Miami Herald (MH) - Sunday, July 28, 1991
Andres Viglucci and Jacquee Petchel; Herald Staff Writers

What the Opa-locka child really needs, his doctors say, is low-cost, preventive medical care and a $150 inhaler his mother can't afford. His hospital bills have cost taxpayers $31,406.91.

In Dade County's disjointed health system for the poor, the pattern is re-enacted daily: For lack of basic care, an easily treatable or preventable illness escalates into an expensive, life-threatening calamity.

"We have deaths from asthma. It's not a trivial issue," said Dr. Rodney Howell, head of pediatrics at Jackson and the University of Miami. "If the good fairy came to Miami -- and I'm beginning to think the good fairy is dead -- we would have an optimal primary care system to care for these children before they're seriously ill."

Critics fault a system that puts too much money into the "back end" -- costly hospital treatment -- at the expense of the "front end," the overloaded, government-subsidized clinics that provide primary care to the indigent and working poor in Dade.

As county leaders push a proposed half-cent sales tax to boost health care for the poor at Jackson Memorial, the debate has acquired a new urgency.

On Sept. 3, voters will be asked to pour about $60 million more a year into Jackson, money that county officials say would relieve overcrowding, cut waiting lists and improve the quality of care at the hospital.

Once again, critics contend, the front end has been left out.

Under the county's plan, most public and subsidized clinics in Dade would not benefit from the tax. Its proponents, who had originally sought a one-cent tax, say half a cent just won't yield enough money.

But clinic backers, though mostly supportive of the tax, say they doubt it will do much to alleviate the health problems of the poor unless a greater share of the money goes to primary care.

"Jackson and primary care don't have a fight. There's no question that that hospital is essential," said Cal Davis, administrator of the Coconut Grove Family Health Center, a federally subsidized clinic.

"But I still feel there's got to be some kind of balance, otherwise you're going to find that the system is going to tip over."

Davis' clinic is one of a network of 13 primary care centers, scattered from Florida City to North Dade, that make up the front end of medical care for the poor in the county.

The network, which includes private nonprofit clinics as well as two county-run centers and state-run Dade County Public Health units, provides basic and preventive medical care -- everything from prenatal care and immunizations to tests and drugs for HIV and AIDS patients.

But the clinics, which are funded by the state, local or federal governments, are overwhelmed. Most have absorbed substantial budget cuts in the past several years.

The Health Council of South Florida, a planning group, estimates the clinics handle less than a third of the estimated 675,000 people in Dade who can't afford health care.

Most of the clinics have waiting lists for some services, including immunizations and other "well-baby" care, and some are forced to turn away new patients. In the past year, the public health unit has had to temporarily close its waiting list for prenatal care, which can make the difference between healthy and sickly babies.

"We're dealing with staffs that are overworked and still underpaid," said Davis, whose clinic can afford an obstetrician only 12 hours a week. As a result, pregnant women must wait a month for a prenatal care appointment.

Unable to get the care they need in their neighborhood, many poor people use Jackson for basic medical attention, stuffing its emergency room, urgent-care ward and outpatient clinics.

"Every time I go to the Family Health Center, it's really packed," said 17-year-old Erica Butler, a single mother whose 11-month-old daughter has been hospitalized several times with asthma. "I hate taking my baby there. We get there in the morning, and we're still there when it closes at night. I always end up back at Jackson."

Her Jackson bill, for several visits: $75,000. She can't pay it. Taxpayers will.

Doctors say at least half of the 25 children admitted to Jackson each month for asthma could have avoided hospitalization with better care early on.

Some poor, pregnant women show up to deliver with little or no prenatal care, and some of their babies wind up in Jackson's newborn intensive care unit, which perennially runs over the hospital's licensed capacity.

Often, parents wait until their children are acutely ill before they seek help -- and by then, they need hospitalization. This month, two children were admitted to Jackson with whooping cough, a disease easily prevented with a vaccine provided free at Dade's public health units.

Neither child had received the shot. Last year, a child died at Jackson from diphtheria, the first death from the preventable disease in two decades.

For years, experts have warned that putting more scarce resources into hospitals such as Jackson is not the best solution.

"Jackson need not be the answer to all health needs," said Vandon White, professor of health services administration at Florida International University.

"Putting additional money into the hospital will enable Jackson to pay some of its bills. But it doesn't do anything to improve the health status of much of Dade County," White said. "Primary care needs to be available within the communities where people live. It's more sensible."

Hospital officials fully agree with the contention.

"It's inexcusable, outrageous to have primary care services being delivered at Jackson when they should be offered right in the community," said Elayne Weisburd, chairwoman of the primary care committee of the Public Health Trust, which runs Jackson. "And if we can take care of people with primary care, it opens up additional space at Jackson where it's really needed."

