Center for Studying Health System Change

are of the poor is not generally described as a significant problem by community and health system leaders in Syracuse. Observers say that Medicaid services are widely shared among the principal hospitals, and they believe that Medicaid managed care will improve access to appropriate care. Similarly, they do not see service for the uninsured as a problem, mainly because of New York State’s tradition of subsidizing hospitals’ bad debt and charity needs. Hospitals say they share responsibility for charity care, but the burden of uncompensated care appears to be concentrated among University Hospital, St. Joseph’s, Crouse-Irving Memorial and the Syracuse Community Health Center.

MEDICAID

Respondents generally viewed the planned introduction of a mandatory Medicaid managed care program in Onondaga County as positive. County representatives claim they are ready to move recipients into managed care, despite what critics have described as a lack of public education or provider education. Some advocates for the poor predict that inadequate preparation will result in service disruptions, increased use of hospital emergency departments and disenrollment of eligible recipients. In addition, advocates and community-based service providers have expressed some concern that managed care may reduce access to expensive therapies and mental health and substance abuse services. It is also unclear at this point what roles state and local government agencies will play in administering the program.

However, most respondents believe Medicaid managed care will improve access to primary care. One 1993 survey found that two-thirds to three-quarters of Medicaid beneficiaries had difficulty accessing office-based physicians and outpatient clinics.¹⁶

Hospitals that provide significant levels of Medicaid services expressed mixed views about the plan. Some respondents see Medicaid managed care as an important revenue opportunity, while others fear it will siphon off outpatient services to doctors’ offices and free-standing ambulatory care facilities. Syracuse Community Health Center, the area’s principal community health center, has attempted to increase its competitiveness by creating its own Medicaid HMO, Total Care Choice, which is staffed primarily by its own providers. Despite this move, the center is concerned it could be undercut by large -- particularly national -- HMOs that can subsidize their Medicaid services from other revenue sources.

CARE OF THE UNINSURED

The proportion of uninsured persons in the Syracuse area is lower than average, particularly in Onondaga County,¹⁷ compared with statewide and national norms. However, some respondents expressed concern that the number of uninsured would increase shortly, as transition benefits to employees laid off by two regional employers lapse. The bulk of indigent care is delivered by hospitals and subsidized through the state’s uncompensated care pool. The community health center reports seeing more uninsured persons recently (as a proportion of its caseload) and has extended walk-in clinic hours to accommodate demand. Other funding sources include a mix of federal and state categorical funds, which are sometimes matched with local dollars. These sources provide for direct medical services and public health functions such as prevention programs.