Purvi Patel

JD/MPH Class of 2010

Tufts University School of Medicine

Department of Public Health & Professional Degrees

Master of Public Health

Applied Learning Experience (ALE)

Project Title: Implementing a Human Right to Healthcare: A Qualitative Case Study in Lewis &

Clark County, Montana.

Project Site: National Economic & Social Rights Initiative

Preceptor: Anja Rudiger, Human Right to Health Program Director

Community Presentation: available at http://www.slideshare.net/patelpurvip/qualitative-research-

on-health-as-a-human-right-in-lewis-clark-county-montana

Abstract Lewis & Clark County, Montana is home to approximately 60,000 Montana residents, many of

them concentrated in a few small towns, such as Helena (the state capital), Augusta, and Lincoln.

The best available data indicated that 21% of county residents live without health insurance.

Furthermore, residents without health insurance experience serious lack of access to healthcare,

factors that contribute to serious health problems such as increased risk of dying from cancer,

serious complications and worse clinical outcomes for chronic diseases like diabetes, cardiovascular

disease, and mental illness. On December 4, 2008, the Lewis & Clark County Board passed a

resolution declaring health and healthcare to be a human right for all of its county residents, and

creating a task force charged with conducting a countywide health needs assessment to investigate

ways to implement the new mandate.

To assist with the county’s health needs assessment, this project (working with NESRI) sought

to evaluate qualitative focus group data gathered from Lewis & Clark county residents regarding

current access to healthcare, quality of services, and barriers to receiving or seeking care, as well as

opinions on the notion of health and health care as a human right. Qualitative research was

conducted by NESRI and the Montana Human Rights Network (MHRN) through eight focus groups

in four towns within Lewis & Clark County between mid-August and early-November 2009.

Groups ranged in size from two to fourteen participants, with a total of 47 participants. Focus

groups sought:

1. To identify how sample populations (rural, uninsured, underinsured, etc.) use health

services;

2. To identify barriers to accessing health care;

3. To identify unmet health needs;

4. To solicit recommendations on what measures the county should take to move toward

universal access; and

5. To obtain feedback on the Board of Health’s resolution

IRB exemption was sought and granted because analysis consisted of evaluating de-identified

qualitative data from focus group transcripts. Group-by-group demographics were gathered through

the use of participant monitoring forms, and aggregated to provide an overall picture of research

demographics for the project. Over half of focus group participants were between the ages of 45-64

years; none of the participants fell between 35-44 years-old, which was seen as a short coming in

the sample groups researchers were able to recruit. Education level was fairly well distributed

among participants, however about two-thirds or participants had $50,000 of income per year or

less. Almost two-thirds of participants depended on employer-sponsored or governments-sponsored

(i.e. Medicare or Medicaid) plans for health insurance; around one quarter of participants were

uninsured.

Qualitative data was analyzed according to a human right to health framework, looking at

themes of access to care (costs and financing), availability of services, quality of care, and dignity in

treatment. Participants of all groups except one (Augusta) were also asked to discuss whether they

believe health and healthcare to be a human right. Participants offered a range of suggestions for

the county in the areas of expanding health care services, particularly primary care, improving care

coordination, improving the navigability of the health system, improving transportation, and

expanding financing options. Based on these findings, we drafted preliminary recommendations for

reform to the Lewis & Clark County Health Task Force.

Problem Analysis Lewis & Clark County, home to Montana state capital Helena, hosts 60,925 residents,1 21% of

whom currently live without health insurance – which amounts to thousands of individuals.2 In

2006, it was estimated that 12% of the Montana adult population in general was unable to visit a

doctor due to cost.3 Such data suggest serious complications and worse clinical outcomes for

chronic diseases like diabetes, cardiovascular disease, and mental illness.4 Montana is also ranked

highest in the country in the number of completed suicides.5 In Lewis & Clark County specifically:

Almost 29% of people in Lewis and Clark County live below 200% of the federal poverty

level (FPL)

21% lack health insurance

7% are on Medicaid

54% of Community Health Center clients were uninsured in 20046

As the 2008-09 debate over national healthcare reform grew increasingly contentious, many

state and local governments increasingly felt compelled to respond to the health needs of their

residents. Based on statistics such as those above, and in the shadow of the ongoing debate over

health reform, and the fierce arguments over a potential national pubic health insurance option, the

Health Board of Lewis & Clark County in Montana approved a resolution in early December 2008

recognizing a “basic human right” to healthcare for all of its residents7.

