Islanders without health insurance will receive an invitation to band together next year in a community-based plan that aims to open the doors to a comprehensive health care system now out of reach for one-fifth of the Vineyard's 15,000 year-round residents.
But many doctors and health care agencies worry that the plan may tip the already fragile financial balance of caring for patients under a paperwork-laden and reimbursement-stingy health maintenance organization system.
"Real insurance with a card to show is the ticket to access," said Cynthia Mitchell, executive director of the fledgling Island Insurance Plan. "If people don't have that, they can't get the care they need."
The solution, according to Mrs. Mitchell and others, begins with patients and their employers instead of the government.
"We're just putting the pieces together in a different way," she said. "We're creating universal health care from the bottom up."
The new program, which was spun off from the Dukes County Health Council a few years ago after the group identified a lack of insurance as the most significant health care barrier facing Islanders, aims to serve most of the estimated 3,000 Vineyarders who don't have comprehensive health care. Mrs. Mitchell hopes it will be up and running in six months.
Doctors and health care administrators have long known the seriousness of lack of insurance on the Island. But the magnitude and severity of the problem came into focus only a few years ago, when a study found that 20 per cent of Islanders had no insurance. That figure is more than double the rate of uninsured residents in the state as a whole.
"Most of these [uninsured] people, sadly, are employed," said Sarah Kuh, director of the Vineyard Health Care Access Program, an agency that connects uninsured residents with available health care resources.
According to the health council, only 35 per cent of Island employers offer their workers any form of health insurance or are willing to do so. And among employers willing to contribute to health care costs, only half said they would contribute more than $100 each month.
With health insurance rates topping $250 each month for an individual and $700 for families, many Islanders are left to pay shares greater than their wages can support.
"There is a lot of anger out there over this situation," Ms. Kuh said. "These people are working hard, paying taxes, contributing to this community, but being taken care of medically is a real struggle. And they resent that it's such a problem."
The expense of health insurance leaves those without in potentially hazardous territory, Ms. Kuh said.
"These people feel incredibly vulnerable," she explained. "They are scared to seek or delay seeking medical care because of the costs associated with it. And then when they do go and have a huge bill hanging over their heads, it makes them think twice before going back."
While the details are still being negotiated, the nuts and bolts of the Island Insurance Plan call for Vineyard employers and self-employed workers to enlist in the program. Mrs. Mitchell said they will target residents earning between 200 and 400 per cent of the federal poverty level - for a family of four, between $36,000 and $72,000 annually. The plan will also invite any patient currently enrolled in MassHealth, the state's Medicaid program, to switch to the new program.
The program will be managed by Neighborhood Health Plan, the same HMO contracted by the state to handle residents covered by MassHealth.
Mrs. Mitchell conceded that the new plan's rates will be similar to those of other insurance plans available to Vineyarders. It will cost around $240 for an individual and about $700 for a family each month - but employer contributions and outside subsidies would lower the cost that subscribers end up paying.
The affordability of the plan, Mrs. Mitchell explained, depends largely on state and federal contributions, doctors' willingness to accept modest reimbursements and a potential tax subsidy. She said she is confident that the innovative community approach will likely attract funding from MassHealth after the Division of Medical Assistance agrees to lift patient financial eligibility to 400 per cent of the federal poverty level.
Some critics, however, fear that state money will not be as available as plan officials hope.
"There's not enough money in the state right now to fix the potholes, let alone to care for the chronically ill," said one Island physician who wished to remain anonymous.
Question marks surrounding funding for the Island Insurance Plan are causing local doctors and health agencies to feel nervous about the financial burden they'll be asked to carry.
"The folks I deal with [doctors and other health professionals] don't want to say no to something like this. But there is a real concern about whether they will be left footing the bill," said Timothy Walsh, chief executive officer of Martha's Vineyard Hospital. The hospital shoulders $3 million in free care each year - an amount equal to about 10 per cent of the institution's revenue stream.
The hospital is not alone in swallowing piles of unpaid bills. And most local primary care doctors and many specialists linked with the Vineyard Health Care access program several years ago to offer free or reduced care for Islanders lacking insurance. For primary care doctors enlisted in this program, they accept $40 or less for a $100 visit.
The Island Counseling Center, a mental health program at Martha's Vineyard Community Services, finished the 2001 fiscal year $190,000 in the hole for outpatient mental health services after providing free or discounted treatment to about 450 patients. Community Services depends on insurance reimbursements from the 950 other patients to help offset the loss. The most substantial reimbursements, at between $70 and $112 per visit, come from MassHealth - a provider pool that will likely be drained if the Island insurance plan gets off the ground.
"There is a problem of trying to offer free care. In order to stay whole, we must recoup elsewhere. It's the problem with health care in America," said Mr. Walsh of institutions like the hospital and Community Services.
Island doctors and health agencies are not alone in grappling with a strained system in which they are expected to do more for less.
"Health care is the most bizarre business in the world," said Dr. Alan Hirshberg, emergency room director at the hospital. "Every year you make less money for more work. They only way to make more money is to see more patients, and somewhere patient care gets lost."
Medicare reimbursements, which are calculated on the basis of diagnosis, not the amount of time spent or number of procedures implemented, have been frozen since 1997, Dr. Hirshberg said.
A concern of some in the mental health field is Neighborhood Health Plan's reputation for demanding large amounts of preauthorization paperwork. An administrator for a Cape-based mental health treatment facility familiar with Neighborhood Health said that if more than a fraction of their patients used this insurer, the agency would be forced to hire another employee solely to handle such documentation.
"The mental health component is not a workable plan yet. While it's a great concept, the current formula places an onerous amount of paperwork on those in the mental health field," said Island psychiatrist Charles Silberstein.
But doctors know that the health care system is reaching a breaking point.
"The current fee-for-service system and insurance superstructure is about to implode," said an Island doctor. "It's not working for patients or physicians,
A field once known to ensure upper-class status for students willing to persevere through a decade worth of specialized training no longer offers those promises.
"You hope in medical school you'll have a good life," said Dr. Hirshberg. "Luckily, a lot of people . . . go into primary care [for reasons other than] the money. You carry a $100,000 debt coming out of med school. Each year you get paid less, and you see that your bills for groceries and gas aren't getting any cheaper."
For physicians with heavy debt loads, the Island's high cost of living makes the Vineyard an unattractive place to create a life. The federal Health Professional Shortage Area program, new to the Island, offers grant money that the hospital can feed to new doctors for startup costs on the Vineyard.
Despite these concerns, doctors and health agency administrators say they are committed to working through these financial details with Island Insurance Plan officials.
"The problem of the uninsured is phenomenal. If we can solve the problem here on the Vineyard on a small scale, it would be incredible," Dr. Silberstein said.