BCC Minutes 09/06/2001 W (w/Health Care Planning and Finance Committee)September 6, 2001
WORKSHOP MEETING OF SEPTEMBER 6, 2001 OF THE
BOARD OF COUNTY COMMISSIONERS
LET IT BE REMEMBERED, that the Board of County
Commissioners in and for the County of Collier, and also acting as
the Board of Zoning Appeals and as the governing board(s) of such
special districts as have been created according to law and having
conducted business herein, met on this date at 9 a.m. In WORKSHOP
SESSION in Building "F" of the Government Complex, East Naples,
Florida, with the following members present:
CHAIRMAN:
VICE-CHAIRMAN:
James D. Carter, Ph.D.
Pamela S. Mac'kie
Jim Coletta
Donna Fiala
Tom Henning
ALSO PRESENT:
Tom Olliff, County Manager
David C. Weigel, County Attorney
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BOARD OF COUNTY COMMISSIONERS PUBLIC WORKSHOP
ON THURSDAY
September 6, 2001 from 9 A.M. - 12 P.M.
AGENDA
Health Care Planning and Finance Committee
Formal Presentation by members of the Committee and Guests
Public Comment
Questions and Comments by Commissioners
September 6, 2001
CHAIRMAN CARTER: Everybody ready? Going live. Going
live, Commissioners.
COMMISSIONER COLETTA: You remember how to do this
now, Doctor?
CHAIRMAN CARTER: Yes, sir. Old habits never die. Good
morning, Commissioners, health care committee members, other
people who will be sharing ideas with us this morning, members of
our participating audience at the board room, and also all of our
listeners on Channel 54. And as we start our workshops --
Traditionally, we always do this, if you would join us in standing for
the pledge of allegiance.
(Pledge of allegiance in unison.)
CHAIRMAN CARTER: I like that enthusiasm. Thank you. As
you know, the Board of County Commissioners has had a series and
continues to have ongoing workshops on very important issues to
Collier County and this community, and I think this is probably one
of the most important workshops that this board will hold that we're
doing this morning on health care.
This is a national issue, ladies and gentlemen, and this Board of
County Commissioners, the committee, and all of those who have
worked so hard on this are to be congratulated for dealing with the
issues. U.S. Today about two weeks ago wrote a front-page article
that addressed this same subject, about how communities are
beginning to deal with health care issues at the local level. The
federal government, state governments are all concluding that the
local communities can best deal with the problems better than huge
organizations outside of the community who do not customize them
or deal with the particular issues.
So this workshop this morning will be a deliberation and a
presentation by a health care committee that, number one, the Board
of County Commissioners said two times -- we went to committee
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and said, "What are the problems in the community?"
And they identified them. Secondly, for a year they worked on
-- our second objective for them was, how do you begin to solve the
problems? What are the possibilities? What are other communities
doing? What can we do at a local level in Collier County? And they
are here this morning to do that. And I believe it takes serious people
to work on serious problems, and that's what you have here, people
who are doing what they were charged to do when they became your
elected officials, those who have volunteered many, many, many
hours to come up with some ideas and how to deal with the issues.
It is a passionate discussion going on in this community, but
there are those very much in favor of it; there are those very much
against it. Somewhere between all of that there are solutions, and
there are ways that -- we will try to find the best way to deal with this
subject.
Peter Drucker, the great writer, management writer, now in his
90s, said about decision making, "It is a choice between two actions
and most decisions are never black and white. They are called a grey
area. When you make that decision, you hope that you are mostly
right." And that's what we want to achieve out of any workshop or
anything that we're challenged with as a Board of County
Commissioners, that we're going to attempt to make decisions that
are mostly right, because if there was such clear-cut answers, it
would not be a challenge; there would be nothing that we had to do.
It would be, as we say, "a no-brainer," and in this case, this is not "a
no-brainer."
So with those remarks and, again, thanking this committee,
thanking the Board of County Commissioners for having the courage
to step up and say we must address these and other very difficult
issues in this community, I would like to turn the program over to
Tom Schneider who is going to do the presentation for health care
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committee.
Mr. Schneider has asked that the Board of County
Commissioners, that each of us, will listen to his highlights of his
presentation and what is going on throughout this report and then
hold our questions till he's had a chance to give us the overview. All
of you will have an opportunity to hear and participate and make
comments. You have to sign up -- the sign-up sheets, Mr. Leo Ochs,
County Manager Tom Olliff both have here to share with you.
So I'm going to turn it over to Tom unless -- Mr. Olliff and
Mr. Ochs, if you have any comments prior to that, feel free to make
them or any commissioner wants to make a comment. Then I will
begin the meeting.
MR. OLLIFF: The only thing I'll add, Mr. Chairman, is just to
welcome the commission back from your break and welcome the
people who are here. This is our most well-attended workshop to
date, which is not surprising given the subject matter.
But for those of you, just as a housekeeping matter, who are
interested in speaking, there will be an opportunity at the conclusion
of the workshop for public input, and there are speaker slips out in
the hallway -- on the table in the hallway. And if you'll fill one of
those out and you'll bring it back here to me, we'll make sure that we
call you in the order we receive those.
And the only other thing that I wanted to add, Mr. Chairman,
after 18 years of working here, we -- we get the opportunity to work
with a number of advisory boards, and I will just tell you from a staff
perspective, I have yet to come across an advisory board that I think
has worked any harder or any more diligently to try and provide
information for the board to be able to make good decisions with, and
from a staff level and I'm sure from the board's perspective as well,
our hats are off and our thanks and congratulations for just a long,
hard summer of work for us. Just really appreciative of all the efforts
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that you've put in. With that, I'll turn it over to Tom and then ask you
to lead us through the workshop.
MR. SCHNEIDER: Thank you, Commissioner, and thank you,
Tom.
On behalf of the committee, we are pleased to be here today and
to present to you the follow-up findings from our earlier
presentations. We are here today to present to you the business plan
for the Collier County Primary Care Program for the uninsured. In
April of 2001, you agreed in principle to our recommendations, but
you asked for more details which we promised that we would come
to you with those details before seeking your final approval. We are
here this morning to give you those details.
I thought what I would do is give you a quick review of the
agenda. I think everybody has one in front of them. We have a
number of speakers today, as you can see, and most of whom who
have been active with our committees and have been involved with
specific aspects of our proposal. And I will introduce each of these
speakers at the appropriate time, but prior to addressing our business
plan, we will have two speakers address the current situation. Phyllis
Busanski will address the national scene, highlighting that while the
problems are national, the solutions need to be local. And we will
also ask Dr. Bill Lascheid, the founder of the Neighborhood Clinic, to
talk about one of our local challenges, the need for enhanced primary
care for our target population.
I also at this time would like to introduce all of you to our
consultant, Dave Rogoff. Dave's been working very, very closely
with our committee for the last six, eight, ten months, and we
wouldn't be here today where we are without his help. I mean, he has
just done a fabulous job. He has great experience, worked for
multiple counties addressing this very same issue in Florida,
including Pinellas, Hillsborough, St. Lucie, and Dade. He's been
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involved in statewide efforts in Florida for this effort, and he's also
worked with other states, like Texas, Mississippi, Michigan, District
of Columbia, Ohio, North Carolina and others, and he's been
involved working as a consultant with the HRSA division of the
federal government trying to help counties and communities do
exactly what we're trying to do. So thank you, Dave. He will not
have a formal speaking, but he's available for questions from
anybody.
I think it's important that we just step back for a second and
review the highlights of our April session where -- when we met with
you at the regular commission meeting. And what I wanted to just
say to you or summarize for you from that meeting is that -- what we
said was the current situation is intolerable. There are thousands of
people who have no health coverage. Our community has a very high
percentage of small businesses. Over 90 percent of the businesses in
the key industries like ag, contracting, service, retail, et cetera, have
less than ten employees, and we rely on low-income wage earners to
support our quality of life here in Collier County. We emphasize the
private industry has not provided insurance to many of its employees
because of the cost factor, because of the small size of the companies
and that there was no legal way for you to make them do so.
We also pointed out that -- that although local donations,
philanthropy and volunteerism has been a big help, there's no way
that they can keep up with the growth of the problem. The overall
effect of that is about 18 percent, almost one in five, of our county
residents under the age of 65 years old is uninsured even though most
of them are working. In effect, the private-sector health care system
cannot work on its own for this target population. In effect, the
current system is based upon the emergency room as a safety net,
often not a true emergency. It just may be the only source of primary
care for these people. And even when it is a true emergency,
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oftentimes it could possibly have been avoided or prevented or
addressed much more cost effectively by early intervention. And,
again, once the episode is over, there is very little follow-up care.
What we concluded was and told you is that we do need the
government help to solve this problem, but the state and federal
government will not help us unless we start by helping ourselves.
The results of that meeting were that you agreed in principle
with us to our recommendation to adopt this coordinated system of
primary care for the uninsured low-income working people and to
fund that request to get started on this program in the budget for this
coming year, subject to, provisionally, us coming back to you with
the details that would give you the comfort and answer your
questions. And we are here today, as I said, to give you those details.
The concepts that you agreed to were: Develop a coordinated
system of primary care, which will be the focus of most of our
presentation and discussion today, but also to take advantage of
already existing programs and funding for organizations that are
already servicing the needs of this target population; most
importantly, protect the school nurse program and build up the
outreach effort for Healthy Kids because we wanted to make sure that
Collier County was leveraging and obtaining all of the state and
federal funds available to it before it began spending Nickel 1 of its
own taxes.
We also -- you also agreed that we would coordinate with other
health care payers such as Medicaid and Medicare so that this plan
would be a payer of last resort and only those people who were not
already eligible or weren't eligible for other state plans would be
covered.
And as you probably know, but I probably need to remind some
folks, that in Florida Medicaid basically only pays for children and
for elderly in need of nursing homes who have spent down their
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private funds. With rare exception, primarily only pregnant women
below a certain income level are covered by Medicaid for anybody in
the ages of 19 to 64. That's in Florida. That's the way Florida has
chosen to allocate its Medicaid dollars. And for most people over 65,
Medicare covers their health care needs.
So at this point, I would ask Phyllis Busansky to come up.
While she's coming up, let me just introduce Phyllis. Phyllis is the
president of the Community Health Leadership Network. This
network exists to provide assistance and guidance to communities
that are addressing health care access for the uninsured, and it's
funded by private-sector money. It's a natural progression from her
previous work in assisting the HRSA, Health Resources Services
Administration of the United States Government, for the last two
years as part of their 100 percent access, zero disparity campaign. In
that capacity she worked with numerous communities throughout the
United States.
Phyllis is a senior fellow of the Hudson Institute's Welfare
Policy Center which I referred to, and most people do, as a
conservative think tank. And the policy center researches innovative
strategies to address welfare and social service reform and assist
governments and community-based organizations in redefining social
services.
Prior to joining the Health Hudson Institute, she served as the
director of the Florida Wages Program, and under her leadership the
welfare case load within Florida decreased by over 80 percent, saving
the state more than $500 million in welfare payments.
She also served, interestingly enough to you folks, as a
Hillsborough county commissioner during the time of the formation
of the Hillsborough plan, and she was one of the champions for
establishing the county's indigent health care plan and it is -- has
received wide recognition throughout the United States as being one
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of the best, if not the best, models. So with that please help me
welcome Phyllis Busansky.
MS. BUSANSKY: Am I old enough? No. No. I can't be.
CHAIRMAN CARTER: Tom, maybe you ought to slide the
microphone over for --
MS. BUSANSKY: And maybe you ought to kick me at the end
of ten minutes. I'm serious 'cause, you know, I -- sometimes I get
into it. First -- first, I want to say that I love county commissions. I
think local government is where the action is. One of our senators,
actually Graham, said, "It is at the county commission level that --
that the front-line forces are employed." None of us can go back to
Tallahassee, you know, and none of us can go up to Washington, and
there are no commissioners who can hide from those people out
there, rightfully so, who are looking you straight in the eye and you're
looking back, and it is the toughest job I've ever done. It is the job I
am the most proud of, and it's the toughest job I've ever had. So I
want to thank you very much.
It's really my pleasure to be here, and I think your introduction
was wonderful, because this is a passionate, passionate subject.
There isn't a person out there that doesn't care one way or the other.
And so the discussion, the fact that you've taken it up, that you've
supported this extraordinary group -- because I think the leadership in
this group is amazing -- and that you're having this discussion in a
serious open-minded way to me is really remarkable.
And I'm here from -- One of the things I do for Hudson is to
travel around the country and talk ab.out health care from the bottom
up. Hudson is very conservative, and they do not believe in waiting
for the federal government or waiting for the state government to
make things happen as far as health care reform is concerned. The
organization, the community health leadership is like Robin Hood.
We will strategize with any community that wants us. We will
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strategize if they can afford it. We will strategize if they can't afford
it. Right? I am here free; right? Because you have a burning,
passionate concern about what to do with health care.
I'm also in Alaska, unfortunately, the 1st, 2nd, and 3rd of
December, right, where there's only two hours, right, to talk to the
State of Alaska. I'm out in Idaho in two weeks to talk to the -- I'm
sorry, Utah -- the governor of Utah who is concerned about making
Utah a state where 100 percent access to primary health care is one of
its goals.
It is happening across the country. You are part of an enormous
movement that is welling up from the bottom, from the people who
are not the bottom, really the top, as we all know. It is welling up,
and it is happening all over this country. There are over a thousand
communities who have taken on primary health care as one of their
major, major missions.
In tact, I was just at a community in Florida who wants me to
come and do a presentation about how they can make their county the
healthiest county in America. That's their goal; right? And so could I
sit down and talk to them. What is the plan for strategically changing
the hospital, the primary care system, the voluntary system, putting
together a streamlined hybrid organization so they can advertise that
it is the healthiest county in the country, and this is a county I will tell
you, since we're all Floridians, that doesn't need to advertise about
health. They can advertise about amusements and entertainment and
weather and that kind of thing. So you -- although it's difficult --
although it's a passionate subject, it is -- you are right in the midst of
what's happening. You're right at the ground floor. It is here. It is
your leadership. It is what you decide to do that is going to move this
county up into a movement and into really state and national acclaim.
We are co-sponsoring a call to action for the State of Florida in
June to highlight all the counties in the state that are doing
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something, and you need to be one of them because you're doing
something now. You need to be one of them when we go up there.
And I have to say that also as part of the movement, one of the things
you do is -- We know that health care is the right thing. We know
that primary care is the right thing. Would you vote against primary
health care or health care? Never. Never. Okay. But it's not just the
right thing. We don't do it just 'cause it makes us feel good. It's
remarkable to find something that not only is the right thing to do, it's
the smart thing to do. It's really smart. I mean, you are increasing
productivity.
We talk about welfare, and I started the program. I believe in
welfare and still do, but how do women -- poor women and children
go to work in small companies or little, little service industries 30
hours a week without health insurance, without being healthy? If we
say work is valuable, then we need to put our money where our
mouth is, and we need to say that workers' health is valuable and
whether they are ex-welfare recipients or the working poor. Doesn't
that strike you as such an anomaly in this country, that we talk about
the working poor? What do we mean by that? We mean people who
can't afford health insurance. That should never be. That's what
you're dealing with now, is, how do you get people up front into
primary health care, to make them productive, to make them healthy
and to make working -- no matter what they do -- something that's of
value. That's what you're talking about, and that's the discussion all
over the country.
I also think that when you start looking and you put into action
the kind of plan that you're talking about, right, that you're really
talking about showing, not only the state but the federal government,
that you have initiative, that you're leaders, that you're innovative.
And what that does for you -- aside from doing the right thing and the
smart thing and saving money -- is it brings you more money; okay?
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No one gets foundation grants. No one that I know of gets a
foundation grant for just sitting there and saying, "We need help."
That was true ten years ago. You could be a little border county;
right? I was just in E1 Paso and you can just say, "Help"; right? It
doesn't work anymore. E1 Paso does not get a million dollars from
the federal government to put together the beginning of a primary
health system.
know Detroit and other communities do not get Robert Johnson
money if they can't show that they've done something. If they've
done nothing, then they may continue to do nothing. I do not
personally-- My organization does not come to places where I don't
think anything whatsoever can happen. I don't go where there are no
leaders. I don't make leaders; okay?
What we do and what you're doing are you're leaders and you're
bubbling up leaders in your own community, and that's where the
action is. You're saying that you want to determine your own health
care destiny. You have every right to do so. In fact, you must
because no one else will.
So, I mean, I can talk a lot. ! will end by saying, I have looked
at your plan. I do not know it inside and out the way the people who
put it together know it, right, but I can tell you, when I look across
the country, it is one of the most imminently reasonable plans I have
ever seen. I have to tell you, it's conservative. Hudson would love it.
My organization thinks it's terrific. It's a hybrid.
It's not jumping off into zillions of dollars. It's saying let's get
started, and you should be very, very proud of the people who have
taken your mandate so seriously and have, in fact, spent incredible
passion, time, energy and intelligence to put it together.
So I'm here to say that you're one of hundreds -- over 500 people
-- communities in this country so far and more; right? They're
growing every day; right? You're part of a great national movement,
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and you've come so far. You've worked it so hard. Don't let it go.
Don't let it go today. Make it happen. You can polish it. You can
change it. Make it happen. And as it starts to happen and unfold,
you will be proud of the direction and can influence the direction.
So my best to you-all. It is not easy. It is always grey, but this
is less grey, and Peter Drucker would be proud. I'm a big fan of Peter
Drucker. He would be proud of the decision that I hope you're going
to make. Thank you.
COMMISSIONER MAC'KIE:
COMMISSIONER HENNING:
Thank you very much.
Mr. Carter, are we going to
wait to the end of the presentation to ask some of the speakers
questions?
CHAIRMAN CARTER: That -- that is what we would like to
do, and Mrs. Busansky will be here to answer those questions. MS. BUSANSKY: Sure.
CHAIRMAN CARTER: That was the request of the committee
chair so we could hear it all, make your notes, and then ask.
COMMISSIONER HENNING: That's fine.
CHAIRMAN CARTER: Is that okay with you, Commissioner?
COMMISSIONER HENNING: That's great.
MR. SCHNEIDER: Next I would like to ask Mr. Bill Lascheid.
I think everybody knows Bill Lascheid, but just in case there are a
few people who don't, Bill is a retired dermatologist, and he and his
wife two years ago founded the Neighborhood Health Clinic, and
they have been getting all kinds of deserved recognition from the
community and outside the community, I think just in the last several
months was recognized by the Community Foundation and was
recognized by the Chamber of Commerce as Citizens of the Year and
just last week recognized by Governor Jeb Bush as one of his points
of light. So we're delighted to have you here.
And Bill's been a very integral part of our committee. He was
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officially a member of the first committee, and he's been involved
with us as an advisor in the second committee. And -- and he has
written and spoken often about their support for what we're trying to
do. And so I asked Bill to come today and share with you some
highlights about the current community approach to helping this
target population and explain the limitations that they have so that we
can put it into context. Bill.
DR. LASCHEID: Thank you very much. And I really
appreciate the opportunity to address this issue once more to the
commission and this is -- As the previous speaker said, it's a unique
opportunity, and we must not pass it by.
I'm here to lend support to the initiative. I do have the utmost
respect for Mr. Schneider and the many members of his committee
who -- the dozens of members of this committee, who spent
thousands of hours exploring this and this -- they have come up with
a plan which is very palatable, and I do believe that we're moving in
the right direction as far as taking care of our people are concerned.
I do represent the Neighborhood Health Clinic. Our mission, the
Neighborhood Health Clinic mission is to provide quality health care
to the low-income uninsured people of Collier County using
volunteer professional staff and supported by private monies;
therefore, I have to tell you that the Neighborhood Health Clinic will
remain autonomous but will be a player in this.
The Senior Friendship Center, the Neighborhood Health Clinic,
St. Matthews House, Catholic Charities, all of these people are
players, and let me tell you, the majority of them are pretty well
maxed out with what they can do. This is a community-wide
problem, and it requires a community-wide solution, and we need
public money to do that.
Where are we going with this, and who are we going to serve?
We're going to be serving low-income working uninsured adults.
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Those people are working very hard for low incomes, and they go
home with little more than enough to put food on the table and
meager shelter over their heads. These people have no health
insurance, and they end up many times ignoring their health problems
and seeking help by going to the emergency rooms when they're in a
crisis stage. And you know what happens when you get to the
emergency room; the costs go up significantly. These people, in my
mind, are true philanthropists to this community. These people take
jobs that the majority of the people in this room would not like to do.
They clean your homes. They clean your toilets. They wash lettuce
in -- in restaurants -- in the back room of restaurants. They cut your
grass. And these people are taking these jobs many times because of
necessity, but they do take them, and they work for 6 or $8 an hour.
And, again, to me, that is a philanthropic effort that these people are
putting forth to the community.
What would happen if these people would disappear because of
health problems or because of other problems? What would happen
to the people who live here and need cleaning help, need people to
cut their grass? Think about it. These people do need to have a
medical home, and this medical home needs to be provided through
public access. They do have a difficult time at the present time
accessing medical care, and once this program is in place, there will
be primary care available for all who really need it, particularly,
though, those who are working, and these are the ones who deserve it
the most.