To comply with the new county health care resolution, the Lewis & County Clark County

Health Board created a locally-grounded Task Force on local Access to Universal Healthcare

charged with assessing the health care needs in the county, and to make recommendations about

implementing the new healthcare mandate. The Task Force is currently developing an action plan

for providing access to universal health care in Lewis and Clark County and moving toward a

universal, equitable system. To this end, the Task Force is expected to produce a final report of its

recommendations by March 2010. Based on the task force’s recommendations, the county Health

Board will then try to design some a plan or system that provides universal health care for the area.8

In the words of one Helena city commissioner and Health Board member, “[the Board] said, ‘Let’s

see what we can do to change the debate, and maybe end up with some solutions that we don’t even

know exist at this point.’ ”9

Description of the Agency and Partners: NESRI & the Montana Human Rights Network As an initial step, the L&C county health Task Force sought the assistance of the Montana

1 Lewis & Clark County population statistics, 2008. Available at: http://quickfacts.census.gov/qfd/states/30/30049.html.

2 Mike Dennison, City-County Health Board proposes universal health care. IR State Bureau, HelenaIR.com, Dec 12, 2008.

3 Lewis & Clark County, 2009 Leading Public Health Indicators, Lewis & Clark City-County Health Department, 13.

4 Draft resolution available at www.nesri.org/.../Local_Universal_Healthcare_Resolution_Final_December.pdf.

5 Lewis & Clark County, 2009 Leading Public Health Indicators, , 12.

6 Health and Health Care in Lewis & Clark County: An Initial Data Review. Human Right to Health Program, NESRI / NHeLP, 18.

7 Dennison

8 Dennison.

9 Dennison.

Human Rights Network (MHRN) and NESRI to better understand the needs of county residents

through a health needs assessment.

National Economic and Human Rights Initiative

The National Economic and Social Rights Initiative (NESRI) promotes a human rights vision

for the United States that ensures dignity and access to the basic resources needed for human

development and civic participation. Towards this end, NESRI works with organizers, policy

advocates and legal organizations to incorporate a human rights perspective into their work and

build human rights advocacy models tailored for the United States. NESRI takes a partnership

approach to building a human rights culture in the United States, and prioritizes partnerships at the

community level.

Preceptor: Anja Rudiger (NESRI)

Anja Rudiger is the Director of the Human Right to Health Program, a joint program run by

NESRI and the National Health Law Program. Ms. Rudiger works with state-based coalitions to

develop human rights approaches and tools for health care reform efforts. She is an expert on

human rights and equality, specializing in policy analysis of disparities in the exercise of civic,

economic and social rights. She has extensive experience integrating a rights-based approach to

policymaking at local, national and international level. Previously, Ms. Rudiger carried out

consultancies for governmental and non-governmental organizations, led the research department at

the British Refugee Council in London, and managed the UK Secretariat of the European

Monitoring Centre on Racism and Xenophobia. She received her Ph.D. in Political Science from

the University of Kiel in Germany.

Collaborators: Montana Human Rights Network Based in Helena, the Montana Human Rights Network (MHRN) is a grassroots, membership-

based organization of over 1400 members. MHRN’s mission is two-fold: 1) To promote

democratic values such as pluralism, equality and justice; challenge bigotry and intolerance; and

organize communities to speak out in support of democratic principles and institutions; and 2) To

challenge hate groups and other extremists who use violence and intimidation as tools for political

activism.

