ALMOST A DECADE AFTER THE AFFORDable Care Act was passed and six years after it began, with its central promise to afford every American good health insurance, about 2.7 million or
13 percent of Floridians have none. That’s the highest rate in 47 out of 50 states, says the U.S. Census Bureau in a report released in September.
The growing rate of uninsured people in Florida strains public hospitals, which are on the hook for millions in uncompensated care every year, along with a network of free and charitable clinics that are helping fill the gap in medical care that insurance is still unable to.
Those people who can’t afford health insurance in Florida are typically working adults, age 19 to 64. Children, seniors, pregnant women and some of those with severe conditions or disabilities qualify for some form of insurance under Medicare or Medicaid.
Throughout the U.S., the census survey found, 27.5 million people or 8.5 percent of the population had no health insurance in 2018, compared to Florida’s 13 percent. State averages ranged from a low of 2.7 percent uninsured in Massachusetts to 17.7 percent in Texas. Georgia and Oklahoma are the only two other states that had higher rates of uninsured than Florida.
One major reason why Florida has such a high rate of uninsured, the report says, is that under Gov. Rick Scott it is one of 19 states that declined to expand federal Medicaid insurance to the state’s “working poor.” Those are people who live in poverty, or officially whose incomes are $16,394 per year for an individual or $33,534 for a family of four (at or below 138 percent of the federal poverty line).
By last year, those 31 states that chose to expand the program had on average half the rate of uninsured people than those that did not, 6.6 percent compared to 12.4. Kaiser Family Foundation estimates some 445,000 Floridians fall into the Medicaid “coverage gap” who would have been eligible with an expansion.
But even if all those in that gap did sign up, that would still leave some 2.2 million in the Sunshine State uninsured. For many of those people, the uneven implementation of the Affordable Care Act (Obamacare) in Florida and other states led to insurance that is anything but affordable. While the ACA sharply cut the number of uninsured people in Florida when it was implemented in 2014, its rising costs align with current rising rates of uninsured people. That’s happening for several reasons, in addition to Gov. Scott blocking Medicaid expansion.
For those paying hundreds of dollars each month for a health care plan with premiums or co-pays they couldn’t afford anyway, it might make more sense to drop their plan. Some people who feel blissfully healthy risk it with no insurance. And others without insurance are middle-income people or higher earners who just choose not to pay for it.
For whatever reasons, the shrinking pool of people with health insurance leads to a vicious cycle of rising health care costs that strain the entire system, explained Ben Spence, chief financial and business service officer for Lee Health, which runs hospitals throughout Lee County.
The rising costs burden everyone: hospitals and clinics as well as those people who do have insurance, who end up paying higher premiums and co-pays to help cover for those not paying in to the system. And for those who can’t afford insurance, quality health care becomes less and less accessible.
“It’s not sustainable in the long run,” Mr. Spence said.
Lee Health’s cost to pay for those without insurance jumped from $79.1 million in 2013 to $119.4 million in 2019 (in fiscal years) as the county has grown, with that being about 7 percent of the system’s gross charges.
Lee Health hospital ERs treat many of those patients. Uninsured patients who need inpatient care also cost Lee Health $1,878 every day, or $47.2 million per year.
Much of the rest comes from writing off charity care for those patients with incomes up to 200 percent of poverty guidelines, and deeply discounting care for those up to 400 percent. LeeHealth also runs charitable clinics for those with the least income.
Adding insult to injury, hospitals lose millions of dollars every year on Medicare and Medicaid, because the federal government does not reimburse them for the full cost of care under those plans.
Yet Lee Health still needs to make money. Even as a nonprofit it sustains a 3 percent profit margin to keep up with expansions and technology in Lee County, one of the fastest growing in the country.
“So when you have a growing number of uninsured who pay nothing, how do you pay for that?” Mr. Spence said.
