Nassau’s health safety net is strong, but challenges remain

Submitted by Anne H. Oman
Reporter-at-Large
April 30, 2015, 9:54 a.m.

Last year, at its well-equipped facility on Jasmine Street, Barnabas Nassau treated 378 patients in the by-appointment primary care clinic and another 500-plus in its walk-in evening urgent care clinic. A few blocks away on Nectarine Street – and in clinics in Yulee and Callahan – the Florida Department of Health in Nassau County provided comprehensive care for 640 adults with chronic diseases and dental care for some 2,600 children and adults. At the intersection of Route 17 with AIA, Starting Point Behavioral Health treated some 3,000 people for substance abuse and mental illness. And twice a month a “doctors’ office on wheels” powered by St. Vincent’s Mobile Health Ministry parks at sites in Fernandina Beach and Hilliard and offers screenings, flu shots, immunizations and treatments for diseases ranging from asthma to heart disease.

All these entities – with the help of Nassau Baptist Hospital and Nassau Cares, a network of specialty providers — make up the safety net that gives access to health care to the more than 10,000 Nassau County residents without health insurance, as well as to many others who are underinsured.

How strong is the safety net? How does it work? What challenges does it face?

“We want to be a medical home for adults in need in Nassau County,” said John Bowles, Health Services Manager for Barnabas. We started our primary care clinic last March with a grant from the Blues Foundation. So many people who were coming into our Samaritan Clinic – our urgent care clinic – had chronic diseases, such as diabetes and hypertension that we realized we were only applying a Band-Aid. We realized that if we could get people coming in on a regular basis, we could make sure they got the care they needed.”

The primary care clinic is open – preferably by appointment (904-261-7000) — Mondays, Wednesday, and Thursday from 8 to 4, and on the first Wednesday of the month from 11 to 7. The Urgent Care Walk-In Clinic, staffed by volunteer providers, sees patients on a first-come, first-served basis Tuesday and Thursday evenings beginning at 5 P M. Patients must show proof of Nassau County residency and of income level below 200 percent of the Federal Poverty Level (currently $11,770 for an individual or $24,250 for a family of four). Fees vary from $10 to $30 depending on income. Barnabas does not currently accept Medicaid or other insurance.

Dental care, mental health counseling, and vision and hearing screening are also available.

“We want to be a medical home for adults in need in Nassau County,” he added.

“Adults are our focus,” said Mr. Bowles, explaining that most low-income children have health insurance through Florida KidCare. .

Mr. Bowles gave high praise to Nassau Baptist Hospital, which performs much of the lab and diagnostic work for Barnabas free of charge, and to Nassau Cares, a network of volunteer specialty providers.

“For instance, if someone needs a colonoscopy we can send them to Borland Groover,” he said.

Nassau Baptist President Stephen Lee characterized the hospital’s partnership with Barnabas as “part of our mission as a not-for-profit community hospital.”He estimated that the hospital provides $800,000 to $900,000 annually in services to Barnabas patients.

“We have a close relationship with Barnabas,” he said. “It was Dr. Tom Washburn who was behind getting the hospital involved. If we treat someone in the emergency room or in the hospital who has no primary care physician, we refer them to Barnabas for follow-up care.”

Chronic diseases are also the focus of the clinical care provided by the Florida Department of Health in Nassau.

“We have a public health emphasis,” explained the director, Dr. Eugenia J. Ngo-Seidel. “That means our goal is to treat the community as a whole. We provide clinical services of public health significance. We decided that the best utilization of our resources was to target the population with chronic diseases.”

To receive primary care from the Florida Department of Health in Nassau, patients must be at 150 percent of the Federal poverty level and show proof of county and state residency. Patients must also have a specific chronic condition, either diabetes, high blood pressure, heart disease, asthma requiring daily treatment, arthritis, chronic obstructive pulmonary disease or hypothyroidism.

The department’s clinics also provide childhood immunizations and dental care.

“We’re the only Medicaid dental provider in the area,” said Dr. Seidel.

In addition, there is a teen clinic, a family planning clinic, and a program to provide education and supplemental nutrition to mothers and babies. (The phone number for appointments and information about the Florida Department of Health in Nassau is 904-548-1800).

On the first Thursday of the month, St. Vincent’s Mobile Health Care Ministry van parks at the Nassau County Health Department office in Hilliard, at 37203 Pecan Street. from 9 to 4, with a physician, a nurse, an EMT and a medical assistant on board. On the third Thursday of the month, the same van parks by the Barnabas Center in Fernandina Beach.

”We provide any service that can be done in a primary care office,” said St. Vincent’s spokesman Kyle Sieg.

The mobile health care professionals treat patients at or below 200 percent of the poverty line. Last year, there were 530 visits in Nassau County. Anyone interested in scheduling an appointment should call the Nassau County Health Department.

At Starting Point Behavioral Healthcare in Yulee, mornings are reserved for “open access” – walk-in patients. The numbers fluctuate, but on a typical day 4 or 5 new patients may show up.