So I ask you to do the right thing. Provide the funding that is
necessary. I realize that in the initial presentation there were some
spots that needed to be picked up. I'm sure that Mr. Schneider is
going to tell you that these areas are now covered, and he will
complete the coverage of this situation. And we need to give these
people a medical home. Let's do it. Thank you.
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CHAIRMAN CARTER: Thank you.
MR. SCHNEIDER: I think it's about time we'll get into the
details of the current plan of the business plan and does everybody --
Did all of you have a copy? There's extra copies, I think, right in
front of you, gentlemen. Do you have one?
COMMISSIONER MAC'KIE: August 2001 ?
MR. SCHNEIDER: Yes. Going to -- just kind of going to
basically spend the time leading you through the highlights of this
written business plan. And if you turn to page 3 -- page 3 of the plan
-- and I believe people in the audience have access to copies of those.
COMMISSIONER MAC'KIE: They're on the table outside if
you don't have one.
MR. SCHNEIDER: You should have the green-covered one.
Mr. Commissioner, you should have it.
COMMISSIONER COLETTA: Okay. This is it. I have my
own notes.
MR. SCHNEIDER: Okay. On page 3 of the overview, I just
want to give you a quick overview of today's recommendation, and
that is, in order to improve access to health care for low-income
residents, we're proposing an integrated system of primary and
preventive-care services.
Eligible enrollees will be 19 to 64, working residents, family
income equal to or less than 150 percent federal poverty guidelines,
and the primary care providers will be responsible for seeing patients
for the ongoing management of their care and, when appropriate,
making referrals to hospitals, to specialty physicians and other
services and therapies through the We Care Program to be
established.
If you look at the chart on page 3, a picture's worth a thousand
words and this is intended--
COMMISSIONER MAC'KIE: Excuse me, Tom, but for the
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viewers, could we put a copy of this on the screen? You could go
ahead. Just some staff member will do that, I'm sure.
MR. SCHNEIDER: Most people have --
COMMISSIONER MAC'KIE: I'm talking about the TV
viewers.
MR. SCHNEIDER: Oh, I'm sorry.
COMMISSIONER MAC'KIE: Tom, will take care of that. You
go right ahead. There it is. Thank you.
MR. SCHNEIDER: Okay. Basically what we're talking about,
this is intended to depict a coordinated system of care including
everything. And if you look in the egg-shaped version, that is what
we are asking the county to support, which is access and includes
outreach enrollment and education and then the core services of
primary and preventative care related to pharmacies and related lab
work and then disease management with these people to help them
manage their disease through an integrative referral system. And
outside the egg, within the rectangle are the -- the portions that would
be referred out, and that would be supported by the private medical
community and not by the county, and that's hospital services,
specialty care, other services and therapies, and social services
provided by other agencies.
If you go to the next page on page 4, which is summarized
quickly, the mission of this program is to facilitate access to primary
and prevention focused health care service for uninsured low-income
working county residents. And the goals for the community are to
improve the health and quality of life of this target population, to
improve their productivity through improved health care and, thus,
reducing absenteeism, reducing turnover, and improving on-the-job
performance. And we're also -- a community goal is to reduce the
community's cost of uncompensated care and, as a result, improve the
health and quality of life of the entire Collier County community.
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The program objectives that we have in order to achieve those
goals is to increase access to affordable health care, provide low-cost
pharmaceuticals, reduce inappropriate use of hospital emergency
room, and reduce unnecessary hospitalization for avoidable
conditions, and then to utilize the success of the program to obtain
additional state and federal funds.
At this point, I would like to introduce Steve Rasnick and ask
Steve -- who has been a member of both of our committees, been
working closely and diligently with us for over two years, and Steve
is a TPA by background, a Third-Party Administrator. He's had his
own firm a number of times. He's managed the largest one in the
United States for travel, and he has his own operation here. So he is
a -- he is very experienced and an expert in the -- a lot of the aspects
of this plan. Steve chaired our subcommittee that worked on
finalizing the details of plan eligibility -- plan design and eligibility,
and so I would ask Steve if you would lead us through that section.
COMMISSIONER MAC'KIE: Steve's the person who wrote
my favorite letter and e-mail on this subject that I wished had been
published in the Naples Daily News that was basically entitled,
"Make Me Proud to be a Republican." Made me proud. Thank you,
Steve.
MR. RASNICK: Commissioner Henning suggested that I
define an acronym TPA, Third-Party Administrator. We administer
claims on behalf of self-insured employers around the country.
COMMISSIONER MAC'KIE: Basically, it's like what the
county has. It's who we call when we have a claim; right?
MR. RASNICK: I'd like to think we're a little bit better but --
COMMISSIONER MAC'KIE: Another discussion.
MR. RASNICK: I know. I know. First off, I'd like to thank the
committee that worked so -- my committee that worked so hard in
developing this. We get a chance to speak to all of you, but frankly,
Page 18
September 6, 2001
the committee -- and the committee's input was terrific.
We worked Saturdays. We worked evenings. They're just a terrific
group of people. I'd be remiss if I didn't suggest that.
Our eligibility goal was to develop a reasonable, cost-effective
program with reasonable, cost-effective eligibility requirements that
satisfy the primary health care needs of our target population and be
consistent at the same time with the objectives and concerns of the
Board of County Commissioners. I think in the details of the
program you will see that, I believe, we were successful.
The specific eligibility requirements are -- I'll follow with them
right now. We want to cover low-income working uninsured
individuals earning 150 percent of the federal poverty guidelines or
less, age 19 to 64. Now, in our report we indicate just what those
federal poverty guidelines are and just how low they are.
MR. SCHNEIDER: That's on page 6.
MR. RASNICK: On page 6 of the report.
COMMISSIONER MAC'KIE: Five.
MR. RASNICK: Tom, I can't see that far anyway.
Just to give you an idea, size of the family of one, the 150
percent of the federal poverty guidelines is only 12,885, and for a
family of four it's 26,475. These people do not have a lot of
disposable income. I think that's an important thing to keep in mind.
We wanted to cover only the working poor, and the individuals as
part of our program must be working at the time they make
application to participate in the program or be involved in some
government-sponsored back-to-work program such as wages.
They must be a resident of Collier County. It's an important
element.
They must not have access to affordable health insurance at their
place of employment. Now, we've defined "affordable health
insurance" as insurance that cost them 10 percent or less than -- of
Page 19
September 6, 2001
their gross monthly income. So they may have insurance, but if it
costs them 50 percent, it's not reasonable, in our opinion, to expect
that they're going to forego food and housing to buy insurance.
They must satisfy all of the requirements that I've just
enumerated in order to participate at least once per year and more
often as determined by the plan.
So, in summary, the eligibility requirements require that an
individual make application for participation in the plan in a form
that is acceptable to the plan-- the plan will determine that -- is in a
class eligible to participate under the program and is determined to be
eligible by -- by the plan, subject to providing the plan with the
required proof. That I won't burden you with, but it's quite lengthy,
and certainly we will share that with anybody at some time -- not in
the future. It's here. We have it, but it's just very, very lengthy.
There is a lot of documentation that is consistent with other state
programs that we're going to require.
We're also going to require as a participant in this plan that they
have a photo ID. I think we mentioned that a long time ago. That
will go a long way with dealing with fraud and abuse problems.
Tom, I think that -- Okay.
MR. SCHNEIDER: You covered, like, the numbers. You want
to go into --
MR. RASNICK: The population?
MR. SCHNEIDER: Yeah.-
MR. RASNICK: We've determined that there are approximately
30,000 individuals that are uninsured. Of those we have
approximately 20,000 -- 20,000 that would be eligible for
participation under this program.
MR. SCHNEIDER: Steve, that was when it was at 200 percent,
but when we dropped to 150, we're now down to 14,000.
MR. RASNICK: Fourteen thousand. And we expect, based on
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September 6, 2001
our estimates from other programs, that we will get at a maximum
anywhere between 50 and 65 percent of those people eligible
participants actually participating in the program. MR. SCHNEIDER: Thank you, Steve.
The next part, then, is on page 6 where we get into the -- into the
primary care services and the vendor provider selection. Basically,
what -- what our committee who looked into -- the subcommittee
looked into this recommended that we adopt a community health
center approach, not dissimilar from Dr. Lascheid's Neighborhood
Health Clinic. Then we would have a free-standing clinic to serve
this target population. And the reasons for that largely is that there is
a shortage of primary care physicians in this community, and there is
a need to recruit the primary care providers to serve these people, and
it would greatly ease administration rather than to try to sprinkle this
target population throughout 50 to 100 primary care physicians in the
community. This would be a county-wide program. The basic clinic
would be here in Naples area, and any of the folks that would qualify
from Immokalee would expect to be served in existing facilities out
there at another clinic.
So our committee who is charged with coming up with the
analysis and recommendation -- the subcommittee met with various
health care providers to determine their interest, their capacity, and
the potential to serve a large volume of patients. And based upon
these meetings, the only organization that came forward with all three
-- the interest, the capacity, and the potential to serve a large volume -
- was Collier Health Services, Inc., and so we are bringing to you a
recommendation that you seriously consider them to be a preferred
provider for you in this program. However, we are not doing that --
we are not by doing that suggesting that you do not follow through
with a formal bidding process to confirm this conclusion and allow
any others to propose that may have either not been contacted by us
Page 21
September 6, 2001
or who have changed their mind or decided they want to do some sort
of a joint venture to do this. This would allow you then to negotiate a
more favorable contract.
Let me just tell you about CHSI. Their mission is to assist in
providing primary care access for the uninsured and for people who
are under various state and federal government programs. And their
basic mission is in the Immokalee area because Immokalee has been
considered as a medically underserved community.
What they do is not by any means an easy job. What we found
in interviewing lots of other providers in this community is that I
think they understand the complexities of dealing with a lot of the
people in this target population, and I think that could have had an
impact on their lack of interest. They are a designated FQHC, which
means a Federally Qualified Health Center, and as a result of that,
they bring with them significant advantages to the county if they
were to be selected as your vendor.
Some of those advantages are that they have an advantage in
recruiting primary care physicians to treat low-income population
through a national network. They also, very, very importantly, have
access to preferred -- preferred pricing for pharmaceutical drugs
under a section called 340-B, and Steve Rasnick is going to talk
about the pharmacy in a few minutes. But just to give you an idea,
the 340-B is the cheapest price that any drug company is allowed to
sell any drug to anybody in the United States. It can never be sold
any cheaper than they sell it to a 340-B vendor which would be a --
CHSI already receives that benefit, and they would be able to extend
it to the county. That would have significant cost savings in the
pharmaceutical cost.
The other thing is, it's very important to realize that President
Bush currently, his administration, is emphasizing the FQHC's as a
focal point for expanding primary care services throughout the
Page 22
September 6, 2001
United States and he is redirecting -- in the process -- they are in the
process of redirecting lots of federal health care dollars into the
federal qualified health care program.
Now, the thing that you have to understand, though, is that, as
Phyllis said earlier, the additional monies that could possibly come
from this program, either directory from the Feds or through the
states from the Feds to the local communities, will only come to
those communities who have demonstrated a financial commitment
of their own.
COMMISSIONER FIALA: Would you repeat that one more
time?
MR. SCHNEIDER: Yes. On President Bush?
COMMISSIONER FIALA: The statement you just made.
CHAIRMAN CARTER: The statement --
MR. SCHNEIDER: The statement is -- I'm repeating what
Phyllis said -- and that is that in all probability it's almost for certain
that no community will be able to leverage any of those new, fresh
dollars that the Federal Government is putting into the federally
qualified health center communities to drive the growth of the
primary care health care for the low-income peoples throughout the
United States -- no community can expect to get any of that money
unless they are able to demonstrate that they have made a
commitment of local tax support for those FQHC's.
COMMISSIONER MAC'KIE: And this president is a
Republican?
MR. SCHNEIDER: Yes. Yes. Also happens to be brother of
the governor; right?
So, anyway, this is all so recent that there's nothing in our
program that we can talk to you about of any promise or certitude,
but I think the excitement for us is that we expect in the near future
that there may be additional dollars that happen. So they bring that if
Page 23
September 6, 2001
they are involved in the delivery of our program.
Okay. At this point I'm going to ask Steve --
If you would then lead them through the pharmacy program.
MR. RASNICK: Thanks, Tom.
As we mentioned early, I'm a TPA. We pay about $60 million a
year to beneficiaries located primarily in Collier County and Lee
County, and of that 60 million, approximately 25 percent of it is
prescription drugs. Prescription drugs are the single most expensive
item that most employers are facing. Prescription drugs are -- The
cost of prescription drugs are increasing at a rate higher than any
other component in any other benefit plan, and so it was a very, very
serious issue when we undertook the issue for the prescription drugs
under our program.
There are a couple of critical things to keep in mind.
emphasized under this program the use of generic drugs.
together a formulary in conjunction with the provider group that will
focus on the use of generic drugs. On our own block of business, a
generic drug costs retail a little over $9, a brand drug is approaching
$70 per script. There is a world of difference, and that is on retail
basis, not on a discounted basis.
So we will focus our plan, we'll focus on the use of generic
drugs wherever practical. We will also focus on, as Tom mentioned,
340-B pricing. 340-B pricing will give us a significant advantage in
the pricing of this program. And it's, frankly, only recently that
federally qualified plans -- health centers have been allowed to
participate in 340-B pricing.
We will also participate in what is known as a compassionate
drug program. Most of the drug vendors -- drug manufacturers have
a compassionate drug program in which they provide free drugs to
programs similar to the program that we're proposing. The problem
with it is, it takes -- it's very labor-intensive to get it, and it takes
We have
We will put
Page 24
September 6, 2001
anywhere from 60 to 90 days in order to get the drugs, but in the
communities that have taken advantage of the compassionate drug
program, the return on that investment has been roughly 4 to 1. So
our program has, as one of its cornerstones, included the
administrative ability to take advantage of the compassionate drug
program and get people the drugs that they need. It's a good
investment.
We will also take advantage of sample drugs. Again, most drug
companies will provide clinics and doctors with samples and we've
all had experiences where you go to a physician -- where you go to a
physician, physician says, "You need to go on this medication, but
before we give you the script for it let's see whether you can tolerate
it." So they go into their cabinet and pull out a sample and give it to
you. Those are routinely available.
The combination of 340-B pricing, the requirement that
wherever possible we use generic drugs, the compassionate drug
program will give us the opportunity to provide basic drug services,
basic pharmaceutical services to support the types of conditions that
are routinely treated in a primary care environment.
Now, because we're concerned about the cost of prescription
drugs and what's happening with them, we've built a safety valve into
our program, and we've said that until we get enough statistical data
to make good predictions as we move forward, we will not pay any
more under this plan than $750 for any participant for prescription
drug use in the initial stages of the benefit program. Quite frankly, I
think that will more than adequately meet the needs of most of the
participants, but it's a safety valve we built in there to protect the
financial integrity of the program and to add credibility to our pricing
illustration. So it's a -- it's a solid program.
Now, where do the people get the drugs? Obviously, if it's a
free sample and CHSI is chosen as the vendor, any doctor's office
Page 25
September 6, 2001
chosen as the vendor, they'll get it there. But on 340-B pricing -- one
of the critical components of 340-B pricing is that they will allow us
to use retail establishments that will agree to segregate the 340-B
drugs in a separate inventory. So it is our plan to suggest that the
county go out for bid to the Eckerd's and Walgreen's and Albertson's
and the Publixes in the world and any others that you might feel are
appropriate that have good representation geographically and put out
a bid and ask whether or not they will, in fact, be willing to
participate in the 340-B program and whether they're willing to take
the time and effort to segregate the drugs and maintain a separate
inventory and, lastly, evaluate them based upon their dispensing fee.
Because there's a critical component of-- In other words, the
dispensing fee is the amount that they charge to dispense the
medication. A critical component of our program is that the
participant will pay the dispensing fee. The participant will pay the
dispensing fee.
That fee should be based upon -- my only personal experience,
should be under $3, okay, and in all likelihood will come in at 2.25 or
2.50. And if it comes in much higher than that, then somebody needs
to be talked to a little bit. But we built the protection in. We built the
protection in. The participant is going to pay for what is viewed as
the administrative cost. We will rely on the free drugs and the
compassionate drug program as the cornerstones of what we
proposed, and we will then rely on 340-B pricing, the most
competitive pricing out there, when we have to -- when the plan has
to go out and purchase drugs consistent with the formulary. MR. SCHNEIDER: Thank you, Steve.
I would next like to ask Wendy Wilderman to come up.
Wendy?
We'll talk about the hospital and specialty referral services.
And, again, now while Wendy's coming up, let me just highlight for
Page 26
September 6, 2001
you that what we're asking as part of the county funding is to support
the primary care, include physician services, the primary care
physician services, basic pharmaceutical, and basic lab work. And
what we're in the process of doing, and have already made great
strides, is to elicit the support of the medical community -- the
medical-provider community to establish a Collier We Care Program,
and Wendy in a minute or two here is going to describe to you the
history of the We Care Program within Florida and talk about her
personal involvement in this.
But I just want to summarize ahead of time, and that is that we
met with the executive board of the medical society, and they have, in
writing, indicated their total support -- unanimous support for helping
us establish a Collier We Care Program which would mean that --
that we would recruit. They would help us recruit all of the specialty
physicians in this county to provide free, pro bono services to the
patients who come through our primary care unit who are referred by
our -- by their primary care provider.
And we've also gotten oral approval from the CEO of NCH
Hospital that they would provide the entire gamut of services that
they have within their entire corporate enterprise, from hospital beds
to significant diagnostic testing, et cetera. So all their services would
also be provided free of charge to patients that need it and referred by
a primary care physician.
And we're very close to -- I believe we're very close to getting
the same commitment from the Cleveland Clinic. We've had
discussions, but they've had a change in leadership, and I have yet to
meet with the new CEO, but it's possible I may do that as early as this
afternoon. But -- this would all be on prorata basis, so the emphasis
would be volunteerism, spread it around, anybody do what they're
best at. And so that will be a big cornerstone for our program.
And Wendy Wilderman is employed by the State of Florida.
Page 27
September 6, 2001
She is headquartered out of Fort Myers. And one of her
responsibilities, among others, is to establish these types of We Care
organizations in various communities, and she's already done that in
Lee County and in Charlotte County. And she'll tell you a little bit
about that and tell you a little bit about the history of the program in
Florida and how many counties are doing it and how she would go
about getting involved. So Wendy--
MS. WILDERMAN: Thank you, Tom.
Thanks for having me here. It's really an honor to be here
speaking with you-all this morning and to be able to talk about the
We Care Programs and the other volunteer programs that doctors in
the State of Florida are involved in. The doctors that we have in
Florida are really wonderful in the free care that they give to people
who need it, and a lot of it, though, has needed to be organized in the
past, and that's a lot of what the We Care Programs do.
As Tom and Phyllis were speaking, I was thinking that this may
be the first leveraged kind of care that you can use this program for
because this is something the county doesn't pay anything for, but
there does have to be a primary care program in place for it to work.
Patients are going to need a medical home to go back to after they
have -- first -- for an examination first and determination that they do
need primary-- specialty care and then to return to once they've had
their treatments. But anyway -- So when we talk about We Care
Programs, I wanted just to point out that those are programs affiliated
with county medical societies. The first one was in Alachua County.
It began in 1985, and it's just a way that the doctors give free care to
an insured low-income people in their communities.
You might remember that back in 1985 when the Alachua
program started, all the health departments in Florida were providing
primary care to low-income patients. A problem was that when
patients needed specialty care, often there wasn't a way to get it.
Page 28
September 6, 2001
Nurses would spend hours on the telephone calling doctor after
doctor begging them to take the patient. Doctors weren't hard hearted.
A lot of them really wanted to do something to help out, but they
were afraid. They had concerns for themselves and their families.
They were -- By the time poor patients get to a specialist's office,
their problems are a lot more complicated than when insured patients
get there. They haven't been treated for a long time, and so they have
a lot more complicated issues to deal with. Often their nutritional
status is poor, and they have other issues that impact the outcome of
their care. So the doctors were afraid they couldn't give them the
same outcome that they can give paying patients, and obviously, then
they were afraid they'd be sued. Some doctors were also afraid that
they would be identified in the community as the "charity doctor" and
with all the ramifications that that has with it.
So to resolve those problems, the Florida Medical Association
and the state agency that was responsible for health departments at
that time got together and proposed a law that would give doctors
sovereign immunity for their free treatment to indigent patients. In
1992 the legislature passed the Access to Health Care Act.
UNIDENTIFIED MAN: Excuse me. Speak closer to the
microphone, please.
COMMISSIONER MAC'KIE: Pull that cord for her there.
COMMISSIONER COLETTA: Use this one right here.
MS. WILDERMAN: Thanks. In 1992 -- in 1992 --
(Microphone feedback.)
MS. WILDERMAN: Have that one back. Okay. -- the --
Florida passed--
MR. SCHNEIDER: It's not going to work.
COMMISSIONER MAC'KIE: Just undo it. Here comes the
technical queen. She's going to save us. Thank you, Katie.
