As cracks emerge in Minnesota's experimental new health care program for the poorest adults, about a dozen counties and hospitals have taken matters into their own hands -- organizing charity care networks or, in some cases, paying insurance premiums so their patients can get better coverage.
"I'm not getting into the politics or whether the state made a bad decision," said Jay Kieft, social services director for Kandiyohi County, struggling to keep the irritation out of his voice. "It's just that we've got people who really need medical and mental health care, and the only way they can get it is show up at the hospital ER or drive 100 miles from Willmar to the Cities."
General Assistance Medical Care (GAMC), which became the subject of a fierce fight between Gov. Tim Pawlenty and DFL legislators last spring, serves about 30,000 childless adults who earn no more than 75 percent of the federal poverty guideline. Most have chronic illnesses, half are mentally ill and 25 percent are homeless.
After much wrangling at the Legislature, a change in state law June 1 slashed the program's funding by two-thirds and transformed GAMC from a statewide managed care system into a hospital-based system -- with participating hospitals bearing much of the risk.
State officials had hoped many hospitals would choose to join the new GAMC, offering local residents coordinated care, even though each would receive a fixed pot of funding and would lose money.
But tensions quickly emerged. Only four hospitals -- all in the Twin Cities -- agreed to participate, and then only after the state changed the rules and agreed to let hospitals cap their enrollments.
Of those, North Memorial Medical Center in Robbinsdale already has hit its enrollment ceiling. University of Minnesota Medical Center Fairview in Minneapolis and Regions Hospital in St. Paul are expected to hit their caps in coming weeks, leaving just Hennepin County Medical Center in Minneapolis to take new GAMC patients.
The result is that many GAMC patients, especially in outstate Minnesota, have to drive to the Twin Cities or seek charity care locally.
'Cracks in the new system'
"Yes, there are some cracks in the new system, as there were in the old system," Human Services Commissioner Cal Ludeman acknowledged Tuesday.
Lack of clinical care outstate is one, he said, "but they are caused more by the health care providers than the law. Most hospitals decided not to participate."
So far, about 10,500 people on GAMC have enrolled in one of the four hospital coordinated care programs. About 800 of them live outside the seven-county metropolitan area.
Here's what is happening:
•Some counties, including Kandiyohi, are paying monthly premiums -- about $4 per patient -- for scores of people who shift from GAMC to MinnesotaCare, a subsidized insurance program intended for lower-income working people.
"It's not the right program for them, but it's better than GAMC," Kieft said. "There are co-pays and a $10,000 annual limit on in-patient hospital care, but at least they can see a local doctor."
•In St. Cloud, Wadena, Mankato and several other communities, hospitals have decided to offer charity care through hospital clinics to GAMC patients -- and in some cases also pay their premiums if they shift to MinnesotaCare.
"We're trying to keep GAMC patients healthier," said David Borgert, director of community and government relations at CentraCare Health System in St. Cloud. "We'll lose less money by treating people in a clinic instead of waiting for them show up at the emergency department in a medical crisis."
In Mankato, "We're in close touch with county social services," said Jim Tarasovitch, CFO of Immanuel St. Joseph Hospital, whose clinics continue to see GAMC patients.
"Let's be honest,'' he said. "For most of them, it's us or nothing."
•Some 65 nonprofit community clinics, operated by 17 federally supported community health service organizations, are continuing to see GAMC patients. Last year they saw about 6,000, 10 percent of them outstate.
Advocates say that even in the metro area, many GAMC enrollees remain confused about their options and continue to show up at hospital emergency rooms when they have medical crises, or just want to see a friendly face.
"If you're having a psychotic episode, or you don't have a very high IQ, or you're not sure where you'll get food today, it's pretty hard to make a good judgment about where to get medical care," said Monica Nilssen, director of outreach at St. Stephen's Human Services in Minneapolis.
In addition to closed enrollment at one hospital, GAMC patients have faced problems finding adequate mental health care and getting specialty treatment such as orthopedic care.
With a small clinic at University Fairview, new patients now must wait until October before they are assessed and see a doctor.
"We're concerned about that," Ludeman said. "We're talking with the hospitals about capacity and waiting times.
"But overall, I think we're doing pretty well," he said. "We're going to learn a lot about how to give better, more effective care not just for people on GAMC but all patients."
Warren Wolfe • 612-673-7253