A congolese friend once told me that you can judge the wealth of a nation by the condition of people’s teeth. His words came to mind when I met with Sonja Norris, the director of Ingham County Dental Clinics, two facilities offering dental treatment on a sliding payment scale. Norris says the teeth of low-income adults and children in Ingham County are in horrible condition: “Most children have severe decay in the back and front teeth, so that many can’t even bite potato chips or burritos.”

People who criticize the state of health in America, especially for the poor, have demanded sweeping reforms in health care for decades. One might still remember Bill Clinton’s election to office in 1992, on the campaign promise of a national health care system. The United States, after all, is the only wealthy industrial nation without one. A decade after this unfulfilled campaign promise, affordable quality health care remains a central political concern across the country today. How do Mid-Michigan residents feel about this issue?

Daniel Sturm/City Pulse

Dr. Sonja Norris, the director of Ingham County Dental Clinics, says the teeth of low-income adults and children in Ingham County are in horrible condition: “Most children have severe decay in the back and front teeth, so that many can’t even bite potato chips or burritos.”

Let’s begin back at the dental clinic. Norris, a Lansing resident born in Ann Arbor, thinks universal health care is the broader solution, and says she’s angry about the labeling of people without health insurance as “underprivileged”: “It’s not a privilege to have health care, or to be healthy. It’s a right.”

In 2001, the director and her 13-person staff treated 1,502 low-income adults at the Cedar Street Center Dental Clinic, and 1,545 children at the Healthy Smiles Clinic. Both clinics are subsidized by Ingham County. The number of low-income patients has risen since 2002, when she says 1,956 children were treated. Patients pay a $3 fee per visit, and their treatment costs are reduced 50 percent to 100 percent, depending upon family income and size.

Norris says that if dental problems remain untreated before children develop their permanent set of teeth, this can severely influence their overall sense of well-being: “Children remember how they felt when they were 4 years old. This is the time when we develop our self-love. Children with painful memories will have trouble with low self esteem.”

Bruce Miller, director of Ingham County’s Community Health Service, thinks the area is in need of more subsidized medical care, particularly dental care. “Many people are not getting their broken teeth fixed, because the dentists in town are busy seeing people who have money and insurance.” In contrast, residents covered under the Medicaid program had very restricted access to dental care, and uninsured people must wait for months to receive a dental appointment.

Sonja Norris

He tells me that Ingham County’s cost-reduced clinics are currently unable to catch up with the growing need for their services. And the three private pediatric dentists in Lansing don’t accept Medicaid children. A nationwide epidemic of asthma is causing more work for an already overworked staff. According to Norris, children suffering from asthma frequently take medication that causes dry mouth, increasing the risk of cavities and tooth decay. Without preventive care and education as children, says Norris, adults often experience severe abscesses. And poor oral health leads to many other health problems.

The dentist expressed worry that many more children and adults will come to the low-income clinics when Gov. Jennifer Granholm’s 2004 proposed budget plan goes into effect. The Granholm administration proposes cutting some optional benefits for the general Medicaid population. About 130,000 so-called healthy adults will lose access to chiropractic, podiatry and non-emergency dental care.

“If Medicaid is cut, we have a problem,” said Norris, a dentist in a private practice before she became dental director in 2001. “Our dental clinics will be extremely full and very busy.”

Some 30,000 Ingham County residents have no health insurance, and an additional 20,000 are covered under the Medicaid program. In 1998, the county government launched an effort to match the needs of the uninsured and underinsured with a project called the Ingham Health Plan. Stepping in to fill a need that state and national governments weren’t addressing, Ingham became the first Michigan county to start an ambitious cost-reduced medical care project.

The Ingham Health Plan targets low-income, uninsured working people and their dependents, employed Medicaid recipients who have exhausted their benefits, other low income uninsured individuals, and medically indigent individuals. Benefits consist of primary care, specialist physician services, laboratory, x-ray and pharmacy services. Hospital care is provided by area hospitals as part of their charity care obligation or community benefit programs. Ninety percent of the Ingham Health Plan enrollees have incomes at or below 140 percent of the poverty level.

Residents with an income under 250 percent of the poverty level who don’t receive other coverage are eligible. Once accepted, members have access to a defined set of benefits through 31 offices in the area. Patients pay $5 per visit to one of several primary care providers (in Lansing there are six locations), $10 for specialist visits, $5 for outpatient x-rays, and usually $5 per prescription.

By the end of 2001 nearly 13,000 uninsured Ingham County residents were enrolled in the plan. Meanwhile nine other counties have copied the model: Barry, Eaton, Mar-quette, Jackson, Kalamazoo, Kent, Clinton, Gratiot and Montcalm.