Methodology

To implement a countywide health needs assessment, the partner agencies began consulting

with community members and collecting their suggestions for improving access to care. Based on

the belief that community members’ health needs and ideas for improvement can best be explored

through qualitative and participatory research, the Task Force and its partners decided to implement

use of a qualitative research component to the assessment through focus groups with community

members. Through focus groups, the Task Force hoped to be able to get useful in-depth information

on barriers to access, diagnose specific issues that need to be addressed, gain views on potential

improvements, and build awareness and support within the community for the planning phase of

project.

[rest of Methods section truncated]

Using a Human Rights Framework of Analysis Initial drafting of the focus group protocol used basic tenets of a human rights framework to

guide the questions asked of participants. The human rights framework protects civil, political,

economic, social and cultural rights. Each right recognized under this framework adheres to basic

principals that are always part of human rights standards and implementation. These principals

include universality, indivisibility, participation, accountability, transparency, and non-

discrimination. Data gathered from the focus groups was analyzed under a human right to health framework,

which assumes that the purpose of a health care system is to protect health of each member of

society. As such, its design must be guided by the following key human rights standards:

Universal access: Access to health care must be universal, guaranteed for all on an equitable

basis. Health care must be affordable and comprehensive for everyone, and physically

accessible where and when needed.

o Affordability: Health care must be affordable for everyone, with charges based on the

ability to pay, regardless of how health care delivery is financed

o Equity: Health care must be distributed equitably, with resources allocated and used

according to needs and health risks.

o Comprehensiveness: Health care must include all screening, treatments, therapies

and drugs needed to preserve and restore health, including reproductive health.

Availability: Adequate health care infrastructure (e.g. hospitals, community health facilities,

trained health care professionals), goods (e.g. drugs, equipment) and services (e.g. primary

care, mental health) must be available in all geographical areas and to all communities.

Acceptability and Dignity: Health care institutions and providers must respect dignity,

provide culturally appropriate care, be responsive to needs based on gender, age, culture,

language, and different ways of life and abilities. They must respect medical ethics and

protect confidentiality.

Quality: All health care must be medically appropriate and of good quality, guided by

quality standards and control mechanisms, and provided in a timely, safe, and patient-

centered manner.

The following principles, which apply to all human rights, are also essential elements of a health

care system:

Non-discrimination: Health care must be accessible and provided without discrimination (in

intent or effect) based on health status, race, ethnicity, age, sex, sexuality, disability,

language, religion, national origin, income, or social status

Information and Transparency: Health information must be easily accessible for everyone,

enabling people to protect their health and claim quality health services. Institutions that

organize, finance or deliver health care must operate transparently.

Participation: Individuals and communities must be able to take an active role in decisions

that affect their health, including in the organization and implementation of health care

services.

Accountability: Private companies and public agencies must be held accountable for

protecting the right to health care through enforceable standards, regulations, and

independent compliance monitoring.

Results: Participant Demographics Of the 47 participants, across eight focus groups, over half (57.1%) were between 45-64 years

of age. Not a single participant fell into the 35-44 years-old range, reflecting a gap in our sampling

pool. Participants’ education levels were considerable more varied. Three quarters of participants

who responded about their education level had either a high school diploma, an associates degree,

or a bachelors degree. An additional 20% of responding participants had obtained a graduate

degree, while 5% had not finished high school.

Over two-thirds (almost 70%) of participants made incomes of $50,000 or less. In 16 of those

cases (41%) cases, participants made less than $15,000 per year. Of those who had health care

insurance at the time of the focus group, about 37% had employer based insurance, while over 39%

had government sponsored program (i.e. Medicare and Medicaid, excluding coverage through the

Department of Veterans Affairs). About one quarter of participants (24) were uninsured.

Racial or ethnic discrimination was not a big issue. The vast majority of participants identified

as US-born Caucasians, with two of the participants identifying as Native American, and one

defining as a naturalized America citizen from China. As a result, racial or ethnic/discrimination

was not as much of a concern as economic disparities between participants.

