Tougher times strike more TB programs as budget axes fall
Immigrants, indigents, recession contributing causes
Across the nation, a receding tide threatens to swamp TB programs’ boats. Causes for widespread declines in local and state funding sources for public health in general, and TB control programs in particular, vary from place to place but share many traits in common. In many settings, falling tax revenues have precipitated across-the-board cuts, with TB programs taking the same hit as everyone else when the budget ax falls. Many programs now find themselves caught between flat or falling revenues on one hand, and increases in foreign-born populations, intrinsically more costly to treat, on the other. In some spots, TB programs’ troubles have ground along for years at a depressingly steady pace; in other places — notably, Los Angeles County — a full-blown crisis has precipitously erupted.
Whatever the cause, the cuts come at an especially bad time for those TB control programs whose burdens have increased. Across the country, not just TB but public health divisions as a whole are searching for alternative funding sources.
Looking for Band-Aids
For example, a half-dozen bills now before Congress seek to use federal money to reimburse border counties for costs incurred in treating undocumented immigrants. "There’s no disagreement among federal legislators that counties bear most of the burden for what is essentially a federal responsibility," says Tanis Salant, PhD, director of the Institute for Local Government at the University of Arizona in Tuscon. "But for fiscal reasons, it’s very hard right now to get a bill passed."
Other states, thirstily eyeing the federal dollars streaming into bioterrorism coffers, are working to cast TB as a potential bioterrorism threat. Washington State has used tobacco-settlement money as a temporary Band-Aid. Los Angeles County is looking to a proposed property tax hike — a long shot by anyone’s guess — to fund emergency services and bioterrorism preparedness. Generally speaking, proponents of all these measures concede that prospects for success are not great.
"We’re hearing from states about their struggles to maintain funding levels, and to find new funding sources," says Joe Scavatto, deputy chief of the field services branch at the Division of TB Elimination at the Centers for Disease Control and Prevention in Atlanta. "We see budgets coming in, and we’re seeing fewer people than what they started out with at the start of the year-to-year funding cycle. We see things missing. There’s no fluff out there anymore; it’s really down to the bone."
Along with the general economic malaise afflicting the country, the foreign-born are frequently cited as a big part of the problem.
Role of immigrants cited
In TB control, foreign-born patients are more likely to present with TB that’s complicated to expensive to treat; they’re also a group needing more specialized and costly services of other kinds, such as interpreters.
More broadly, since they often work at poor-paying jobs with no insurance, the foreign-born are more likely to turn to expensive emergency-room services for their primary source of health care, some experts contend, thereby sucking dollars out of the overall health infrastructure. "Emergency care for illegals is terribly burdensome for all border counties that maintain public hospitals," says Salant. Treating undocumented immigrants may cost hospitals in border states alone $2 billion a year, according to a recent report issued by National Association of Counties. Eighty-six percent of 150 counties nationwide reported an increase in uncompensated health care expenses in the last five years, the report found.1
Of those reporting an increase, 67% cited a growing number of immigrants as a factor in the expenses; while 72% cited an increase in uninsured patients, a category that includes, but is not limited to, indigent foreign-born workers, notes Jacqueline Byers, executive director of the association.
Most of the bills pending before Congress that aim at reimbursing border states or counties for the costs of treating illegal immigrants "suggest that there needs to be a way to distinguish the level of service being provided to illegal immigrants, since that level varies so much from one place to the next," says Robin Herskowitz, a senior consultant with MGT, a consulting firm working for the U.S./Mexico Border Counties Association. Some epidemiologists are now considering asking TB control programs to start doing what previously was unthinkable — that is, ask TB patients to reveal their visa status.
To some, problems associated with mounting costs incurred by the medically indigent and the foreign-born suggest it’s high time for the feds to step up to the plate. "I’m no health economist, but when it comes to health care reimbursement, perhaps there should be a single third-party payer," says Annette Nitta, MD, Los Angeles County’s TB controller.
It’s not likely Salant would agree: "These grass-roots groups who leave water in the desert for illegals trying to cross and so forth don’t realize is the terrible social, economic, and environmental toll illegals are taking," she says.
A litany of fiscal woes
Regardless of how they frame the causes and solutions of the problems, many TB controllers around the country say their programs are in trouble. What follows are comments from a random sampling of TB controllers who happened to be in their offices and taking phone calls during a one-week period last month:
In Mississippi, the number of public health nurses statewide has been cut in half over the last five years. "We’ve had to close some clinics, convert others to part time, and assign some nurses to work several clinics at once," says state TB controller Mike Holcombe, MPPA. "That makes it much harder for patients to figure out what days and what hours a clinic will be open." Nurses complain they have less time to do follow-up or to make home visits, he adds. "These days, if a patient is noncompliant, all they can do is call them or send them a note in the mail," adds Holcombe. "But making a phone call or sending a note in the mail — that’s not the right way to do public health."
The story is less urgent but similar-sounding in Arkansas, where state budget cuts over the last two years have diminished TB controllers’ manpower and pool of expertise, says state TB controller Frank Wilson, MD. "Case are down, but we aren’t able to do follow-through and other things we once did as thoroughly as we’d like to," he says.
In Minnesota, all state agencies, including TB control, have had to submit proposals for trimming 20% of employees, reports Wendy Mills, MPH, state TB controller. "That’s especially hard for us," says Mills, "since we’re seeing a case increase — the biggest last year since the 1970s." To make matters worse, 80% of cases in the state are now foreign-born, "which are very complex and require many more resources," she adds. In Kansas, all state agencies have endured 5% cutbacks. "This year, the impact on TB has been minimal," says state TB controller Phil Griffin. "Next year, it may affect our ability to pay for TB medications for latent infection."
The same goes for Iowa, says state TB controller Allan Lynch. There, state agencies’ budgets were cut 7%. "If this keeps up, we won’t be able to pay for medications," he says.
In Maine, "the little money we had hasn’t been cut back, but the little we’ve got doesn’t permit any expanded initiatives," notes Kathleen Gensheimer, MD, MPH, state director of TB control. That’s too bad, she adds, since two months ago, a group of more than 1,000 Sudanese migrated to Maine. "That’s going to put a terrible strain on resources."
In Indiana, "times are tough, and there are cuts afoot, with no raises and a hiring freeze," says TB controller Sue Percifield, RN. Luckily, TB advocates there have succeeded so far in using the threat of bioterrorism to leverage a modest safety net for TB control, she adds. "Money to buy medications for our patients wasn’t cut this year, so we came through pretty well unscathed," she adds.
In Louisiana, state TB controller Charles DeGraw reports there’s been level funding for five years, "which cuts into our ability to hire new people." But that overall, TB control has been spared the budget cutters’ knives.
With no state income tax or other safety nets, the situation feels much more precarious in Washington State, says Kimberly Field, RN, MSN, state TB controller. Motor vehicle taxes that once underwrote the cost of public health have been slashed; and tobacco-settlement money used as a temporary "backfill" is about to run out. Even populous Seattle/King County has had to place a cap on TB screening; now, the big question is whether some of the small counties’ TB control programs will actually have to close their doors. Either way, Fields adds, "2003 is looking pretty grim."
1. Canedy D. Hospitals feeling strains from illegal immigrants. The New York Times. Aug. 25, 2002; A16.
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