Center for Studying Health System Change

reenville does not have an organized "health care safety net," despite strong evidence of a need for indigent care services. Greenville’s average per capita income is 15 percent below the U.S. average.¹⁶ Some observers report that Greenville’s economic growth has been a "beacon" for poor families in rural Appalachia looking for work, and many have found employment in service industries, but without health benefits. These factors, combined with the state’s stringent Medicaid eligibility criteria, reportedly have resulted in a substantial number of Greenville residents without health insurance. There does not appear to be much public concern about indigent care, but the providers and social service groups that serve these populations contend that it is a serious problem.

Several hospitals and clinics were consistently mentioned as the major providers of indigent care in the Greenville community. Greenville Hospital System is generally considered the largest provider of indigent care; it reported charity care charges of $27 million, or about 6 percent of its patient load, in 1995.¹⁷ Spartanburg Regional reported $20 million in charity care charges in 1995. St. Francis reportedly provides charity care equal to about 4 percent of its total patient charges.

During the early 1990s, the county opened the Greenville Community Health Center (CHC), a federally qualified health center that sees about 25,000 patients annually. About 37 percent of its patients are Medicaid recipients; 38 percent are uninsured and pay according to a sliding fee scale. The Slater Marietta Family Health Center serves rural Pickens County, north of Greenville, as a satellite of the Greenville CHC. The CHC receives about $500,000 annually in federal grant funds. Greenville Hospital System historically has provided financial support, in-kind contributions and patient referrals to the CHC. Greenville Hospital System supplied the current CHC’s physical plant and plans to donate land for a replacement clinic site.

The Greenville Free Medical Clinic is staffed with volunteer physicians and health professionals who serve uninsured walk-in patients. Its hours of operation, however, are limited, allowing only 30 people to be served daily. The overflow is referred either to the Greenville CHC or a hospital clinic. Both Greenville Hospital System and St. Francis provide free diagnostic services to the clinic. The clinic’s future reportedly depends on continued financial support from Greenville Hospital System.

Medicaid patients reportedly have difficulty getting appointments with private physicians, particularly pediatricians and primary care providers. Among the reasons cited for these access problems are: low payment rates, the state’s "burdensome" claims processing system and a lack of capacity. Many of these patients ultimately are served by the same providers that deliver indigent care, especially the Greenville Hospital System outpatient clinics and the Greenville CHC. A substantial number of Medicaid patients are also served by the North Hills Medical Group and the Slater Marietta Family Health Center.

Public health in the Greenville MSA is the responsibility of Appalachia Public Health District Two. The agency’s annual budget is approximately $15 million, of which 70 percent is devoted to personal health services. Approximately half of the budget is derived from home health and long-term care service revenue. Recent public health initiatives include a media and education campaign to reduce the percentage of births to women with inadequate prenatal care, which dropped from 11.4 percent to 5.7 percent between 1988 and 1993.¹⁸ Pediatric immunization has also received increased attention under the state’s new "no shots-no school" policy. Immunization rates among children ages 2 and younger on the rolls of the Greenville County Health Department rose from 53 percent in 1992 to 85 percent in 1995.¹⁹

Greenville’s health care systems for the poor have changed little during recent years. Establishment of the Greenville CHC and the Greenville Free Clinic added primary care capacity to the system, but with the failure of the Palmetto Health Initiative, state efforts to expand health insurance coverage and introduce managed care to providers serving low-income populations have been put on hold.