HEALTH AND HUMAN SERVICES

Citizens are proud of the variety and quality of Howard County's health care services.

"We are very fortunate.  We have
two great hospitals, many excellent physicians, and good community clinics to serve the under and uninsured."

For the well insured, the chief complaint is that some people continue to go to Indianapolis for health care even though specialized services are now available locally.  Health care providers say it is difficult to attract and retain medical personnel in Kokomo, particularly specialists; like other professionals, they are drawn to the amenities of more cosmopolitan habitats.  A handful of survey respondents perceive counterproductive competition between the two hospitals.

The greatest health care concerns are for the under and uninsured.  Three clinics offer indigent primary care and private physicians and dentists have been generous with pro bono and discounted services.  However, it is not always possible to get same-day appointments for acute conditions, and waiting lists are long for non-emergent care.  Emergency rooms are too often the point of entry for medical care, especially after hours – an expensive solution but the only one many people know about.  There is concern that tightening Medicare and Medicaid reimbursements combined with growing demands from the under and uninsured have pushed private providers to their charitable limits. As is true throughout the U.S., burgeoning health care costs and shrinking insurance coverage have everyone worried.

While health care is regarded as one of the strongest of Howard County's systems and services (7th of 26), mental health services are described as close to critical.  After years of level state funding, providers are reeling from recent cutbacks. Medicaid mental health services are transitioning to managed care, and private insurance guidelines are becoming more restrictive. All of this seriously limits treatment options, especially for the most perilously ill.  Consequences include the following:

• Last year the Family Service Association discontinued its counseling services.
  
• In March 2007 Howard Regional discontinued pediatric inpatient psychiatric care.  The most seriously disturbed children now must leave town for treatment, an impediment to family-based treatment, or even visits from mom and dad.
  
• With less casework personnel, caseloads are larger and quality of service suffers. Still seen as a community strength, once-seamless continuity of care is lapsing into fragmentation, leaving clients bewildered and creating inefficiencies in the system as a whole.
  
• In the past, initial authorizations for treatment were typically for 20 visits; now they are for four.
  
• The wait between diagnosis and beginning of treatment is five to six weeks.
  
•  "Interventions" for substance abuse are a thing of the past.  The standard of care has plummeted from thirty days' inpatient treatment down to four.
  
• Therapists turn over quickly, many through "musical chairs."  As new therapists gain experience they leave their jobs for promotions, sometimes out of town but often with other Howard County providers.  Either way results in harmful disruptions in continuity of care.

Aside from mental health treatment per se, health and human service deliverers agree:  A major obstacle to recovery – whether from substance abuse, child abuse, domestic abuse, psychiatric disturbance, or incarceration – is the lack of stable housing.  People need something between sheltered care and self-sufficiency, and there is precious little to be had.  As a result, those in recovery return to the abusive, chaotic, and/or tempting situations from which they came, and often relapse.

Health and human service providers expressed deep concern about the State's outsourcing of welfare administration to a private partnership between IBM and a Texas firm.  The region that includes Howard County is among the first up in the phased rollout; full implementation is scheduled for September 2007.  Changes are already beginning, with the staff of Howard County's Department of Family Resources slashed from 38 caseworkers to 8.  Eligibility determination for TANF (cash assistance), food stamps, Medicaid, and assorted other supports for the poor will take place in Marion, an hour's drive away.  The plan is to use electronic communications to deliver the necessary information to Marion.  This means, first, that public assistance decisions will be made remotely, with no human face in the equation.  Second, people who need welfare generally lack telephones, fax machines, and Internet access; the expectation is that the job of feeding data to the office in Marion will fall on the nonprofit sector.  How this actually plays out remains to be seen. 

Every cutback in public support for the disadvantaged creates demand on the nonprofit sector to fill the gap.  Growth in the disadvantaged population has the same effect. When that growth stems from economic downturns, charitable giving declines as well, leaving agencies with fewer resources to perform more service.  The charts on the next page show the patterns we would expect, given Howard County's employment picture.  The number of people and families in extreme economic need began growing in 2000, the same year employment started to fall and unemployment began to rise.   Likewise, contributions to United Way of Howard County began falling in 2001 and have declined every year but one since then.

In 2005 an estimated 3,500 Howard County families – 13.2% – were living in poverty.  "Poverty" is a stringent measure, currently set at $16,600 per year for a family of three.  A more realistic estimate of basic costs of living is the self-sufficiency standard of the Indiana Coalition on Housing and Homeless Issues.  For Howard County in 2005, it was $31,666 for a three-person household consisting of one adult, an infant, and a preschooler – an amount that increases with the children's ages.

Fortunately, Howard County's safety net is wide, a source of pride to community leaders.  Together, the County's nonprofits succeed in plugging most of the holes left by state and federal assistance programs.  Though gaps still exist, help is available for most problems associated with poverty, disability, parenting, aging, abuse, and a plethora of personal and family crises. 

In 2006 alone, I&R/211 fielded more than 6,700 calls and made referrals to 325 different programs and organizations that were likely to be able to help.  In only 185 cases was there nowhere at all to go, but those cases reveal some worrisome gaps.

Putting the 211 call data together with reports from community leaders yields the following list of services that are altogether missing:

•  Gasoline for anyone who is not employed or in school
• Transportation for people with no money, unless they are older than 55 or disabled
• Emergency shelter for fathers and their children
• Shelter for abused men
• Shelter where a couple with no children may stay together
• Food stamps, subsidized housing, or any other federally-funded assistance for convicted felons

The following services are offered in Howard County, but in seriously short supply:

• Dental care
  
• Rent assistance or affordable housing (the average unsubsidized rent was $606 per month in 2005)
  
• Utility assistance
  
• Assisted living for developmentally disabled adults
  
• Gasoline vouchers for going to work or school
  
• Out-of-town transportation (for medical appointments, etc.)
  
• Childcare that is affordable for low-wage workers, or even middle-income families with several children (the going rate is $155 per week for infants and toddlers)
  
• Childcare at any reasonable price for people who work nights or weekends
  
• Childcare at any reasonable price for children who are sick (colds count)

Food pantries, on the other hand, are considered to be in oversupply.  There are dozens of food pantries in any given year, each operated on a small scale, mostly by churches.  They spring up, disappear, and change hours so often that I&R/211 has difficulty keeping track.  Efforts are underway to improve coordination, possibly to include a rolling food pantry.

Health and human service professionals acknowledge room for improvement in coordination and see promise in stronger collective advocacy.  For the most part, though, providers contend that they collaborate effectively among themselves, especially in coordinating services around individual clients and patients, and refute the charge of duplicative efforts.

The human services focus group walked us through the illustration of emergency shelters.  Four current overnight facilities and one in the works all cater to different clientele. The largest accepts both men and women.  The others are for women only: one for the single and pregnant, one for victims of domestic violence, one for recovering substance abusers, and one for women and their children.  These groups are kept apart for good reason, providers argue, and the total capacity is right.  Most beds are filled most nights, and there are just enough folding cots for nights when the temperature dips below zero.