CHAIRMAN CARTER: I think they have found a mechanical
Page 29
September 6, 2001
adjustment in seating that will probably resolve the problem.
COMMISSIONER MAC'KIE: Okay.
MS. WILDERMAN: In 1992 -- can you-all hear me now? Is
that better?
CHAIRMAN CARTER: Get close to the mike, ma'am.
MS. WILDERMAN: Let me prop it up on top of these books.
In 1992 the Florida Legislature passed the Access to Health Care Act.
This gives any health care provider who's licensed in Florida
sovereign immunity for indigent patients that they treat free of charge
under certain conditions, and we contract with them. So if anyone
wants to know more about the program, please contact me later or see
me after this. But this legislation not only removed the fear of
lawsuits, but it also put a few funds in the department's budget to
create the volunteer health care provider program, which is the
program that I work in.
We insure that the volunteers who want it have risk protection
from sovereign -- from malpractice lawsuits, and we develop
programs with enough volunteers that they can rotate by specialty.
This allows many doctors to share the workload so no one feels
overburdened.
From the one program that was in place in 1985 without any
kind of protection, Florida now has 22 We Care Programs that serve
residents in 27 counties. There are also many other volunteer
programs throughout the state that are not associated with medical
societies. In Collier County the Neighborhood Health Clinic is an
example. But each program is designed to meet the circumstances of
each particular community. That's one of the great things about this
program, is that we have a lot of flexibility in it to build what works,
whatever place it happens to be.
So Collier right now has three neighboring counties that have
We Care Programs, Broward, Lee, and Charlotte County, and I work
Page 30
September 6, 2001
with Lee and Charlotte counties so I can give you details of those
two. Generally, for patients to be eligible in each one, they need to be
residents of the county, but Charlotte also takes residents of one -- of
rural counties as well, and then patients need to be uninsured, and
their income needs to be at or below 150 percent of the federal
poverty levels.
In Lee County there are four agencies right now that provide
primary care to low-income people, and so it was set up that each of
those agencies has a case manager. One of their own employees was
designated as a case manager and has the additional duties -- when a
patient needs a specialist, they do the eligibility screening and follow
through with all the paper work and get them out to see one of the
specialists.
In Lee County -- Charlotte County, the health department still
does primary care, and so they handle that all internally. But in Lee
County approximately 125 doctors and all the hospitals participate in
the program. In the state's 1999 to 2000 fiscal year, over 300
individuals received free care that was worth an estimated $538,000.
In Charlotte County there are 83 volunteers. All the hospitals
participate there too, with one taking a-- the majority of the patients.
And in the '99 to 2000 fiscal year, they received a value estimated at
$367,000.
I have annual reports for the commissioners that show -- this is
from the state's '99 to 2000 fiscal year, that shows the amount of free
care that was provided throughout the state through all the volunteer
programs. There are many reasons these programs are successful.
One is that they give them a way for doctors to organize the help that
they give the less fortunate and to share equally in the workload.
They offer their services without worrying about putting their
families at risk because the state sovereign immunity gives them
protection. At the same time, it gives patients an avenue for relief if a
Page 31
September 6, 2001
lawsuit -- if a mistake is made. Patients have a medical home to
return to. They don't become a consistent patient of a specialist. The
patient's screening is already done. Doctors know when the patients
get there that they really are indigent and they really do need their
care. And it's hassle-free administration. The doctors can practice
medicine the way they love to do it. They don't have an insurance
company telling them how to practice, what they can do and what
they can't. And, finally, it's the first time that doctors have been able
to accumulate the value of their free services and share that
information with the community.
So, as Tom mentioned, in Collier County, Medical Society is
already supporting this program and the hospitals. Naples has --
Naples Community Hospital has given its verbal support. We hope
the clinic will soon too. And the Medical Society has agreed to be
the administrative arm of the We Care network. So thank you.
CHAIRMAN CARTER: Okay. Thank you very much.
I'm going to check with magic fingers. Are you about at that
point? She is about at that point.
Tom, I see where you want to get to governance administration
and budget, which certainly will have everyone's attention, so I
suggest that we take ten minutes and break, give our recorder a few
minutes rest, and we'll be right back. Thank you. (Short recess taken.)
CHAIRMAN CARTER: Ladies and gentlemen, if you'll have
your seats. Try it this way: Ladies and gentlemen, please take your
seats. Thank you.
COMMISSIONER MAC'KIE: It's a gavel. It's kind of like a
gavel. Whatever it takes.
CHAIRMAN CARTER: Sometimes our sound systems are
picking up the other side. A little weak on this side.
All right. Everybody have a seat. We thank you for your
Page 32
September 6, 2001
patience and being with us again. I've learned during break that the
cable is out in North Naples, so part of our community does not have
the opportunity to watch this workshop and hopefully that there will
be tapes available for those who -- and replayed on Channel 54. So
as they finish laying fibreoptic cable, everybody will be able to tune
in.
Mr. Schneider, if you would continue, please. I believe we are
to governance and administration.
MR. SCHNEIDER: Yes, we are. Thank you.
Just one note I wanted to mention, is that when Wendy talked
about the We Care Program for the specialist, I mean, that's -- I just
want to drive home again that it's basically -- it's the shortage of
primary care physicians -- primary care physicians in the county that
precludes us from realistically expecting that we could get those
services provided pro bono, so that's why we have this program.
Okay. On governance administration -- and that is on page 9 of
the -- of the business plan. Basically, what we're suggesting is that
you form a voluntary advisory board appointed by and reporting to
you, and that board -- that advisory board would represent all of the
major stakeholders in this plan, which include the county, the health
department, various provider groups or the physicians, not-for-profit
social and health care agencies, citizens' groups and the clinic users.
And what would they do? They would address the major areas of
program policy and oversight such as management, financial
performance --
COMMISSIONER MAC'KIE: Katie, come up, help us with
that ringing, please.
COMMISSIONER COLETTA: Move it over here.
MR. SCHNEIDER: Thank you.
COMMISSIONER MAC'KIE: She's a miracle worker.
MR. SCHNEIDER: She sure is. So they would be responsible
Page 33
September 6, 2001
for program policy and oversight such as management, financial
performance, medical issues, and patient relations. And this is a
governance structure that has worked well in other programs for the
uninsured in Florida and elsewhere in the United States.
As far as the administration goes, our plan pushes most of the
administration down to the primary clinic and to the We Care. And
what little additional administration is left would be either handled by
the Public Health Department and/or the county social services
department which would include eligibility screening and the contract
oversight.
And then a third-party administrator. What type of tracking --
Steve was describing what a third-party administrator does, but
basically the clinical utilization -- the data review of encounters and
cost effectiveness and the quality of care and accountability. And for
this program, because it's a single clinic basically going to be
providing most or all of the care, a TPA would be used mainly for
oversight and for future planning, not for claims preparation or bills
collection since there would be no bills being sent. And most of the
data would be collected at the site -- at the clinic site and then be
monitored, and then that information then would be reviewed and
shared with the program manager and the county and the board in
terms of making sure that the person who -- the organization who is
responsible is doing what they're supposed to be doing. And so that
takes care of governance and administration.
I would like next to turn to the budget, and there we're on page
10 and 11. Just give you some oversight on the budget. That is, that
when we put this budget together, we solicited input from various
sources, including the Public Health Department, the county
government, CHSI, and the research and professional opinion from
our consultant, Dave Rogoff. What we are attempting to prove to
ourselves and to you is that the reasonableness of our plan and the
Page 34
September 6, 2001
budget assumptions fit within the constraints of what we had
estimated back in April for you in terms of on a per-patient basis.
And we also submitted our plan and the budget assumptions for a
reasonableness check, and they were confirmed by an actuary whose
report is in attachment 5 of the business plan at the end.
So when you look at the chart itself now on page 11, this
summarizes -- intended to summarize for you the proposed primary
care budget for the first four fiscal years of operations. What it
shows is that the program is projected to begin on April 1st, 2002.
So, therefore, the first fiscal year -- your next fiscal year would only
have six months in it. And the model that we used in making these
budgeted projections -- and, by the way, there is additional detailed
budgets in the attachment for year by year, but we're just looking at
the summary here. But it's intended to show that the program, as I
say, can be achieved in what we proposed in April of 2001.
It's important that you recognize that it's not intended to dictate
the specifics on how the clinic must operate. Those specifics of
operation would be determined during the competitive bidding
process, the subsequent negotiations, and then be fine tuned in future
years.
But we're projecting an annual cap would be reached of 7,000
enrollees by the fourth fiscal year which would be 2004-2005. And
what you can see there is that the bottom line -- the second line from
the bottom which says public expenses and current dollars for the
fourth year, when we begin the year with 7,000 and end the year with
7,000, we've reached our -- our projected cap of patients to be
included in this plan based on today's population statistics would
show that the estimated costs would be 5 to 10 percent less than what
we had projected for treating 7,000 people for a full year in our April
presentation and request, which is included in your budget.
So let me just tell you some of the differences in this budget
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September 6, 2001
versus the April budget. Again, originally we viewed 7,000 people
being enrolled as the first step towards reaching 20,000 people that
we estimated were uninsured working poor with incomes below 200
percent of federal poverty. Now, our plan is to ramp up to 7,000 by
the fourth fiscal year. That would be the cap, and the lower number
is because we lowered eligibility from 200 percent to 150 percent.
That eliminated thousands of people that would have otherwise been
covered. And we also are aware that no other successful program of
this nature has ever reached and treated more than 65 percent of their
patients in any one year. And we also have other not-for-profit
organizations, such as the Senior Friendship and Lascheid
Neighborhood Health Clinic that are serving this very target -- some
of those. We're intending to fill the gap to meet the need of those that
aren't being seen by those people.
So I think all of that brings us to the conclusion that 7,000 is a
very reasonable, defensible estimate for a projected cap based on
today's population of 250,000 people.
And then the other thing you need to understand is that we're
recommending in here that the county negotiate a contract with the
provider that would be based on a flat fee, based upon a negotiated
cost-plus agreement to open up a clinic, and we think that that's the
most practical and least expensive, and it meets the needs of
everybody. And we would do that instead of a discounted fee for
service every time somebody came, or doing it on capitation, which
is not generally a well-received form of funding and by the physician
community, particularly in Collier County area.
So when we look at that four-column page on page 11, let me
just discuss a few of the key things for you so you have a better
understanding; that is, that we'll talk about the first year and show
you how it's ramping up through the fourth fiscal year. Each year
uses the average of our projected enrollment volume at the beginning
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September 6, 2001
and at the end of the year. What we were projected start with zero,
and we believe it will be April 1 st by the time all of the
preimplementation is done, which include such things as having to
negotiate the We Care, to having to put this thing out for bids and to
negotiate a contract and all of that stuff. It'll be at least -- It'll be
April 1 st as a realistic target date to start.
And then, as you can see, going across the top there, that we --
we are targeting then that we would end the year next September,
next fiscal year end with 2,000 enrollees and then begin the following
year with 2,000 and ramp up to five and then the next year from five
to 7,000. Then we hit 7,000, and we say we would end the year with
the same number under today's population, ignoring growth in the
county population. This would give you an indication of what the
cost would be when you got to -- to the projected cap.
Now, the -- the clinic operations -- as you can see there, we have
the cost broken down into category with the clinic operation,
pharmaceutical, program administration, and in Year 1 we have start-
up capital that's required. The clinic operations, as you can see,
going -- well, it grows going across. That's based primarily on
volume, although the first year it's primarily all fixed costs.
And we are projecting again -- in the bottom line of the top
quarter section there, we say "hours open per week." We would
expect the first year to be open only a 40-hour week, but that 40
hours would include several evenings and a weekend day. And then
starting on the second year going forward, we would expect the clinic
to be open the neighborhood of 60 hours a week, include every
evening and Saturdays. But the feeling was that it wasn't justifiable
to be open beyond 40 hours. When you're in a fixed cost mode and
starting with zero population, you're going to have a lot of unused
capacity that first year. So it didn't make sense to staff up and be
open 60 hours, but we can cover the need for patients to see their
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September 6, 2001
physician in the evening by arranging those hours.
Now, the staffing, by the way, based on our assumptions
underlying the budget is based on primary care teams being led by a
physician or a physician extender. And each team would be able to
serve the needs on an annual basis of somewhere between 1,500 and
2,000 patients, and that compensates for the extra complexity that's
been discussed earlier about the needs that a lot of these people have
when they first come in so that they will take longer to -- to treat than
a typical person like -- who has insurance and goes to a doctor on a
regular basis.
Now, the pharmaceutical costs are also basically for the most
part are the purchase -- are based on volume. The more people you
have, the more prescriptions you're going to have to write.
The program administration includes the administrative staff and
the indirect cost to support the clinic staff. And then when you get
down-- we get into the administration, we're talking about-- the
program administration includes the -- somebody to be responsible
for the program, and it also includes the eligibility clerks, which
would vary based on volume and based on the number of hours open,
so that the longer you're open, the larger number of people, then the
more eligibility clerks you'll need. So we factored that in.
Then the tracking, accountability, and quality assurance varies,
again, based on volume and assumes most of the monitoring work
will be done within the clinic itself.
And then the first year you see the start-up capital that's
required. And basically to open up a clinic, you need to find a
location, you need to build out the site, you need to get the equipment
into place and that type of thing. And then we expect some smaller
amounts of start-up capital required for the pharmacy program and
the program administration, to negotiate these contracts and that type
of thing.
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September 6, 2001
So, again, look at the bottom there. The summary is that for the
first fiscal year, which is really a half year, we're estimating
$700,000, which includes start-up capital of $230,000. The second
year we're projecting $1,350,000, and that would grow to $1,900,000
and level out at 2.150 -- $2,150,000.
Now, as you can imagine that ramping of this and its impact has
a significant impact on the cost per patient, and that is because you
have all of these fixed costs, start-up capital required, and small
number of patients initially to be able to be seen, and so all of that
translates into a higher initial. But as -- If you track the numbers, you
can see that the patient volume is growing much faster than the cost
of caring for that patient volume and that's -- that's no different than
any other business that any of us have been involved in. With the
fixed cost and increased flexibility of staffing for higher volumes of
people, the cost per patient is greater in the earlier years than it is in
the later years. But the program has to start somewhere, and it will
take a while to communicate its existence to the potential eligible
people.
And then we would expect that in the first year all of the
systems would be developed, implemented, and fine tuned. And,
again, I just refer to you -- I don't intend to cover it today -- but
certainly be happy to answer any questions based on the individual
year budgets in more detail are in appendix 4.
So that covers the budget. Now, what I'd like to do -- Is Ramiro
here? There he is. We had asked the legal department to look at
several specific questions because we wanted to make sure that we
weren't running afoul inadvertently of any federal, state, or local
laws, and the legal department did a lot of that work and then
reviewed it with -- with our outside legal counsel. And they did issue
a legal opinion letter, and I thought that it was important that Ramiro
give us some of the highlights of that letter.
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September 6, 2001
MR. MANALICH: Good morning, Mr. Chairman,
commissioners, members of the committee, members of the public. I
am Chief Assistant County Attorney Ramiro Manalich. Also with
me today are Jaqueline Hubbard Robinson, assistant county attorney,
and Robert Abreu, legal assistant, and ! want to thank them for all the
hard work they've assisted me with in this.
As Mr. Schneider mentioned, there was a memorandum of law
distributed to you that we had prepared through the collaborative
efforts of my office and retained counsel of the law office of
Neighbors, Gibland, specialists in local government law. Copies of
that memorandum are available for the public. They are on the front
desk up here. There's a number of extra copies there.
I will keep my comments brief today. Basically, what I want to
point out is that the program as proposed is fundamentally in
compliance with the legal requirements that we have analyzed. And
what I'd like to do is very briefly just highlight to you the things that
we looked at legally that may be of interest to you and our conclusion
on that, and I'll just follow through on the memorandum.
The first area -- and I give credit to both county staff through
Leo Ochs' office as well as to Mr. Schneider and his committee for
checking with us on different issues. Obviously, these are complex
questions, some of which have constitutional ramifications. But I
think we've come up with some basic answers here, and I'll be very
brief in running through those.
The first one has to do with residency requirements. The
conclusion there is -- and there is constitutional law on this -- is that
we cannot have a durational residency requirement, but we can have
a residency requirement. The difference I'm referring to is, we
cannot -- For this type of program which has to do with some, you
know, basic health care needs, constitutionally we cannot require
that, to be a resident, you have to be here a certain period of time.
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September 6, 2001
All we can require is, in fact, you be a resident in the sense that
you live here and have the intent to remain here. So that's the
residency, and that is included within the program.
The next category that we looked at was -- and this is a little bit
of a side issue but -- and at one point I believe Mike Carr from the
Executive Republican Committee had raised this to us, and that was,
could you have, if the county so desired in the bidding requirements
of the county for county projects, a requirement that employers have
health insurance. And the answer to that was, we found federal law
in Florida which indicated that we could not have that be a
disqualifying factor for county bidding, but it could be a weighted
factor if we chose to do that.
The next area had to do with occupational licensing fees, and I
know there's been some interest in the community on this.
Unfortunately, the conclusion that we have come up with so far has
been that we cannot have a occupational licensing fee system that
distinguishes as a class between those employers that provide health
insurance and those that do not. Now, there was a possibility that we
could charge the same fee to all employers and then have a refund to
those that provide that type of health insurance. That was a potential
option. I spoke to Guy Carlton, the tax collector. I think he -- My
impression is he generally views this in the same way we do from the
legal perspective.
Another question that came up, can the county refuse to provide
medical benefits to nonqualified aliens? And, by the way,
"nonqualified alien" is a term of art. It's used in the federal statutes.
The answer is yes, but obviously, there are some administrative
concerns as to how you make that determination of whether someone
is a nonqualified alien or not. I'm not saying it's insurmountable, but
obviously, we're not INS officials here. We would have to develop
the expertise based on what other properly authorized agencies
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September 6, 2001
utilize.
The last topic I wanted to just briefly touch upon is sovereign
immunity, that you heard some comments about that from an earlier
speaker. With regard to sovereign immunity, the earlier speaker is
correct, that there is under Chapter 766 of the Florida Statutes the
Health Care Act which would extend sovereign immunity --
governmental sovereign immunity to those physicians that provide
unpaid voluntary services. I think the question gets a little more
complex if we deal with -- as we are planning to do generally here --
if we deal with independent contractors. The memo outlines some of
the case law on this. Depending on the degree of control and
supervision that the county would exercise over these independent
contractors would determine whether or not there would be such
sovereign immunity for them. Then, again, I think they would be
able to get insurance through their methods.
But those are the basic legal issues we looked at. Again, my
conclusion is that fundamentally the program does meet legal
requirements as I explained them.
MR. SCHNEIDER: Thank you, Ramiro, but I -- just one other
thing. We had gotten an original opinion letter on an issue all by
itself. Maybe you ought to just cover that too.
MR. MANALICH: I'm glad you mentioned that.
There was another significant question here -- and I'm sorry I omitted
it -- which had to do with whether by county ordinance we could
require employers doing business in Collier County to provide health
insurance to their employees, and the conclusion on that was a rather
emphatic no. Under the ERISA Federal Statute, we are preempted or
that's reserved only for the federal government under that act, and we
cannot do that, unless we went through Congress like Hawaii did in
one of the cases and actually got a specific exception to that
requirement as a state.
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September 6, 2001
COMMISSIONER HENNING: What's the risk of the county?
Do we have any sovereign immunity on funding this program?
MR. MANALICH: Well, I think, obviously, there are always
some risks, even with sovereign immunity in place which, as you
know, caps the amount of damages that can be sought against a
governmental entity. There is, even if we use independent
contractors, a risk of some type of litigation about negligent retention
or hiring of those contractors depending on the level of health care
they provided. I tend to think, with the good services that I think
have been mentioned here today, that would be a reduced risk. That is
one.
Jackie, is there anything else you can think of from a sovereign-
immunity perspective of risk to the county you might have
encountered in your research?
CHAIRMAN CARTER: You will have to come to the
microphone and identify yourself and speak, please.
MS. ROBINSON: Good morning, members of the committee. I
think Ramiro summed up our conclusions regarding sovereign
immunity. It does exist. It will exist throughout the program. It will
depend upon as far as the outside consultants being the doctors or the
agency that's retained by the county to administer the program.
Sovereign immunity will apply to them depending upon their
relationship they ultimately have with the county. So the more they
are independent contractors and the further away they move away
from the county's control, the less protection they have -- would have
under our sovereign-immunity limits.
COMMISSIONER MAC'KIE: But probably that's going to be
such an important feature for -- feature for physicians to participate,
that we'll need to draft it in a way that they can have that protection
and know it's very important for volunteer positions. Jackie
Robinson.
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September 6, 2001
CHAIRMAN CARTER: Identify yourself, please.
MS. WILDERMAN: I'm Wendy Wilderman with the State of
Florida. When we talk about the governmental contractor for the
volunteers, with the We Care Program, it would be the State of
Florida and not the county.
COMMISSIONER MAC'KIE: So as to the specialist referral
part of the program, the state sovereign immunity would cover them.