Another 3,600 low-income residents are enrolled in the Capital Area Prescription Program (CAPP), designed for any residents of Ingham, Clinton, and Eaton counties who do not have other drug coverage. Owners of a CAPP card can get prescription drugs at participating pharmacies with an average discount of 20 percent.

In April 2003, Ingham County applied for a $500,000 federal grant to receive funding for a third subsidized dental clinic. If built, the facility would become the eighth in a network of reduced-cost medical clinics in Lansing. The new dental clinic would be established at the St. Lawrence Community Health Center, located in a professional building next to the former St. Lawrence Hospital. The federal grant would also provide funding for staff, a new mental health program, and seed money for an expanded medical clinic.

Miller believes the application has a good chance of being approved, because the health care needs in the targeted area of Lansing’s westside neighborhoods are apparent. A project summary shows dramatically that 60 percent of St. Lawrence’s health center users are uninsured. The report concludes that the evident health disparities are disturbing, especially for newborns. The mortality rate of African-American infants in the area is 15.1 per 1,000, as compared with mortality rate of 4.0 per 1,000 for caucasian infants. The overall infant mortality rate is 7.6 in per 1,000 Lansing and 6.8 in Ingham County.

Norris said that a third clinic would be the only way to accommodate the community’s needs if Medicaid cuts are to occur. The new facility could be in operation as early as October 2003, providing service to another 1,500 patients. Although the county government is doing all it can to provide help for the underinsured, Miller believes that building a new clinic is only “the tip of the iceberg.”



Asked whether he found the Ingham Health Plan a sufficient means of meeting the needs of the underinsured, Michigan’s Green Party chairman, Marc Reichardt, answered: “It’s hard to say that it’s not a good thing, as the county is responding in the only way it currently can.” Reichardt argues that too many programs are designed to treat symptoms, while nothing is being done to improve the entire health care system. Added Reichardt: “What happens to Ingham County finances as the income gap continues to rise and the economy continues to suffer? What will they do when the number of low-income residents doubles or triples in a short period of time?”

Reichardt said Granholm’s recent plan to provide Medicaid to an additional 62,000 residents was an example of what he called “poking away at the symptoms.”

Those residents have income levels at or below 35 percent of the federal poverty level.

Ray Ziarno

According to federal poverty level measures, a family of four that makes less than $18,400 per year is considered impoverished. Noting the income limitations, Reichardt feels Granholm’s plan has little to do with reality: “Anyone with a shred of common sense knows that it’s difficult to survive alone at that level, much less with a family of four.” What the governor is suggesting for the new state Medicaid budget is that a family of four must make no more than $6,440 per year to qualify for free health care. Added Reichhardt: “Many people who enjoy annual incomes in the $20,000 range and have family units of one to two to support still cannot afford regular doctor visits. I don’t think this measure is anything more than a feel-good effort for public consumption.”

Ray Ziarno, Michigan’s Green Party candidate for secretary of state in 2002, said that the state’s difficult financial position is no excuse for a budget cut of this nature. The North Lansing resident added that: “The longer we wait to change the system, the longer we forego the benefits of universal coverage. Waiting for the perfect time to make the change is a losing approach, and displays a lack of future focus.”

When asked what they thought of universal health care, physicians, legislators and other area professionals generally showed enthusiasm but did not seem to think this was a realistic option. Norris said that like many other physicians, she believed universal health care was a wonderful idea but that it might be too difficult to implement.

According to the Kaiser Commission on Medicaid and the Uninsured, a Washington-based policy institute analyzing health care coverage and options for reform, universal health care is not so much a matter of money. A Kaiser study recently published in Health Affairs estimates the cost of medical care for the nation’s 41 million uninsured at roughly 3 percent to 6 percent of total health care spending. The study concluded that universalizing national health care would range from between $34 billion and $69 billion per year, depending upon the approach taken. According to the Kaiser Commission, this would be “a very worthwhile investment when considered against the benefits of improved health, increased longevity, and potentially greater national income.”

Reichardt points out that “we spend $350 billion per year on the Pentagon, and need to shift priorities.” In fact, plain numbers show that the cost of universal medical coverage for the entire country would be less than the approved 2003 budget increase for military spending ($46 billion). Reichardt just may have a point.

One of the Democratic candidates running for 2004 presidential nomination, Dennis Kucinich, has announced that he would adopt a policy of “Medicare for All” — a universal, single-payer system of national health insurance that could be carefully phased in over a 10-year period. Kucinich wants to remove private insurance companies from the system, along with their “waste, paperwork, profits, excessive executive salaries, advertising, and sales commissions” and to redirect resources into actual treatment. Funding would come primarily from existing government healthcare spending (more than $1 trillion), and a phased-in tax on employers of 7.7 percent (almost $1 trillion). According to Kucinich, companies with private insurance plans currently spend more than 8 percent of their budget on employee health care costs.