Groups Conducted (8 groups, 47 Participants)

Group Date # Participants

Experts 8/17/09 3

YWCA 8/17/09 7

Canyon Creek 8/19/09 2

Lincoln 1 8/20/09 2

Augusta 8/25/09 13

FoodShare 10/13/09 10

Lincoln 2 10/14/09 3

Helena 4 11/5/09 7

Gender Percentages

Male Female

40% 60%

Residency Status

(Unknowns excluded) number percentage

US-born Citz. 45 98%

Naturalized Citz. 1 2%

Immigrant 0 0%

Race/Ethnicity number percentage

White 45 96%

American Indian/

Alaskan Native

2 4%

Educationno HS Diploma

HS/GED

Associate's

Bachelor's

Graduate

 Education Level

(Unknowns excluded) number percentage

no HS Diploma 2 5%

HS/GED 14 34%

Associate's 4 10%

Bachelor's 13 32%

Graduate 8 20%

Income< $20,000

$20,000 - $49,999

$50,000 - $100,000

$100K+

 Household In come

(Unknowns excluded) number percentage

< $20,000 16 41%

$20,000 - $49,999 11 28%

$50,000 - $100,000 9 23%

$100K+ 3 8%

Average Age = 52.0 years-old (Unknowns excluded)

Age Range number percentage

18-24 years 2 5%

25-34 years 5 12%

35-44 years 0 0%

45-54 years 11 26%

55-64 years 13 31%

65+ years 11 26%

Health Insurance StatusUninsured

Employer-based

Gov-sponsored

Individual

Other (e.g. VA,

parents)

NOTE: some participants had more than one source of insurance

Insurance Status

(Unknowns excluded) number percentage

Uninsured 11 24%

Employer-based 17 37%

Gov-sponsored 14 30%

Individual 6 13%

Other (e.g. VA, parents) 5 11%

“Some of the doctors, that are listed in the yellow pages, they’re full. I’ve been having trouble finding a family doctor because I was going to one, but I can’t see him anymore. I’m trying to find a new one, but the people that people have been referring me to, they’re full so they won’t take any more. And I stopped looking, but I’ve had that happen a few times.”

YWCA Focus Group

Results: Key Findings

GENERAL OVERVIEW

Availability of health care– lower income residents generally felt there was a shortage of service

providers in the county. Rural residents felt this particularly acutely. Low income residents also had

difficulty finding health care providers. Higher income residents experienced fewer problems with

finding service providers, with the possible exception of in-county mental health services.

Access (Cost) – Most participants, particularly

low-income and middle-income residents have

experienced difficulty finding insurance, using the

insurance they have, or paying out of pocket.

Quality – There were many positive statements

regarding quality of care, particularly regarding the Lincoln Clinic. However, across the board there

were serious quality concerns, about aspects of care, particularly related to St Peter’s Hospital.

Acceptability/Dignity –Concerns about dignity during provision of service were raised by low-

income residents – particularly the uninsured and those on Medicaid – as well as residents seeking

long-term mental health care.

Health Care as a Human Right –The majority of participants did consider health care to be a

human right. Several others emphasized ethical obligations to meet health care needs, but did not

feel comfortable expressing that in human rights terms. Many participants stressed that to have a

healthy community, the government or community needed to help everybody to be healthy.

Suggestions for reform – participants offered a range of suggestions in the areas of expanding

health services, improving care coordination, improving navigability, etc.

Discussion

Availability of Services

Availability of health services in Lewis and Clark County can be poor. Availability of primary

care to local residents is impeded by a shortage of primary care providers, as well as a lack of off-

peak office hours during which patients can make appointments without conflicting with their work

schedules. Residents also noted a shortage of specialists, particularly quality dental care for low-

income residents as well as mental health providers in general. Referrals to specialists often require

“The cost of medical care is probably the number one thing preventing anyone from going to the doctor” Augusta Focus Group

patients go out-of-county or out-of-network for services, the latter resulting in the patient having to

pay out of pocket for care.

Physicians working within the current health care model are required to operate as businesses.

Because their financial survival depends upon making smart business decisions, health care

professionals may only open practices in areas that promise large populations to care for and the

potential to recruit and retain staff. Consequently, rural populations will lack local services, and will

consequently have to travel great distances to find available care. This can also be a particular

problem for low-income patients because, working within a market model, health care professionals

may only take patients with insurance, may restrict the number of publically-insured patients that

they care for, or may not accept Medicare or Medicaid patients altogether.

