Going Naked

By Hannah Wallace January 31, 2007

What crisis is hitting our region's economy at least as hard as red tide and hurricanes, but rarely makes headlines?

Here are a few hints. The symptoms include Sarasota public school employees beginning to drive their children to charity walk-in clinics; Publix clerks' smiles showing off Third World-like tooth gaps; residents in the solidly middle and upper middle class Lakewood Ranch area losing their homes to foreclosure after a family member experiences a serious accident; and a for-profit hospital chief in Manatee County resigning in the face of doctors' outrage over uncompensated emergency room duties.

The crisis caused by the rising number of people without health insurance has descended upon our regional economy like a cold front, and it's not just migrant farm workers and single moms who feel the chill.

The lack of insurance is a plague affecting a continuously rising number of people in the United States for at least two decades now. According to the latest available U.S. Census data, the share of uninsured people of the nation's total population jumped again last year from 15.6 percent to 15.9 percent. That's a total of 46.6 million people whose last remaining safety net is the emergency room.

Even protected suburban life won't shield you from the problem anymore.

"When I parked my car at a mall recently, I saw a five-year old girl balancing on the curb. Her father said, 'Don't you fall! Daddy doesn't have health insurance,'" says Mary Ruiz, CEO of local healthcare provider Manatee Glens.

For a long time, the uninsured crisis has been portrayed mainly as an abstract burden on federal and state treasuries. But as the feds and Tallahassee are passing on the bucket, it is quickly becoming a local headache. Unpaid and under-compensated health services are beginning to unnerve physicians, seriously affect the bottom line of hospitals, raise public hospital taxes, and draw growing funds from county budgets.

Only spotty regional data exists on the growth of medical outcasts, but nothing indicates a slowdown.

The South is the nation's worst-hit region, with its share of uninsured people rising to 18.6 percent in 2005. Manatee County's picture looks even bleaker. Apparently a function of its agricultural roots and small service business-based economy, Manatee's estimated share of the uninsured has climbed well above 20 percent of the non-elderly population and is quickly reaching the 50,000 mark.

Meanwhile, the Sarasota County non-elderly population's official share of the uninsured as of 2002-the last year with available data-was "only" 12.8 percent, better than the national average. This still amounts, however, to nearly 30,000 people just one car accident or illness away from disaster. Also, the fast rise of the immigrant population in Sarasota County is expected to push that number closer to the South's average over time.

Why should businesses take notice?

First of all, the rising number of uninsured employees and consumers poses a roadblock to growth of our regional economy.

Research has established that lack of health insurance and bad health goes hand in hand. And, as Jack Hadley of the Urban Institute concludes in a recent article, "Poor health reduces annual earnings from work, primarily through reduced labor force participation and work effort." Improving the health of workers would lead to a 15- to 20-percent increase in earnings, Hadley says, and thus boost the overall economy.

Or, in more pessimistic terms: The continued growth of uninsured people could get us stuck in a Third World-style downward spiral of lower productivity, lower wages and lower consumption.

Of course, the crisis also has a more immediate aspect for businesses. For one, everyone providing medical services knows what not being paid means. But non-healthcare companies are also feeling the pinch of low productivity, as sick employees do shoddy work, take leaves or drop out.

"Business is nothing without its people," says Fred Strobel, who teaches economics at New College of Florida. "Not providing benefits affects your productivity."

Many area business owners get this lesson in an indirect way: Non-health insurance employers are in a tough spot when it comes to attracting and retaining good workers these days.

"It's always mentioned by people that we interview," says Donald Owen Jr., whose family owns a two-lot auto dealership in Sarasota with more than 30 employees (and recently decided to provide them with health insurance). "The first thing candidates ask is whether there's any (health) insurance available."

This pressure is a function of low unemployment along Florida's Gulf Coast.

"We have a tight labor market," says Steve Queior, president of the Greater Sarasota Chamber of Commerce. "If a company can offer health benefits, they're in a better position to recruit and retain."

