A safety net for many in need

from the South Florida Sun Sentinel

Staff report

Millions lack health insurance and access to care. The problems are many, but University of Florida faculty and students are trying to break down some of these barriers.

It was five minutes until 6 p.m. and nearly two-dozen people had lined up outside the downtown building. Some limped, using canes to steady themselves. Others cooed at infants tucked in their arms.

"Sorry guys, we can only take 15 tonight," a man called from inside the doorway of the UF Equal Access Clinic, a free student-run clinic medical students and faculty hold every week.

Tammy Gunn stood 15th in line.

"Take my place, please," she said, offering her spot to a mother waiting with her preteen daughter. "No ma'am," the woman replied. "My daughter's healthy. You go ahead."

In the packed waiting room, Gunn beamed as she talked about her wedding plans. The newly engaged 48-year-old plans to sew her own dress and hopes her sons can come from Wisconsin.

But as she shifted in her chair, her smile turned to a grimace. She's been in pain for a week since slipping down the stairs of her sister's backyard deck. It's the latest addition to a list of ailments Gunn faces. She had to quit her job at the Family Dollar in 2002 because of her health and subsequently lost her health insurance. She has been awaiting approval for Social Security disability since March.

"It is scary," Gunn said of living without health insurance. "It took me almost a year to find this place."

She is not alone.

For a variety of reasons — economical, social, geographical, cultural — the United States, one of the world's most prosperous, service-driven nations, is home to millions who don't have access to regular health care.

In 2006, nearly 47 million Americans lacked health insurance, according to a U.S. Census Bureau report. Florida ranks third in the number of uninsured by state. Only New Mexico and Texas had more uninsured residents in 2006.

"All of these numbers are awful," said Paul Duncan, Ph.D., director of the Florida Center for Medicaid and the Uninsured at UF. "Health insurance is a key financial ticket to accessing health care. Most people who are uninsured are not getting the health care they need."

The problem is vast but faculty members and students from UF's Health Science Center are working to break down these access-to-care barriers. Teaming education with community outreach, UF has established a number of safety-net resources for the uninsured and underserved population in Gainesville and surrounding areas.

Nursing students educate the homeless about their health at the St. Francis House. Medical students run the Equal Access Clinic. HSC faculty and students volunteer in rural clinics across the area. Nurse practitioners care almost exclusively for the underserved at a nurse-managed clinic in Archer. There are so many programs for the underserved that few HSC students leave UF without a firsthand grasp of the issues.

The Barrier

Rising premiums, co-payments and deductibles have priced health insurance way beyond what many Americans can afford.

In the past, most workers relied on their employers for coverage. But now employers, pressed to cover rising health insurance costs, are shifting the burden to their employees or dropping coverage altogether. The number of Americans receiving coverage from government programs also declined in 2006, the Census report states.

Lack of health insurance isn't the only barrier to health care, either. People in rural areas face a shortage of providers, lack of public transportation and long commutes to and from clinics. Those who do not speak English face language barriers.

But if access to health care is bad, access to dental care is worse. A 2006 Centers for Disease Control and Prevention report shows for every one adult without health insurance, there are three without dental insurance.

"Dental insurance is not universally available," said Micaela Gibbs, D.D.S., an associate professor of community dentistry and director of community-based programs in UF's College of Dentistry.

If dental insurance is not offered through an employer-based benefits package, Americans are left to pay out of pocket for care, which can be extremely costly, Gibbs said. Though Medicaid provides comprehensive dental coverage for America's poorest children, it offers only minimal coverage for adults.

And of the 9,464 practicing dentists in Florida, only 912 are active Medicaid providers, according to a 2007 Florida Department of Health Public Dental Health Program report. Some Florida counties don't have dentists at all, Gibbs said.

"Unfortunately, dental care is just not considered a basic necessity," Gibbs said.

The Gamble

Going without proper medical and dental care can mean risky business for many Americans.

"If they are lucky, the basic consequences are nothing," said Duncan, also a professor and chair of health services research, management and policy in the College of Public Health and Health Professions. "The real issue arises when something bad happens, and they have nowhere to go."

The uninsured are less likely to seek preventive care and if certain conditions go untreated, the consequences are serious.