In a compromise, Jackson President Ira Clark has proposed spending about $4 million next year to expand hours and services at county-run clinics in North Dade and Liberty City, and to help pay for expansion of a county-funded South Dade clinic run by Community Health Inc.

Jackson officials also say the clinics will benefit indirectly, because many of them already have close links to the hospital. The clinics send patients there for tests and treatment, and some also hire Jackson residents and physicians to work at the centers.

But the Primary Health Care Consortium, which represents all the Dade clinics, says that's not enough. The group has asked the county to use its $20 million share of the proposed tax proceeds to restore funding cuts, help open a new center in West Dade, where there are no clinics for the poor, and allow existing clinics to open at night and on weekends.

The last is critical, backers say. Too many people face a choice of missing work or skipping the doctor.

The consortium's angry president, Emilio Lopez, has staked out his own position. He opposes the tax.

"Dumping more money and centralizing more services at Jackson is just going to create more confusion and more delays," said Lopez, administrator of the Borinquen Health Care Center in Northeast Miami.

The biggest problem primary care centers face, he said, is getting their patients into Jackson for tests and surgery.

"We send somebody to Jackson for an operation, they go on a waiting list, and they wait until it becomes an emergency, and then it costs $50,000 instead of $5,000," Lopez said.

But Metro officials say the financially strapped county can't afford to turn over any sales tax proceeds to the primary care clinics.

"We just can't give them any more," said Metro Commissioner Larry Hawkins, a tax proponent who has warned that the measure, even if passed, is not meant to solve the county's health crisis by itself.

Hawkins has joined a chorus of voices urging other, more wide-ranging reforms. Dr. Lynn Carmichael, chief of family practice services for the Public Health Trust, says expanded primary care is only part of the solution to Jackson's problems.

"It's not so much dollars that we need, as much as coordination and integration," he said. Carmichael wants to add more "urgent care" centers similar to those established through two primary care centers, CHI in South Dade and the Stanley C. Myers clinic on south Miami Beach, where patients who need quick, competent medical attention near home can get it.

Stanley Myers, funded by the federal government, has an agreement with South Shore Hospital next door. It can, for example, send patients covered by Medicaid for basic tests such as ultrasounds, for which the waiting lists at Jackson can be months long.

Still, clinic administrators say they have other pressing needs they can't meet. Stanley Myers, founded 14 years ago to care for South Beach's elderly Jewish population, now must contend with a flood of Latin American refugees, most of whom don't qualify for Medicaid or other government health programs.

The bright, ample clinic handles 1,200 pregnancies a year. Its HIV caseload is rapidly increasing. There is a six- to eight-week wait for children who need checkups or immunizations. The only pediatrician, Dr. Richard Gonzalez, sees about 30 children a day. Last Monday, he saw 40.

"You barely get to see the doctor for a minute," said Lisbeth Lopez, who was there for a throat problem. "Too many people come here, too many of us who don't have $100 to pay a private doctor."

Yet, she said, for $6, the standard fee, she can get regular tests at the clinic such as pap smears and mammograms.

"We can't complain," she said.

Nearby, Milton and Gloria Ibanez waited with their 3-month-old daughter. Their other girl, 22 months, had to wait four months for an appointment at Jackson when she needed leg braces for a common orthopedic problem, they said.

They said they were so frustrated with the waits at the clinic they were going to enroll the children at Mt. Sinai Hospital, where a family clinic accepts Medicaid.

But most of the patients at Stanley Myers don't have that option.

"Having Medicaid over here is a luxury," said Dr. Jorge Rangel, a University of Miami medical school faculty member who oversees residents working at the clinic.

Thus, most of the clinic's patients who need tests or hospitalization wind up at Jackson, where the waits, Rangel said, often border on the "absurd." He cites three recent cases:

* A woman with a possibly abnormal pregnancy was scheduled by Jackson for an ultrasound -- after her due date.

* A woman who suffered a head injury in a car accident three months ago soon began suffering headaches. Her appointment for a brain scan at Jackson is in November.

* A patient with gall stones has been bumped from Jackson's overcrowded operating rooms several times for more urgent cases. Rangel said she'll probably not have the operation until she's so sick she gets in as an emergency.

Rangel said he's not optimistic the tax, which he supports, will reduce those logjams.

"They can just keep growing over there," he said. "I don't think it's really going to help our patients over here."

CAPTION: PHOTO Karen and Hakeem Abraham (CHILD, color); Marilyn Ibanez (in Frst color CLINIC), Ricvhard Gonzalez with Yarobi Echazabal (ran in State CLINIC)

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