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PHC officials question county claims
Say demand for big dollars makes little sense

Commissioner Shannon Whitfield's insistence on raising the rent 8,800-percent for Primary Health Care Centers' clinic in Rossville is being met with dismay, incredulity and a willingness to settle the matter in court.

"We disagree with the commissioner," said Diana Allen, CEO of PHC and its six clinics.

During a meeting with PHC administrative officers, she rebuked Whitfield's claims that the Rossville facility has cost the county more than $1 million since opening in 2008, that it has relied on taxpayers footing its utility bills and insurance premiums.

"It sounds like we mooched — that we've taken advantage of the county," said Chief Operations Officer Melanie Forsythe.

Noting that they had not been asked to pay for utilities until this fall, Chief Financial Officer Julie Hackney said that changed this past August.

"The biggest misunderstanding with the public is that we're costing the county," she said. "Now that we're paying for utilities, we cost the county nothing."

Non-profit PHC was incorporated 38 year ago, with a single clinic in Trenton. Thirty-eight years later, PHC has full service medical facilities in Catoosa, Chattooga, Dade, Polk and Walker counties.

Having been with PHC for 17 years, Allen recalled how and why the expansion to Rossville and later to the other sites came about.

The building now occupied by PHC has previously been a branch of the state's Public Health Department and had provided space for the Department of Family and Childrens Services.

But budget constraints caused the health department to close and DFCS moved to new, purpose-built offices in Rock Spring. After that, the county-owned building sat vacant for about four years with only minimal, if any, maintenance being performed, PHC officials said.

"I contacted Commissioner Bebe Heiskell," Allen said. "We had an opportunity for an expansion grant, one that would provide additional funding to hire staff."

Many of those being served in Trenton were not natives of Dade County, they were traveling around the mountain, and with Hutcheson hospital scaling back on its McFarland Avenue clinic, there was a growing need for medical and dental care.

Heiskell suggested the empty health department building as a possible site, "she saw there was need for health care in Rossville," with few strings attached.

Allen recalled the building's condition had deteriorated —there were serious issues with moldy walls, floors and ceilings; its roof leaked and there was some structural damage (including a breached exterior wall) — to the point that critters were its sole occupants.

A Georgia Department of Community Affairs grant allowed PHC to move into the building and expand its mission of serving the serving the underserved.

It was that roughly $400,000 grant that Commissioner Whitfield seems to reference when asserting the county paid for renovations necessary to make the building on Suggs Street useable.

Allen said the DCA grant was awarded specifically for renovation of the site. Heiskell applied for a grant that included stipulation of it being used to provide community health. The county acted as the fiscal agent for the grant that was 100 percent state funded.

"The county gave us space and got health services," Allen said.

PHC accepts patients who have no health insurance, who can qualify for a sliding fee for services scale; those with private or company insurance; and those with Medicaid and Medicare.

Though it has a physical presence in five counties, PHC's patients come from Tennessee, Alabama and far flung counties of Georgia. It is a federally qualified health center, meaning federal money is available to provide medical care in low income/high poverty areas.

The services provided include adult medical care (acute care, physical exams, checkups, immunizations, diabetes/hypertension and other chronic disease management), infant and children services (acute care, sports physicals, screenings) and testing and screenings or businesses. PHC also provides general dentistry for both adults and children.

In addition to treatment, PHC provides case management services and assists patients filling out paperwork required for Medicaid, food stamps, the ACA and acts as a liaison with schools and other providers of social services.

"We connect the dots," Forsythe said. "We try to meet every need."

Sandy Matheson, the director of community relations and development, said having PHC provides services that otherwise would be beyond the reach of the community it serves.

"We help keep families together, "she said.

The disagreement with the commissioner is not about what PHC provides but about its finances.

Allen said that while Whitfield uses a valuation of more than $1 million for the property its value on the county tax rolls is about $350,000.

While it has leased the site for $1-per-year, administrators point out that PHC took over a building that was essentially a shell in 2008. Aside from fixing the roof and doing "band aid repairs" on it HVAC system, all maintenance and upkeep has been performed without county funding.

