Outside In :: Serving homeless youth and low-income adults in Portland Oregon

Medical clinics struggle with another rules change

Portland Business Journal Copyright 2007;
Written by Robin J. Moody;

Medical clinics are bracing for a new rule that's apt to cost them big bucks, and limit medical access for underserved populations.

Enacted July 1 as part of a federal budget deficit reduction act, the rule requires certain patients to show proof of citizenship -- a passport or a birth certificate plus an identification card -- for clinics to get reimbursed by the government for medical services under Medicaid. It was passed as an immigration reform measure.

In Oregon, the state's Family Planning Expansion Project provided a grace period after the rule passed, paying clinics for family-planning patients without papers on a one-time basis from the general fund. The state-administered program expands Medicaid coverage for family planning services to low-income people with the aim of reducing unplanned pregnancies.

On March 1, the grace period ends, and the state will no longer pay for patients who fail to furnish proper documents. Similar rules for Oregon Health Plan eligibility kicked in last September.

Clinics most affected are those with large Medicaid populations who provide family planning services. The rules also hurt U.S. citizens who don't have the money or advocacy skills to obtain the documents.

"The key to providing good care is breaking down the barriers for access to appropriate care when it's needed. This throws up another barrier," said Craig Hostetler, executive director for the Oregon Primary Care Association, a nonprofit that advocates on behalf of safety-net clinics.

Outside In, a Portland nonprofit providing homeless youth with medical and social services, expects to lose $150,000 a year in clinic reimbursement due to the rule, said clinic director John Duke. That's more than 8 percent of the clinic's budget.

"We may have to cut back on services," Duke said, noting the hit comes on the heels of cutbacks in the Oregon Health Plan's standard program. Those cuts eroded more than 20 percent of the clinic's income.

Patients served by Outside In are homeless, often estranged from their families, and rarely carry a birth certificate or a passport. Nearly all are U.S. citizens.

Planned Parenthood of the Columbia-Willamette Inc. expects to lose $1 million, or about 6 percent of revenue, as patients are scared away by the new eligibility requirements.

"It's poor public health policy," said David Greenberg, CEO and president of Planned Parenthood of the Columbia Willamette Inc. "The state will ultimately spend more money to pay for the births of those babies than to prevent the unintended pregnancies."

The agency's Oregon reproductive health clinics experienced a 10 percent decline in patient visits since November, when clinic staff started asking patients to bring in new identification documents to prepare for the new requirements. Planned Parenthood's Washington clinics, also affected by the federal rule, saw patient visits drop 30 percent.

Teenagers often lack access to key identification papers held by their parents, Greenberg said. Other patients, confused by the rules, are simply staying away.

One of the ironies of the rule is that it limits access to preventive services, both for citizens and noncitizens, while another federal law requires emergency department treatment for most noncitizens to be reimbursed under Medicaid. Emergency departments are the highest-cost medical care settings. Primary care is relatively cheap.

State workers say they are doing everything they can to help patients and clinics adjust.

"We are working with [patients] as best we can to get the documents, including purchasing documents for people in case of hardship, or extending deadlines to present the documents," said Karen House, program manager at the Oregon Department of Human Services.

The rules have created additional work for program staff, House added, and lengthened the Medicaid eligibility process. The eligibility problem mostly affects people born outside Oregon, as the state can quickly verify residency for native Oregonians.