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Obamacare Odysseys

Promise of Affordable Care Act Falls Short for Harris Health

Harris Health, the county’s public hospital and clinic system, has long been the safety net for the uninsured. But this year some of those patients had a choice: continue to get care at Harris Health (and pay a tax penalty for being uninsured), or sign up for private insurance through the Affordable Care Act. Most stuck with the safety net. Health educator Denise LaRue says lots of patients were unfamiliar with health insurance and didn’t see the benefit of paying premiums, deductibles and co-pays.


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The Affordable Care Act was created to help uninsured people, and by extension, relieve the burden on public hospitals like Harris Health. But that promise fell short for Harris Health, at least in this first year of enrollment.

The subsidized plans, offered for the first time earlier this year through an online marketplace, wouldn’t have covered everyone who visits Harris Health. Residents under 100 percent of the federal poverty level don’t qualify for the marketplace, neither do patients who may be here illegally.

But Harris Health estimated that about 48,000 of its patients were eligible to purchase a subsidized, commercial health plan. The system made a big effort to enroll people in the plans, training 300 of their own workers to walk patients through the sign-up process. During the enrollment period, from last October through March, those workers were stationed at outpatient clinics and other sites where Harris Health does outreach. The hope was that after they got insured, the patients would choose Harris Health as their “medical home” and the system would reap the payments from the commercial insurers.

Harris Health Smith Clinic, named in honor of philanthropists Lester and Sue Smith, is designed exclusively for outpatients requiring specialty care. The five-story facility, opened in October 2012, has more than 100 exam rooms, and houses many diagnostic and specialty clinics, as well as radiation therapy, oncology, and infusion services.

Mike Norby, the system’s chief financial officer, said it was a tough sell. In the end, Harris Health was only able to convince 27 people it was a good idea.

“I’m not surprised,” Norby said. “If you look at the math, it would have been surprising to have a large number of people sign up.”

That’s because Harris Health already offers attractive payment plans for low-income patients. Norby says there wasn’t enough incentive to switch.

Even though some of the new plans had modest premiums, like $50 a month, that’s still more than required at Harris Health. For example, the system’s “Plan 2” covers residents between 100 and 200 percent of the federal poverty level. No monthly premium is required, although there are co-payments, such as $10 for a clinic visit and $150 for a hospital stay. 

“On the one hand it speaks to the fact that the majority of that population that’s getting service at Harris Health is satisfied with the services they’re getting,” Norby explained. “Because if they were really dissatisfied they would have figured out how to pay $50 a month and go find someplace else.”

“On the other hand, it’s disappointing because it really would have provided a revenue source, a much-needed revenue source for the organization,” Norby added.

“They didn’t do anything unexpected,” he said of the eligible patients who didn’t sign up. “They did exactly what any of us would have done when faced with ‘I can pay X or I can pay Y, and I can get reasonable services either way, I’m going to choose to pay less.”

Denise LaRue is a senior health educator at Harris Health. She and other outreach workers helped people shop for coverage on the online marketplace,

LaRue says most patients felt reluctant to make that change, especially if they were unfamiliar with how insurance works.

“They’ve never had it, so now you’re asking them to fork out more money, possibly at different times: monthly for premiums, a big chunk up front for a deductible, every time you go in for a co-pay,” LaRue said. “That can be really devastating to a family.”

In addition, many patients felt uncomfortable with a decision that might require leaving Harris Health and going elsewhere for care. (Harris Health accepts 30 of the 42 plans sold on the marketplace.)  

“They had a lot of questions,” LaRue said. “They say ‘We’ve been coming here for years, you know, this is what we know. They speak my language. I’m comfortable here. Where am I going to have to go?’”

The question now is whether Harris Health can persuade more uninsured patients to sign up in 2015.  If so, the system could get millions more in revenue from insurance companies. One estimate put the potential annual revenue from the Affordable Care Act at $31 million.  

Harris Health Lyndon B. Johnson Hospital is a 328 licensed-bed acute care hospital offering a full range of medical services. It is a verified Level III trauma center, and with approximately 70,000 emergency patient visits each year, it is the state’s busiest Level III trauma center.

Norby says one option would be requiring those patients to first check if they qualify for a marketplace plan before turning to the county for treatment.

“If in fact there are options, we shouldn’t be stepping in to provide care in lieu of those options,” Norby said, adding that he was speaking for himself and not the system’s Board of Managers.

“We are supposed to be the last resort. But right now our policy really doesn’t allow us to tell patients that you have to go sign up for the health insurance marketplace, or you don’t get coverage here.”

Any change in eligibility would have to get approved by the board of managers for Harris Health and possibly also by the Harris County Commissioners.

Another option to motivate patients would be to help them pay those monthly premiums on the marketplace plan. Norby says the federal government won’t allow hospitals to do that themselves, but a private foundation could step up and subsidize the premiums for low-income patients.

A third option is just to wait. Patients will grow more familiar – and comfortable – with the Affordable Care Act over time, according to many local health advocates in Houston. And federal tax penalties for not buying insurance will rise next year, and in future years, possibly providing additional incentive to get covered.