"The building was un-rentable, it wasn't suitable for use or for renting," Allen said, contradicting the commissioner's assertions.

As to not paying for insurance, Allen pointed out that the county, as landlord, is responsible for insuring its building and grounds. PHC, like any renter, pays for its liability and malpractice insurance.

Stipulations included in the DAC grant require that the facility must be used to provide community health services and cannot be sold without the county repaying the grant amount.

The lease is renewable for five-year periods, but since August there has been no formal agreement between the county and PHC.

Allen said that two weeks after Whitfield's being elected in 2016, she contacted him via email to discuss the Rossville facility.

In April, the commissioner wanted to meet, she said, and in May, PHC agreed to review costs associated with the building's utilities.

The county secured an appraisal of the building, presented it to the PHC board, "and he asked what we wanted to do?" Allen said.

Whitfield has told the PHC board that he wants monthly rent of $8,800 for a three-year period. He has also asked that the Rossville clinic, which has had no signed leasing agreement since Aug. 31, pay three months of back rent.

"Rather than coming to us with a proposal, the commissioner did nothing until he said 'here's an appraisal of its fair market value,'" Allen said. "We offered to pay $2,500 a month ($6 a square foot) which was doable — our board could approve that — and is comparable to what we pay at our other clinics."

The administrative staff agreed that the use of grant money has allowed the clinic to hire and retain skilled staff while at the same time making it possible for PHC to pay for and maintain its electrical, plumbing, security, telephone and tech systems.

"If it (the former health department building) is worth anything, it's because we're here and have been maintaining it," Allen said.

While Walker and PHC are at loggerheads, Matheson said it is more often the case that counties approach PHC about partnering with them.

"We bring value and support," she said. "We are able to provide a safety net that no other entity could provide.

"We've stepped up to fill a void created by the local hospital failing. The health department cannot fill the need — we accept referrals from health departments."

In addition to its Rossville clinic and a clinic at Gilbert Elementary School, in LaFayette, the PHC corporate offices are located in a countyowned building that is diagonally across from Commissioner Whitfield's office in LaFayette.

The impasse over rents and leases includes the corporate office (the school system has control over the Gilbert site) that will eventually be resolved by PHC relocating to Catoosa County. The PHC board has approved purchase of what once housed the rehabilitation and hospice services of Hutcheson Medical Center.

Located directly across the street from what was Hutcheson, then Cornerstone and this week becomes CHI Memorial Hospital Georgia's emergency room entrance, the building will require substantial renovation and remodeling before PHC can relocate.

When asked what will become of the Rossville clinic if no agreement can be reached, Allen said PHC intends to keep a satellite clinic in Rossville even after eventually moving to the Fort Oglethorpe campus.

"What keeps us going is the people we help every day," Matheson said.

ACA receives death blow from lawmakers
As many as 250,000 Georgians will be uninsured

Congressional attempts to "repeal and replace'' the Affordable Care Act met with failure after failure this year.

But early Wednesday, Senate Republicans passed a bill that would abolish a central tenet of the ACA: the individual mandate for Americans to have health coverage or face a tax penalty.

The mandate repeal is part of a massive tax overhaul that the Senate passed on a partyline 51-48 vote. The bill must return to the House to resolve minor procedural flaws in the version already passed by that chamber.

Lawmakers used the tax bill to undo part of the ACA because the U.S. Supreme Court, in upholding the health law in 2012, defined the individual mandate as a tax.

President Trump heralded the Senate action in a tweet: "The United States Senate just passed the biggest in history Tax Cut and Reform Bill. Terrible Individual Mandate (ObamaCare) Repealed."

Both U.S. senators from Georgia, Republicans Johnny Isakson and David Perdue, praised the passage of the legislation, calling it "historic."

The repeal of the insurance mandate would take effect in 2019.

The idea of compelling people to have health insurance has been the most unpopular part of the ACA, and Republicans have regularly attacked it. Yet ACA proponents have noted that the concept was originally floated by some conservatives, and it became law in Massachusetts under Republican Gov. Mitt Romney before it became part of the federal Obamacare legislation.