Finally, a consumer backlash against health insurance deadbeats is forming that keeps getting stronger. Activist groups have begun to call for boycotts of large retailers such as Wal-Mart who rely on a workforce of part-timers not eligible for benefits. Employers not providing insurance create a burden on taxpayers, the activists argue, and therefore consumers should spend their dollars with companies that protect their employees.

Not surprisingly, the local businesses that have been lashed hardest by the uninsured crisis are some hospitals and doctors' practices.

In Sarasota, a tiny group of physicians, including doctors such as pediatrician Dr. Carola Fleener, has taken on an inordinately large share of under-compensated Medicaid and uninsured patients. According to a 2004 study by Sarasota County Openly Planning for Excellence (SCOPE), only one in roughly three doctors' practices took on Medicaid patients. In fact, just 10 physicians were taking care of 45 percent of all Medicaid recipients in Sarasota County.

Some community service-conscious doctors have had to resort to applying for bank loans to meet payroll, but so far these physicians have not taken their displeasure beyond the moaning-and-groaning level.

That's in contrast to the headline-triggering brawl that exploded in 2006 at Manatee Memorial Hospital, which is owned by Pennsylvania-based Universal Health Service Inc. (UHS), a for-profit hospital chain.

Differing opinions as to who's to cover the dollar gap left by deadbeat patients at the hospital's emergency room caused a surgeons' rebellion. In January 2006, 15 surgeons signed a letter threatening to quit. Nine months later, Manatee Memorial CEO Brian Flynn surprisingly resigned.

Reflecting a nationwide trend, Manatee Memorial's emergency room has been swamped with patients over the past few years, many of them uninsured and unable or unwilling to pay their bills. Total bad debt and charity care losses at Manatee Memorial rose from $48 million in 2004 to $49.7 million in 2005, and again to a projected $51 million in 2006.

Unpaid emergency room duty has placed an undue burden on doctors, physicians say, and caused the number of medical specialists to shrink in Manatee County.

"We're unable to recruit new physicians to this area, because they can't make comparable income," says Dr. Thomas Braxtan, a kidney specialist and former chief of staff at Manatee Memorial who has been a vocal defender of physicians' interests in Manatee County. "We can't replace the specialists that are retiring."

Manatee Memorial Healthcare System physicians scheduled a meeting with the hospital last November. Both parties agreed in principle on a voluntary call program for the emergency room; in other words, E.R. duty would not be mandatory anymore. The program will be effective Feb. 1, but they have yet to figure out the details. In the meantime, new hospital CEO Moody Chisholm told The Bradenton Herald he would try to seek more county funds to pay emergency room doctors.

The conflict is a symptom of a large structural gap in Manatee County. In Sarasota County, the presence of a public hospital, coupled with a lower population share of the uninsured, has helped cushion the impact of the crisis. But in Manatee, which sold its public hospital in 1984, there is no one-stop, taxpayer-backed healthcare institution that could provide a safety net. Add to that the high share of uninsured people in Manatee County, and the patient flood at the emergency department of Manatee Memorial makes perfect sense.

The hospital's ER predicament has triggered several responses.

For one, Manatee County officials and healthcare providers have tried to re-route patients whose problems are below emergency room level, and set up triage centers elsewhere. Manatee Rural Health Services, a public-private charity organization, opened a walk-in clinic across the street from the hospital, and Manatee County just financed three new triage rooms at the nonprofit Manatee Glens.

Also, for the first time ever, the county tapped the principal of a $60 million fund in 2005, established after the sale of the county hospital two decades ago for indigent care to subsidize Manatee Memorial's emergency room services. The county has subsidized the for-profit hospital to the tune of $1.5 million a year for its emergency room services. But this doesn't amount to much more than a band-aid on a gaping wound, doctors and hospital administrators say, and the money is usually spent after the first eight months of the year.

