to take Tristen's outstretched hand. "I'm right here, bubby."

"We've got a nose bleed," calls out Pat Ruopp.

"Oh, I should've warned you guys that when he gets upset his nose bleeds," Tracey says, wiping the blood from Tristen's nose.

Tracey said those oft-bursting capillaries could be corrected with some allergy medication, but Medicaid won't pay for it. As a result, he may have to undergo another sinus surgery to fix the problem.

"I want to go home," Tristen says in a muffled cry. Tears are streaming down his cheek.

Tracey grimaces. "It'll be over soon, bubby."

trehagen@semissourian.com

335-6611, extension 137