There is also poor availability of transportation options to get rural residents and the elderly – other

than private transportation or dependence on family and friends. The ambulance service in Helena

is too expensive for many residence, although residents in Lincoln and Augusta praised the service

provided local volunteer ambulances. Issues of transportation go hand in hand with geographic

isolation from medical facilities, especially for the elderly and northern county residents.

The structure of the current system and its many different forms of administration means that

each person, depending on their insurance (or lack of insurance), requires a different set of

information in order for them to successfully navigate the health system. Patients often do not know

where to go to get the information they particularly need in order to access the available health

services that they can personally afford. Information about ways to obtain cheaper medication or

insurance is also difficult to come by, and prices for services may not be uniform in different

locations, making it difficult for patients to determine whether or not they are getting the best deal.

Thus, availability can be restricted financially, physically, and through a lack of knowledge of what

is available. Lastly, children and teenagers may face additional barriers such that, even if they do

know where to get the services they need, they may not feel comfortable with telling their parents

about their health needs, or might have parents who wish for their children not to seek services.

Access: Cost & Financing

Almost all respondents felt that health care and health insurance was too expensive, and many

residents had (at some point) chosen to forgo health insurance or healthcare, or both, due to

financial considerations. In some cases, uninsured individuals were uninsured simply because of a

calculated decision that insurance was too expensive to be worth purchasing. As a market good,

access to health care is based on a person’s ability to pay for it, but there is overwhelming evidence

that market mechanisms fail to provide equal access to health care.

Although most respondents had insurance, many

had very meager plans with high deductibles that

precluded them from using their insurance to obtain

needed care, instead reserving insurance for use only in

“You know, I grew up pretty darn poor. And I remember 15 years of early marriage paying 5 or 10 dollars to a whole bunch of separate medical providers. And not being able to, I mean, it takes 15 years to pay off something. Well that’s going on all over the country right now. And there’s a whole bunch of people that aren’t getting service at all. I mean that makes me sad.”

2nd Lincoln Focus Group

“[I]f you don’t have money, then you don’t have the right to care.”

Helena 4 Focus Group

cases of extreme emergency. Because of the expense, participants reported forgoing care or waiting

to get care until they can no longer avoid it. In some cases, people felt that it would be better for

them to die so that financial burdens on their families could be eased. When care was sought,

information about bills was in several cases confusing or incomprehensible without assistance. In

some cases, bills contained errors that patients had difficulty getting corrected. Many respondents

felt threatened by medical bills, did not feel supported by their insurer, and in some cases, feared

legal repercussions on their finances.

Government-sponsored insurance was generally seen as a positive option; however there were

problems with its availability and administration. There was concern that people who needed

government-sponsored insurance but were not eligible (particularly poor people who made too

much for Medicaid and retired individuals that were not yet old enough to qualify for Medicare).

There was also concern that applying for the programs, particularly the Medicaid application

process, was too difficult to navigate alone.

Quality of Care

There were many services in Lewis and Clark County that garnered praise. However, such

comments were overshadowed by many negative comments about quality of care received. The

quality of care at the Lincoln clinic, county WIC services, the Helena Foodshare, and volunteer

ambulance services especially were highly praised. Some concerns were related to the current

system’s rewards for the use of technology and pharmaceuticals rather than quality, appropriate

care. Repeated concerns over quality of care were raised regarding St. Peter’s Hospital in Helena,

particularly for emergency care.

Some, participants, particularly those without financial means, and those with specific health

conditions, felt judged, stigmatized, and treated badly in the local health care system. They

attributed this to their inability to pay for their care, or a lack of proper understanding of their health

problems. For example, participants raised multiple concerns over quality, patient-centered mental

health care tailored to what was appropriate for the individual patient.

Participants also reported a lack of communication between providers in cases where they were

seeing multiple providers, both regarding patient care as well as valuable knowledge and

information. This created frustration for patients, who may have been subjected to inefficient care.