The Congressional Budget Office has estimated that repeal of the mandate will mean 13 million fewer insured people by 2027. That would translate to an estimated 200,000 to 250,000 Georgians, said Bill Custer, a health insurance expert at Georgia State University.

Georgia already has one of the highest uninsured rates, at 14 percent.

The repeal is also expected to raise premiums by 10 percent each year more than they otherwise would rise.

The 13 million would include many middle-class, older Americans who get insurance on their own but don't qualify for subsidies in the exchange, and would face even higher premiums than current rates, Custer said Wednesday.

Also dropping insurance would be many younger, healthier Americans, he predicted. Many such people would skip buying coverage, as happened before the ACA was passed, because they think their likelihood of needing it is low.

Repealing the insurance requirement may induce some people who are offered employer-based coverage to reject it, Custer added.

The ACA insurance exchanges eventually "will look much more like Medicaid managed care,'' he said.

Meanwhile, the No. 2 Senate Republican, John Cornyn of Texas, said the tax bill would make the Obamacare "unworkable," which he hopes will force Democrats into negotiations to replace the law, Bloomberg News reported.

"Arguably, doing away

with the individual mandate makes the Affordable Care Act unworkable — not that it was particularly great beforehand," Cornyn said. "Hopefully this will precipitate the bipartisan negotiation on what we need to do as an alternative."

Republicans are considering another effort to repeal and replace the broader law next year, but presumably will have one fewer vote to do so after Democrat Doug Jones won the Alabama Senate special election.

Aside from repeal attempts, the Trump administration has killed some subsidies for the insurance exchanges, cut the enrollment period in half, and drastically reduced the Obamacare marketing campaign.

"It's wounded," said Jon Kingsdale, who ran the Massachusetts health exchange, the prototype for Obamacare, Politico reported. Yet he and other policy analysts noted that the basic framework of the ACA — the online marketplaces, the consumer protections, the subsidies that help millions afford insurance — remain in place, as does Medicaid expansion, which brought insurance to about 12 million newly eligible people. (Georgia, like some other states, has not expanded Medicaid, with officials saying it would be too costly).

As long as that core survives, the ACA can be rebuilt, Kingsdale said, should such a political moment arrive, Politico reported.

Laura Colbert of consumer group Georgians for a Healthy Future, which supports the ACA, said Wednesday that the repeal of the individual mandate "exacerbates the problems that consumers are already facing in the insurance market, namely rising premiums and a limited choice of insurers. Instead of enacting policy that will result in fewer people with insurance coverage and higher costs for those that remain insured, our elected officials should be focused on how to cover more people more affordably."

Because the mandate repeal doesn't take effect until 2019, insurers would have time to raise rates to account for the extra risk, or withdraw from the ACA market, as many have already done, the Wall Street Journal reported. Health insurers, an overwhelmingly domestic industry, will reap enormous benefits from the tax bill's sharp cut to the corporate rate. Analysts project that the companies initially could see sharp increases in earnings.

Meanwhile, some experts caution that the tax legislation will have big downstream effects on funding for Medicare, Medicaid, ACA subsidies and other federal and state health care programs. That's because the projected $1.5 trillion increase in the federal budget deficit resulting from the tax cuts would put pressure on Congress to slash health care spending, Modern Healthcare reported.

There are two ACA stabilization bills on the table that aim to stabilize health insurance markets and lower premiums. But their fate is unclear, as is extending funding for the Children's Health Insurance Program, known as PeachCare in Georgia, which covers 177,000 kids here.

Looking North: Can a single-payer health system work in the U.S.?

TORONTO — For Dr. Peter Cram, an American internist who spent most of his career practicing in Iowa City, Iowa, moving here about four years ago was almost a nobrainer.

He's part of a small cohort of American doctors who, for personal or professional reasons, have moved north to practice in Canada's single-payer system. Now when he sees patients, he doesn't worry about whether they can afford treatment. He knows "everyone gets a basic level of care," so he focuses less on their finances and more on actual medical needs.