It's only the primary care that we're discussing that would need for
the county sovereign immunity to be extended.
COMMISSIONER FIALA: Isn't primary care in the-- in the
health department that's covered by the state?
MR. SCHNEIDER: Yeah. I think -- Let me just clarify. If
you're talking about -- and I don't think Commissioner Henning was
talking about the physician. He was talking about the county. But
from the physicians' standpoint, the physicians that operate within the
federally qualified health clinic of CHSI that we're talking about is
protected by even something better which is called the Federal Tort
Protection, and again, no doctor who's being compensated for treating
these people, which the primary people would be, would be covered
by a sovereign immunity at the state level. It's only those that would
be doing it for free. So it would be -- all the referral physicians
would get the sovereign immunity through the state, and that has to
be tied in through the Public Health Department, which it would be.
The primary physicians that are servicing these people through -
- if it's CHSI, would have federal tort protection which is even
stronger. And from a county standpoint, we went back to every one
of the communities that we have been working with and studying
their programs and asked the specific question, and not one county
has ever been filed with any litigation on any aspect of their plan in
up to ten years. So it may be that there is some potential exposure,
but I think it's diminimus from what I can see from actual experience
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September 6, 2001
of other communities doing this.
COMMISSIONER HENNING: But it is possible?
MR. MANALICH: Yeah. There is. As I mentioned, even in
one of these arrangements, there could be under some circumstances
negligent retention or hiring-type cause of action, but I tend to think
the risk is small.
COMMISSIONER MAC'KIE: Do we get sued? Are we subject
to losses? Never mind. I'm not even going to go there.
MR. SCHNEIDER: Okay. Thank you, Ramiro.
COMMISSIONER MAC'KIE: We build a road, every time we
build a park, everything government does we are subject to suit.
MR. SCHNEIDER: I would like to ask Jim Tindall, a member
of our committee who's worked very closely and extensively with us
for the last ten months, to address the community concerns that have
been raised and to give you his commentary.
MR. TINDALL: I know a number of citizens here -- are here
who want to express their concerns individually, but I want to make a
point on behalf of the committee that we have read and have
dialogued with any number of members of the community on this.
We respect their opinions, and I would simply like to comment
briefly on some of the most frequently voiced concerns or objections.
And at the top of the list is the belief on part of many that property
taxes are an inappropriate way to fund a program like this.
The board asked our committee to do two things, to develop a
recommendation with costs and to develop a funding mechanism, and
we have done that. And we've given you our recommendations on
this program, and our recommendation is you fund it with property
taxes. And I don't mean to sound like I'm distancing myself from
those recommendations 'cause we're in print on those, but it is clearly
the option of the commission if you choose to do so to separate those
two issues. They are linked, but they could be dealt with separately.
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September 6, 2001
You could say, "We like the program. We don't like the funding
mechanism," or vice versa. There may be other funding streams
available, but we believe it could be done and should be done through
property taxes, but you have the option to separate those two things.
There are a number of people in our community who feel there
should be a referendum on this issue, and clearly the board has that
prerogative. If you do that, I think it sets potentially for a
complicated precedent on an issue of this size, two or three million
dollar program. What will be the ground rules in the future for what
goes to referendum and what doesn't if this proposal does?
A number of writers to us individually and to you collectively
have said this program will expand, quote, "exponentially" and will
have, quote, "limitless bureaucracy." Clearly, there's voter anxiety,
maybe even distrust, concerning government programs, any
government program and any health care program. The proposal that
we've shared with you today calls for a specific set of benefits to be
phased in over a three-year period to 7,000 or 14,000 of eligible
adults, 19 to 64, who are working in Collier County.
We're not asking the county to cover everyone. We believe that,
in combination with other care providers, we can -- the collective
efforts will treat the vast majority of people who are eligible, maybe
not everyone, but it will be an enormous step forward if the county
were to do this portion of it. The people providing the medical care
on a day-to-day basis, we propose, would be employees of a
subcontractor, and the employees of the county exponential
bureaucracy associated with the county would be enrollment clerks
and a contract manager.
When and if there is a motion to -- on our recommendations, my
only suggestion to you is, you may want to consider including some
legally permissible language that clarifies what this board's intent is
with regard to the enrollment, with regard to the scope of benefits and
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September 6, 2001
so on, so that those who are concerned that the nose is under the
camels tent, it's primary health care today, but it's -- it's extraordinary
health care down the road can have those concerns assuaged.
There's a lot of confusion about what other counties in Florida are
doing. One letter writer recently said that adjoining counties, Dade
and Broward, had no health care program, and so everyone would be
drawn like a magnet to Collier County, and that's not quite true.
Dade and Broward, in fact, do have health care programs for the poor
in their communities; in addition, so does Palm Beach County,
Hillsborough County, Orange County, Marion County, and Leon
County.
Also, in Florida a number of health departments are continuing
to provide primary health care services, primarily in rural counties
through the health departments. We're not doing that in Collier
County. But in aggregate there are well more than 20 counties in the
State of Florida who are providing some benefits to folks and in the
categories we're talking about, and some of those benefits are
substantially greater than we're talking about here. The program in
Hillsborough and the program in Palm Beach are two are ten times
what we're recommending here. None of the programs are exactly
alike what we proposed to you. We believe this is an appropriate
solution to Collier County, and we don't believe it's appropriate and
necessary or desirable to have exactly the same kind of program that
they have in Palm Beach or in Hillsborough. But there are a number
of precedents with regard to other counties in Florida, and we can
learn from their experience. We are not on the bleeding edge here.
A number of people have said this will be like putting a giant
sign out and all the entrances to the county, "Bring all your poor here
for this health care program." The average benefits under this plan
will be $300 to an individual, $25 a month. To be eligible, you have
to be a productive member of society, you have to have a job here,
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September 6, 2001
and have to have a residence here. We've talked to -- We've taken
that concern seriously, and we've gone back to people who are
operating plans and have been operating plans for more than ten
years and have said, "Have you had any experience -- have you-- is
there evidence in your community or in your state that people have
moved there as a result of their health care plan?" And the answer to
that is no.
There are people who believe it's inappropriate to include funds
for school nurse program in our recommendation. We haven't spent a
lot of time on that, but we have -- both in our April recommendation
and today are recommending that if the monies aren't provided
through some other source, some other body, particularly the school
board, that the county should provide a couple of hundred thousand
dollars to preserve the school nurse program. We think it would be
more inappropriate for the school nurse program to be killed for lack
of funding and to strip out of our community that level of primary
health care and early detection that we have today. If the problem --
If the school board will step up to the plate and address that issue,
then, obviously, those funds aren't needed. But we think it is
definitely the lesser of two evils for some county money to go into
this on a partnership basis with the school board than to have the
program simply cut the nurses unemployed and put kids at risk.
There are some that say that Healthy Kids should stand on its
own or be funded by corporations. I'm not quite sure where that
letter came from -- but stand on its own. What the letter writers don't
necessarily understand, because it's a complicated issue, is that there
is an -- there's a window of opportunity in this Healthy Kids Program
to increase our enrollment in Collier County, but to do that, we need
to be proactive through Joan Colfer's department. And so there's
$50,000 recommended to enroll families in Medicaid and Healthy
Kids Programs because we believe that not a single dollar of county
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September 6, 2001
money should be spent until we've maximized the available dollars
from the state programs and federal programs. But to do that, you
have to reach out to people. You have to go to them with the
applications, sometimes with a translator, and walk them through the
process. We did that -- The committee did that through the help of
Steve Feign and Dr. Colfer's Health Department at an elementary
school in Immokalee, and the school board has expressed a
willingness to help us with that. So we have a means of doing the
outreach program and in this particular -- that particular school, 47
families were eligible, 14 or 17 were enrolled in Medicaid, and 4
were enrolled in Healthy Kids. So this kind of program can work,
but we have to be proactive to take advantage of it.
There's been criticism of the committee for lack of details or
confusion over the details, and we take responsibility for that. We
came to you in April with a contingent recommendation, and we did
that, frankly, because the alternative was a referendum a year from
November which would not have any impact as far as the county's
fiscal year until another year out. And our judgment was that the
problem is so severe and so acute in Collier County that we would
rather take our lumps coming to you with a partial recommendation
to be completed today than to do nothing and have to deal with a
more difficult problem down the road.
There is confusion about the numbers. The 30,000 number
which we've used includes children. Thirty thousand uninsured
people in Collier County includes children. There are 24,000 adults
as best estimate and 6,000 kids who are uninsured. Of the 24,000
adults, 14,000 would be eligible under this program. The original
proposal was for-- for the upcoming fiscal year, was for-- not for
$16 per 100,000 of valuation, but $16 for the average homeowner,
condo owner in Collier County. The current proposal is $5.70. The
question's been asked--
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September 6, 2001
COMMISSIONER FIALA: For 100,0007
MR. TINDALL: No. The average home in Collier County
according to Guy Carlton -- or condo is about $160,000 and so --
COMMISSIONER FIALA: $5.70 per $150,000 home value.
MR. TINDALL: Yeah, 160,000. Correct. Correct. Thank you.
A few writers have asked, if this plan reduces the load on hospital
emergency rooms, will the hospitals then reduce their rates. We can't
speak for the hospitals on that issue. They're going to have to speak
for themselves.
There have been many letters about self-reliance and self-
discipline and that health care is a matter of individual responsibility
in the community, and some have said that the primary health care is
affordable to those so-called indigent. Those of us on the committee
have had the opportunity to go to places like the Neighborhood
Health Clinic and see the patients being treated and talk to them and
hear a little about what goes on in their life on a day-to-day basis.
And I know, Commissioner Mac'Kie, you were there recently. And
we've had that opportunity and the committee -- and the community
at large has not. My wish would be that everyone who has a concern
about that could come to the Neighborhood Health Clinic or come to
Joan Colfer's Immunization Clinic and so on, and I think your heart
would be changed. I think you would come to a different conclusion
when you look people in the eye and saw what they were dealing
with on a day-to-day basis. It is not affordable for these individuals.
So we're here in closing because the -- our national system for
providing health care through employers has broken down here in
Collier County, and there are some Collier County specific reasons
for that. The nature of-- the number of small businesses, the
industries that are -- that populate our county -- in particular,
agricultural and construction -- are industries that on a national basis
have lower uninsured rates than other industries. But we have to deal
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September 6, 2001
with -- with our situation today, and the question before the board is,
what are we going to do about it? You've done something already in
bringing the issue to the public floor.
If nothing else happens, the community dialogue associated with
this has been healthy. It hasn't always been pleasant. Some of us
have gotten calls, as you probably have, late at night, and so on, with
people very concerned about this issue. But I think it's been a
constructive step forward. It put the issue right squarely on the table
and hear the views of various people and groups in the community
about what they think should be done about it.
One option having taken that step, though, is always to do
nothing, and predecessor boards have chosen to do that, and some
have even gone farther and gutted the health department budget and
taken out -- stripped out whatever primary care program it was
already providing.
There are lots of ways you can decide not to do nothing. You
can decide to do nothing because the use of property taxes is
inappropriate. I've given you an alternative there. You can decide
it's a very complex issue; we need to study it more. You could find a
flaw in the plan we've recommended and say, no, we will not go
ahead on this. It's such an important issue, we'll not go ahead with
this until we have a perfect plan, not a plan with a flaw. Someone
could propose a new alternative and put it on the table at the 1 lth
hour. You could decide this is an issue for the state, and we could
direct our legislative delegation to be very aggressive in Tallahassee
in solving this problem for all Floridians, or finally, you could say,
let's put it to the people, and let's have a referendum and live with the
precedence that results from that.
There is that old philosophy problem that you were asking in
grade school. If a tree falls in a deserted forest, does it still make a
sound? And the people who are disadvantaged by access to the
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September 6, 2001
primary -- to primary health care are a little like that situation. The
suffering and even the death that will result from not moving on this
proposal will occur. It just won't necessarily get to you or get to your
in-box in an e-mail. Our local newspaper will probably not run a
story that says inaction on primary health care causes death of mother
of four in East Naples, but you know, because you studied this issue,
that the suffering is there, that the suboptimization of an employee's
productivity, a student's productivity is there because they don't have
access to even the most rudimentary health care.
And so you have a real dilemma. Now you know too much.
You know what the reality is, and you face a difficult political choice.
We're with you in that -- in that, and we're confident that you will do
what is right or what is mostly right.
COMMISSIONER HENNING: Mr. Tindall, I need to
understand something. A statement you made that you identified the
30,000 need, 6,000 being children, 24,000 being adults, you're
looking to service 14,000, but in the four-year plan, I'm looking at
servicing 7,000.
MR. TINDALL: I said 14,000 are eligible. The program would
be capped at 7,000 to be served. In addition to the provider -- county
provider, you've got the Neighborhood Health Clinic, you've got the
Senior Friendship Center, and there will be a continuing involvement
of our hospital emergency rooms on this, but we're not proposing the
county cover 14,000. I'm glad you asked -- you clarified that.
COMMISSIONER MAC'KIE: And records from other
programs show that we can't expect to get 100 percent of the eligible
participants.
MR. TINDALL: There's a road-saving thing. People come to a
clinic like this because they're sick, and when they're well, they don't
present themselves again, which is too bad in a way because
education and preventative care would be very helpful in keeping
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September 6, 2001
them from coming back. But there is a cycling that goes through
where people are involved one year and not involved the next.
Our recommendation is the county only fund a portion of the
eligible adult residents and that we leave the health of kids to the
Healthy Kid Program and do our very best efforts to get all those
eligible kids enrolled in an insurance program where the family pays
$15 a month, and all doctors in Collier County will accept that
insurance coverage. And they can be treated where ifs most
convenient for them, and the parents have a responsibility in sharing
the cost of that program.
COMMISSIONER MAC'KIE: I want to say that you guys need
to know that your report has literally answered a prayer for me
because several years ago when we started down this road, the former
board looked me in the eye and said, "You're dreaming, Pam. There's
not a health care crisis in Collier County. We don't have unserved
people. We don't even have underserved people in Collier County."
And -- and I was able to convince them to at least let us form a
committee and see if that was true. And once that happened -- now
the prayer is that the lack of information being gone, they can't look
in the face of the truth and do nothing.
COMMISSIONER HENNING:
the hospital for care?
COMMISSIONER MAC'KIE:
You're saying they can't go to
I'm saying, when they go to the
hospital for care, they get the presenting illness treated, and they are
dismissed, and that is not health care.
COMMISSIONER HENNING: But it is health care.
COMMISSIONER MAC'KIE: No. It's treatment of the
presenting of the crisis.
CHAIRMAN CARTER: Commissioners--commissioners, we
have to go to public comment on this. And, Tom, I know you have a
couple things to say, but there's one other aspect of this, is that people
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September 6, 2001
who temporarily need this, their income levels increase, become
noneligible for the program. They evolve out of it. MR. TINDALL: That's correct.
CHAIRMAN CARTER: I don't know what the stats are on that.
I suspect there are some. We may be getting those accumulated over
time, but I think that's an element that we never want to lose sight of.
People are not always underemployed and do have a chance to -- to
improve their life status.
MR. TINDALL: Absolutely. And I would tell you that the
families who would be eligible for this program would like nothing
more than to be uneligible for the program because they are over the
income level. That's what they're striving for and working two jobs
for and so on.
CHAIRMAN CARTER: One other thing that I will note -- and I
got it from this, and I have to say it is that from a business
perspective, productivity is key in any business. Unhealthy people
don't come to work. They're absent more. They cost you more.
When they're healthy, they're there and they do their job. So there is
a productivity factor in here, that I believe statewide they're
beginning to try to build the stats in a model that demonstrates that.
So that's other information that none of us can ignore, is that healthy
people work; unhealthy people don't.
MR. TINDALL: In the -- in the wage group that we're talking
about, if these folks don't work, they don't get paid, and that only
compounds the problems of meeting the necessities of life.
CHAIRMAN CARTER: Mr. Schneider, do you have a couple
of--
me?
MR. SCHNEIDER: Yeah. I just want to wrap up. Can you hear
Is this mike working?
COMMISSIONER MAC'KIE: Yup.
MR. SCHNEIDER: Our recommendation is that you fund this
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September 6, 2001
program as budgeted in the budget that we showed you and also to
recognize, though, that because the first year is only for a six-month
period, from April to September, you'll be into your next budget
cycle before we start spending any appreciable money and seeing the
first patient; and, therefore, there won't be, you know, actual statistics
and everything. So I think realistically you have to be looking at
commitment of at least 18 months, in your own minds anyway, to
meet the needs of whatever organization who wants to apply for this
and -- and also for yourselves in terms of-- because you're not going
to have a whole lot of additional information.
And, again, the program has to start someplace. We're starting it
small. It's very conservative, and it's going to take until you get up to
the five, 7,000 level of people in order to get the benefits of the
volume and to reduce to the average cost per patient.
The -- once the funding is approved, I just would summarize
what I think the next steps are, is that the county needs to select a
primary care provider and through a process of-- a bidding process
and through subsequent negotiations and contracting and actual
implementation.
We also have to have the We Care system implemented, which
will be a significant task, which will involve Wendy Wilderman and
people probably from Joan Colfer's department and others and the
Medical Society to recruit physicians and other providers and then to
put into place all the processes and mechanisms for making those
referrals so everybody feels like they're being treated fairly and
adequately.
We also need to put the pharmacy plan into place, and we would
need to appoint the board of advisors that we recommend and then
put into place a mechanism to administer the program, including
contracting with TPA.
So there's a lot that has to be done before. That's why we
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September 6, 2001
identified April 1 st.
I guess my closing comments, very briefly, bottom line is,
access is a huge problem here in Collier County, and I think most
everybody agrees with that now. The board certainly did when it
appointed a second committee and asked it to find a solution. And
our committee did make this conceptual provisional recommendation
to you last April, and you accepted that, and you accepted our request
to put in on a provisional basis the funding for the budget based on
the levels that we had set.
We identified for you the primary care was a critical part of the
health care delivery system, and I can't emphasize that enough. I
mean, the emphasis is on primary care because that's where the best
bang is for the buck, and that's where the cheapest part of it is as well.
There is a shortage of primary care providers in this community,
particularly in season, and that is why we are recommending that
physicians be attracted here and a clinic be opened and compensation
be involved because, otherwise, we didn't think it would work at all.
The low-income people here do not have ready access to
primary care providers, and our solution was to create this public-
private partnership to deliver primary care to the target population.
At that point in April, we had estimated $2 1/2 million roughly to
provide services for 7,000 people, including administration, and you
agreed and voted to include that in the budget, contingent on
completion of the details. This morning we did share with you those
details, the details such as services to be covered, who would be
eligible, how the care would be provided, how the program would be
governed and administered.
We also give you a detailed budget for four fiscal years which is
a -- I believe, a very conservative business approach. That we're
starting slowly. We're only covering primary care and why -- we
talked about why we need to ramp up more slowly and begin later.
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September 6, 2001
And I think all of this -- all of us here must realize that the
problem has only been getting worse and cannot be solved without
the county's financial support, and we believe our recommendations
are sound and that they represent a great value to the community. Not
only do we think it's the right thing to do and smart thing to do, but
it's time to join the growing list of communities that are creating win-
win situations. We look forward to your questions in gaining
approval of our recommendations. Let's now begin to solve the
problem. Thank you.
CHAIRMAN CARTER: Okay. Mr. Schneider, I thank you and
your committee for an outstanding job of doing what we asked you to
do. It does not mean that everybody agrees with what they bring to
the table, but they have done what they were asked to do and done a
very thorough job in presenting the information to us.
One comment I'll make because I hear it sometimes, "I never
accept any government assistance." How many people are on Social
Security? How many people get Medicare? Those checks that you
get are funded by everyone that works in this country and today, if
you're on those programs, God love you, but you will take more out
of them than you ever put into them. And everyone that works, the
lowest income producer contributes to those programs. And I'm
willing to say and bet that few or very few will ever be there to
receive much of the reward from contributing to it. So the guy that's
cutting your grass and the person washing the lettuce, they are
contributing to those programs.
So we never can divorce ourselves, in my judgment, and say I'm
not a part of it. Does that mean you shouldn't accept it once you have
qualified to do it? Absolutely not. You should accept it. It's there.
That's what it was provided for. So we all participate. We all
benefit. So we need to address these issues.
I do not know what the decision will be of this board. All I
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know is, we've been given a tremendous amount of information, and
we'll look for any other comments or ideas as we deal with this.
So according to the schedule, Mr. Olliff, you want to go to
public comment, and I know we have a number of people who want
to speak, and then the commission needs to deliberate.
MR. OLLIFF: Mr. Chairman, you've got 18 registered speakers,
and it is after 11:30. So I'm going to ask the speakers if they would --
We've cleared a seat here at the table for you. And if I call your
name, if you would just come up to the table and go ahead and -- and
you go ahead and speak there at the microphone.
And I'm also going to call the next speaker. If the next speaker
would, if they could just come and be ready and sit in the front row
and be prepared to jump up to the microphone when the speaker in
front of you has concluded, that would help us.
First speaker is Elaine Wade. Ms. Wade will be followed by
Scott Bonham.