The answer completes the vicious circle once again: higher costs for individuals and businesses who are insured or can afford to self-pay. It also falls on hospitals and a local network of free and charitable clinics.
Solutions: filling the gap
Hospital emergency rooms are unfortunately often a first point of contact to treat the uninsured. That’s one of the most consistent results of having inadequate insurance. People who are struggling to afford the most urgent costs such as food tend to put off things like mammograms.
But there are much better options for the uninsured. Local public, nonprofit hospitals like those run by Lee Health typically offer discounts for those whose incomes qualify (private, for-profit hospitals usually don’t). But hospitals aren’t set up for primary care, which can help keep people out of their high-priced ERs and inpatient rooms.
That’s one of the main reasons why hospitals also run their own or work alongside a statewide network of free and charitable health care clinics for patients with lower or no incomes. In many cases, these are patients who would remain uninsured, even if Florida had expanded Medicaid. They draw support from volunteers, local health care providers, philanthropists, community groups and government grants.
Each clinic has its own requirements, which usually include that patients are at or below 200 percent of the federal poverty guidelines, have no other means to pay and have been denied Medicaid.
Those clinics and their network of supporters provide the safety net that insurance right now does not. They save lives and offer patients access to at least some basic level of comprehensive services that helps keep them out of the ER and at work, even if that work is underpaid.
Services may include dental work, mental health care, surgeries, a pharmacy and prescriptions, primary care visits, up-to-date exams and check-ups, and education on overall health and well-being.
NCH, which runs hospitals in Naples, discounts hospital services if patients qualify based on income.
“We try to make it so the payment would never get in the way of accessing health care,” said Paul Hiltz, who started as the new CEO of NCH on Sept. 1.
But for the county’s lowest income patients, Mr. Hiltz points to the Neighborhood Health Clinic in Naples as a potential model for filling in Florida’s coverage gap. It only accepts Collier County residents.
“Really their goal is to keep people out of the emergency department, so I envision stronger partnerships with groups like that,” he said. “The health care system can be kind of fragmented, generally speaking, so I for one would like to work more closely with other providers to make a network of care.”
The Neighborhood Health Clinic’s CEO Leslie Lascheid calls it the “safety net of those safety nets” because even those who might have qualified had Florida expanded Medicaid wouldn’t qualify here.
“This is the population that was never going to be insured,” she said, adding that often the patients here are employed in the service industry. And it is not uncommon for them to find the clinic when they are already in poor health.
“So often we get patients from the ER or we get them as they’re being released from the hospital,” Ms. Lascheid said.
Naples resident Maria Gullen, 53, has worked for 17 years for a cosmetics company and never had health insurance. The Neighborhood Clinic has monitored her health as she moves forward after surgery in 2017 that has helped free her of kidney stones. She raised money for her own surgery.
Speaking partly with the help of a translator and her doctor at the clinic, Ms. Gullen recounted a painful, more than decade long journey from being diagnosed to starting her own GoFundMe account to fund a procedure in Miami.
She was at the Neighborhood Clinic that day for a regular checkup.
“For me, it’s the best clinic ever, it’s like my home,” she said. “And I’m grateful for all the services. All the people are very professional, very friendly. Beautiful people.”
If she would have gone without surgery for the stones, Ms. Gullen, in addition to a more painful life, would also have risked kidney failure, her doctor pointed out. That would require dialysis for the rest of her life, a condition that would be covered by Medicaid, adding to taxpayers’ expense.
Like other patients who have found a medical home here, staying healthy also enables her to live and work.
“That’s what saves the county money,” Ms. Lascheid pointed out. “These people are able to work every day, give back to the city.”
The clinic has some 12,000 patient visits each year, Ms. Lascheid said, with its generous supporters funding about $18 million in pro bono work well as $6.5 million in medication.
Three counties north of the Naples Clinic, Sarasota Memorial Hospital with its Community Specialty Clinic is a major safety net for patients who qualify for free care with incomes at or below 200 percent of the poverty line.
