Michelle Trummel says she's always struggled to make sure children in her class at Washtenaw County Head Start get their required health exams.

But in the past year, that struggle has intensified.

Trummel, an Ypsilanti resident, said she's seen more of her families run into increased financial strain. Those families are part of a growing trend tied to Michigan's economy as job losses mount and budgets are crunched. Experts say the local health care system is strained - and getting worse.

More families are losing sources of income and access to employer-provided health coverage; others are finding it harder to locate a local physician who accepts Medicaid coverage.

“What are people going to do? They are going to be forced to inundate the emergency rooms,” Trummel said recently while getting a required checkup for her job at the Packard Health clinic in Ann Arbor.

Earlier this year, the Washtenaw Health Plan - an insurance designed to cover low-income families who can’t afford coverage but also don’t qualify for the Medicaid program - closed enrollment indefinitely due to high demand. Officials say preventative care programs also are in danger of being cut.

Safety net providers like Packard Health have reported increases in demand for reduced-rate services, while hospitals have seen huge increases in bad debt and charity care.

Local experts say Washtenaw County is experiencing an increasing crisis in providing health services to struggling residents.

THE COUNTY

For several years, the Washtenaw Health Plan was the county’s “plan B” for providing health insurance to low-income adults who didn’t qualify for Medicaid.

The program gradually grew - about 15 percent a year until 2007, said Ellen Rabinowitz, executive director of the program.

“In 2007, it went up 40 percent and just continued to grow. By the time we closed the program’s enrollment, we had close to 9,000 people,” Rabinowitz said. “That was a direct effect of the declining economy.”

The plan is still providing coverage for enrolled adults, but no new enrollments have been allowed since May.

“Our community is really in crisis,” Rabinowitz said. “There is more demand than there are resources available.” 

County officials are keeping an eye on the federal debate over health care and on state funding for programs - but there's no easy answer, she said.

“We are really fortunate the local hospitals and local physicians in the community have steeped up and donated millions of dollars in uncompensated care,” Rabinowitz said.

THE HOSPITALS

Charity care and bad debt have more than doubled in Washtenaw County in recent years.

In a report released earlier this year, the Center for Healthcare Research & Transformation reported uncompensated debt in Washtenaw County's hospitals jumped more than 70 percent from $64.5 million in 2004 to $111.8 million in 2007.

The center is a nonprofit partnership between the University of Michigan and Blue Cross Blue Shield of Michigan to research health care access and outcomes.

The University of Michigan Health System has seen huge increases and expects to see additional hikes in charity care this year. It had $70 million in bad debt in 2005, which grew to $170 million in 2008.

But Tom Marks, senior finance director at U-M, said the economy can’t solely be blamed for the increased bad debt and the toll it’s taking on the health system’s bottom line.

He said the factors are largely two-fold: The state has a rising population of older residents who require more medical treatments, and there's an increase in the number of people using Medicare.

Both government-funded Medicaid and Medicare pay lower reimbursement rates than what it costs for hospitals to provide services, he said.

With rising unemployment and employer cost-cutting, more residents in Washtenaw County and surrounding counties are also enrolled in Medicaid. In 2007, one in 12 Washtenaw County residents was enrolled in Medicaid.

One of the largest factors calculated in bad debt is low federal reimbursement for services provided to Medicare and Medicaid populations. For fiscal year 2009, 44 percent of the U-M hospital’s business was made up of Medicare and Medicaid recipients, up from 42 percent in fiscal year 2008.

“We have had to work very hard to cut costs,” Marks said. 

Attrition and layoffs have been among the hardest cost-cutting measures and have been coupled with strategies to increase productivity, he said.

The health system announced earlier this year it would layoff 45 employees, a smaller cutback than its original plan to eliminate 80 positions.

Ann Arbor-based Saint Joseph Mercy Health System has cut jobs and has also found ways to be more efficient and is being more careful about spending decisions, said Rob Casalou, St. Joseph Mercy Hospitals president and chief executive officer.

In May, the health system said it would cut 350 full-time jobs this summer at its four area hospitals, including Ann Arbor, Saline and Howell, while the hospitals deal with a projected $52 million shortfall.

“What happens in a bad economy, when businesses like ours get stressed, they start looking at there they can cut,” Casalou said. “Every hospital in the state of Michigan, especially southeastern Michigan, is looking at staffing levels.”

U-M hospital is closely monitoring ways to reduce the number of people who return to the hospital for a recurring problem.

“From the standpoint of a hospital, we cannot afford to keep absorbing losses indefinitely,” Marks said. “(We may) potentially have to look at whether it needs to cut certain services. We’re lucky at U-M that we’re a healthy (institution). We’re still a place where people want to go. At this point I don’t think we’ve sacrificed quality, at least not in a substantial, noticeable way. So far, we have not had to cut back on any programs.”

U-M hospitals and health centers have a normal annual turnover of 7 percent to 8 percent in staffing, according to figures released earlier this year.

THE SAFETY NETS

Packard Health’s office is located in a small building sandwiched in a strip mall on Ann Arbor’s east side. It’s a bustling and somewhat cramped doctor’s office playing the role often called the safety net provider.

The office serves as a general health provider to the insured, but also provides services uses a sliding scale based on income qualifications. The clinic is seeing more and more health care trouble among its clients. About 45 percent are uninsured or underinsured.

“There is more need and less financial means to meet those needs,” said Raymond Rion, one of the physicians at the clinic. “All these employers have been crushed, the automakers are cutting back. It’s all trickling to Packard.”

Packard clinic announced it would open a second location, largely because demand has increased for services so much. It's one of several local doctor's offices serving as a safety net provider.

The increase in uninsured has played a large role in the health decisions that physicians see patients making. Specialists report seeing fewer patients, and statistics show patients are delaying elective surgeries.

When patients make it into the clinic, more of them are presenting symptoms at later stages because they're are delaying care, Rion said.

“In the clinic, we’re seeing less preventative care, but we’re seeing more ‘I’m depressed and I can’t handle what’s going on in the economy,’ care going on,” Rion said.

Photo by Lon Horwedel, AnnArbor.com: Dr. Raymond Rion examines patient Steve Sherwood of Ypsilanti at Packard Health in Ann Arbor. Packard Health provides both general and safety net care for individuals who are uninsured, or underinsured and can't afford health care otherwise.

Tina Reed covers health and the environment for AnnArbor.com. Reach her at tinareed@annarbor.com.