June 28, 2009-Bismarck Tribune

The 65-year-old had sliced open his left hand on a Wednesday afternoon while working on a garage door at his Hazelton home. He held a paper towel to the bleeding wound while his wife escorted him into the Linton Hospital, just a few miles down the road.

An hour later, Fortner had received four stitches, a tetanus shot and was ready to head home. Medicare would pick up the bill for the routine procedure.

But things hadn’t always been so easy for Fortner, a semi-retired carpenter.

Like many Americans, Fortner lived most of his life without health insurance, paying out of pocket for doctor visits while hoping nothing serious would happen.

Last year, Fortner finally started to receive Medicare, the government-funded health insurance for those 65 or older, and started a supplemental policy with Blue Cross Blue Shield of North Dakota.

“Basically most of my life, I just took care of myself,” Fortner said, donning a Chevrolet baseball cap while lying on the emergency room table as a nurse practitioner finished the sutures. “I guess I never did complain about it because when you’re sick or you need help you really don’t want to sit there and complain about the cost of it.”

For much of his life, Fortner was one of the estimated 46 million uninsured Americans, a number that is expected to climb to 72 million by 2040 if current trends continue, according to a report by the Council of Economic Advisers to President Barack Obama.

This summer, Congress is debating sweeping health care reform, one of the most difficult issues in American politics that has eluded presidents dating back to the original Rough Rider, Theodore Roosevelt.

The questions are big and the costs just as large, which are estimated in the ballpark of $1 trillion to $1.6 trillion over the next 10 years.

Congress is mulling bills in five committees with proposals ranging from tax subsidies for the uninsured, to a publicly funded insurance provider to one proposal that has its roots in North Dakota’s rural, progressive past: cooperatives.

Sen. Kent Conrad, D-N.D., introduced the plan to establish health care cooperatives in all 50 states with government providing the startup costs, which he said could amount to $3 billion to $5 billion.

It is a proposal that has earned support from those on the right who oppose any government-funded “public option” and barbs from those on the left who want to see a public insurance plan signed by the president this year.

Despite Obama throwing his weight behind a public plan, Conrad contends the votes are not there to pass it.

“There are certainly strengths to a public option. The problem that one has is that there is strong opposition among some Democratic and virtually all Republicans to any of the public option concepts, because what they fear is a government takeover of health care,” Conrad said. “That’s why I was asked to come up with a compromise to bridge these differences.”

Sen. Byron Dorgan, D-N.D., and Rep. Earl Pomeroy, D-N.D., have both said they would support a public option as long as it wouldn’t put private insurers out of business. Dorgan also said he would be supportive of Conrad’s proposal as he learns more details.

In North Dakota, medical providers are watching the health care debate with interest while the details are hammered out on Capitol Hill.

The problems facing the Peace Garden State - which has some of the lowest health care costs in the country - are different than issues facing other states, namely low Medicare and Medicaid reimbursements to North Dakota health care providers and access to hospitals in rural areas.

“We’re at one of those pivotal 20-year periods,” said Brad Gibbens, the interim co-director for the Center of Rural Health at the University of North Dakota. “There’s going to be a lot of opportunity for explosive change.”

What is the status

of health care?

While many details of the health care reform debate are still fuzzy, the problem can be boiled down to three issues: how to stop the rising cost of health care, how to cover Americans without insurance and how to pay for it.

There also seems to be a general agreement among Americans and those in the health care system: “There’s a rather compelling set of facts and evidence that indicates that health care has got to change,” said Jim Cooper, CEO of Medcenter One in Bismarck.

But what those changes are will not be determined by Congress until later this summer, if at all.

The public also has indicated to polling firms that it overwhelmingly wants a change in the health care system, with recent poll for CBS News and the New York Times finding 72 percent in favor of a public system for all Americans that would mirror Medicare.

Policy writers also point to a disturbing trend in the country’s health care system: 18 percent of the country’s gross domestic product is spent on health care. That figure could grow to 28 percent of GDP by 2030 and 34 percent by 2040 if current trends persist and nothing is done to stop them, according to the CEA.