The hospital offers low-income patients above that threshold discounts based on individual circumstances. Sarasota Memorial has seen the cost of bad debt and charity care write-offs rise from $34.6 million in 2014 to $48.4 million last year. As health care costs rise, it has also seen a sharp rise in losses from Medicare and Medicaid payments.
At the Community Clinic, about 160 area doctors see patients pro bono, filling most major medical specialties from cardiology to dermatology.
“Any specialty you can think of we have,” said Kathryn Cantley, a nurse and the clinic’s manager. “… Often what we see here are people who have more advanced illness because they either haven’t sought treatment early on out of lack of insurance or just fear of having a lot of bills they can’t pay and so they delay their care until they can’t ignore it any longer.”
The patients are usually in their 40s through early 60s, Ms. Cantley has found. Some of the care they need then is typical for that age group. Hip and knee surgeries are common. So are chronic conditions such as diabetes.
“A lot of them are working poor who are not offered insurance through their employer and they’re making minimum wage,” she said. “I would see that’s the vast majority of people who we see. We do have an element of homeless people but it’s not that large it’s probably about 5 percent of our population.”
She read from a patient surveyed who wrote: “I wouldn’t be able to have health care if it wasn’t for you. Thank you and God bless all of you.”
“So that kind of says it in a nutshell,” Ms. Cantley said. “Most of the people who come here they have no other option so they’re extremely grateful for what’s available to them.”
Just south of Sarasota in Charlotte County, the Virginia B. Andes Volunteer Community Clinic in Port Charlotte has also seen an increase in the need for their services, up about 20 percent over last year, said CEO Suzanne Roberts.
As is true with the general population, lack of exercise, nutrition and disease management are problems for patients. The clinic encourages patients to lead a healthier lifestyle and get off medication if possible, though it dispenses about $5 million per year of medication in retail value, said pharmacy director Robert Wellins said, about that of a small corner drug and convenience store.
While the clinic is able to take care of most of its patients’ needs, and Charlotte County hospitals nearby provide some pro bono care such as limited surgeries, there is also a backlog of services needed for patients here.
Port Charlotte resident Karan Raby, 53, has worked retail jobs, though her employers have not provided it and she can’t afford insurance through the Affordable Care Marketplace. She has found a medical home at the clinic, where she had come that day for a checkup and to renew her blood pressure medication.
The Andes Clinic sees some 12,000 patient visits each year. Among its support are 220 volunteers and 78 local providers and specialists.
Across the state from the Andes Clinic on the east coast, the Health Care District of Palm Beach County’s system of charitable clinics is growing. About a year before ACA first went in to effect, it began a program to provide comprehensive medical care to adults and children at its C.L. Brumback Primary Care Clinics.
The clinics started at four locations in 2013. There are now 10 throughout Palm Beach County operating as Federally Qualified Health Centers, funded primarily by local taxpayers and grants. They offer a range of services including family care, dentistry, psychiatry, a pharmacy, and women’s health services. The system also includes a mobile clinic designed for caring for homeless individuals and families. One of the first things it helps patients do, if they haven’t tried, is sign up for insurance or Medicaid.
As with other clinics designed to offer charitable services, it helps save other local hospitals money at the emergency room and helps keep thousands of people working, even if those jobs aren’t offering them enough to pay for health care.
“I think in a general sense that’s always been a concern that if you don’t have access to primary care services you put things off (and end up) in the ER,” said Thomas Cleare, vice president of strategy. “And that’s really one of the drivers of us having the primary care clinics throughout the county where it’s much easier to access care and prevent people from having to use the emergency room for their primary care.”
The Health Care District reports that more than 44,500 patients received care in 2018, up about 6 percent from the year before. They are part of the Health Care District’s other operations, which include a hospital in Belle Glade, a school nurse program and trauma services. It has also expanded in to addiction treatment due to the opioid epidemic. ¦