The presidential candidate points out that publicly financed, privately delivered health care has worked well in other countries, none of which spend as much per capita on health care as the United States. “We’re already paying for national health care—we’re just not getting it,” Kucinich said. He points to a study conducted by the General Accounting Office, which concludes that if the United States were to shift to a system of universal single payer coverage, as Canada has, the savings in administrative costs (10 percent for private insurers) would more than offset the expenses.

Ann Arbor resident Reichardt agrees, pointing out that initiatives at the local and state level were easily attainable. He mentioned recent legislation in Maine, where two weeks ago Gov. John E. Baldacci signed “Dirigo Health,” the nation’s first universal health care plan, into law, establishing a new public-private agency. The plan works with private insurers to provide health care coverage to 180,000 uninsured Maine residents by 2009, according to the Bangor Daily News.

Lisa Dedden

In addition to expanding Medicaid eligibility, the plan provides coverage to self-employed residents, and people whose employers do not offer health insurance. To finance the universal health care plan, Baldacci is using $52 million of Maine’s share of state aid (packaged with recent federal tax cuts), a 4 percent fee on state insurance company gross revenues, premiums paid by employers and the self-employed, and Medicaid funds.

While the State of Michigan no longer has the basic funds needed to keep schools open, or clean up its pollution, another $10.3 billion in tax dollars from state residents were paid to the Pentagon in 2002. County Commissioner Lisa Dedden, who chairs the Ingham County Human Services Committee, said she was aware that even recent attempts to establish new clinics for underinsured residents were not a general solution for Ingham’s health care problems. “In a way we’re only filling the gap,” Dedden said.

Blue Cross and Blue Shield is Michigan’s largest health insurance provider, providing coverage for more than half of the state’s working population. Referred to as the “Blue Whale” because of its size and political influential, the not-for-profit health care provider is a major contributor to both Republican and Democratic candidates in Michigan.

A 2001 report issued by the Michigan insurance commissioner, Frank Fitzgerald, found that BCBSM had serious problems, including $400 million in losses in its small group market, archaic technology, and a cumbersome board and management structure. Fitzgerald criticized an apparent conflict of interest in which representatives of medical providers sat on Blue Cross’s 35-member board. “Also, the board is dominated by self-insured interests who only use Blue Cross Blue Shield of Michigan for administrative services, yet they set policies concerning Blue Cross Blue Shield of Michigan’s underwritten book of business,” criticized Fitzgerald.

Okemos resident Sylvia Chappell-McCollough is no fan of the Blue Whale. When we began to discuss the Michigan Green Party’s proposal to cut out the middle man, and Maine’s example of universal health care, she said enthusiastically.

The long-time Democrat said that the straw that broke the camel’s back was her visit to a doctor last fall. Waiting in line at the hospital pharmacy counter, she stood behind a senior citizen who’d just received a $250 prescription bill. “The little lady practically fainted. She left the office saying that she really couldn’t afford this,” recalls Chappell-McCollough.

“In this country there’s no excuse for not letting everyone receive coverage and get the drugs they need to stay healthy,” she said. The political consultant emphasized that she preferred “pure politics” and hated the heavy-handed power-games that usually dominate the state capital’s political landscape.

She found the health care situation in Michigan upsetting because of its apparent socio-economical disparities. While 964,900 uninsured Michigan residents have no idea how to get their teeth fixed or pay for expensive medication, retired state politicians who’ve served at least five years in legislature are guaranteed free dental and health care, with just a 10 percent prescriptive co-pay. The health premium is operated through BCBS, and the first generation of politicians aged 55 and older will start receiving benefits in 2004.

As the former wife of state senator, Patrick McCollough, Chappell-McCollough has insider knowledge. When the legislature voted to make Blue Cross and Blue Shield a tax exempt nonprofit insurer as a “last resort” in 1980, Chappell-McCollough remembers how the former Michigan attorney general, Frank Kelley, helped BCBS lobbyist Richard Whitmer (now BCBSM’s president) draft the bill.

According to the annual report of the Michigan Legislative Retirement System, 247 retirees, spouses, and dependent children received benefits in 2002. The total benefit package, which includes coverage for medical, survivor, death, dental and health benefits, was $9,942,870 for 2002, which is more than double the cost of the program in 1993.

“A huge number of politicians and their spouses will receive free health care for their entire lives,” commented Chappell-McCollough. She pointed out that the Blue Cross and Blue Shield Program was originally put in place to provide health insurance for low-income people, but that with growing political influence during the 1990s, its agenda has “completely mushroomed.” Added McCollough: “Meanwhile our senior citizens can’t even afford prescriptive medicines, and we have to have a taxpayer-subsidized health care system to take care of the ‘poor.’