In some cases, participants stated or implied that service providers prioritized profitability at the

expense of quality care. When health care is viewed as a commodity to be bought and sold, low-

income people that are unable to pay for their care may be seen to be taking advantage of the

system, or receiving “charity”. The presence of this view was reflected, and particularly apparent, in

prejudice by other participants against alleged “welfare” recipients (a term sometimes erroneously

used to refer to anyone participating in a government-sponsored program) or “illegal” immigrants.

“I was really in pain, and nobody came out in all this time to say ‘ok, is there anything we can do?’ … And I was getting madder and madder, but there wasn’t anything I could do about it because I couldn’t move. [He] gave me a couple of pills, and said I could take one or two of them, and said, ‘Alright, I’ll have the nurse get you a walker so that you can get home alright.’ I have steps going up to my house, and my bathroom was upstairs, I live alone, and I told him this. And he said, you know, ‘I’d really like to admit you but I can’t.’”

Taskforce Focus Group

Acceptability & Dignity in Treatment

Some respondents, particularly low-income participants, expressed concern about being treated

with respect by health providers. Multiple participa9nts felt that doctors had been dismissive of

their concerns, and in some cases, were made to feel that they had no right to express concerns over

quality of care simply because they were not paying for the full cost of their care.

There was also concern about mental health care, and particularly a lack of understanding

among county providers about differen mental health disorders (ex: understanding about PTSD

among medical providers outside the VA system). Patients reported being given excessive

medications, or not receiving adequate care such that when their condition worsened, they were

reported to the police rather than mental health providers.

Health and Healthcare as a Human Right?

All but one of the focus groups were posed the question of whether they considered health care

to be a human right, and the majority generally agreed that health care was a human right. Low-

income participants, as well as Medicare and Medicaid beneficiaries overwhelmingly agreed on

health and healthcare as a human right. Some participants qualified their agreement with a caveat

that healthcare went hand-in-hand a certain degree of personal responsibility to keep oneself

healthy. Of those who stated that they did not believe healthcare to be a human right, participants

still placed high importance on healthcare, and often associated the availability of healthcare with

ethical responsibility. For example, some participants qualified healthcare as a “human need” rather

than a “human right.” When asked to explain the term “human need”, the explanation was couched

in human rights doctrine, suggesting that it was the terminology of “human right” that participants

hesitated to use, rather than reservations about the concept itself.

Participants were more split over the question of government involvement in providing residents

with healthcare. While many participants (especially Medicare beneficiaries) were in favor of

government involvement in providing healthcare coverage, several other participants – especially

rural participants – were resistant to the idea of government involvement. Some participants chose

“I believe [health care] is a right, but it does come with responsibility, and that's the challenge for society, to impress upon people what their basic responsibility is to each other, as a society what we're all responsible to each other here to do our best to be contributors to society, to be honest, to be good parents, good friends, you know it's the community. Somehow we have to rise up better, I think, than we do."

Lincoln 2 Focus Group

“I went in Wednesday, pulled a tooth that was abscessed. I told them I needed antibiotics, and they said no. I went back Friday as my face was even more swollen than it is now. He kind of laughed and said, “Well, I guess we should have started those antibiotics anyhow.” Then reminded me that I was getting the care for free. … I’m going to get into a different dentist that will take payments because it broke one tooth, pulling one out, and I was reminded twice that I was getting the service for free.”

YWCA Focus Group

a middle ground of “moderate” guidance by the

government in healthcare matters. Participants did

generally agree that children should be covered by

health insurance. For those who opposed government

involvement, there was a general agreement that where

individuals had difficulty taking care of themselves,

the community should provide some assistance in

filling the gap. Some participants voiced skepticism

that there was anything that could be done at the

county-level to address their concerns, but there was

some hope that the county could maybe address some

transportation issues, improving funding for facilities

like the cooperative health center, and engage with neighboring counties to better address the needs

of residents on the borders. There was, however, a general agreement that some collective

obligation exists to ensure access to health care for all, especially in order to have a healthy

community. Most participants saw some role for either government or the local community to help

everybody to be as healthy as possible.