Health care in North Dakota is comparatively cheap, averaging $6,108 for Medicare reimbursements while the nationwide average is $8,304, according to the Dartmouth Institute for Health Policy and Clinical Practice. In McAllen, Texas, the nation’s most expensive city for health care, Medicare reimbursements are nearly $15,000.

But those low Medicare and Medicaid reimbursements are also hurting North Dakota health care providers, especially in the state’s 39 rural hospitals who say they are operating on the edge of a financial cliff. Medicare reimbursements are a common payment many hospitals receive in North Dakota, considering its aging population.

Roger Unger, administrator of the Linton Hospital, said the time has come for change. He is wary of some of the proposals in Washington, specifically plans to cut Medicare reimbursements as a way to rein in costs.

“If I get a cut in my reimbursement levels, I’m out of business,” Unger said. “I cannot pay my bills. It is just that simple.”

That problem will continue to worsen as North Dakota’s aging population continues to climb. By 2020, 46 counties are expected to have 22 percent of their populations over the age of 65, according to a June study of the state’s health care environment that Gibbens co-authored at UND.

North Dakota Insurance Commissioner Adam Hamm said the state lags about 30 percent behind the rest of the country in terms of Medicare reimbursements.

“So by the federal government not paying its fair share in North Dakota, hospitals and clinics obviously can’t eat that entire amount, so what do they do?” Hamm said. “A part of that gets passed on to the private health insurance companies, the Blue Cross Blue Shields of the world, who then pass that on to the policy holders.”

Blue Shield Blue Cross of North Dakota premiums also have increased in recent years, including a 7.9 percent rate increase for group rates that takes effect on Wednesday.

Other problems persist in the state. About 51,900 North Dakotans, or about 8.2 percent of the state’s population, are uninsured, according to the UND report.

The state’s uninsured rate is low when compared to the national average, which is about 15 percent, and a far cry from some states, such as Florida, Nevada and California, that have uninsured rates hovering around 20 percent or more, according to the U.S. Census Bureau.

Meanwhile, 12 percent of North Dakotans live in poverty.

Jackie Grunefelder, a family nurse practitioner at the Linton hospital, said it’s not uncommon to see a person debate which drugs or tests to forgo because of high costs.

“I think they’ve become more selective, sometimes they wait too long or they really are sick because of the cost for them,” Grunefelder said. “And you do see them picking and choosing which medications they’re going to be on because of cost.”

Unger’s also noticed another trend in the four years he’s worked in Linton: the “charity care” his hospital provides for patients who are unable to pay has tripled from $20,000 a year to nearly $60,000.

“What has happened is fewer people have the ability to pay,” he said. “If somebody’s depending on a job at the Gas Plus down here, they’re probably not going to have enough money to pay the medical bills if it’s anything serious.”

But North Dakota has many bright spots, too. The state is among the highest when it comes to medical quality, ranking 13th in the nation, according to a 2007 Commonwealth Fund report.

Youth smoking, a leading cause of heart and lung disease, also has decreased by nearly 20 percent since 1999, and seat belt use was at an all-time high of 82 percent in 2007.

Still, Gibbens said there is room for improvement, especially when it comes to preventing future disease and injury. In North Dakota, 65 percent of the adult population is overweight or obese, 21 percent smokes and the state has the second-highest rate of binge drinking in the nation at 23 percent.

Gibbens said more could be done to help decrease patient infections during hospital stays - a growing problem around the country - as well as increasing preventative care among patients rather than treating problems when they occur.

The proposals

The last time a president tried reforming health care was in 1994 under former President Bill Clinton, whose proposal fell with a thud on the floor of Congress despite a similar Democratic majority in the nation’s capital today.

Two presidencies later, things are “15 years worse,” Gibbens said.

But what the political realities are in Congress will determine the outcome later this year.

