Thread: Prenatal cases flood local clinics for the poor

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Prenatal cases flood local clinics for poor
Robyn Shelton
Sentinel Medical Writer

March 11, 2007

Medical clinics that serve the poor in Florida are being overwhelmed by illegal immigrants and other uninsured women needing prenatal services, creating a looming crisis that already has forced at least one health department to close its doors to pregnant patients.

Two groups that serve the poor in Orange County say they are booked to capacity for prenatal services, with women waiting up to five weeks to get an initial appointment at the busiest locations.

That's the good news.

Mark S. Williams worries that local women may not get care in the future because providers do not have the staff, money or ability to meet the rising need. In Orange County, the number of women seeking prenatal services from these groups has climbed 65 percent since 2002.

"We are at our limit; we have to begin to look at how we can just maintain what we have or reduce the number of patients that we see for prenatal care," said Williams, chief executive officer of Community Health Centers Inc. "If the growth in the region continues -- and we have no reason to believe that it won't -- there will be patients who just aren't going to be seen."

Counties throughout Central Florida are reporting an increasing demand for prenatal services, but Orange stands out for its sheer volume. Its main providers for poor women are the Orange County Health Department and Community Health Centers, a nonprofit organization that offers a variety of health services.

Combined, the agencies treated more than 6,300 pregnant women in 2006, up from about 3,800 in 2002. But doctors say the number of individual women doesn't tell the whole story.

Each patient needs ongoing care during her pregnancy, accounting for a combined 36,292 prenatal visits to both agencies in 2006, an 84 percent increase from 19,718 in 2002. The Orange County Health Department, which has a higher patient load, has opened two additional sites for obstetrics care in recent months and is trying to recruit more nurse practitioners.

"Almost as soon as we open [a new location], we're fully booked with appointments," said Patricia Nolen, the department's program director for women's health.

Yet the problem is not simply the rising numbers -- it's that more patients are uninsured.

Many are illegal immigrants, who do not qualify for government coverage for the poor through Medicaid. But there's also a growing number of uninsured U.S. citizens who earn slightly too much to qualify for Medicaid but too little to buy private insurance.

As a result, providers are treating more women but getting paid for a smaller proportion of their clients.

For example, about 80 percent of the prenatal patients at the Orange County Health Department were covered by Medicaid in the past, leaving about 20 percent who were uninsured. Today, the breakdown is closer to 50-50, said Dr. Kevin Sherin, Health Department director.

Statewide, an estimated 650,000 women of childbearing age have no coverage.

"There's a significant number of moms who cannot access health insurance for a variety of reasons," Sherin said.

This creates crushing budget demands for centers that serve these women.

Demand keeps growing

Danielle Phillips, 21, is among the thousands of prenatal patients at the Orange County Health Department. She works in a clothing store and didn't have medical insurance when she became pregnant. Phillips now is covered by Medicaid and grateful for the care she receives at a clinic near her home.

"I really like it there," she said. "I was surprised at how well they take care of you."

It's expensive to provide the services. This fiscal year, the Orange County Health Department expects to bring in about $3 million from a variety of funding sources to cover women's-health expenditures. However, the total cost of the services is expected to run about $3.4 million, creating a $400,000 shortfall.

Officials say illegal immigrants are contributing to the crisis because of their growing numbers and lack of insurance because of restrictions on the use of Medicaid for non-U.S. citizens. The Pew Hispanic Center estimates there are about 850,000 illegal immigrants in Florida and about 12 million nationwide.

In Florida, these women can get short-term Medicaid coverage for prenatal care while their paperwork is processed, but they quickly drop off the rolls when they do not have valid Social Security numbers and required documentation. As a result, the bulk of their pregnancy care is uncovered.

One way to gauge the growing burden in Florida is through the state's "emergency Medicaid deliveries" that cover births by non-U.S. citizens.

Many of these emergency patients are undocumented, and state statistics show a fourfold increase in their numbers since 1996. That year, Medicaid paid for 4,556 emergency deliveries at a cost of more than $10 million in state and federal funds. By 2006, the number surged to 20,099 deliveries costing more than $85 million.

Turning away patients

Illegal immigrants are just part of the prenatal-care picture. The overall population boom in Florida has been straining the system for years, said Ann Davis, immediate past president of the Florida Association of Healthy Start Coalitions. The coalitions are private, nonprofit groups that help poor, pregnant women and their babies throughout the state.

Davis said Healthy Start's budget was flat for years, and even with an increase last year, there aren't enough funds.

"For years, we did not have any increases, and yet, the fastest-growing segment of our population are young women of child-bearing age," Davis said. "This is not rocket science. There's not going to be enough" money to serve everyone.

Many counties are sounding the alarm about the problems they see down the road. In Okaloosa County, the crisis already forced the Health Department to stop offering prenatal care in July. The small county went from an average of 30 to 40 prenatal cases each month to more than 130 a month in recent years.

Dr. Karen Chapman, the department director, said her local Healthy Start coalition was providing about $167,000 annually to help pay for prenatal services, but the actual cost was almost four times that much. After covering the shortfall for years, the department couldn't do it anymore.

Chapman said poor women now must travel to clinics in other counties or see private doctors willing to put them on payment plans. In the end, she said, some women surely are falling through the cracks.

"It was a very painful and difficult and traumatic decision for us," Chapman said, "but even as a government agency, we still have to make payroll and pay our bills. It's just a real tragic situation."

A look at solutions

In Orange County, advocates for the poor are pushing for a number of changes:

The state could increase the income limits for Medicaid eligibility, as other states have done, so more poor women would qualify for coverage, said Linda Sutherland, executive director of the Orange County Healthy Start Coalition.

Florida could fund prenatal care for illegal immigrants.

Williams said this would be a cost-saver in the long run because women with inadequate prenatal care are more likely to have low-birthweight babies, who often require expensive hospitalizations. Taxpayers end up footing the bill for their care one way or another, he said.

"The immigrant issue is a tough one that people aren't going to agree on," Williams said. "I think there are moral issues here, and there's a right thing to do, but you don't even have to feel that way to see that there are also economic issues."

Private doctors could bring much-needed manpower to the system. In Brevard County, the Health Department has recruited local obstetricians to work for hourly wages in its clinics. Dr. Heidar Heshmati, department director, said the system is financially viable because the hourly compensation is slightly less than what the department can bring in through Medicaid reimbursements.

Until something is done, medical providers expect to grapple regularly with the prenatal-care demands of their communities. More closings are possible.

"It's clearly one of the options that [groups] have to keep in mind," said Dr. William Sappenfield, state epidemiologist with the Florida Department of Health. "They do have a limited budget, so they have to figure out how to provide services, and if they spend money in one direction," then less remains for other needs.

Robyn Shelton can be reached at rshelton@orlandosentinel.com or 407-420-5487.


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There is no need for this crap! We know what is causing the problem and we know the solution to the problem, but unfortunately our elected leadership doesn't have the will to do it.

I hate to think that American citizens are actually being delayed, or going without treatment all together because of our governments failure to rid this country of those that are here illegally. A combination of attrition through enforcement and deportation is the only thing that's going to work. Legalizing 20 million criminal aliens will do nothing to solve the problem, it'll only shift more of the cost to tax paying American citizens and lessen their ability to fight it. How can you fight against caring for American citizens?

Simple solution: here legally, you get care. If here illegally, you get deported

Ditto!