Cram treats his move as a sort of lifesize experiment. As a U.S.-trained physician and a health system researcher, he is now studying what he says is still a little-understood question: How do the United States and Canada — neighbors with vastly different health systems — compare in terms of actual results? Does one do a better job of keeping people healthy?

For all of the political talk, in many ways it is still an open question.

"The Canadian system is not perfect. Neither is the United States'," Cram said over coffee in Toronto's Kensington Market. "Anyone who gives you a sound bite and says this system should be adopted by this country ... I think they're being almost disingenuous."

Still, American support for government-run, singlepayer health care, once a fringe opinion, is picking up momentum.

Sen. Bernie Sanders, the Vermont independent who emphasized singlepayer health care in his 2016 presidential bid, helped move Canada into the U.S. spotlight.

Lawmakers in California and New York have taken steps toward such programs on a statewide level, and the concept is a hot topic in gubernatorial campaigns in both Illinois and Maryland.

In addition, polling finds doctors and patients increasingly

supportive, though the percentages in favor typically drop when questions are focused on the taxpayer costs of such wa system.

In Canada, medical insurance comes through a publicly funded plan. And, while covering everyone, Canada still spends far less on health care than the United States does: just over 10 percent of its GDP, compared with the United States' 18 percent.

To many American advocates, Canada's health system sounds like the answer to the United States' challenges.

But in Toronto, experts and doctors say the United States first must address a more fundamental difference. In Canada, health care is a right. Do American lawmakers agree?

"The U.S. needs to get on with the rest of the world and get an answer on that issue before it answers others," said Dr.

Robert Reid, a health quality researcher at the University of Toronto, who has practiced medicine in Seattle.

It's an obvious disconnect, said Dr. Emily Queenan, a family doctor now practicing in rural Ontario. Queenan, 41, grew up in the United States and did her residency in Rochester, N.Y. By 2014, after about five years of frustrating battles with insurance companies over her patients' coverage, she had enough. She found herself asking, why not Canada?

She moved north. Gone, she said, are the reams of insurance paperwork she faced in America. Her patients don't worry about affording treatment.

"We have here a shared value that we all deserve access to health care," said Queenan. "That's something I never saw in the States."

Sanders has pushed the discussion, with a "Medicare-for-All" bill in Congress and in a visit to Toronto this fall. It was part fact-finding mission and part publicity tour. On that trip, doctors, hospital leaders and patients painted a rosy picture where everyone gets top-notch care, with no worries about its cost to them.

"They have managed to provide health care to every man, woman and child without any outof-pocket cost," Sanders told reporters while speaking on the ground floor of Toronto General Hospital. "People come to a facility like this, which is one of the outstanding hospitals in Canada. They undergo a complicated heart surgery, and they leave without paying a nickel."

It sounds idyllic. But the reality is more complicated.

While progressives tout the Canadian system for efficiently providing universal health care, the Commonwealth Fund, a nonprofit research group, puts it just two spots above the United States — which ranks last — in its health system assessment. It suggests that in timeliness, health outcomes and equitable access to care, Canada still has much to improve.

"If you deny there are trade-offs, I think you're living in wonderland," Cram said.

The Canadian Vibe

In Canada, everyone gets the same government-provided coverage. Provinces use federal guidelines to decide what's covered, and there's no cost sharing by patients.

"Come to our waiting room," said Dr. Tara Kiran, a family doctor at St. Michael's Hospital, in Toronto. "You will see people who are doctors or lawyers alongside people who are homeless or new immigrants. People with mental health issues or addiction issues together with people who don't."

But that insurance — which accounts for 70 percent of health spending in Canada —addresses only hospitals and doctors. Prescription medications, dentists, eye doctors and even some specialists aren't covered. Most Canadians get additional private insurance to cover those.

In countries such as Britain or Germany people can opt out to buy private insurance. Canada prohibits private insurers from offering plans that compete with the government, a restriction some doctors are suing to lift. It's not a popular view in Canada, experts said, but the implications are significant.