“Everything is on the table,” Unger said. “So it’s very hard to say which direction it’s going to go.”

Conrad has said his proposal would establish 50 nonprofit cooperatives, one in every state, which would be run by a board of directors elected by the cooperative’s members.

After an initial government-funded start up, “They would not be eligible for any additional federal insurance; that’s one of the key elements of this, that it not be government controlled,” Conrad said.

States with smaller populations, such as North Dakota, would be allowed to team with other states of similar size, such as South Dakota and Montana.

“I think in D.C., they’re not used to thinking outside of the box,” Gibbens said. “So when Kent Conrad starts talking about an old progressive idea from out of the 1930s, this is a real North Dakota contribution to the debate on health care.”

Conrad’s proposal also has the support of some health care providers in the North Dakota.

“I understand from Sen. Conrad’s proposal, it’s a way to fashion an insurance program that has local roots yet doesn’t have the government control at all,” Cooper said. “I think it would be a mistake if the government controlled everything.”

Any new system is going to have to address the payment disparity, he said. “I think we’re all of the mindset that would welcome a system that pays us on quality, outcome and performance rather than a system that we have now.”

There also is plenty of skepticism.

“I think the issue is, and we don’t know the details about it, how is this going to be funded?” said Andrew Wilson, CEO of St. Alexius Medical Center in Bismarck.

For example, Wilson said, will there be a group rating and a pool of members to negotiate coverage? Or will it be underfunded by the government?

“If it’s going to be an alternative to the insurance industry, and not a health care purchase cooperative under the traditional sense,” Wilson said, “then it will be disastrous to hospitals in North Dakota.”

Hamm said all ideas, from public options to cooperative, should be on the table despite any philosophical or party differences.

“All of that stuff needs to be in place, day one,” Hamm said. “Otherwise, I don’t know how it controls costs, expands access and pays for itself.”

Obama has pushed for a system that would include a government-backed insurance program that would compete with other health care providers as a way to cut insurance costs. It’s an idea that has the support from Dorgan and Pomeroy.

Obama also recently told CNBC that he would support a cooperative concept similar to Conrad’s if “that is a better way to reduce costs and help families and businesses with their health care.”

Among other key proposals in Congress are Sen. Edward M. Kennedy’s bill, which would provide government subsidies for health care premiums for Americans with incomes of up to 500 percent of the poverty line, or $110,000 for a family of four.

The proposal also includes expansion of Medicaid coverage, the government program that covers the poor, to 150 percent of poverty, or a family of four earning $33,075 a year.

Republican critics, as well as some moderate Democrats, have distanced themselves from any “public option,” including Conrad, who has remained skeptical of such a proposal passing the Senate with 60 or more votes.

Dorgan said he would support “some kind of backstop public plan,” noting that most health insurance would be provided by private insurers.

“I will support health care reform if it will allow everybody to keep their own health plan. If they’re satisfied with their health plan, they should be able to keep that,” Dorgan said. “No single-payer government-run plan. I am interested in seeing an approach that would get some control on health care cost.”

Pomeroy said the state’s largest insurer, Blue Cross Blue Shield of North Dakota, needs competition, noting revelations over the more than $1 million in annual compensation and $2.2 million severance package going to ousted Blues CEO, Mike Unhjem.

“I’m for more competition in health insurance. You look in North Dakota, you have a one-company environment,” Pomeroy said, adding, “It needs to play fair on a level playing field. I’m not for a public plan option that would give the public plan significant advantages over any private company would have.”

Back in Linton

Two years ago, Melvin Fortner experienced something much more serious than a wounded hand. He suffered a heart attack.

He was rushed to the Linton Hospital, where the staff there did all they could until they determined Fortner would better off going to Bismarck for specialized care. It was the nearby hospital ambulance that helped save his life, he said.

Fortner also notes that he is lucky he didn’t suffer a heart attack at 40.

As a young man, Fortner said he considered getting health insurance, but decided he couldn’t afford the cost.

So he waited.