Children left behind on health care

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The Hulse family staggered into North Georgia in January with $630 and hope for better times. Gary Hulse had lost his plumbing job in Arkansas, and the family had lost their home there.

After arriving in Georgia, Melissa Hulse applied for Medicaid health insurance coverage for her four children. Three were accepted. But Avery, who has juvenile diabetes, wasn’t approved — the result of bureaucratic misinformation, says her doctor, Martin Michaels. Medicaid, a program for the poor and disabled, never should have rejected Avery, Michaels said.

Meanwhile, Avery’s medical bills quickly mounted. “We sold our wedding rings to buy insulin,” Melissa said. For months, though, they couldn’t afford a second form of insulin and supplies to monitor their daughter’s condition. The result: Avery, 16, twice had to be taken to a local emergency room. The bills totaled about $1,500.

After several months, a new caseworker was assigned to the family, and Avery now has joined her siblings on Medicaid.

That basic story is being repeated all across Georgia, according to pediatricians and children’s health advocates. They say administrative and other roadblocks prevent coverage for thousands of children who are eligible by family income for Medicaid and PeachCare, an insurance program for children of parents whose incomes are slightly above those on Medicaid.

Despite the state’s steadily rising population over the past two and a half years, the number of Georgia children covered by the two public insurance programs has dropped by more than 100,000.

All states have many uninsured children who qualify for public benefits, and some have seen recent enrollment declines because of tougher signup requirements. But Georgia adopted eligibility rules for both programs that ”are among the most restrictive” in the nation, says Donna Cohen Ross of the Center on Budget and Policy Priorities, a Washington research organization.

A deteriorating economy typically sparks more applications for public assistance, and Georgia officials say there has been a recent uptick in Medicaid applications. This economy-related push for government health benefits, though, coincides with the state’s widening budget shortfall — and Medicaid and PeachCare, as always, loom as possible targets for deep spending cuts.

When eligible children fail to get health benefits, families can feel severe financial and medical consequences.

“I’ve had kids with chronic medical conditions go without care,” says Dr. Michelle Zeanah, a Statesboro pediatrician. “Their parents can’t afford the $90 a month for daily medicines.”

Many end up in emergency rooms, much more expensive than a doctor’s visit.

Michaels, a Dalton pediatrician for 24 years, contends that at least 160,000 Georgia children go without public insurance, even though they’re eligible, due to new requirements and other obstacles, such as inconsistent information to families.

Michaels has led a personal crusade about uninsured children, discussing the problem with legislators and officials at the state Department of Community Health, which runs Medicaid and PeachCare in the state. He introduced a reporter to several Dalton-area families whose children were eligible but went uncovered for months until being accepted.

One of the children Michaels cited, Jessica Wyatt, 13, of Resaca, has hypertension, and was uninsured for seven months before finally receiving Medicaid in July.

During that time, the family racked up thousands of dollars in medical bills, says her mother, Sharon Wyatt. “She missed quite a bit of school,” Wyatt says. “We had a benefit yard sale for her to see a specialist.”

Michaels first noticed a problem with children not being covered in fall 2006.

“Low-income kids had asthma and didn’t have Medicaid, and couldn’t afford to buy inhaled corticosteroids, and they’d end up in the ER,” he says. “Or we’d have kids not coming in for immunizations or well-child visits.”

That year, new federal Medicaid rules began requiring families to show proof of citizenship and identification. Georgia also tightened its Medicaid rules on verifying family income, requiring pay stubs, W2’s or letters from employers.

Restrictions came amid the state and national outcry over illegal immigration.

Georgia officials say they have no statistics on the number of fraudulent enrollments they found. Nationally, few if any fraudulent signups surfaced. A study by the House Committee on Oversight and Government Reform found that despite spending millions of dollars in new oversight costs, six states found only eight undocumented immigrants on Medicaid. Adds Diane Rowland of the Kaiser Family Foundation: “I don’t know any substantial reports of people hiding income for health insurance coverage for themselves and their kids.”

Still, in 2007, Georgia imposed similar proof of citizenship rules for PeachCare, plus income requirements. The new rules were designed ”to improve program integrity,” said a spokeswoman for Community Health.

State officials acknowledge the new documentation requirements caused enrollment declines.

Besides Georgia’s tougher rules, experts say the application process is cumbersome. “There doesn’t appear to be as much focus on enrolling kids,” says Linda Lowe, a consumer health advocate. “There should be an effort to help families get the documentation. Not everyone works at a job that has a pay stub, or has an employer who’s willing to write a letter [on a worker’s income].”

Georgia Medicaid officials say they are clarifying and simplifying application forms. And PeachCare this year reached out to parents when the school year started, after two years of inactivity.

“We’re open to ideas to do better,” said Mark Trail, the state’s longtime Medicaid director.

Even when families turn over the necessary paperwork, it sometimes gets lost or mishandled, according to child health advocates.

State Division of Family and Children Services staff have high caseloads and heavy turnover, says Susy Martorell, a medical social worker in DeKalb County. “All kinds of mailings get lost,” she says. “Applications and other documents. It’s a huge waste of our tax money. I think it’s getting worse.”

Marisol Morin of Dalton says a local DFCS office lost her children’s birth certificates. Now her children have coverage, but not until her son needed stitches in a hospital. She had bills for $930.

Madalynn Jones of Dalton, a single mother, applied this year for Medicaid for daughter Kylah. “Medicaid denied me first,” Jones said. “They referred me to PeachCare. PeachCare denied me next.”

During this back and forth, Kylah, 17 months, had a heavy vomiting episode. Jones took her to an emergency room and later got a bill for $506. After months of no insurance, Medicaid finally accepted her daughter.

As a model for improvement, Michaels and other pediatricians point to Alabama, which has a much lower percentage of uninsured children than Georgia has — 7 percent vs. 12 percent — and has a single application for both its Medicaid and PeachCare equivalent. Georgia families must apply to one program and, if rejected, then go through another application process.

“We put a lot of emphasis on outreach,” says Cathy Caldwell, director of an Alabama program that’s equivalent to PeachCare. “We went 15 months straight with record enrollment. Our legislators are extremely supportive of the program,” which doesn’t require proof of citizenship for applicants.

Georgia officials say they will ease the process of referring children’s applications from PeachCare to Medicaid. Children’s Healthcare of Atlanta took the enrollment problem into its own hands recently, launching a program to assist parents to sign up for Medicaid or PeachCare at its Hughes Spalding hospital. The effort has cut the hospital’s uninsured rate from nearly 16 percent of patients to 10 percent.

But better enrollment ”would save the state an incredible amount of money,” says Avril Beckford, a Cobb County pediatrician.