"Health care can be miraculous," Duncan said. "But if you don't have access to it, the consequences can be deadly."

Periodontal disease has been linked to heart disease, and, in the worst-case scenario, an abscessed tooth can lead to death, Gibbs said. Other consequences of dental disease include missed work, unemployment and low self-esteem. Children often fare the worst, she added.

"Kids can't learn in school if dental pain eclipses everything else," Gibbs said. "All of our educators' work is undermined from the start."

The Safety Nets

On Thursday evenings, the Family Practice Medical Group transforms into the Equal Access Clinic, an entirely student-run clinic that provides free health care to Gainesville's poor and uninsured. Under the supervision of UF doctors, medical students assess and treat patients who come.

"This place is perfect for learning your skills and refining your skills," said Logan Schneider, a fourth-year medical student and former co-director of the clinic. "Plus, it kind of defines health care for me. To be able to fulfill people's right to health care is pretty awesome."

Hidden along a highway near Brooker, the Alachua County Organization for Rural Needs Clinic provides medical, dental and psychological care to patients in need. Many of the folks who come here live at or below the federal poverty level. Getting to a bigger city for care generally isn't an option. So far in 2007, UF faculty and students from the colleges of Medicine, Nursing, Dentistry and Pharmacy have volunteered nearly 8,000 hours at the clinic, care valued at more than $922,000.

"ACORN Clinic would not be the facility it is today without the assistance of and the collaboration with the University of Florida," said Amy J. Davis, M.D., the clinic's managing director. "Without them, it would not exist."

Much of the HSC's service efforts would not be possible without UF's Area Health Education Centers Network, which funds initiatives for HSC faculty and students to volunteer in underserved areas. The program also operates offices that provide continuing education and training for health-care providers in underserved areas.

"The efforts of UF and AHEC are trying to fill a huge gap, and I think we have been highly successful in getting resources out to the underserved communities," said Larry G. Rooks, M.D., a UF associate professor of medicine and AHEC's medical director. "Sometimes the attitude is 'they should to come to us,' but I think sometimes it's up to us to go to them."

In the past 25 years, nurse practitioners have emerged as a driving force in filling the nation's access-to-care void. UF College of Nursing students and faculty are no exception.

The Archer Family Health Care clinic, a UF nurse-managed clinic, now provides more than 3,000 patient visits each year. About 85 percent of the clinic's patient population earns below 200 percent of the federal poverty level, and more than half do not have health insurance, said Dee Williams, Ph.D., the associate dean for clinical affairs in the College of Nursing. Established in a tiny brick building in 2001, the clinic is now a nationally recognized model for nurse-managed care.

The clinic also serves as a clinical teaching site for more than 75 nursing and pharmacy students each year.

"We hope that more of our students will choose careers working in rural areas or with the indigent," Williams said.

The Dental Problem

As the need for dental care grows and the number of dentists who accept Medicaid lags, many Americans, especially the poorer ones, are struggling to find affordable dental care. But through its local and state clinics, UF's College of Dentistry provides 10 percent of care to the state's neediest patients.

"For a small dental school such as UF to provide 10 percent is pretty huge," said Gibbs.

The College's Statewide Network for Community Oral Health was established in 1997 to provide oral health services to low-income and low-access populations in Florida. The network, with facilities staffed by UF faculty, boasts clinics in Jacksonville, St. Petersburg, Miami and soon, Naples.

The College also partners with six safety-net providers across the state who allow UF dental students to volunteer in their clinics for 20-day stints.

Between its Shands at UF and Eastside clinics, the College of Dentistry's department of pediatrics also is the largest Medicaid provider in North Central Florida, said Marcio Guelmann, D.D.S., a UF associate professor and chair of pediatric dentistry.

Guelmann said he encourages students to be sensitive to the needs of the underserved.

"We encourage them to be Medicaid providers," he said. "We don't train them just to be private-pay practitioners. We train them to be aware of the situation and make space for the underserved population."

The Future

While some hope for a fundamental policy change that would grant all Americans access to health care, in the meantime UF experts are committed to researching the source of the problem.

That's why UF researchers are leading The Florida Health Insurance Study, which will identify major problem areas in hopes of implementing a set of programs to meet the needs of the uninsured.