MS. WADE: I am Elaine Wade. I'm director of the NCH
School Nursing Program. And I'm glad to have this opportunity to
speak to the commissioners and to the board and to the committee.
I would just like to just sort of echo what Jim mentioned, that
you need to spend a day in one of the schools to see the care that is
given, to see the people, families, children without care. I can speak
for-- We have nine nurses at NCH. They're out in the schools. They
see 40 to 50 students a day in the health room. A very large
percentage of these students you might see a symptom, call a parent,
a parent that can't leave a job. A parent if they leave a job for another
hour might lose this job. We also see these families that if we say,
"Can you take your student or your child to the physician," they don't
have a physician to take them to. They perhaps don't even have
transportation.
We see this day after day, and I'm just encouraging you, when
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you look at indigent care, to take the opportunity to look at school
nursing as the link to the community. We're the port of entry. We
oftentimes are the only health care provider that many of these
families see.
Monday mornings principals want nurses. Why? Because all
the issues that occur occur over the weekend. We've had child abuse
that has occurred. The student has been abused all weekend waits till
Monday morning to come into the health room to tell the nurse.
We see students that have been injured over the weekend,
fractured arms, fractured ankles, that come in because they don't have
any other place to go. We've actually had students that needed 911
calls. Families do not want them transported because they don't
know how they'll really pay for this. We see this every day, and I
don't think there is a day that goes by that our nurses are dealing in
the schools with families that really can say, "I really have it all."
Every day at the end of the day, we would -- I oftentimes think
we can't -- we're only a tip of what really needs to be done. We are
care coordinators out there. We are working and linking to the
community, to the physicians that are out there. Oftentimes, yes,
they might go to the emergency room because they're wheezing.
They're given inhaler. Can they get the prescription filled? Perhaps
not. Do they know how to use an inhaler? Probably not. Do they
have a health care provider that can follow and really diagnose that
this is a condition of asthma? No.
In the last year, our nurses at NCH saw about 50,000 students.
We had about 15,000 referrals. That means referrals, not easily
referred to their own provider, but oftentimes making lots of calls,
making application to Healthy Kids, helping families fill out
applications on the spot, doing home visits. We oftentimes get
medications in school that are not appropriate for students. Extra
Strength Tylenol is not appropriate for a little four- and five-year-old,
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September 6, 2001
but it's the only medication that some of these families have in there.
So I'm just asking you to really consider the school nurses as an
integral part of the health care in Collier County. I think we're very
fortunate to be on the agenda. I have been in school nursing and
school health for 24 years. Times have changed. We used to do
hearing, vision. We still do. But now we're care coordinators, case
managers. We're constantly trying to work with families in seeking
care.
or --
So I'll take any questions you might have about school nursing
COMMISSIONER HENNING: Maybe a comment and a
question. You know, your program is very worthwhile and one I
commend you and your colleagues for being there. My question is,
do you just see the kids with the family as less fortunate and not
being able to provide health care?
MS. WADE: No. I mean, our nurses see any student that comes
through the health room, and any of the schools deal with across-the-
spectrum students. The students that stand out are the ones that don't
have easy access for caring for a symptom or getting a medication.
COMMISSIONER HENNING: Do you feel that the student can
-- is able to learn better when they are healthy? I think that's a no-
brainer. And that's why my point is -- and I think this is the school
board's position to step up and fund this program totally. It's not the
county commission that is (applause) -- that should be mettling in
school board issues.
COMMISSIONER FIALA: How can we force them to do that?
Oh, I'm sorry.
COMMISSIONER HENNING: We can't. The public needs to
do that.
COMMISSIONER MAC'KIE: Mr. Chairman, are we going to
debate each issue from each speaker, or are going to wait until the
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end?
CHAIRMAN CARTER: I think it would be most appropriate to
hold that. I understand Commissioner Henning's point, but I think
with 17 more speakers to go, we need to hear from everybody, and
then we can have our deliberation.
MS. WADE: Thank you for this opportunity.
CHAIRMAN CARTER: Thank you.
MR. OLLIFF: The next speaker is Scott Bonham. Scott will be
followed by Dennis Vasey.
MR. BONHAM: Thank you very much for this opportunity to
speak with you. I heard about this. I read an article in Naples Daily
News on the 22nd of July. I believe it was written by Jeff Lytel.
First I heard of this proposition at all in Collier County. One of the
first things I did, seeing the word "indigent," was to go to Webster's
Dictionary and found that it literally means, according to Webster (as
read): "Destitute of property or means of sustenance." And the
definition of "sustenance" is, "That which sustains life." I also
looked up in the dictionary the word "government," "govern" which
is extended to say "government." The definition is, "To direct, to
guide, to control."
This proposition to me sounds like socialized medicine which
does not work in many nations, Canada, England, France, Germany,
et cetera. We had a proposition for Hillary Care in Washington.
Thank God that was denied. What are we going to call it in Naples?
Collier Care?
By the way, I believe that the sign, when it's erected in front of
the public, will draw people to Naples because there's no place in
Florida as nice as Naples to live.
Government does not implement programs well. The private
sector does. There is already Medicare for those who need it. Some
people do not value insurance; therefore, they don't buy it. It's a
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September 6, 2001
choice for each one of us as citizens in this country. Before HMOs
and health insurance, medical costs were paid by the recipient. I was
reared with that ethic and lived the early years as an adult therein.
To me, there are important points to an individual. One is
individual responsibility. We find more and more in this country that
that is being set aside because it's always someone else's fault,
someone else's responsibility. Financial priorities, if you can't pay
for it, don't buy it. Know that unexpected expenses will come and
you must plan ahead. I'm sure that everyone at this table is aware of
all these and, to some degree, conducts their life under these
guidelines.
I believe that personal integrity and sense of accomplishment are
very necessary to every individual. This would take some of that
away from the individual. All of us will receive a gift, some
gratefully, some with a feeling of entitlement. This is not a gift
without cost to the recipient. When there is true need, our public
sector meets the need. There is quicksand in front of us. Please don't
take the first step. There is a better way. Is anyone in our county
refused medical care now? I would suggest to -- help people to help
themselves.
Sitting here this morning -- As I said, I was just exposed to it
recently. Sitting here this morning I had some thoughts. A possible
solution: A private volunteer organization to educate and direct, to
service -- that is one word hyphenated-- needy people. Yeah. Do
not state and federal governments recognize private-sector activities
as demonstrated financial commitment? Must we have larger
government?
I was happy to hear about the Neighborhood Health Clinic. I
wasn't aware of that. I'm glad that we have that. And some people
bring assets to Collier County; some people take assets from Collier
County.
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September 6, 2001
I have been in the category early in my adult life where the
nomenclature that you have proposed would fit me to this program.
And it's not a good place to be, but being there with some people
gives them ambition to get out of it, to move beyond it, to be able to
provide for themselves and their loved ones.
I recognize that five-minute beep. Thank you again for your
allowing me to speak on this. I feel very strongly. I too am a
registered Republican. It's obvious, I guess, that -- I guess that I'm a
conservative registered Republican. To my mind, anyone on the
other side -- that is, the Liberal side, shouldn't call themselves a
Republican because in the Federal Government for sure (applause) -- CHAIRMAN CARTER: Sir, I'll have to ask you to wrap up.
I've got 16 more people.
MR. BONHAM: I want to wrap it up. For sure there is a
delineation between the parties on the federal scene. We all see that
on our boob tube every day. I wish that delineation applied in this
county. Thank you, again, very much.
CHAIRMAN CARTER: Thank you, sir. And next speaker,
please.
MR. OLLIFF: Next speaker is Dennie Vasey followed by Erika
Cook.
COMMISSIONER MAC'KIE: At the end of the public
comments, I'm going to be reading an excerpt from our President's
proposal on working poor health care and how it involves local
governments. So you might stay tuned to who good Republicans are
or if you think the President is one.
MR. VASEY: Thank you very much. Mr. Chairman,
Commissioners, and members of the indigent health care finance and
planning committee, I can't tell you how much I appreciate the
dialogue. It has been instructive, and I have only one thing to say to
all of us: Bravo for doing this.
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What we don't have in Collier County, a medical infrastructure
to support the masses of people that come here. We make it on the
normal residents, but when we start to load up with guests, there is a
problem. County commissioners past and present to some extent, not
a condemnation or an admonishment, have made this happen. But
we've also seen this year where our water system has failed; we've
seen where our road system has failed; and now we're seeing our
medical system break. And look at what happens when it's
overwhelmed.
What Commissioner Carter stated in his opening remarks about
America's challenge is also true in Collier County, and that is that we
have a broken health care delivery system that is different from
indigent or working-class health and primary health care.
How many people really will access this program? Last June we
were told that a two-year study found that -- 30,000 adults in Collier
County between 19 and 64 with no health insurance. This figure
seemed consistent with Chairman Schneider's statistic that 39,000
working poor had streamed through the emergency room last year.
Now, three months later the indigent health care committee tells us
that only 14,000 need assistance and only 7,000 will enroll. How
does this track with the 39,000 who needed care last year, and the
two-year study projection of 30,000? Such a large change shakes my
confidence in the committee's current 7,000 figure.
The program opens the door also to litigation. What happens
when we allocate enough money for 7,000 people and 14,000 or
21,000 or 28,000 or 39,000 show up for care? Who will you take
care of, and who will be rejected by our enrollment clerks? There
have been situations where indigents have sued to get their
entitlements.
Mitigation to Collier County -- Migration to Collier County to
get benefits. The health care committee maintains that people will
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September 6, 2001
not move to Collier County to get free health care. This is totally
realistic -- unrealistic. I'm from Wisconsin, a state that provides very
generous social payments. Many people who lived and worked in and
around Chicago moved across the border to Wisconsin to take
advantage of those benefits.
Spiraling costs. This program has incredible potential for
skyrocketing costs. I don't for one minute believe that in four years
there would only be 7,000 people in the program and it would only
cost around 3 million. This sounds like the old low-bid contracting
philosophy; bid low, get the contract, raise the cost once you have the
job or, in this case, the social program. Health care costs and
prescription costs have increased dramatically in recent years.
What would make this situation change?
Community support. The Collier County Republican
Executive Committee voted an overwhelming 91 percent to put this
question on the ballot. They wanted to know a lot more about the
issue, and then they wanted to vote on it, recognizing the implications
of this major new social welfare program. Medical funding should
not be in addition to everything else, and it should be funded without
additional taxes.
A look at the increase on the notice of proposed taxes, a $50
property tax last year with insurance grows to $84. That's a 68
percent increase. Sixty-six dollars without, that's a 31 percent
increase. That's what's on the current issue.
Across the nation people who go to the hospital emergency
department seeking treatment for sprains, chest pains, or a child's
spiking fever are not met with a speedy service they expect but,
rather, with delay and frustration. It used to be that ERs got
swamped just doing winter flu outbreaks or just inner-city
neighborhoods on Saturday nights. Now emergency departments are
overwhelmed year-round. They are maxed out, as Dr. Lascheid
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stated in his remarks. And world-class institutions like Johns Hopkins
Hospital, the University of California, San Francisco Medical Center
and others are turning away patients because they don't have the
capacity to deal with them.
A remarkable number of people in America end up in the
emergency departments each year, and that number's rising fast.
From '92 to '99 emergency visits rose 14 percent, according to the
Center for Disease and Prevention, to 103 million a year. People
show up at emergency departments with a dizzying array of
complaints. And thank you very much, ladies and gentlemen, for this
opportunity. 1
CHAIRMAN CARTER: Thank you, sir. Next speaker, please.
MR. OLLIFF: Next speaker is Erika Cook followed by
Humbert Gressani.
MS. COOK: Good morning. I welcome the opportunity to
address you today about this very important subject. As citizens of a
democratic republic, we have chosen to elect our officials to
represent us and our point of view. When these very sentiments were
conveyed to one of the current commissioners by someone else in
this room, not myself, the reply was that the commissioners would
decide for us what was best for us. That is 100 percent wrong. You
are here because we put you here. Your responsibility is to reflect
our point of view, the majority's point of view, and if you're not sure
of the majority's sentiments, then put it to a referendum. Of course, if
you choose to disregard your responsibilities to your electorate, you
will have to answer for that on election day.
As we -- We have here a situation where you are attempting to
force upon the voters a matter that needs to be brought to a vote, not
arbitrarily dictated, especially such a volatile and controversial issue.
Dr. Carter so eloquently expressed his concern about the indigent
health care program when he said he had concerns about fraud, abuse
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in the system, cost estimates, and the fact that the proposal lacked
specifics. How perfectly said. Here we have a proposal that lacks
specifics. Well, today we got some specifics, but I question quite a
few of those specifics, a program that would be expensive no matter
how you attempt to soften the impact, a proposal that is ripe for abuse
from both the bureaucratic side and recipient side. This cries out for
a vote from the people who are being asked to subsidize the
socialistic nightmare.
The people that would directly benefit from the shifting of any
health care responsibility from themselves to the taxpayers are the
agricultural, construction, and small business groups. I suggest you
take this issue up with them.
With an indigent health care program, Collier County would
become a welfare magnet. All our county services, our roads, our
law enforcement would be overwhelmed. And to think that
something of this magnitude is being reviewed when most of the
taxpayers are not here is ludicrous.
Just to refresh your memory, Collier's taxes average $1,538 per
person, the third highest in the state. And if Collier County is
compared to three other counties of approximately the same size
population -- namely, Marion, Leon and Manatee -- their taxes per
person are $584, $717, $909, respectively, versus Collier's $1,538 per
person. So the argument that we have the lowest tax rate in all of the
67 Florida counties is specious. We have the third highest assessed
value. And since all those counties provide the same services to their
people, I would like to know how the counties can provide the same
services for $629 to $954 less per person than Collier.
And what do most taxpayers get for their outrageously high
taxes? No roads, inadequate sewers, water restrictions, and runaway
growth. These are sentiments that have been conveyed to me, and
now these very abused taxpayers are expected to pay for every
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indigent's health care that comes to Collier County. This is not fair.
This is not democratic. This is pure socialism. If there were ever an
issue that required a referendum, this is it.
And one last question regarding taxes: How do you explain that
-- even though property values have risen dramatically in Collier
County and the taxpayer and the tax base has increased considerably
because of the tremendous growth that has occurred, how is it that
property taxes for residents keep rising? This is, in essence, a welfare
program fraught with a tax that is not fair, age discriminatory. It's
basically forced charity and a charity that's being dictated by the
county government. Charity is fine when voluntary but not when
dictated and especially when it would benefit the select group at the
expense of others.
Personal health care and expenses involved are individual
responsibilities. It is very apparent that this program does not belong
under the Collier County government umbrella.
And, in conclusion, I would like to quote the Naples Daily News
editorial of August 31st. Quote, Any rush, big or small, to the public
trough because insurance is too costly for private employers is upside
down from the start, unquote. Thank you.
CHAIRMAN CARTER: Thank you. And the next speaker,
please.
MR. OLLIFF: The next speaker is Mr. Gressani followed by
Jane Varner.
MS. FREELAND: I have to go to work.
CHAIRMAN CARTER: Ma'am, I'm sorry. You'll have to
come to the microphone.
MS. FREELAND: I have to go -- only because I had health care
insurance at one time and, unlike most of you, I work one, two, three
jobs. I work 80 to 120 hours a week. I now don't have health care
insurance. When I needed necessary surgery, unfortunately, the
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September 6, 2001
insurance company wouldn't pay for it. So I went to a state agency,
vocational rehab, that went ahead and said, "Yes, we'll pay for it."
Unlike the surgeon, the only surgeon in the State of Florida that
would touch me with the chronic infection I carry will not take the
amount of money you've got from people out there that are sick.
Like me, I started when I had insurance. Now, I don't. I am on
$25,000 worth of medication for every single month at Naples
Community Hospital, and I can't afford to do it anymore. I have an
infected pore. Unlike most of you, I can't go and have it removed and
replaced. And if it doesn't go into effect, you're all fools, because
you're going to run into a lot more messes than just me. Thank you.
CHAIRMAN CARTER: Could I have your name for the public
record, please.
MS. FREELAND: Brenda Freeland.
CHAIRMAN CARTER: Thank you.
For the public record, if that was captured by the recording
secretary, was Ms. Brenda Freeland. Thank you. Go ahead, sir.
MR. GRESSANI: Workshop members and commissioners,
thank you for allowing me to speak at this workshop.
CHAIRMAN CARTER: What is your name, please?
MR. GRESSANI: Pardon me?
CHAIRMAN CARTER: Name?
MR. GRESSANI: My name is Humbert Gressani.
CHAIRMAN CARTER: Thank you.
MR. GRESSANI: Thank you. I am a resident of Collier County
and have been paying taxes on properties that I have owned here for
over 15 years. In my family I was the first-bom American. My
father, mother, brother, and sister were all bom in Italy. They came
to their adopted country, learned the language, worked hard making
something of themselves. I was taught values and not to go looking
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September 6, 2001
for handouts, but to work for what you wanted. It was not always
easy.
I moved to Naples full time 13 years ago. During that time,
other than working, I have volunteered my time to several causes,
such as the Civil Air Patrol. As a member of Naples Senior Squadron,
I became their squadron commander. I also sat in Mr. --
Commissioner Coletta's chair for six years as a member of the Collier
County Contractor's Licensing Board.
My comments are more directed to the county commissioners
than the other participants of this workshop. During the past 13
years, I have followed the Collier County commissioners' action, or
lack thereof, on many issues that -- many issues that the taxpayers --
from the taxpayers' point of view. What a waste of time. It has
seemed to me that the commissioners had already decided what stand
they would take. When are you going to listen to the general public
and not political interests that will feather your own bed?
Primary care is another new program that will multiply and
grow and will add a larger burden each year to the taxpayers of
Collier County. The start of primary care is like the tip of an iceberg,
the mass of which is hidden under water.
Yes, our population will continue to grow with people looking
for more free handouts instead of honest to goodness work. We the
taxpayers of Collier County should have the right to vote on this
important matter. I would suggest as a commission, work harder on
the more important issues that confront us, like roads, sewers, and
waste disposal. Thank you very much for allowing me to present my
point of views.
CHAIRMAN CARTER: Thank you, sir. Can we have the next
speaker, please.
MR. OLLIFF: The next speaker is Jane Varner followed by Ty
Agoston.
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September 6, 2001
MS. VARNER: I'm Jane Vamer, and I'm not sure if the woman
who just spoke back there -- an unfortunate situation -- I'm not sure if
this would apply to her at all. I don't know. I don't think that her
case would be addressed by this. We have conveyed our opposition
to this health care plan and given you our reasons.
COMMISSIONER MAC'KIE: Who is "we"?
MS. VARNER: Taxpayer Action Group.
COMMISSIONER MAC'KIE: Thank you, ma'am.
MS. VARNER: And-- and we've given you our reasons. I'll try
to briefly summarize them.
First, the school nurse program belongs in the school budget.
It's their responsibility, and we've given them more than enough
money to pay for it. Second, Healthy Kids is a program in itself. It
should stand alone on its own merit.
As for the main program itself of indigent care, the county, state,
and federal governments already subsidize low-income workers in
the form of many programs, such as food stamps, housing assistance,
Medicaid, aid to hospitals, call disproportionate chair, free school
lunches for children, innoculations, Planned Parenthood and many
more we're not even aware of.
Also we have innumerable volunteer charitable organizations
that offer a lot of help, earned income tax credits or outright checks
given to working people from the federal government. That's we, the
taxpayers, and can be over $3,000 annually for some families. Day
care assistance is provided. And, we, in the community pay higher
medical fees because of the hospital stays and medical procedures
that low-income people receive but do not pay for.
We, the taxpayers, have given a great deal, and it seems that it is
now incumbent upon you not to ask us for more but to ask the
recipients of those benefits to bear some responsibilities for their
needs. They are being subsidized in ways that people in the past,
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September 6, 2001
who are much poorer than they, were never subsidized. It is not wise
to expect to -- so little from the recipients as individuals and so much
from those who always pay the bills.
We do know, once a program such as this begins, we don't know
where it ends. And the committee report -- First their beginning
report recommended 100 percent access to county's health care,
stating every resident has an equal right to access our full health care
system regardless of how the provider is ultimately compensated.
Under future activities for the fund, the committee says, and I
quote, For Collier County to fund fully a comprehensive health care
program, the expenditure would exceed 30 million annually.
Then over time, they say, as the county funding increases,
subsidy of additional specialty and referral health care services
should be added. These costs do not seem to encompass future
growth of the county or the medical inflation rate that they say has
increased 10 to 15 percent per year over the past two years.
What figure above the 30 million annually can we expect to see?
I must say the report is overtly honest about its goals. It has an
idealistic vision of what the committee would like to see enacted. So
we must be wary, because even though the committee has reduced its
monetary request to make it more palatable, their goals for the future
are unchanged and remain as a reminder of what we eventually may
be pressured or forced to pay.
Also we have to consider, when an entitlement is enacted, what
legal liabilities do we face to fully fund the expectations of everyone
deemed eligible.
