Health care providers across the Greater Houston area are grappling with the effects of an evolving Medicaid program. Because Medicaid was not expanded in Texas under the Affordable Care Act, some have turned to alternative programs in Montgomery County for affordable health care.

“So many people fall through the cracks because they don’t make enough to get private insurance, and they earn a bit too much to get on Medicaid,” said Adeolu Moronkeji, Montgomery County Hospital District Health Care Assistance Program manager. “[These] program[s] really help those people.”

Expansion details

The ACA assumed each state would expand Medicaid coverage for parents or childless adults at or below 138 percent of the federal poverty level—more than 1.2 million Texans—who would not qualify to purchase a subsidy through the health insurance marketplace. However, the Supreme Court ruled the expansion would be optional by state, and Texas decided to opt out.

While it was initially thought the decision to opt out of the expansion would affect public hospitals the most, particularly in urban areas, it has affected all hospitals, said John Hawkins, senior vice president for government relations for the Texas Hospital Association.

“I think the reality is, with the high number of uninsured people in the state, and just the existing number of Medicaid patients and low payment on rates, it impacts all hospitals,” he said. “Any hospital that is running a true emergency room is going to see a lot of uninsured [patients] coming in the ER.”

The only groups that can qualify for Medicaid in Texas are pregnant women, children and disabled adults, said Ken Janda, CEO of Community Health Choice, a nonprofit health plan that provides insurance to individuals across the Greater Houston area.

“The rationale is that [other populations are] able-bodied adults who should go out and get a job,” he said. “But when you look at the details of who they are, most of them are women taking care of small children or have chronic mental health conditions that make it impossible to keep a job.”

Uninsured patients end up becoming charity care patients for hospitals because they are not reimbursed [by Medicaid], said Dennis Laraway, executive vice president and chief financial officer for the Memorial Hermann Healthcare System.

“That really places a greater reliance on the safety net hospital system,” Laraway said.

Hospital district programs

Several local health care providers offer safety net programs that aid those who do not qualify for Medicaid. The programs use alternative funding methods, such as levying property taxes or federal grants, to cover the cost of patient care.

The Montgomery County Hospital District provides indigent care for about 1,800 eligible residents each year through its HCAP, which is funded through a countywide hospital district tax that is allocated for the HCAP and emergency medical services programs, Chief Operating Officer Melissa Miller said.

The program provides qualifying uninsured Montgomery County residents who earn no more than 133 percent of the federal poverty level with up to $60,000 per year in medical costs through partnerships with medical providers in Montgomery and Harris counties. If more than $60,000 a year in medical costs are required, MCHD connects patients with other health care resources in the Greater Houston area, Moronkeji said.

HCAP allows the district to pair patients with an eligibility specialist to determine if they qualify for Medicaid or other assistance programs. The program also helps patients meet with pharmacy representatives who work to find them cost-effective medication and case managers to help patients navigate the health care system.

“We are not just putting people in our program. We are trying to really see how we can help them get to the next level of function,” Moronkeji said.

Miller said the program encourages uninsured residents to visit doctors regularly to manage health concerns proactively. Because hospitals and health care providers are reimbursed for uncompensated care costs for Medicaid through federal, state and local programs, she said the HCAP program reduces the cost to taxpayers in the long run.

“Whether it is about joblessness, [being] handicapped or whatever reason they are on the program, the health care system is going to get their money, and their money comes from taxpayers regardless,” Miller said. “Dealing with people’s medical needs early in a preventative maintenance situation saves the whole system money.” [polldaddy poll=9197321]

Health center resources

Uninsured residents can also receive low-cost health care at the Lone Star Family Health Center in Conroe. The federally-qualified health center uses federal grants to provide affordable care to patients living within 200 percent of the federal poverty level by adjusting their fees based on the patient’s income, said Tiffany Rutledge, LSFHC director of development and communication.

“The health care safety net options [in Montgomery County] are few and far between,” Rutledge said. “We are one of the few providers that offer a discount sliding fee scale based on ability to pay.”

Rutledge said providing affordable alternatives to patients without insurance helps keep the cost of health care down because physicians are able to address health issues proactively. She said some uninsured patients might wait to seek care until symptoms are so severe that they go to the emergency room for care—which can cost more than three times as much as visiting the clinic.

“[This program] is much more cost-effective, and a patient gets plugged in with a health care home,” Rutledge said. “We provide a one-stop shop [for primary care]. Patients can establish a relationship with physicians and be a partner in their health care instead of showing up at the emergency room to get treatment for nonemergent issues.”