To create long-term relief, the Manatee County Commission set up a nine-member healthcare task force in the summer of 2005 that is expected to develop proposals on how to best tackle the county's uninsured patient crisis in 2007. The one outcome favored by nearly all healthcare players would be the creation of a special taxing district to fund indigent care, provided via existing healthcare institutions.

Manatee Memorial CEO Chisholm described a special taxing district as "our only option."

Whether Manatee voters are inclined to swallow a special tax is a whole different story. An indigent healthcare tax would be more digestible for voters if it were to go to a public hospital, such as Sarasota Memorial. But in Manatee, a large share of the tax would help bolster the bottom line of Manatee Memorial's for-profit owner.

For companies, the most immediate problem is skyrocketing health insurance bills. Many small business owners are struggling to cover themselves and their families, let alone their employees.

Some local players have taken the problem into their own hands and are trying to provide local solutions.

One of them is self-insurance. The basic idea behind this concept: Health insurance companies are a layer that can be eliminated.

Healthcare provider Manatee Glens, which was struggling with actually providing healthcare for its own employees, decided to become self-insured by joining Healthcare Sarasota Inc.

Healthcare Sarasota is not a newcomer, but it has operated in relative obscurity since its inception. Set up in 1993 among Sarasota County, the city of Sarasota, Sarasota County School Board and Sarasota Memorial Hospital, this alliance covers 26,000 employees in both counties. To join, companies must have at least 50 employees. Healthcare Sarasota gives Manatee Glens' 480 employees access to the Gulf Coast Provider Network-a large physicians' network-and the Sarasota hospital system. Healthcare Sarasota also arranges for Manatee Glens' reinsurance. This stop-loss insurance kicks in when an employee faces catastrophic healthcare expenses.

Self-insurance requires committing the resources and time to learning about and keeping track of healthcare needs, and it has clear risks. But the new approach so far has produced cost savings for Manatee Glens.

"It has financially worked out," says Glens CEO Ruiz.

A handful of private-sector companies such as Sarasota Pathology, the Ringling School of Art and Design, and the area's largest law firm, Williams Parker Harrison Dietz & Getzen, have also joined the ranks of the self-insured and the Healthcare Sarasota alliance.

So could self-insurance become the next big thing? Even Robert Blinch-Edwards, the director of Healthcare Sarasota, is cautious. "Unless you really understand the implications, you shouldn't do it. It's a little daunting to leave the big insurance, because they're the ones taking the risk."

And it works best with larger companies. "The smaller the company, the higher the premium," he says of stop-loss insurance.

To fill this void for small businesses, another team-with Sarasota Memorial Hospital as its leader-started a different insurance venture last year. The hospital joined with the Greater Sarasota Chamber of Commerce and Sarasota insurance agency First Benefits Group Inc. to set up the Charter Plan, a comprehensive set of health plans anchored and subsidized by the hospital.

"We help to get the word out, the hospital delivers the healthcare services, and First Benefits processes the paperwork," says Chamber President Steve Queior. "Teamwork pays off."

To comply with Florida insurance regulations, the Charter Plan makers had to agree to only accept businesses that have not provided their employees any health insurance over the past half-year, and whose workers don't make more than two-and-half times the federal poverty level.

Under Charter Plan rules, the employer must pay at least 50 percent of the employee cost.

Even so, companies are joining at a fast clip. Up to 50 businesses with 250 covered employees have already signed up. The number of insured people is expected to grow to 1,000 by the end of 2007, says Terry O'Brien of First Benefits Group.

The Charter Plan rates are about 50 percent below those of comparable fully-insured rates in the region, O'Brien says. Chamber members receive a 10 percent discount. Not surprisingly, 70 percent of the plan's clients are Chamber member companies.

So is this pragmatic approach by small, locally controlled, low-cost healthcare enterprises such as the Charter Plan the future of healthcare?

Maybe, local healthcare players say. But as long as there is no national effort to provide health insurance for everybody, local successes could actually backfire.

"Clearly, we need a federal solution," Ruiz says. "Let's say, we find a brilliant solution locally. Wouldn't we draw poor people here from other places? We cannot afford to ignore the crisis elsewhere. We need a national healthcare policy."


