Plankton's Testimony on Global Warming
Counties struggle to provide services to those who can't pay.
by Angela Spivey
In 1997, shortly after Congress passed the Welfare Reform Act, North Carolina's county health departments started calling Jill Moore for help. Moore had just arrived at Carolina's Institute of Government (now the School of Government) as assistant professor of public law and government. Welfare reform had restricted the services that immigrants are eligible to receive. The health departments wanted to know — how were they supposed to interpret the new rules?
Moore did a legal analysis. The new rules were complicated to say the least. But for the health departments, the conclusion ended up being pretty simple. Almost all the services they offer fit under one of several exceptions to the rules restricting eligibility. So pretty much every immigrant — documented or not — is eligible for local health department services in North Carolina. In fact, health departments aren't allowed to even ask about a client's immigration status.
But how to pay for those services? Under the new reforms, Medicaid is available only to some documented immigrants, and most of those must undergo a five-year waiting period. "So we have this odd situation created where many immigrants are eligible for the service, but they're not eligible for the program that would pay for the service," Moore says. "That leaves this unmet cost."
In the years since welfare reform, Moore has heard from many local health directors that their uncompensated costs, especially for prenatal care, are increasing. Some even said they were considering cutting back on services.
In 2004, Catherine Pierce, a graduate student in Public Administration, tried to confirm what Moore had been hearing. Pierce focused her study on prenatal care, which a 1999 survey by the North Carolina Center for Public Policy Research found was one of the most important health issues for Hispanic women in North Carolina. Responses to Pierce's e-mail survey of the state's county health directors show that from 2000 to 2003, uncompensated costs for prenatal care increased by an average of 26 percent. When asked about possible reasons for the increase, 50 percent of the respondents said they thought it was the growing number of undocumented immigrants that their health departments serve — the most frequently cited reason in the survey.
Moore says, "Health directors tend to report their perception that the problem with uncompensated prenatal care is a problem associated with undocumented immigrants, but I think it is more accurately stated as a problem associated with Medicaid-ineligible immigrants." That includes undocumented immigrants but also those who are documented but in the five-year waiting period, those here on student or work visas, and others.
The accuracy of the health directors' perceptions can't be verified, since health departments don't ask about immigration status. But Pierce tried to get some idea of the number of unqualified immigrants by looking at related indicators — the number of foreign-born residents in the county and the number of health-department clients who ask for language assistance. She found strong evidence of an association between these two variables and the rise in uncompensated prenatal costs. Other variables, such as poverty rate and the percent of clients who are uninsured, were not associated with the amount of uncompensated services.
"My study does indicate that there may be some validity to the claim that there is a connection between the rising uncompensated costs and the Medicaid-ineligible immigrant population," Pierce says.
Those costs are not small. A 2001 telephone survey by the North Carolina Association of Local Health Directors found that county health departments needed a total of $7 million to cover uncompensated costs of prenatal care. That figure was included in a bill requesting additional state funding. But the bill did not pass, and no additional money was allocated.
In Pierce's survey, almost 80 percent of the respondents said that they were either somewhat or very likely to change something about the prenatal services they offered because of costs of uncompensated care. Three respondents said they had already eliminated specific services to save money. Other solutions health directors have tried include moving money from family-planning and child-health programs and billing some patients at least a small amount. In Randolph County, for instance, expectant mothers whose income is more than 100 percent of the poverty level pay on a sliding scale.
These small payments somewhat offset the costs of care to those who can't pay, says Mimi Cooper, health director in that county. Cooper says she'll continue to look for such solutions. "We're pleased to be able to provide early prenatal care for women who need it and aren't eligible for Medicaid," she says. "Is it creating a big financial burden? Yes. But we'll keep trying to find ways to finance the program because the alternative — women going without prenatal care — is horrible."