Here, the debate focuses more on bringing down health spending — a concern in the United States, too, but one often overtaken by politics.

Canada's provinces put, on average, 38 percent of their budgets into health care, according to a 2016 report from the Canadian Institute for Health Information, a nonprofit organization. Canada's single-payer system is supported by a combination of federal and provincial dollars, mostly raised through personal and corporate income taxes. (A few provinces charge premiums, which are income-based and collected with taxes.)

"We make improvements or change things only to have additional debates about other things. Those debates are constant, and they should be," Reid said. "[But] most of what you hear in the U.S. is back to the tenor of the insurance framework, whether [they] should have Obamacare or not."

Taxes in Canada are generally higher than in the United States. Canada, for instance, collects a levy on goods and services and also taxes wealthier citizens at a higher income tax rate.

But many here call that a concession worth making, and also note that they don't have to pay separate premiums for health care as people in the United States do.

"We can't have what we have if we don't pay the taxes," said Brigida Fortuna, a 50-yearold Toronto resident and professional dog groomer, while on her way to a medical appointment. "But you have to take care of your people. ... If you don't have good health care, you're not going to have a good society."

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The Trade-Offs

That said, it's not a perfect system. Canadian health care doesn't cover prescriptions, physical therapy and psychotherapy. And there's the concern that Canadians wait longer for health care than would Americans with robust health coverage.

There are cases, Reid said, when cancer care in Canada is delayed enough to yield health problems. Expat Cram pointed to research that suggests low-income people are likely to wait longer for medical care — which can result in worse health outcomes.

"We do have a twotiered system," he said. "Most know it. Few will admit it."

Typically, experts said, people with serious medical needs will jump to the front of the line for medical care. Kathleen Wynne, Ontario's Liberal Party premier, said the Canadian government is actively trying to improve wait times.

But so far, it's unclear how effective that's been. A 2017 report from the nonprofit Canadian Institute for Health Information found that wait times had dropped for hip fracture repairs. But waits for, say, MRIs and cataract surgery have actually gotten worse. Depending on their province, the average wait for cataract removal ranged from 37 days to 148 days.

Many patients, though, said the waits were a trade-off they were willing to make. Toronto-based Nate Kreisworth, a 37-yearold music composer and producer, called it an obvious choice.

"You are not going to die because you're waiting," he said on a recent sunny morning while walking with his dog near Kensington Market. "Better wait times for everything? Sure, why not. But as long as the major issues are being covered, then I don't think it's really much of an issue."

As Fortuna put it: "If you go for a headache and someone else is going to lose their arm, of course they're going to take care of that person. I'm OK with that, because someday that could be me, too."

Waits aren't the only concern, though. There's financing — and what it would cost for the United States to implement a system like Canada's.

Because Americans have higher expectations about what a health plan should cover, it would be more expensive to adapt a Canadian approach, said Dr. Irfan Dhalla, an internist and health quality researcher in Toronto. And the quality may differ from what they are used to.

And in Canada, "everyone gets Kmart care," Cram said. "There's no Neiman Marcus care."

Of course, some amenities that drive up costs — fancier food, softer gowns or private rooms — don't necessarily produce better results.

A 2017 study found that patients with cystic fibrosis fared better in Canada than in the United States. But on the other hand, 2015 research comparing surgical outcomes found better results in the United States than in Canada. The Commonwealth Fund's most recent ranking places Canadian health outcomes above America's, but only by two slots.

Even so, many Canadians said they couldn't imagine living with an American system. It's a question not just of efficiency, but of fairness. Kreisworth compared his experience to that of family members in the United States.

"I talk to my brother's girlfriend who is a part-time worker who has no [health] benefits — who would just be sick and not go to the doctor because she couldn't afford to pay," he said. "I can't imagine that here. It seems like — it's so wrong. It just seems utterly wrong."

Note: This story has been corrected to reflect that health care takes up 18 percent of the United States' GDP, rather than 16 percent as originally reported.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.