Now, since you, the commission, are very aware that the people
of Collier County do not want this welfare program and tax enacted
and you were elected to represent the people, not your own interests
and ideas, are you going to either vote no on this proposal right now,
or are you going to at least do the democratic thing and put forth a
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referendum that is specific and limited so we can decide what we
want to pay for? We do not like dictatorships, but if you purposely
refuse to acknowledge our majority, well, then we and you must
admit this is looking a lot like a dictatorship, and we don't deserve
that. Thank you very much. (Applause.)
CHAIRMAN CARTER: Thank you for your comments. And
next speaker, please.
MR. OLLIFF: The next speaker is Ty Agoston followed by
Nancy Lascheid. Mr. Chairman, between speakers she needs about
two minutes to make a call to her office.
MR. AGOSTON: Good afternoon, ladies and gentlemen. My
name is Ty Agoston. I am a voter and a resident of that endangered
and disadvantaged Golden Gate Estates. And I also am co-president
of the Taxpayers Action Group of Collier County, and I'm speaking
for them.
There was a headline in the Naples Daily News today that
Republicans are proposing a tax decrease. Let me underline
"decrease." And I am, by the way, speaking to the commissioners
primarily because I have no real influence, whether I have any way or
not is another story. But the committee was appointed, and as such,
they represent their own interest, but the commissioners, hopefully,
listen to their constituents. That doesn't appear to but let me just give
you a little background.
I came from Hungary. It's a communist country. You guys
don't know what poor is until you go and visit one of those countries.
So when someone here, the greatest country on earth, with the
opportunities boundless, cry poverty, I have a very, very difficult
time with that because I came to this country with this much money
(indicating). I raise five children, sent them to colleges, advanced
degrees and what have you. So it's -- If I can do it -- and I'm not all
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that smart -- most people can.
Now, there's an additional thing you might consider, that we
have a third-world country on a southern border. If you are looking
for poor, let me assure you that they could replace the poor as you are
raising the current residence living standard -- replacing it every year,
every year, every month. They can come in, unless we learn how to
control that border. They'll be here forever.
If you want to listen Mr. Fox, the president of Mexico, he is
recommending that we grant amnesty to our current illegal aliens. I
wonder what that does to the committees' projections if that comes to
pass? Because we have more than our fair share of illegal aliens.
You mention, sir, that this issue was not sufficiently expensive
enough to bring it to the voters in the form of referendum. Well,
there are a couple counterarguments to that right from the get go.
First, I believe that all your projections are way low. I'm from New
York. You know, everybody hustles there. I mean, you know, it's
just the nature of the animal. You guys sound like New Yorkers. I
almost got homesick here listening to you.
CHAIRMAN CARTER: We're just trying to make you feel
comfortable.
MR. AGOSTON: That's the whole idea here. You know, you
talking about the switch-and-bait issue. You know, you coming in
low and then you even lowered that, and do you really expect-- I
mean, the people in this county are relatively intelligent. At least
they speak the language, so they should be able to understand just
where you're going. I have always had a problem with Collier
County advisory committees that essentially establish an agenda-
driven advocacy group rather than an advisory committee with --
which is balanced -- which represents the county and can make a
judgment based on the county's population as opposed to just -- I --
The areas that I was going to mention about school nursing and
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what have you is really immaterial. Some other people have already
mentioned it.
CHAIRMAN CARTER: I have to ask you to wrap it up.
MR. AGOSTON: Okay. I own, as I have mentioned a number
of times, a lot for every one of my members of my family. I got a
notice that one of the 2 1/2-acre lots I have for my children you
propose a 51 percent increase. Doesn't your conscious bother you?
You know, you don't seem to want to listen to anyone.
Maybe the idea is to start a recall election. Thank you very much.
CHAIRMAN CARTER: Okay. Thank you. And the next
speaker, please. Please keep in mind it's the county appraiser's office
under Mr. Skinner that appraises your properties, not the Board of
County Commissioners. Thank you.
MR. OLLIFF: Nancy Lascheid is your next speaker, and then
we'll need to take about a one-minute break to allow her to call.
CHAIRMAN CARTER: Is this a better point?
MS. LASCHEID: Would you like me to wait?
CHAIRMAN CARTER: Why don't we do that. I'm sorry. I
forgot. Taking only five minutes, folks. (Short break taken.)
CHAIRMAN CARTER: Ladies and gentlemen, we need to take
our seats. We need to continue with public comment. Again, I will
ask each speaker that you have five minutes to present your ideas. If
you are able to do that in a shorter period, it is appreciated. We have
ten more speakers. Thank you. And, again, anybody that just
arrived, please make sure that you have your cell phone off. Thank
you.
MS. LASCHEID: Nancy Lascheid, L-a-s-c-h-e-i-d.
MR. OLLIFF: Following Ms. Lascheid will be Paul Van Stone.
MS. LASCHEID: I'll be brief. First of all, I'd like to thank the
commissioners for permitting that young lady to make a very
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passionate appeal on her concern. I will tell you that we did seek her
out, and I have invited her to call, and we'll try to do something to be
of help to her.
I'm asking to speak to you because we've walked the walk. I'm
asking to speak to you because we are 100 percent in favor of the
proposed plan. We have reviewed it, we have been counseled on it,
we have advised on it, we have scrutinized it at our kitchen table, and
we feel that it is a very viable and workable program.
I believe that when you talk about the emergency room and kind
of diagnoses that are made there, it would be helpful for you to know
that in the Neighborhood Health Clinic we have recognized over 800
different diagnoses. So we're not just talking about respiratory
infections or urinary tract infections.
Our biggest budget item is medication. So I would like to
charge the commissioners to please give serious consideration--
when you review this package, that you take a look at the medication
costs. Once the program is in effect, as ours is, we can use case
management pursuit and obtain some compassionate medication
programs. It's very time consuming, but it is cost-effective.
Regarding the school nurses and Healthy Kids issue, I think that
you need to know that our average patient is in their mid-30s and is a
white male who lives within a five-mile radius of Naples Community
Hospital. We are dealing with the parents of these young children. It
is a family issue.
Quality of life is definitely something that we need to talk about.
And, Commissioner Carter, you are absolutely right. We do have
people graduate from the Neighborhood Health Clinic. We reassess
them every four months as far as their earning capacity is concerned,
and we do pass them on to the next level and back into the private
sector.
In addition to that, I think that you need to give some serious
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September 6, 2001
consideration to the types ofjobs that these individuals are doing in
serving you. They are your food handlers. They are in your home.
They are taking care of your children. They are taking care of your
elderly parent. So keep in mind that their health has a trickle-down
effect into that -- your life in other ways.
The last thing I would like to do is talk about the future on this
project. We frequently are questioned as to how we in the
Neighborhood Health Clinic see this fitting into the scheme of things.
We would welcome them to the table of helping us find solutions for
all of these people. It's important that we sit down together, we
discuss the problems. We have the most recent experience, as I said,
with 800 diagnoses. We can discuss it, and we can come up with a
viable option to take care of the less fortunate in our community.
In closing, I would like to reiterate Mr. Tindall's invitation to
you. I know that you have been there, Commissioner Mac'Kie. I
would also like to extend this invitation to everyone in this room or
any other interested party in Collier County. I'd like you to come and
put a face on the issue. Thank you for your time.
CHAIRMAN CARTER: Thank you.
(Applause.)
MR. OLLIFF: Mr. Van Stone will be followed by Peter
Gerbosi.
MR. VAN STONE: My name is Paul Van Stone. I'm a co-
president of the Taxpayers Action Group. I'm also in charge of the
membership committee, and I'm happy to tell you, our membership
has virtually tripled in the past year, to give you an idea of how
important we take some of these issues. We're getting people that are
contacting us trying to find out how they can join us because they are
very insensed about all the different taxation problems they have
encountered.
I'd like to make a couple of comments on the woman who gave
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the first talk this morning. I didn't get her name, but she quoted Peter
Drucker twice. I'm a -- a retired business executive. I've met him on
two occasions. I sat across from him at lunch. Mr. Drucker has
written several books -- I've read three of them -- having to do with
management and marketing, and he is a refugee from Europe, and he
is as far as -- farthest thing from being a Socialist that you can
imagine. One of his books is called "Entrepreneurship" and, yet, he
was quoted twice on this Socialist program. I don't understand that.
She also referred to this as a conservative program. As a
Conservative, I'm insensed by that. I think that's a wrong term
because it's a socialist program and has nothing to do with
conservatism.
The last speaker talked about visiting some of these places. I
would like to ask the board to meet with a couple bank tellers and
talk to them on what happens Friday noon when all of these indigent
people come with -- in with paychecks and write out money orders to
send down to Mexico. I've had friends have to wait in line with
maybe 20 or 25 people ahead of them all writing up money orders.
So a lot of that money is leaving the area. Some of these people
could pay a lot more if they didn't have to take care of another family
in Mexico.
The school nurse program has already been talked about. I think
it's a political ploy to try to add it to this program. It's like the old
democratic approach of Clinton's: This is for the children. They
wanted to get something like that into this program in case it came to
a referendum so that we would be sure and vote for something that's
for the children.
I look at the five-cent-a-gallon gas tax that we were told about
five years ago. It would only be in effect for five years, and then it
would sunset last June 30th. Without any knowledge, that was put
through for an additional 20 years without any input from anyone.
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There's a 1/2 percent sales tax been talked about. There's this Hillary
Care Program. These are all democratic-type programs. I'd have to
say it reminds me of a bunch of rhinos. Republicans in name only is
what I'm hearing.
You talked about $750 maximum on pharmaceuticals, not times
the 30,000 people that you think would be included in this program
but perhaps 7,000 by the fourth year. As a businessman I always had
to look at those numbers as saying, "Well, the maximum 750 times
7,000 people eligible for the program, my exposure is $5,250,000."
That's how much the pharmaceutical portion could conceivably cost
me if I cut out that 7,001 person and tell them I won't service them.
So I think those are all things that bother me.
They talk about productivity increases and one of the wonderful
things about this program is it will increase the productivity for our
businesses here in_ town. Apparently, it doesn't increase productivity
enough to cause the employers to provide insurance for their people,
so apparently they're willing to live with a little less productivity
rather than paying for insurance to improve that productivity. Thank
you very much.
CHAIRMAN CARTER: Thank you for your comments, sir.
Next speaker, please.
MR. OLLIFF: Next speaker is Peter Gerbosi followed by Carl
Bontemps.
MR. GERBOSI: Good afternoon, ladies and gentlemen. I did
not come with any prepared notes. I just came to listen and express a
few concerns. What concerned me is these ads. I've seen more
advertising pro this and dollars spent for this program than I've seen
by any politician ever running in this county or this city and even in
this state. Who's paying for this? Private citizens? I doubt it.
Maybe private organizations. And I would like to know what
organizations and what's their ulterior motive.
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I see the president -- he's not here right now -- of NCH at every
one of these meetings, and then he disappears. What's his motive for
being here? They talk about $30 million that they spend in their
emergency rooms, and they want to reduce these costs. Is that going
to come back to the citizens if we need the help? Sure. I also believe
in Santa Claus and the Easter Bunny.
The ad talks about 30,000 people. Are we scaring us? Then you
tell me it's only 14,000 people. Then you tell me it's only 7,000
you're going to take care of. Who's going to select the 7,000, and
what are the other 7,000 going to do? Sue us, each and every one of
us?
I hear that other counties like Dade has some excellent plans. I
do business in Dade. I do business in the Latino section, sir. And
you ask them about their indigent health plan, and they laugh in your
face. They have no plans any worth to them at all, and they get no
benefits from it.
Yes, you will have migration. I too come from New York City
when -- and I was born in 1929, and my father still blames the
Depression on me (laughter). And we put in a welfare program in
New York City- New York City and New York State, and the
people migrate. Vito Mark Antonio was bringing people from Puerto
Rico in by the boatload just so he could get votes and put them all on
the welfare program. This is what you're going to eventually invite
yourself to.
You talk about increase of productivity. If you take away the
incentive to work, you're not going to get any productivity. I had an
incentive to work at that age and in the Depression. I had to go to
work practically from the minute I was able to walk, whether to cut
grass -- I wasn't ashamed of cutting grass. I cleaned out cess pools, !
delivered ice, I shoveled coal, whatever I had to do to bring money
home to the family. My first paying job was at the age of 11 working
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September 6, 2001
voters. Let the voters vote on it.
you.
at a Chinese laundry pressing shirts for 10 cents an hour. I was not
ashamed. I earned that money. I remember my mother telling me
when she had to rush me to the doctor, it cost her a pay of shoes
because she had to pay for the medical doctor. The children were
most important.
If anybody -- If you take away that productivity -- the work
ethnic (sic) from the people, you're going to have a problem, and this
is what that's going to do, take away work ethnic (sic).
I had nobody paying for my education. Nobody paid me to go
to medical school that I can say, This is wonderful. We should
provide everything. Nobody paid me to go to law school. I had to
work every minute I was in school, after school, and hours. I had to
work. And after I graduated from high school, I worked full time,
went to college on my own. Nobody paid for any part of it. And
while I was going to college, I was married and holding three jobs at
the same time.
I am able to afford and live here and pay for my own insurance
because I had this work ethnic (sic) and was willing to pay for what I
-- willing to work for what I wanted. Take that away from people
and you'll lose that. You're gonna lose the whole essence of this
company. The work ethic is what people came here for. They strive.
They dug the ditches. They built the roads. They built the business.
Nobody gave them a thing. I feel strongly about this.
If this plan is so good as it sounds, wonderful; sell it to the
Put it up for a referendum. Thank
Carol Potter.
MR. BONTEMPS:
(Applause.)
CHAIRMAN CARTER: Thank you, sir. Next speaker, please.
MR. OLLIFF: The next speaker is Mr. Bontemps followed by
Good morning, Mr. Chairman, board of
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commissioners. I'm very proud to be here and thank you for the
opportunity to speak briefly. Regarding Peter Drucker, I've also been
a fan of Peter Drucker's for about 50 years, and he's the most
outstanding businessman that ever came down the pike. And if he
read Tom Schneider's and his group's program, he would say this is
right on track and on the ball and the best thing that could ever
happen to Collier County.
Now, the presentation, I think, has been outstanding. It's been a
-- It's been a very great morning. Now, why do we all come to
Naples? We come down here for the water and the trees and the
weather and everything. And now everybody's cutting down all the
trees and building houses, and a few other things are going down and
-- I'm highly involved in the environment -- but there's not enough
qualified help down here anymore. It's true all over the United
States. Companies and businesses or even volunteer organizations
are taking people on to responsible positions or just coming to work,
and they don't have a clue what they're doing. I mean, they're hiring
people they wouldn't have touched with a 1 O-foot pole five years ago.
That's what's going on here in Naples.
Now, I'm just describing what's going on down here. The
wealthy get preferred entry to hospitals and to the doctors. The poor
workers have to wait. The children have to wait, and the parents get
upset.
We're all living well down here, poor workers and children at
the bottom of this great community. Why shouldn't it be relatively
pleasant for everyone? Are we proud of what's been created? I'm
not, hardly. No one thinking could be proud of it.
If we don't get an overall health program for all, it's going to
cost us much more money later to right the system. If we wait
several more years, five more years, what we're talking today is
penny ante of what it's going to cost.
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Back home programs for everybody are in place in most of the
United States, why not here? Workers have been pushed aside. They
are not responsible for us coming here and monopolizing the medical
care. We all came and flooded down here, and all of a sudden there's
not enough people. We've got to do the right thing and move ahead
now. We can't wait for something better to come along next year,
next year. And, as I said, Peter Drucker and myself approve Mr.
Schneider's program and his group, and we need to move now, not
wait. It's the right thing to do. It's the right thing to do for the people
who aren't getting served. All of us who are in good shape, no
problem, but that's not our problem. The problem is the people who
aren't getting anything.
Now, further-- let's see. I'm trying to make sure I don't get this
screwed up. I think I'm doing all right. We must do the right thing
and move ahead now. We've got to step up to the plate and hit some
home runs and win this thing. This is a must and a proud thing to do.
To be against this politically or in any other way is to put down your
own constituents and sound community growth. Thank you.
CHAIRMAN CARTER: Thank you. Next speaker, please.
MR. OLLIFF: The next speaker is Carol Potter followed by
Harvey Swope.
AUDIENCE MEMBER: Swope is absent.
MS. POTTER: Hello. I'm Carol Potter, and I will waive most
of my time because practically everything I had to say has already
been covered two or three times.
So I do want to say, though, that I'm a private citizen, a
registered voter in Collier County. I care about what goes on. And I
don't have any ties to anyone else, but I do know that I feel that this is
really the first step in socialized medicine. I disagree with it
completely, as does my husband. I tried to get him to come with me,
but he said I talk enough for both of us so -- but he did say, the last
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thing you do is let them know that they should put this to the voters
because this is something that everybody in Collier County is
concerned about, and the voters should have a say in this and not
dictated to us.
I do want to say one other thing though. I do a lot of volunteer
work. I have for years. I volunteer right now over at the Senior
Friendship Center, and I don't know if any of you are familiar with
Dorothy Campbell who runs that. It's a beautiful place. It's
wonderful. She is a fine lady. She does an outstanding job. And we
could take on more people probably over there if we just -- if people
knew about us and wanted to come volunteer and help, because she's
willing to do most anything. She'll take the shirt off her back for
anybody. And the Senior Friendship Center hasn't been getting the
recognition that they need.
I'm just a volunteer over there a couple times a week, and I am
helping her run this assistant drug program which is very, very time
consuming but it's very worthwhile when you see the people to come
in and pick it up. So that's all I have to say. Thank you.
CHAIRMAN CARTER: Thank you, ma'am. May I have the
next speaker, please.
MR. OLLIFF: The next speaker is Kathleen Slebodnik followed
by Tom Macchia.
MS. SLEBODNIK: I didn't know I was the next speaker or I
would have been in the front row. Good afternoon -- it is afternoon --
Commissioners and committee members. I am Kathleen Slebodnik,
and I am speaking this afternoon for the League of Women Voters.
We have been involved in this project for quite a while, generally
through Ann Campbell who has been our social policy representative,
but she is not in town, so I'm speaking for them. The -- in--
As far back as 1993 the League of Women Voters of the United
States has a position, which is to promote a health care system for the
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United States that provides access to a basic level of quality care for
all U.S. Residents and controls health care costs. This program fits
into that position very, very nicely. The -- Controlling health care
costs, the best way to do this is through local control, and this
program has that facility. It is -- You are able to appoint a local
committee with local oversight, and I think the cost part of it, which
is a major concern of the people who are critical of the program, can
be addressed.
As you-all know, government is set up to do those things which
the private sector either cannot do or is unwilling to do, and let me
emphasize the "unwilling to do." The private sector has not stepped
up to the plate on this issue, and to deny we have a problem is to put
our heads into the sand. It is government's responsibility, if we
acknowledge that there is a problem, to take on at least some kind of
a solution to providing basic health care to those in our society who
cannot afford or are not participants in some kind of a health care
program.
We've listened to a lot of people asking for a referendum on this
issue. I couldn't help but think in 1930 what if Social Security had
been put up to a nationwide referendum. It took a lot of courage on
the part of the congressmen in the 1930s to pass Social Security.
And, indeed, that was the first step down the road to socialized
medicine. Now -- now, we have considered so -- we have considered
Social Security so much a part of our national program that any
politician who tinkers with it is on the road to disaster.
I'd like to comment -- commend the committee members on the
excellence of their presentation this morning, and we hope that the
commissioners also have the courage of those politicians in the 1930s
and pass a program that is sorely needed by our citizens.
COMMISSIONER HENNING: Are you saying that the league
would be against putting this to the voters?
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MS. SLEBODNIK: No. No. No. No.
COMMISSIONER HENNING: I'm sorry. I almost
misunderstood you. Thanks for the clarification. MS. SLEBODNIK: Uh-huh.
CHAIRMAN CARTER: Next speaker, please.
MR. OLLIFF: Tom is your next speaker. Following Tom will
be Dawn Jantsch.
MR. MACCHIA: Hello. I'm Tom Macchia, and since I oppose
this plan, I think I ought to give you some bona fides. First of all, I
love children. It's very important to know that I love children. I was
a child myself (laughter). I had three children of my own, and I now
have four grandchildren. I'm also -- As you can tell, I'm old. So I
like -- I have an affinity for elderly people, so I also like old people.
And I was poor once. I lived in New York City. I lived in a five-
story walk-up. Used to call it a cold flat, and the cold flat had no cold
water and no heat. So I have an affinity and remembrance of what
it's like to be poor.
I start off by saying that I implore the commissioners not to send
out another committee -- government committee to find a problem,
because there are so many problems out there, I'm not sure that the
taxpayers can afford such another adventure. Now, this plan is small.
It's given to us as a small amount of money, but it's something like
dying the death of a thousand cuts. We now pay for Healthy Kids,
intangible tax, six cents gas tax, five cents additional gas tax, federal
gas tax, Green tax, Head Start, estate tax, income tax. We pay for
free lunches, phone taxes, documentary stamp taxes. We pay for Kid
Care, Medicare, Kiddie Medicaid and property tax interest, which
we're talking about now, and sales tax, which you're going to be
pursuing in November. I do not believe that you want to put it to a
referendum because I believe that you firmly know that it would go
down in defeat. And ! don't expect you to admit that, but I think we
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all know that.