Recommendations The focus groups yielded a host of suggestions from participants about what needed to be done

in order to improve health care for county residents, most of which centered on expanding existing

services, improving care-coordination, improving navigability of health services, and expanding or

improving financing options. While some suggestions referred to issues outside the county’s

authority, many others would require only minor changes. In many instances, participants did not

readily think of systemic changes and instead focused on specific improvements to make their usage

of the system easier. Some participants, mainly from Augusta, voiced skepticism that there was

anything that could be done at the county level to address their concerns.

Residents particularly pointed to a need to expand primary care services, especially for low-

income and more rural patients. Suggestions included improving funding for satellite or traveling

clinics to northern parts of the counties, and expanding office hours to include some options for off-

peak hour appointments. There were multiple suggestions to improve the availability of children-

centered services, both primary care and mental health services. Improved coordination of health-

related information sharingwas a major issue raised in several contexts: disseminating health

services information to residents, improving communication between providers, and coordinating

with neighboring counties to ensure adequate services for northern county residents. Multiple

suggestions to improve transportation, particularly for the elderly, were also made.

Among the recommendations that may need to be addressed at the state level are extending

eligibility for Medicaid, requiring employers to allow paid sick days, and addressing high costs of

coverage and care. Some suggestions however could be easily implemented at the county level,

starting with improving the availability of comprehensive, user-friendly information and advice

about health services, for example through creating a health information center or an 800-number,

and improving public transportation, particularly within Helena and between Lincoln and Helena.

More systemic changes, however, are clearly needed and demanded. Expanding primary care

services, including dental care, through the Cooperative Health Center and satellites would fill

crucial gaps particularly for rural and lower-income communities. Finally, based on participants’

“We’re human beings; it doesn’t matter whether we make $7 an hour or six digits a year. We’re humans and we all have something to offer. … Why can’t we get room deserves excellent doctors and caring, patient people. Why is our income a factor in that? I don’t understand that. So it should be a right, and it is very much about respect.”

YWCA Focus Group

comments, the role of the hospital in the community would need to be improved with some

urgency.

Limitations

The fact that we were not able recruit

participants quite in the manner as we had

hoped to do under the sampling framework

presented a major limitation. Of the eight

focus groups held, four of them had either

only two or three participants, while two

groups had ten or more participants. Thus

the distribution of participants among focus groups was not as even as we would have liked.

However, the larger groups were held outside of Helena, and while some of the Helena groups were

smaller, there were more groups conducted in Helena (4) than anywhere else. The other issues in

sample can be seen in the fact that none of our participants fell into the 35-44 years age group. The

average participant age was over 50 years-old, indicating a generally older set of participants.

Aside from sampling limitations, there was also acknowledgement that uniformity in how each

of the groups was conducted might be difficult to ensure. This is due to the fact that while the first

few focus groups were conducted with representatives from NESRI (trained in qualitative research),

later groups were run solely by MHRN and Task Force representatives, who had been trained by

NESRI but were themselves new and much less familiar with conducting qualitative research.

Conclusion

Overall, the participants and partner response to

the project seemed positive, and hopefully, the project

will provide the county health Task Force with some

ideas for county-level improvements to the existing

system. While the county might not have the funds to

open a full clinic in August to serve northern county

residents, a small satellite clinic or traveling services

to the northern areas of the county might fill some of the gap. Furthermore, although the county

may not be able to require more providers to accept sliding-scale fees or payment plans, increased

funding to the community health center or a new similar facility would help increase the availability

of primary care and dental services to low-income patients. The county also needs some way of

monitoring respect issues – maybe setting up a forum for residents to voice concerns about care at

local facilities, and possibly addressing concerns to a county health coordinator position if one is

created.

We’re Medicare, and it’s wonderful. It’s wonderful. I mean I wish everybody in the country had it.” 2nd Lincoln Focus Group

“The group we did last week…it’s not a reflection of the entire community, but it’s a reflection of some parts of the community…”

Researcher, about one focus group