Free Clinics Beat Insurance, for Some
With open enrollment for health insurance ending in just two weeks, the push is on to get everyone who qualifies signed up. But some of the uninsured are balking, and it’s not only the so-called “young invincibles” who think they don’t need it.
Gary Babcock of Clearwater, for example, is neither young nor invincible. He’s 55, with diabetes so severe he has to give himself daily insulin shots.
At his income level, he could choose from several Affordable Care Act plans with no premium, fully subsidized.
But he didn’t sign up last year and won’t enroll this year either, he said, because he gets everything through the St. Petersburg Free Clinic – drugs, supplies, checkups and classes on diabetes management.
“They’ve been really great giving me everything I need,” says Babcock, who hasn't had health insurance the 11 years he has lived in Florida. “I can’t say enough about the people that work there …It’s unbelievable.”
Free clinics are a lifeline for the uninsured with incomes too low for the federal Marketplace – 100 percent of the federal poverty level, $11,770 for a single adult and just under $16,000 for two. Those above that income level have been enrolling on the HealthCare.gov Marketplace, with most qualifying for premium subsidies.
Susan Easter, health center director for the Free Clinic, says they encourage patients who qualify for a private plan under ACA to enroll, and a navigator comes in once a week to help them do it. But people like Babcock who refuse to enroll in a private plan won’t be turned away.
“If they’re saying, ‘We can’t afford that’ and we feel they’re low enough income, we’ll see them here,” she said.
A non-profit with a full-time nurse practitioner, the free clinic depends on donations and grants and many volunteers, including physicians. It treats adults between ages 18 and 64; the total last year was about 6,000.
The health law “is clearly meeting the needs of some individuals because there were quite a few who did leave and have not come back,” Easter said. But not all.
“We’ve seen some of those individuals migrate back,” she said. “They’re finding they can’t afford all these costs out of pocket that they were not used to paying and weren’t expecting.”
On the other hand, the Affordable Care Act requires that the uninsured be enrolled if they meet the minimum income guidelines and aren’t in one of the exempt groups. If they don’t, they owe a penalty at tax-filing time.
The penalty is laid out online, and in general, in 2014 for a single adult, it is $95 or 1 percent of income that’s over the tax-filing threshold, whichever is greater. For 2015, it’s $325 or 2 percent. In Babcock’s case, that’s about $120 penalty for not having coverage last year.
The threatened penalty infuriates Babcock.
“They shouldn’t force me to apply for health insurance. I shouldn’t have to be forced into it and pay a penalty for not having it,” he said. “I’m American, I should be able to make my own decisions, I shouldn’t be told I have to do something.”
There is considerable irony in that many uninsured Floridians who badly want to enroll in a plan on the Marketplace can’t do so because their household income falls below the poverty level. Florida’s Legislature has not yet accepted the federal funds under the Affordable Care Act that would pay for their coverage. (The funds, originally pegged for Medicaid expansion, are being used to pay for private plans in some states).
The number of those who want to enroll but can't qualify because of the state's decision is variously estimated at between 750,000 and 1.2 million.
The federal government reported this week that Florida has racked up 1.3 million enrollments in an ACA plan so far this year, including those who just kept their plan from 2014. That means Florida accounts for nearly one in seven enrollments in the federal Marketplace, which serves 37 states.
“Clearly, many people in Florida do want coverage,” said Jodi Ray, who directs a federal grant program that pays for enrollment assistance statewide.
One advantage of enrolling in a plan rather than relying on a free clinic is coverage for hospital treatment.
Alison King of Brandon, 48, said she faced a $1,350 bill after visiting a hospital emergency room for a throat infection last year. She has her own small pool-cleaning business, which provides only a modest income, so she didn’t have the money to pay the bill, she says. She ended up negotiating a settlement of $375, which she paid on the installment plan.
After that experience, King would be a likely enrollee for a private health plan on the Marketplace -- if not last year, then for 2015. But so far she has not signed up, for a mix of reasons.
For one thing, she said, she wasn’t sure how to do it, assuming it requires computer skills. For another, she thought an Obamacare plan would cost hundreds of dollars a month, unaware that her $18,000-a-year income would make her eligible for a full subsidy.
But the main reason she hasn’t hurried to enroll is the Brandon Outreach Clinic, which supplies nearly all of her considerable health-care needs. A diabetic, she needs frequent check-ups, blood-testing strips and insulin.
She also has high blood pressure and severe sleep apnea, a condition in which the airway gets blocked temporarily. The clinic arranged for her to have a sleep study, which showed she stopped breathing many times each night and her oxygen level dropped to 70 percent. The clinic then arranged for the donation of a positive-air pressure (CPAP) breathing mask and oxygen concentrator for her to use at night.
“If I were to lose my care that I’m getting at the Outreach Clinic I would be in a real jam,” King said.
She said she doesn’t like or trust insurance companies after a bad experience with a property carrier, but her failure to enroll in a health plan seems more related to confusion than aversion. She said she has tried to get more information but wasn't successful.
By contrast, Babcock just plain isn’t interested.
He says he worked with race horses in New Jersey and had health insurance until he moved to Florida to be closer to his mother. He fell into property-maintenance work just to have a job, but it doesn’t pay a lot and he is technically self-employed, with no benefits.
He thought it didn’t matter – he never went to a doctor – until last April, when he stuck his finger with a thorn from a palm tree.
“The first three days it was fine,” he said. “Then the fourth day, it started to turn red and get infected. This finger here blew up to the size of a cucumber.”
Redness was creeping up his hand. He had to seek help at an emergency room, where his blood-glucose levels were found to be nearly 600; he could have gone into a coma at any time.
Babcock spent seven days at St. Anthony’s Hospital in St. Petersburg, including four in the intensive-care unit. The bill must have been huge, but he says he never saw it. It isn’t clear if the hospital sent one.
But St. Anthony’s referred Babcock to the free clinic, where he has received the best of care ever since, he says. He said he doesn’t worry about not being able to pay for his own health care.
“Everything is a donation, you know. It’s people that are helping other people.”
Such thinking exasperates Linda Quick, president of the South Florida Hospital and Healthcare Association. “Well, it’s not donated," she said. "Someone is paying for it.”
Bill Allen, professor of medical ethics at University of Florida, says people don’t like to change their doctor or treatment center once they’re comfortable with it.
“Some folks are used to getting their care a certain way and don’t want to go through what they may perceive as a paperwork hassle," he said. "Some people have been taught to be suspicious of signing paperwork that they don’t understand.”