I would like to address the Social Security that's been brought up
a couple times, first by Commissioner Carter and then by the woman
from the League of Women Voters. First of all, when I was brought
up, I believe -- 1933, I believe it was -- only 2 percent of your income
was -- went toward Social Security. And I make an analogy about
the small amount of money that you say it's going to be on our
property taxes. It's only $5.95. First of all, I'm not a big fan of Social
Security. I'm trapped in it. I was forced to take it. It is -- it does not
cover people. It does not help people. People cannot live on Social
Security. The government -- it's a government subsidy that they don't
use any money to. They don't invest it in anything. They borrow
from it. So I'm not sitting up here applauding about the Social
Security system or Medicaid either.
When I was in my union, my union took care of all my
problems. I paid for it. We paid up to $1.60 an hour for it. When
Medicaid came in, the insurance companies got the biggest break of
all because all of a sudden they didn't have to pay.
Anyway, to end it off, I believe Hillary Clinton would be proud
of the four rhinos on the board here who will push every welfare
thing I've ever heard of. And to try to make an analogy between
President Bush and Hillary Care and this thing is ludicrous. Thank
you very much.
CHAIRMAN CARTER: Thank you, sir. Next speaker, please.
MR. OLLIFF: Next speaker is Dawn Jantsch followed by
Dexter Groose.
CHAIRMAN CARTER: Thank you. Sorry for the interruption.
MS. JANTSCH: Good afternoon. I'm Dawn Jantsch, president
of the Naples Area Chamber of Commerce. The efforts of the Collier
County Health Care Planning and Finance Committee -- and I wrote
that down, Mr. Schneider, to make sure the committee was
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recognized by its full name and not by some of the others we've heard
today. It should be commended for its meeting extensively for three
years and for the hard work and dedication that this committee has
put in to grapple with a very, very difficult issue. You have worked
very, very hard to find common ground that would compromise and
satisfy needs with what little resources are available. We appreciate
the time and effort the commission has also put into the issue and will
for the next few weeks in the final decision-making process.
Today you have heard the well-researched facts of the program
in a very detailed and well-presented manner. The committee should
be admired for its determination to provide access to primary care.
We urge that the board consider anything that the county can do on
these issues, particularly obstetrics care for young mothers, in
particular. I wish you luck on this issue, and thank you very much
for the hard work and the program that you've put together.
CHAIRMAN CARTER: Thank you very much. Next speaker,
please.
MR. OLLIFF: Dexter Groose followed by Patrick Neale.
MR. GROOSE: My name is Dexter Groose. First, let me assure
you, I do not have a proxy to speak for Peter Drucker.
COMMISSIONER MAC'KIE: Peter who?
MR. GROOSE: However, I am a cost-efficiency expert and
someone who has served as chairman of the Public Health Care
Center Advisory Board in Dade County. I feel that the commission
will probably approve of this health care plan, but I do have a few
ideas that I think could help assuade the public's concern about fraud,
waste, and abuse.
I'd like to suggest three ways to improve the eligibility, the cost,
and performance of this program. The first is to set the eligibility
level at 110 percent of the FPG or Federal Poverty Guideline. The
Federal Poverty Guideline does not include the value of federal, state,
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or local assistance such as food stamps, public housing, et cetera. So
I think if we set that eligibility level at 110 percent, that's reasonable.
Secondly, I think the plan should require that all participants
produce a tax return to establish their eligibility. A W-2 alone is not
enough. A family might have two or three W-2's and they only bring
one to the table. Also, tax returns identify their earned income tax
credits that may not show up otherwise.
And, thirdly, I'd like to suggest that the commission establish a
$10 co-pay to receive care in addition to the $6 co-pay to receive care
up within the network. I think there has to be some very slight
deterrent that every time they go there, there's going to be a little
minimal pay, and $10 is very reasonable.
I think that if we adopt these three ideas, to set the eligibility at
110 percent of FPG, require tax returns for eligibility, and establish a
$10 co-pay, we will assure that we will be taking care of the most
needy 7,000, not necessarily the first 7,000 that come in.
In summary, I'd like to say, let's start slowly if we must start.
We can loosen the requirements in the future if the budget allows.
Thank you.
MR. OLLIFF: Next speaker is Patrick Neale followed by
Margaret Williams.
MR. NEALE: Thank you, Commissioners and members of the
panel. I am appearing here today as the -- in my very honorable role
as the volunteer president of the United Way of Collier County. I
feel honored to serve in that capacity, and my board of directors has
authorized me to come here and make a statement to this committee.
We had supplied Chairman Carter with a copy of this letter via fax
last evening, and I'll leave a copy for the record.
The board of directors of the United Way of Collier County has
followed with great interest the work of the health care review
committee regarding tax-assisted medical care for the working poor
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of this county. We commend the committee members for their
dedicated effort. I think everyone does that. A review of the
committee's findings bolster the antidotal evidence provided to us by
the 27 United Way agencies that medical services to the indigent and
working poor of Collier County do not meet the needs of that
segment of the community. The consequences of this lack are wide
ranging, though not readily apparent to the entire population of
Collier County. Indeed, the consequences impact Collier County in
broad fashion that ultimately result in county residents as a whole
bearing higher insurance and medical costs in addition to the social
ills that arise from failure to obtain or pay for medical treatment.
The issue of medical care for the working poor and indigent is a
county problem. It must be acknowledged. Once acknowledged, the
leadership of this community cannot turn away from seeking a
resolution to these issues. As the elected leadership of Collier
County, it is fitting for the county commission to take its place in
resolving this pervasive problem that affects so many of its
constituents. In overseeing the welfare of the citizens of this county,
medical care for the working poor is no less within the jurisdiction of
this commission than roads, parks, housing, or sanitation.
We are confident the commission will assume its rightful role in
addressing this particular Collier County issue, and this is the
position of the board of directors of the United Way of Collier
County.
CHAIRMAN CARTER: Thank you very much, sir.
(Applause.)
MR. OLLIFF: The next speaker is Margaret Williams followed
by -- The last registered speaker I have, Mr. Chairman, would be
Tom Harp.
MS. WILLIAMS: Commissioners, committee members, my
name is Margaret Williams. I'm the executive director of Collier
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September 6, 2001
County Medical Society. We are a professional association--
professional association of physicians in this county. We are
affiliated to the Florida Medical Association. I represent more than
350 physicians. And the president, Corey Howard, and the members
of the society fully endorse the findings of the committee and fully
endorse, we hope, what the commissioners will decide.
I think everybody recognizes the need for the primary care, and I
know this is what the committee are addressing. But for these
specialists, which is the next group -- Most of our members are -- are
specialists. In fact, we have representatives from every specialty
group. These doctors are only too willing to volunteer their services
for the We Care Program as it will be called. A lot of them already
volunteer their services on an ad hoc basis. They are very aware that
a lot of indigent workers end up in their offices. They choose the
specialty, whether it be gastroenterology, dermatology where, in fact,
this could have been treated at the primary level. If this becomes
more organized through a We Care Program, this would certainly
take the load off some of the physicians.
That's about all I need to say, and I hope the commissioners will
vote to support this. Thank you.
CHAIRMAN CARTER: Thank you, ma'am. And next speaker,
please.
MR. OLLIFF: Tom Harp.
MR. HARP: I'm Tom Harp. I'm the pastor at Vanderbilt
Presbyterian Church, but I'm speaking for myself. I am somewhat
hesitant to say this, I'm a Liberal Democrat. So take a look 'cause I
guess I'm the face of evil, and from what some of the things I've
heard said this morning, so are you.
Rejoice at the conversation that's going on. I think it's healthy.
We've had some of this conversation in my congregation. When I
came here five years ago, I came here from New York. We referred
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to that several times. I would like to say to you that you could triple
my property taxes and they still would not equal what I left behind in
New York. And I came here because I got a job here, not because
there was free health care.
COMMISSIONER MAC'KIE: Because there's not.
MR. HARP: I want to say that the people who you will be
helping with this health care proposal are not here today because
they're out cutting my grass or cleaning my pool or doing other
things. There was one -- and I was glad that you allowed her to
speak, though she wasn't really going to take no for an answer. They
are invisible.
They're -- I have been amazed at how many people around --
when I came here. I'm up North, all the problems are down in East
Naples. No, they're not. I have people all the time coming to me,
coming to my staff for help. When I left this morning to come down
here, there were about eight people sitting there, all waiting for help.
I got word this morning that St. Matthews House is really in
trouble financially. Why are they in trouble? There are people all
over the county helping out, but the need is awfully great. That's all I
know. I think they're doing an excellent job. We support them as
much as we can.
Some problems are simply too big for a voluntary response. I
believe -- I think my religious tradition believes that government has
an obligation to provide for the well-being -- I want to use the word
well-being of the populace, not welfare, well-being. It's not just
roads. It is sanitary sewer. It is health care. Our tradition has a long
history of establishing hospitals as well as schools in addition to
churches. It's not an accident. It's because we believe all of those
things work together for the well-being of community.
I simply encourage you to consider this. I think they've done an
excellent job. I'm not suspicious of their motives. I hope you'll take
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the role of leaders and lead us down the path that will be helpful.
Thank you.
MR. OLLIFF: Mr. Chairman, that's all your registered speakers.
CHAIRMAN CARTER: Okay. I thank you very much, Mr.
Olliff. I thank every speaker for your input. I thank the committee
for everything you've shared.
We are running out of time here because there is another group
that needs to meet in here at one o'clock. What I'm going to ask is
that we get the Board of County Commissioners' comments as
expeditiously as we can, and there really isn't any discussion required
at this meeting. We can -- We will have opportunities before the
final budget approval -- There are two budget hearings before this is
approved where we can have a thorough discussion among ourselves
and have a chance to digest everything. So with that pressure that's
on us because of the situation, I would like commissioner comments,
please.
COMMISSIONER HENNING: I have several questions so --
and, you know, I'm not going to vote for it anyways, but I think these
questions need to be asked. If you want to continue this workshop, I'd
be in favor of that.
COMMISSIONER MAC'KIE: But we don't have a room. I'd be
happy to stay here until dawn.
CHAIRMAN CARTER: It doesn't make any difference to me
either. All I know is we have another board that's going to meet in
here. Is there any alternative for them?
COMMISSIONER COLETTA: I think our priority here is
higher than theirs. I'll be honest with you.
CHAIRMAN CARTER: Okay. We have the Vehicle Advisory
Committee out in the hall. Is there another place --
COMMISSIONER MAC'KIE: What about --
MR. OLLIFF: You keep workshopping, and I'll see if I can find
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an alternative location.
CHAIRMAN CARTER: Okay. Thank you.
COMMISSIONER MAC'KIE: So we could seek one out.
CHAIRMAN CARTER: Let our county manager work on that,
and if you could continue with us, we'd appreciate it.
So let's go to questions by commissioners and a discussion.
Again, I thank members of the public for all your input this morning
to us. We value it. We listen and we have to digest and work with
everything that we know.
COMMISSIONER MAC'KIE: I have just one --
CHAIRMAN CARTER: I'm sorry, Commissioner Mac'Kie.
Commissioner Henning has the floor.
COMMISSIONER HENNING: Ladies first, please.
CHAIRMAN CARTER: All right. This married life has had an
affect on you already.
COMMISSIONER HENNING: Hopefully for the better.
COMMISSIONER COLETTA: Undoubtedly.
COMMISSIONER MAC'KIE: Actually, all I just wanted to do
-- because I'll probably have other questions too -- is just distribute to
the members here a copy of something on the Republican question,
and I have copies available for members of the public if they'd like
them as well. This is just the Republican Presidential Health Care
Platform presented by our then governor of Texas and now president
of the United States, Republican president, and I'll read this one little
excerpt. During his first public speech on health care in Cleveland,
Ohio, in early April 2000, then Governor Bush announced that his
plan -- his plan for health care would, quote, "promote individual
choice. We will rely on private insurance. In my administration," he
continued, quote, "low-income Americans will have access to high-
quality health care." And he had five points that he proposed for
implementing the Republican Party's health care platform, and one of
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those I will read to you, and that is (as read): "Increase the number of
community-based health centers using $3.6 billion in federal funds
over five years" -- which hopefully we will be able to access now that
we have a local program -- "to create 1,200 new centers nationwide.
These centers will be community owned, locally administered
medical-care clinics that offer preventative care, free vaccine clinics,
health alerts, disease screening and counseling." And I just offer this
out of frustration to the people who claim the Republican Party
doesn't have a heart. It does. I am and so is my president. Thank
you.
CHAIRMAN CARTER: Commissioner Henning.
COMMISSIONER HENNING: Thank you. Maybe we can get
President Bush to fund the whole program here in Collier County.
COMMISSIONER MAC'KIE: I think he thinks like most
Republicans, that local government serve local issues best.
COMMISSIONER HENNING: What I see is mandates being
pushed down, and you know, in the decisions that we should be
making, they're doing it for us. That's fine. And the question I have
is, why didn't the committee take a look at future population? I think
that we all know that our county is going to grow, but it's based on
today's population.
MR. SCHNEIDER: Commissioner, that's a good question, and
the answer is something that I expressed in an earlier speech that I
gave to the Republican Party, and that is that it's our view that the
growth in the general population will track the growth and the people
who would be eligible -- new people who would be eligible for the
program so that the burden for taxpayer per -- for the program would
be the same. It would not grow as a result of that. Even though the
total cost to the county would grow, the cost to the individual
taxpayer would stay about the same.
COMMISSIONER HENNING: So you didn't factor in there
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because of that reason?
MR. SCHNEIDER: That's right.
COMMISSIONER HENNING: And the gentleman about the
pharmaceutical with the $750 max to each recipient of this health
care plan, his figures are showing $5 million over the next four years.
MR. SCHNEIDER: I'll let Steve deal with that and give you the
first answer to that. The overview is that the -- we are talking about
primary care and only medications for-- medicines, prescriptions that
would be prescribed by primary care, family doctor type of physician.
We're not talking about exotic, specialized, expensive medication.
And all of the tests and studies we have looked at in other programs,
we have -- a range of the average cost per year per patient for those
medications runs, you know, well less than $100 a year, and that--
that doesn't even include the benefits of 340-B pricing or the
compassionate drug program or the free samples.
But as Steve Rasnick has pointed out to all of us time and time
again, there's an element of-- because we're only dealing with
primary care, we don't have to worry about the -- the really
significant medical conditions like a cancer or heart replacement or
bypass surgery or something like that. The only thing we have to
worry about is catastrophic frequency; and therefore, it was his
recommendation that we put in a cap per person so that we wouldn't
-- we would further protect ourselves against any catastrophic
frequency so that we fully expect on average that the medication cost
would be somewhere $30, $40 a year. But just to make sure that the
average doesn't get out of whack because certain individuals are
required are so high, that we set a cap at 750, which Steve says we
don't even expect to meet hardly at all in an individual, much less
every person. His numbers were taken -- first of all, a 30,000
population number multiplied by $750 when, in fact, we're not
talking 30,000. We're saying there are 30,000 people who don't have
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insurance. We're not planning to take care of all of those. A lot of
those people are children. A lot of those people are wealthy enough
to afford their own. And, in fact, there may even be others that are
illegal or unqualified immigrants that wouldn't apply for the program
COMMISSIONER HENNING:
MR. SCHNEIDER: I'm sorry.
COMMISSIONER HENNING:
based it on average instead of peak.
MR. SCHNEIDER: Absolutely.
budget together.
COMMISSIONER HENNING:
too.
Getting back to the question --
-- so what you're saying is, you
You have to put a realistic
We've done that with our sewer
MR. RASNICK: I'd like to qualify that because that's not the
case at all. What we did is, we built in a safety valve which was
prudent because we didn't have statistical evidence for two or three
years we could analyze. We also took the prudent step of taking all
of our financial estimates, sending it out to an independent actuarial
firm and having that actuary not only validate all of the estimates, but
give us their opinion as to what the individual costs were going to be.
You have as a part of this package the actuarial report. The
actuary believes -- and he's not a very conservative basis. The
actuary believes that the costs will be $60 per member per year for
pharmaceutical, notwithstanding -- that's a pure cost --
notwithstanding the impact of 340-B pricing nor notwithstanding the
free samples. So that is through the -- and the compassionate drug
program. That is a pure drug cost based upon this population.
Commissioner, it's at the back end of the report.
COMMISSIONER HENNING: Thank you. Another question
is, how are we getting to define "residency" or determine residency in
Collier County?
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MR. SCHNEIDER: Steve, do you have the details with you on
that?
MR. RASNICK: Yeah, I do.
Commissioner, bear with me.
CHAIRMAN CARTER: Question is, how are we going to
define "residency" in Collier County.
MR. RASNICK: First off-- First off, we've turned to the legal
department for considerable help, so we're going to determine it
within the context of what they say we can determine, but we have --
COMMISSIONER HENNING: Well, I have that and appreciate
it. And one of the questions that came up is one of the requirements
of using a tax return as a basis for somebody to be under this
program. That's something that I hope our legal committee can
answer or -- in the near future.
MR. SCHNEIDER: That is part of our plan, is it not, Steve?
MR. RASNICK: Yes, it is. We've got several answers -- a
couple things to answer your question. There is specific wording in
our document that talks about determining county of residence, and
essentially we're going to look at documentation which could be any
one of-- minimum of two of these documents, property tax bill, voter
registration card, mortgage statement, deed, rent receipt, lease
application, auto registration, utility bill, school registration,
declaration of domicile.
And, furthermore, for the purpose of determining residence, a
visit to another county for any purpose does not make that person a
resident of that county nor does temporary living arrangement prior
to admission to a medical facility. The length of time a person
physically resides in a county is not a factor in determining residency.
If the applicant maintains a permanent residence in another county,
then the county of residence is the county in which the primary
residence is located.
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That's the criteria that we -- that's the -- They all say devil's in
the details. Those are the details behind the proving of residency.
We have similar details for other elements as well.
COMMISSIONER HENNING: So if I have a rent receipt, it's a
possibility that I could receive this --
MR. RASNICK: You need a minimum of two we built into the
plan. That is, the plan may require any information that the plan
reasonably believes is appropriate. So if there is a question that they
have in determining eligibility, they have the right to ask for a third
or a fourth piece of documentation in order to confirm that the
individual is a resident.
COMMISSIONER HENNING: And I guess where I'm going
with this is, can an illegal resident or alien resident receive this health
care?
MR. MANALICH: Well, a couple of comments. First --
COMMISSIONER MAC'KIE: What is an alien resident?
COMMISSIONER HENNING: That's somebody with a green
card.
MR. MANALICH: First of all, as to residency, the bottom line
on that was -- we told you that we didn't think legally we could
require the durational aspect of that. I think the items that he
mentioned can be requested. Now, whether a tax return can be
required, we may get into some privacy and confidentiality issues
that we're going to have to work through as far as the criteria we set
up. Certainly those items of proof can be requested.
You know, residency, the bottom line on it that we found was --
basically has two components; presence in the county with the intent,
that you can show, to remain -- So, for example, someone traveling
from Miami to Tampa who happens to have, you know, some health
problem on the way, that's not a resident, but someone who is here
even if for a very brief time but has made arrangements to show an
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intent to remain would be eligible.
COMMISSIONER HENNING: Okay. The -- I know it first
was reported -- the first report said there was four different groups of
needs out there. One was farm workers. One was hotel workers.
One was restaurant workers. Can you help me out on that, Tom?
MR. SCHNEIDER: We had lawn care. We had more than four,
and we just used those examples that we thought a lot of-- a good
high percentage of the people who would be eligible for this program
probably working in one of those job capacities or another.
COMMISSIONER HENNING: The reason I bring this up is, I
see this as a burden of the single-family homeowner in Collier
County, and I think that we all know that hoop -- that's the one that
pays the most property taxes in Collier County. It's not the
commercial because it is not a good balance. And my concern is, this
is putting -- puts the burden on the single homeowner and we're not
capturing the tourists that are -- utilize our hotels, crowd the
restaurants -- we're glad to have them here. I'll be working on
something that, hopefully, this'll be more of a burden where it should
be and being on the tourist.
I must say I think the committee has done an excellent job. I see
this as a well-rounded universal insurance with the Healthy Kids, the
We Care program is where residents of the poor can receive basic
care all the way up to hospital care, if that's what I understand. To
me, that's any -- that's what I understand the We Care program is. It's
with specialties, and plus I heard that a hospital will be involved in it.
COMMISSIONER MAC'KIE: For those specialty care.
COMMISSIONER HENNING: Exactly.
COMMISSIONER FIALA: Both hospitals?
COMMISSIONER MAC'KIE: We don't know that yet.
MR. SCHNEIDER: I said NCH has given me oral assurances
that, completely, they would -- every program that's offered through
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the hospital or any of their related subsidiaries -- organizations like
DSI for diagnostic services, all of those would be included. And I
mentioned earlier that I don't have that officially yet from the
Cleveland Clinic, but I'm pretty close, and it's only because of the
new changed leadership.
