Universal health clinic opened on Vineyard

By Scott Allen, Boston Globe, August 13, 2004

EDGARTOWN -- The state's first rural health clinic for low-income and uninsured people has opened on the edge of this tourist-clogged downtown, capping a six-year campaign to solve one of the most pressing and least visible issues on Martha's Vineyard.

Despite the island's affluent image, the 16,000 year-round residents are three times as likely to be uninsured as Massachusetts mainlanders. And with just seven primary care doctors on the island, even the insured sometimes wait a year for a routine exam.

In one of New England's most ambitious local efforts to provide universal health care, Island Health Inc. expects to help thousands of people get more timely medical attention, by operating the clinic and starting to offer discounted insurance this fall to low- and moderate-income families.

The nonprofit group has been awarded a $500,000 federal grant, in part to hire a medical staff of six for the clinic, which is open to anyone but is free to low-income residents. The Legislature has agreed to subsidize the islanders' premiums, expected to amount to about $300,000 the first year.

"They're trying to completely change the delivery of health care," said Brian Ayars, president of New England Rural Health RoundTable, a New Hampshire-based group. Martha's Vineyard, he added, "will be a case study for many other communities."

Three weeks after the clinic's opening, word has spread among the island's 2,000 or more Brazilian residents that it will provide free care for the uninsured, as well as a Portuguese translator, attracting scores of patients like Gormi Miller, a 50-year-old construction worker who needed medication last week for high blood pressure and a sore back.

"They take very good care of me," he said through an interpreter. For the two years he has been in the United States, Miller said, he has relied on the emergency room at Martha's Vineyard Hospital and on the mainland for health care, but he has had no regular doctor to prescribe drugs for chronic conditions.

Out here, delays in getting medical care can turn small medical problems into big ones. Earlier this year, an uninsured immigrant from Brazil was airlifted to Boston after he tried to cure an abscessed tooth with traditional Brazilian remedies and developed a life-threatening infection.

Other residents, drawn by the convenience of same-day appointments, have flocked to the clinic, along with an assortment of tourists.

"We're probably going to grow out of this really quickly," said physician's assistant Carol Anne Lindsey, surveying the two examining rooms shared by the staff, which includes a part-time doctor. Clinic officials believe that they can handle 11,000 office visits a year.

Martha's Vineyard, with houses that sell for $731,000 on average and a summer population of 90,000, is an unusual model for rural communities to emulate. The vast majority of rural health clinics overseen by the federal Office of Rural Health Policy are in towns with fewer than 2,500 residents. These clinics, which rely on nurses and physician's assistants to provide much of the care, receive higher reimbursements from Medicaid and Medicare to help draw medical professionals to isolated areas.

But rural healthcare specialists say the Vineyard is much like the rest of rural America: Year-round residents see doctors and dentists less often than urban residents; they are more likely to suffer from chronic diseases, such as diabetes and obesity; and they are more likely to lack health insurance.

Commissioners in Dukes County, which includes the six Vineyard towns, set up a council in 1996 to improve health care, but the panel encountered serious obstacles. The tourist economy had very few large employers who offered insurance to their employees, forcing people to buy it on their own. With a cost of living 15 percent to 20 percent higher than on the mainland, 1 in 5 islanders had no coverage, giving the Vineyard one of the state's highest percentages of uninsured residents.

Meanwhile, immigrants from Brazil had begun moving to the island in large numbers to work in construction, landscaping, housecleaning, and other businesses. Not only were these new arrivals lacking insurance, but many couldn't speak English, and they came to rely on the emergency room at Martha's Vineyard Hospital when were hurt or seriously ill.

Not surprisingly, doctors didn't find Martha's Vineyard a lucrative place to practice, especially if they weren't directly employed at the hospital. The federal government has designated it a Health Professionals Shortage Area, just like the hinterlands of Maine or the Great Plains. That made the island eligible for a rural health clinic, one of the few locations in Massachusetts that met the requirements.

In 1999, the county government established the Vineyard Health Care Access Program, which helps an estimated 1,000 people get health care on the island each year through government and charitable programs. But healthcare advocates said some waited too long to get care.

"We've had people who have ignored the pain, and it turned out to be cancer," said Mary Leddy of Health Care Access.

Faced with such realities, health advocates led by former West Tisbury selectwoman Cynthia Mitchell began the long effort to open Island Health, winning approval from both the state Department of Public Health and the federal government. The clinic opened July 22 inside a former doctor's office next to a drugstore in Edgartown.

The clinic is open to all patients, but it offers free care for uninsured families earning up to twice the federal poverty level, $37,700 for a family of four, and it charges a sliding fee for people who make more.

Silvia Macial, 29, who came in last week for treatment of a pinched nerve in her shoulder, said Island Health is less disruptive than going to the emergency room. "I don't have to wait for two hours," she said.

Some analysts say the most distinctive part of the island health campaign will come this fall when the Island Health Plan becomes available to employees of small businesses at work. Expanding on a statewide program that provides premium assistance to certain employers, the Island Health program will offer discounted premiums of about $100 a month for families of four earning less than $47,125. The state will pay $85 a month to employers for each family that enrolls in the Island plan.

"They're unique," said John Gale of the Maine Rural Health Research Center at the University of Southern Maine. "A lot of communities use health networks, clinics, critical access hospitals. . . . They are really trying to provide an insurer."

Mitchell, now executive director of Island Health, said she expects that the health plan, which required legislative approval and an override of Governor Mitt Romney's veto last spring, to enroll about 750 people the first year. Although the governor's office was concerned about the plan's cost, Mitchell predicts that the state will ultimately save money as people switch out of the state-funded MassHealth Medicaid program.

It remains to be seen whether other communities can duplicate the Vineyard's ambitious efforts, but Mitchell predicts the results, providing both health care and a way to pay for it for virtually everyone on the island, will be hard to argue with. "We think that we can essentially close the gap," she said.

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