James McCloud is the founder and CEO of a private walk-in clinic in Sarasota. The organization pays him a salary, he drives a Mercedes-Benz, and he lives in a condo on Longboat Key.

But things aren't what they seem: McCloud hasn't had health insurance for years, nor has he accumulated any retirement benefits. His Benz is 20 years old, and he rents the condo way below market rates, thanks to the gracious landlord who happens to be a board member of his organization.

That organization is Genesis Health Services Inc., and while it could be called the opposite of a concierge-style clinic, it's at least as cutting-edge.

McCloud's current lifestyle actually looks obscenely plush compared to past austerity. After graduating from Antioch College with a degree in political science/social change, he lived for years in a halfway house he founded in Nokomis. The only car he drove belonged to that organization.

"Solve, solve, solve," is McCloud's mantra.

The Palmetto native has dedicated the past half-dozen years of his life to get Genesis going. It operates as a clinic of last resort in Sarasota County for people who find medical care unaffordable. From one site at a strip mall in north Sarasota and another one in Nokomis, Genesis has been offering primary care and some specialty care since 2000.

The organization is treating thousands of patients a year-with a rock-bottom budget of $125,000.

Genesis has made an impact by offering mental health services, and it is the only place in the region that tries to offer comprehensive dentistry at affordable rates.

"There's great need in Sarasota, and the biggest right now is dental care," McCloud says, showing a scrapbook with 150 handwritten dental appointments. "Sarasota has Third-World dental problems."

Because Genesis hasn't been able to find volunteer dentists to replace one from Long Island who pulled out after he was diagnosed with cancer, Genesis patients have to make do with one volunteer who works once a month for four hours at the clinic. "Dentists here don't seem to have a culture of volunteering," McCloud says.

Although Genesis is a well-kept secret-there's no publicity except word-of-mouth-the number of patients treated by the nonprofit is going through the roof. Through October, Genesis treated some 5,000 patients in 2006, twice as many as the 2,500 for the entire previous year. Part of this may be attributable to a new cardiologist and an improved HIV program, McCloud says. However, the lack of health insurance is probably the main driving force behind the growth.

"Our patient visits here have doubled this year alone," he says. "And this is supposedly a good economy."

Genesis' business model rests mainly on two financial pillars: Free work by volunteer doctors and nurses, and sliding-scale payments by patients. The organization enjoys only limited funding through private grants and donations.

"What's glaringly missing is support from the big community-based foundations and from the county," McCloud says. "We have proven we're effective, but we were treated like a speck on the wall. There's no support for a model like ours."

In fact, after filing repeated requests in the 1990s, Genesis has given up wasting its time on grant applications with the big area pots of charitable money, relying instead on out-of-town grants and patient payments.

"Nothing is free here," McCloud says about Genesis. "The patients are the stockholders in this. Their part is to help us out with cash."

An estimated 90 percent of Genesis' patients fall into the below 200 percent of the federal poverty line category. But more and more patients live above that threshold.

"Many of them have a middle class lifestyle, but they're thrown into a situation without disposable income," McCloud says. "They're mortgage-rich but cash-poor. We help them. We're here to help, not to sell their house."

Genesis should actually expand to two or three full-service clinics, McCloud says. But before getting there, they might have to overcome another existential challenge at their sole existing full-service clinic. As a Wal-Mart will go up across the street from the clinic on North Washington Boulevard soon, you can bet that rents at the strip mall will rise considerably.



Non-elderly uninsured age 0-64 (2002): 21 percent or 46,122

Adults with no personal health care provider (2002): 19.6 percent

Percentage of population below 200 percent of federal poverty level: 35.2


Non-elderly uninsured age 0-64 (2002): 12.6 percent or 28,900

Adults with no personal health care provider (2002): 18.3 percent

Percentage of population below 200 percent of federal poverty level: 22.5

SOURCE: Florida Department of Health 

Filed under
Show Comments