COMMISSIONER MAC'KIE: There's no reason to think we
won't likewise get that from the Cleveland Clinic.
CHAIRMAN CARTER: And as good practice we would
require them to state that in writing to us.
COMMISSIONER MAC'KIE: Of course.
CHAIRMAN CARTER: But, you know, at this point we have
that assurance, but I want to see it in writing, T's crossed, I's dotted, if
that becomes a part of the program.
What I also believe I understand is, to qualify for some of these
other programs to enhance your possibility of funding, you have to --
to have a local initiative of some sort in place in order to leverage
your dollars. We have already spent -- Those dollars have already
been taken from us in one form or another, and they reside in the
great sky in Washington.
Now, the choice becomes, do you get some of those dollars back
by having a local initiative that says, send us money down here so
you decrease your exposure locally to begin to meet the needs? And
that I think is an unknown in all of this. But each year the Board of
County Commissioners looks at a budget, makes a determination;
what are we going to do or not going to do? So it is not a thing that
says whatever the board decides to do, that it's there forever. It's not
true. It is there for a fiscal year, to be reviewed annually to determine
how it will be continued to be funded or not funded.
COMMISSIONER HENNING: Commissioner Carter, you
make a very good point on bringing the federal tax dollars back down
to Collier County. My concern is -- It's just like the funding that we
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out.
do receive. The Cops Program is one for the sheriff's department
that's going to end. Those cops are employed here in Collier County;
therefore, the property taxpayers of Collier County is going to pick
that up.
COMMISSIONER MAC'KIE: Or we could start sooner and
pay for them today instead of letting the grant pay for them for the
first five years.
COMMISSIONER HENNING: And those grant programs run
CHAIRMAN CARTER: You're correct, Commissioner.
COMMISSIONER HENNING: I'm afraid that once this
program gets started, what commissioner can say no in the future?
CHAIRMAN CARTER: Well, they may be forced to say no if
the dollars are not there in order to only deal with what is fiscally
responsible that is available, and that is, again, an alternative of one
of the funding sources. There's a lot-- There is potential funding or
revenue streams, but unless you do and have some program in effect,
as I understand it, you diminish your opportunity to participate in
those programs, and that, to me, is an important consideration, to
know what we can do and how we can do it, what is the most
equitable lines of revenues to help me do what we need to do.
COMMISSIONER COLETTA: Commissioner Carter, you
brought up a good point. Historically, this county has drifted in and
out of these programs over the years, and they brought them up to a
certain point. Then a new administration came in, cost cutting took
place, and those programs disappeared. I've seen this time and time
again since I moved here in '84. In '85 1 seen a great example of what
we call -- I'm not going to get into the terminology. I might get into
trouble with some of my fellow Republicans. But I was very much
offended back in '85. We had a major freeze in Collier County, and
the migrants that came down here to harvest the crops were put out of
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business. The Collier County Commission at that time had the ability
to authorize the Federal Department of Agriculture to come in and
issue food stamps. They declined to do it because they were worried
of ruining the work ethics of these people that came in to harvest the
crops. I think sometimes some of our directions get misplaced.
And I want to tell you something. I've been involved in this
thing from Day 1. You, in your good graces, appointed me to work
with the health care committee, and I want to tell you something; it
hasn't been fun. It's been a whole summer. I cancelled my trip to
Alaska, I cancelled my trout fishing trip to New York State, and I
stayed with them. And I don't think I made their life that good either.
I want to compliment you, Tom, for putting up with me. I held
Tom's feet to the fire. I didn't go back to his group, but personally I
would drag him in, and I'd start laying it all on them. And I probably
upset them, but if anything, he kept modifying his plans to try to
include some of the concerns I was bringing to him which was a
reflection from the community in general.
The last time I talked to him, I was looking to come up with a
plan that would have been -- instead of involving the government
itself, it would have been more of a grant-type thing, trying to breed
something more closely to a Lascheid Clinic. However, after his
modification to this program, he's so close to the grant idea, that I
really don't see that much difference. Possibly in the coming year if
this program has a life that goes forward and if we see that the
possibilities go forward with a grant rather than with administering
from the government county and might bear some fruit, that's
something we'll want to look at.
But I tell you, my research has been pretty extensive. The only
place -- well, we came down to -- some of the issues that came up
were added to the tax -- the tax -- the license fees for the-- the
contractors and all the -- for everyone out there. I met with Guy
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September 6, 2001
Carlton a number of times. He was very supportive in the beginning,
and after quite a bit of research, we found out that was totally
impossible.
Then the other one came up about making the employers bear
the cost of the insurance. Well, that led me to Hawaii. In Hawaii
they have a very successful program, and their cost of insurance is
about half of what it is here because of the fact that everybody's in
the program, but it was done at a state level. Number two, Hawaii is
very unique in that it's isolated. It doesn't have to compete with the
outside world. You go to Hawaii, you can't bring in help
indiscriminately, or you can't go someplace to buy a product. You're
stuck there. So, I mean, that particular program would only work
probably on a national level. And if that ever comes to be, I can't tell
you.
I think the direction we're going with this is very good, but there
are a couple things I have concerns about. One is the co-pay. I come
from a fairly extensive background of social service agencies,
working with them in a number of capacities. I think we might want
to revisit the co-pay as being a little bit low for the most part;
hospitals, a little higher; and also make it so that it swings from a low
to a high. And then what I can do is, I'll go out to some different
agencies and see if I can secure money from the private sector to pay
for those few people that won't be able to make that payment, period,
but try to get a payment from everyone that comes through the door
in some form. And it gives the service a real value.
CHAIRMAN CARTER: I think-- I don't mean to interrupt you,
Commissioner, but that is an excellent point, that you may have a
scale of co-pay.
COMMISSIONER COLETTA: It wouldn't be a wide scale
'cause you don't have that much money.
CHAIRMAN CARTER: No, but you have that opportunity and
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September 6, 2001
I have been in -- one of my criteria was, it must have a co-pay of
some sort when that person comes in. They have to be willing to do
something.
COMMISSIONER HENNING:
Right.
COMMISSIONER COLETTA: What we can do -- and I'm sure
I can go out there to Community Foundation or something and come
up with forty, $50,000 that will pay for those few people that are at
the very bottom of the scale and absolutely need to have service and
they don't have the co-pay.
COMMISSIONER HENNING:
COMMISSIONER COLETTA'
Tom. You've got to be realistic.
Ask him for $2 million.
No. I'm not going to do that,
But the other thing I would strongly recommend is -- the stigma
of indigent care that we have placed on this, that is the dumbest thing
we have ever done as a commission. I would strongly recommend
that we drop the indigent-care tax and put this back where it was
originally in line items. And then if we have a problem some time in
the future, we can go to the single line item and deal with it one on
one.
When you get right down to it, the school nursing program is not
indigent care. It's just not. And neither is the Healthy Kids. You
have families that are in the lower median income range that are
paying, like, $90 a month for Healthy Kids. It's subsidized for some
small part by the state government. That is an indigent care.
Lumping it in there, it puts a dimension that -- Some of these people
brought up a good point, the fact that they said, "Well, you've got that
in there, so we sneak by the other ones." They've got a point there.
So by separating them out and putting them through the budget where
they belong so they can be discussed as individual items I think we'll
serve the public better in the future.
Yeah. I'm personally not swayed by the threats, however, I
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September 6, 2001
make my decision what's going to happen to me politically. When I
ran for this office, I made promises that I was going to do something
about a number of different issues. One was the roads. One was
public health. I was very up front with what I would do. There's no
hidden agenda. I've had a lot of people I talked to about this. They
say, "Well, we didn't believe you when you were telling us that."
Well, I'm here, and I do believe in it, and I plan to keep on top of this
issue. And it's probably going to consume probably about 25 to 30
percent of my time over the next three years and two months. And
during that time that particular committee I'm putting together, the
Horizon Committee on Health and Social Services, we're going to be
addressing these issues to see what we can do more with the private
sector because that's where I come from. I know how they work very
well. They work a lot better than we'll ever work, by the way.
What I want to do is bring them into the mix more and more to
see what we can do to utilize all the resources that are out there and
that exist to try to make this thing flow smoother in the future. That's
going to be the commitment that I'm going to make to this. Right
now I know more about this subject than I ever want to know.
CHAIRMAN CARTER: All right. Commissioner Coletta, I
appreciate your comments --
COURT REPORTER: May I please change my paper?
CHAIRMAN CARTER: Yes. Needs to change her paper.
Okay. I won't lose my thoughts. I promise.
COMMISSIONER HENNING: Yes, you will.
CHAIRMAN CARTER: I guess I caught your share of trout
this summer. Sorry about that.
COMMISSIONER COLETTA: Yeah, shame on you.
COMMISSIONER FIALA: That's because you weren't up
there.
COMMISSIONER COLETTA: Next year I'm going to Alaska
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September 6, 2001
and nobody -- nobody better get in the way. I want this thing put to
bed once and for all.
COMMISSIONER MAC'KIE: Salmon fever.
COMMISSIONER COLETTA: Probably cheaper to buy it.
Thinking about putting them in the suitcase.
CHAIRMAN CARTER: They'll certainly notice when you
arrive in town.
You ready?
COURT REPORTER: Yes, sir
CHAIRMAN CARTER: My thoughts were this: Like you,
Commissioner Coletta, I have been briefed on the possibility of a
grant process, and regardless if it was that or this, the same criteria
would have to apply in terms of qualifying to be in the program,
administration. All of the same criteria is there. And I like your idea
of going to line items. I would defer that to our county manager and
Mike Smykowski as to how we begin to look at each piece of that to
determine where you need to be. Healthy Kids may come down to an
opportunity where we will get the hospitals plus us to further reduce
our commitment to that.
School nursing, I heard the comments about that. My heart says,
totally, I believe it is the school board's responsibility to do this, and I
will challenge them to put it into their budgetary process and not look
to us as the one that's always going to be there to support it. I do
believe that we have to deal with the issue as it exists today. I don't
want to lose the program, and I don't want to hurt kids. And I came
from -- One guy told me that he worked for whatever cents an hour it
was. I got him beat. I started working for a quarter an hour when I
was ten, so I understand what it's like to be -- Today we would have
qualified for being poor. We would probably qualify for-- you
know, I love the county, but I hate the people that live here. Well, we
would probably qualify for -- in my family we don't like you very
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September 6, 2001
much because, you know, you might not be able to carry your own
weight.
I think that, you know, we have opportunities. I want everyone
to have that opportunity, and I want initiative, and I want
entrepreneurism. And I believe you're right by working for Horizon
Committee. The public sector responds well to entrepreneurial kinds
of suggestions and ideas, and my feeling is, we sort all of this out to
capture the best of both.
And that's really I think-- All questions I kept writing down
have been answered by the committee. There's -- There's all kinds of
possibilities in here, and I wanted to see it fully laid out when we get
to the budget to see, you know, what do we do for this -- this fiscal
year and how do we have the controls or monitoring process that
says, as you go, is it doing what you want it to do or are there things
-- it is not doing what you want it to do and how do you correct those
things. So it never becomes a program that is taken for granted that
is there and that, hey, nobody's paying any attention to it. I don't
believe that.
My last closing comment is, the first campaign I ever worked
was for the late Barry Goldwater, and later after that campaign I met
him personally and had a chance to talk to him about what it means to
be a Conservative. And what he taught me, and what I believe, is,
you want to reduce the size of the federal government, you want to
reduce the amount of taxation and keep that money at the state and
local level to let communities address best -- what they can do best,
and that is deal with local issues. And that is a Conservative
philosophy. It says you do not centralize it in Washington. You do
not have central agencies doing this. It is taking care of your own at
the local level for the least amount of expenditure. That's what the
senator taught me.
Now, I may be all wrong in my definition of being a
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September 6, 2001
Conservative, but that's what I learned from him, and that's what I
practice today, and I practiced it all my life, and that's my position. I
am proud to be a Republican. I've been in this party all my life and
George Raisley once told me that when you go to Congress, you go
to a legislative area. You can take that philosophy that we will not do
anything and always lose and or you work with everybody that's there
and win something. He says, "I prefer to win."
So it has been my philosophy that I will work with all groups to
find the best solutions because I much prefer winning and resolving
issues and solving complex problems than I do in saying, What did
you ever do as a commissioner? I did nothing. I voted against
everything; and, therefore, I walked away saying I was a true
whatever it is. What did I do for my community? Because it says to
me, I was more concerned about getting elected to the office, or
reelected, than I was doing my job, and that is to make tough
decisions.
COMMISSIONER COLETTA: One last comment, if I may, on
that. I have had held up to me as an example what I should be. Two
former commissioners have been indicted. Forgive me for that, but I
had to say it, and I found it extremely offensive that people found that
their method of governing was considered superior to what exists
today.
COMMISSIONER MAC'KIE: Ditto. I-- I, like you,
Commissioner, had most of my questions answered, although I had a
long list, but I appreciated the committee's advice to us that we wait
because I did get most of them answered.
I had really just one question left and then -- about the 340-B
pricing on drugs and the fact that we can get -- the best way to get
cheap medicine is through this 340-B pricing, and the CHSI is the
entity that has that in our community. Is that -- Who would know
about that? Is that something -- you look at them both pointing at
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September 6, 2001
each other -- is that something that -- How does one get that
designation? Is CHSI the only one who might be able to get that, or
is it something that county government could seek out? Because
that's very important benefit. As everybody recalls, that's the one
where it allows you to buy drugs at the very cheapest possible price.
MR. ROGOFF: Well, there are -- 340-B refers to part of an act
that was federal. It's been around for a while, and the agencies that
are allowed to use the 340-B pricing are federally qualified health
clinics, county health departments, disproportionate share hospitals,
the VA, what's called the rural crisis hospital, and it's maybe missing
a couple others. Now, what -- to be exact, if CHSI were the entity, it
would be a lot easier to get it, because the final determiner of who it
is, is the Office of Pharmacy Affairs which is part of the Department
of Health at the federal level.
And a couple months ago they came up with some guidelines
that actually made it easier for communities. One of the things
historically has been in there. It has to be on behalf of people directly
served by the entity. So where you could put together a program
through others and would be doable, it would -- and I believe you
would do it ultimately. It might be more difficult. It's more
streamlined to do it if it was CHSI. I can't say it's -- that that's the
only way to do it.
COMMISSIONER MAC'KIE: We're not -- and it's a workshop,
and we're not making decisions today. So I'm not making the motion
that's on the tip of my tongue to accept the committee's
recommendation and go forward, but expect to hear that at the
earliest opportunity. But I do think that as we develop the RFP, that
hopefully we'll follow the board's decision. This 340-B pricing for
pharmaceuticals -- since it's not PC to say "drugs" -- I'm sorry -- is a
good -- is a really important element that needs to be factored into the
RFP, whether it's -- and that's why I'm glad to know that other entities
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September 6, 2001
who might be interested in bidding could seek that qualification or
otherwise promise to provide drugs at the price that would be
available through 340-B pricing.
The only other comment that I wanted to take the time to make
is, because in the media we often get so much of the misinformation
reported as opposed to the true information presented by the
committee, apparently there was a great deal of misunderstanding of
how we have reduced the number of available participants from
30,000 to twenty to fourteen to seven. So just to repeat -- Committee
members, tell me if I have this right. When we were talking 30,000
potential members, we are at 200 percent of the federal poverty level.
We've now reduced -- Because we want to be more conservative on
who can access this system, we have reduced that to 150 percent of
federal poverty -- of federal poverty. What that means is, you have to
be poorer to qualify for the program. And we've said, okay, maybe
30,000 is too much, and maybe the 200 percent of federal poverty is
too much, so we're only going to allow poorer people to qualify. So
we didn't -- like the numbers just magically changed because it was
politically correct. It was in an attempt to provide -- to recommend a
more conservative program so that only the truly, truly poor of the
community -- $27,000, I think, for a family of four -- could possibly
qualify. That's where the 14,000 comes from. It's because the
program has become more conservative.
And then the 7,000 number comes from the statistics that
indicate that about 50 percent of the eligible population is what we
should reasonably expect to ever participate in the program and --
that, coupled with the fact that there are other providers, Senior
Friendship Center, the Neighborhood Clinic, the emergency room.
COMMISSIONER FIALA: Can I add that with the truly, truly
poor, they're already covered with Medicaid. So they're not eligible
either.
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September 6, 2001
COMMISSIONER MAC'KIE: That's right.
MR. TINDALL: Your statement's correct, Commissioner
Mac'Kie, with one minor correction. There are 30,000 uninsured in
Collier County according to the state insurance study, and that
includes children. And so if we take the children out, we're down to
24,000 adults. When we reduce the income level to 150 percent is
where we get the fourteen.
COMMISSIONER MAC'KIE: I appreciate that. I just want to
be sure, because that -- you know, I don't want anybody saying we're
playing voodoo with the numbers. These are real numbers, and the
reason they've reduced is because we've gotten much more
conservative to whom the program will be available.
MR. SCHNEIDER: That's right.
COMMISSIONER MAC'KIE: Thanks.
CHAIRMAN CARTER: Commissioner Fiala.
COMMISSIONER FIALA: Okay. The committee answered a
lot of questions for me too. I had pages of them, as you probably
noticed, but I'm down to just a few.
I have to say, one of the things that was brought out that I was
not aware of is, I didn't realize how many other counties, not only in
Florida, but across the U.S., have already adopted health care
programs. That means that we can learn from other people's
experience, and I found that to be very encouraging. I was
wondering, do we have an idea how many counties in Florida have
this program? Did you say 27 or 20?
MR. TINDALL: Have the We Care Program, volunteer
program.
MR. RASNICK: There's 27 counties that are covered, and I
think it's 24 programs but 22 programs with We Care. But, in
addition, there's some counties that have full-blown programs, like
Dade County and Hillsborough, that don't have a We Care Program
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September 6, 2001
but have a program to deal with the population. So that's -- When
you combine those, you're talking over half the counties in Florida
have one program or another, and it, by far, represents the vast
majority of the population.
In addition, that's just this program. There is something called
Project Access that was actually started in Asheville, North Carolina,
Polkton County, and that's been replicated across the country and is
very similar to the We Care concept. In addition to Florida, this
concept is very much going on across the U.S., and that's just one
model. There's a bunch of other models.
COMMISSIONER FIALA: Well, the good thing about that I
see is, if we choose to accept this plan as it is today and you say we
need it in place for at least 18 months to gather demographics, we
then have that 18 months to also look at what other counties have
found as an alternative way of funding this program so that possibly
we might even be able to keep those costs down -- I thought that was
very exciting -- and learn from others so that we don't stub our toe as
badly.
Let's see. Oh, I have some more. That is what I wrote about,
was other funding sources. So we might also find out that we are
eligible for grants from the state, from the federal government or
whatnot, and that might also help to keep our costs down. So by
taking this first step, it gives us a path to follow to find other funding
sources over the next 18 months, which to me is very encouraging.
Those were more comments than questions, I guess. I heard
today that the majority of residents I heard mention over and over --
but I was interested to note that the League of Women Voters was
here, and I think they have a great membership. And United Way, I
believe that they have a power-packed membership. And I know the
churches have a lot of members. And so I thought-- I don't know
that it's always the majority. I think that maybe it was just the
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September 6, 2001
majority of people that were here and not working today that were
able to represent themselves. And I think I have one final thing to
say, or do I? I think that's it. Is it? Yes, that was it.
COMMISSIONER MAC'KIE: I'm just going to take two shots
and -- just by being the senior person on this board and say, there
have been days that I have been ashamed to be a county
commissioner. Gratefully, today is not one of them. Today is the
day I'm very proud to be a county commissioner, and it's with most
sincere gratitude to this committee -- to both of the committees and
the work that you have done. You have served us well, and we are
forever in your debt, and you have left quite a legacy that's going to
be a very powerful and very positive one in this county. MR. RASNICK: Proud to be a Republican.
COMMISSIONER MAC'KIE: Proud to be a Republican. That's
right.
CHAIRMAN CARTER: Any other comments by the board?
Mr. Olliff, any comments to us?
MR. OLLIFF: Only a notice to the public that this meeting will
be replayed immediately following the board's budget public hearings
tonight. So if anyone up in the North Naples area in particular who
didn't get the opportunity to watch, it will be back on later this
evening.
Other than that, Mr. Chairman, I think Peter Drucker would
recommend that we adjourn.
CHAIRMAN CARTER: Thank you. We stand adjourned.
Thank you-all for being here.
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September 6, 2001
There being no further business for the good of the County, the
meeting was adjourned of the Chair at 1:42 p.m.
· ..<,~ .~.',.."
t~,t,~~ge minutes approved by the Board on ~. g ~o/
presented / or as corrected .
BOARD OF COUNTY COMMISSIONERS
BOARD OF ZONING APPEALS/EX
OFFICIO GOVERNING BOARD(S) OF
SPECIAL DISTRICTS UNDER ITS
CONTROL
JAMES D(~ARTER, PH.D, CHAIRMAN
, as
TRANSCRIPT PREPARED ON BEHALF OF DONOVAN COURT
REPORTING, INC., BY CAROLYN J. FORD
Page 115