“Research shows that if someone has to wait for mental or behavioral healthcare, they’re less likely to seek it after the crisis has passed,” explained Dr. Laureen Pagel, Starting Point’s Executive Officer.

Patients receive treatment for substance abuse, drug dependency, PTSD, and psychiatric problems such as depression, anxiety, and schizophrenia. Insurance and personal payments are accepted, and there is a sliding scale for fees based on income. Last year, about half the organization’s expenses were covered by fees from Medicaid and other insurance and the rest by grants from Florida’s Department of Children and Families and other government agencies. Starting Point also teaches Mental Health First Aid to law enforcement personnel and other first responders and runs a drop-in center for mentally ill adults in Fernandina Beach.

Currently, two developments occurring outside the county’s borders could put a strain on Nassau’s healthcare safety net. One is a legal challenge to subsidies to people who signed up for insurance under the Affordable Care Act –aka “Obamacare”—in states, including Florida, that did not set up health care exchanges. The U.S. Supreme Court heard the case, King v. Burwell, on March 4, and is expected to announce its decision by early June.

According to the U.S. Department of Health and Human Services, more than 2,200 Nassau County residents had signed up for health insurance under the Affordable Care Act by the end of January 2015. It is not known how many of the county enrollees receive subsidies in the form of tax credits. Statewide, 1.6 people have purchased policies under the Affordable Care Act, and 1.5 million of them receive subsidies. The average subsidy in Florida is $294 per month.

If the Supreme Court rules that subsidies under the federal exchange are illegal, an estimated 2,000 Nassau County residents could lose their health insurance and might have to rely on the county’s safety net.

“After Obamacare, more people came in with insurance,” acknowledged Dr. Pagel of Starting Point.

“If people lose coverage, we would definitely take up the slack any way we could,” said John Bowles of Barnabas.

“Obamacare has not had a dramatic impact on the hospital,” said Nassau Baptist Hospital President Stephen Lee. “We’re more concerned with what the state legislature does about Medicaid expansion.”

The Florida legislature is embroiled in a debate on whether to expand Medicaid to 138 percent of the poverty level, which would extend health insurance to 800,000 additional Floridians. The state Senate has approved the measure, but the House has not. Federal officials have threatened to discontinue the federal contribution to Florida’s Low Income Pool, which amounts to $1.3 billion a year, at the end of the fiscal year, June 30, unless the state expands Medicaid. LIP funds help hospitals care for low-income patients. Governor Rick Scott has vowed to sue the federal government for the funds. Time is running out as the legislative session is due to end this Friday, May 1, but a special session may be called later.
The Florida Hospital Association is on record in support of Medicaid expansion, and the Nassau County Medical Society has urged its members to fight for LIP funding.

State Representative Janet H. Atkins said in a statement that “the budget impasse centers on the Senate’s desire to link LIP and Medicaid Expansion that would implement a key element of the Affordable Care Act in Florida. The Supreme Court has clearly stated that the federal government cannot coerce states into expanding Medicaid.” She pointed out while the federal government promises to cover 90 percent of the cost of new enrollees under Medicaid expansion, “with a federal government that continues to operate without a balanced budget, one would have to expect that at some point they would retreat from the promise of 90 percent payment. Today, even a one percent shift in the match would cost Florida an estimated $180 million each year.”

Rep. Atkins, who chairs the K-12 Subcommittee of the House Education Committee, indicated she would fight against reducing funds for education in order to expand Medicaid.

Locally, the county health department receives about $80,000 a year from the Low Income Pool, which funds an adult dental project and a diabetes project in conjunction with the St. Johns River Rural Health Network. Nassau Baptist Hospital receives “under $200,000”, according to Hospital President Stephen Lee,

“Obviously, any loss would be felt,” he said. “But would it be catastrophic? By no means.”

Mr. Lee estimated that the hospital spends about $9 million a year for uncompensated care.

The hardest hit local health care provider would be UF Hospital Jacksonville, the major safety-net hospital in the area and the only trauma hospital. The hospital could lose $95 million in LIP funding, a loss that could force the hospital to close within months, according to CEO Russell Armistead.

Are Nassau County residents getting the healthcare they need? Is the health safety net adequate?

“Overall, yes,” said Mr. Lee of Nassau Baptist. “But would I want to see it improved? Absolutely.”

“I think we’re all doing a good job,” said Dr. Seidel of the county health department. “There’s very effective collaboration among safety net providers.”

Dr. Seidel pointed to the Community Health Improvement Plan and its goal of increasing the percentage of adults with a usual source of care other than an emergency room to 90 percent by December 2015.

Said John Bowles, the Barnabas Health Services Manager: “Is the safety net adequate? Is there ever enough healthcare for everyone?”

Editor’s Note: Anne H. Oman relocated to Fernandina Beach from Washington, D.C. Her articles have appeared in The Washington Post, The Washington Star, The Washington Times, Family Circle and other publications. We thank Anne for her contributions to the Fernandina Observer.