Without federal support, hospitals and health systems in Texas are hampered in their efforts to help the uninsured enroll in health insurance exchanges.
Texas providers with large uninsured patient populations are hoping to have a hand in making enrollment in the health insurance exchanges (HIX) smoother, but for now, it's a waiting game.
Fort Worth, Texas–based JPS Health Network, which includes a 537-bed acute care safety-net hospital as well as 50 community health and specialty centers, illustrates the situation. The health system wants to help its patients understand what is happening with their health insurance, but it can't.
JPS, which applied to the federal government to become a certified entity so that some 60–65 of its staff could be HIX application counselors, says its efforts are stalled.
"We're still waiting to hear from the federal government," says Jill "J.R." Labbe, vice president of communications and community affairs for JPS.
Labbe says once the health system receives federal approval, counselors will be most likely placed in JPS community centers where patients are already enrolling in JPS Connection, a program that offers discounted health care services to patients who meet certain income requirements. It's possible that the JPS counselors could fan out to help patients in other venues, too.
"If we go beyond our own facilities, we will probably go to churches and senior centers," says Labbe.
JPS is not the only organization in Texas waiting on the feds. East Texas Behavioral Health Network (ETBHN), a consortium of 11 community organizations across 75 counties that serves chronic and severe mentally ill patients as well as people with developmental disabilities, received the state's second largest Navigator grant—$1.3 million. But, it still hasn't been able to fully staff its centers.
"We had a tough time filling positions," says Gary Bramlett, executive director at ETBHN.
Bramlett says he's been able to hire 16 navigators so far. He plans on hiring 24, which would put two navigators at each of the 11 centers, plus two lead navigators in different regions of the state to collect data and act as a resource for the other navigators.
Of the 16 who have been hired, a little over a handful are out in the community helping patients enroll.
"Seven are fully trained," he says. "The rest are in the process and almost finished with their training."
It's not where Bramlett wanted to be, but federal government approval of ETBHN's grant application didn't come until late August. The application was submitted in June.
Dallas-based Los Barrios Unidos Community Clinic, a federally funded health center serving the area's large, uninsured and underinsured Latino population, echoes the delays experienced by JPS and ETBHN. Unlike JPS, however, it has already received approval to certify some staff as application counselors.
"We just started enrolling this week," says Joleen Bagwell, director of development and marketing for Los Barrios Unidos, which received federal approval also in late August. "It took us that amount of time to [train]."
Hospitals and health systems like Los Barrios Unidos, JPS, and ETBHN, are eager to see HIXs succeed because it will impact the populations they serve.
Bagwell says about 14,000 of its patients are uninsured, and the Los Barrios Unidos staff who are certified application counselors are charged with reaching out to its own patients as well as the community at-large so that it can ultimately drive down costs.
"Right now, we can get our patients in for discounted or even free services," says Bagwell. "For example, we work with agencies on breast health. [Our patients] are tied into the healthcare system through Los Barrios, we have the resources and collaborations to allow women to have testing and treatment. If this same woman has insurance, the options open to her are greater. We have great options, but with health insurance exchanges, it will ease up on the system."
Both Parkland Health & Hospital System, the Dallas-based safety net system and the American Hospital Association have questioned the Centers for Medicare & Medicaid Services about whether hospitals can pay premiums for patients who enroll in the HIXs.
The answer remains murky, as does the road to Medicaid expansion in Texas. Governor Rick Perry has held the line at a firm "no," despite outspoken opposition from providers.
"[HIX]is going to help some more of our indigent population, but there's some that will be left in a hole without Medicaid expansion," says Bramlett. "I hope that Texas decides to expand Medicaid."
Without the expansion, the Texas Hospital Association says the exchanges' effectiveness will be muted.
"Hospitals and other community-based groups are working hard to get as many uninsured Texans as possible enrolled in the best coverage option," says Dan Stultz, MD, FACP, FACHE, CEO of THA.
"Unfortunately, the missing piece of Medicaid expansion means the impact of health reform to reduce the uninsured population will be blunted. The state's decision to sidestep Medicaid expansion is an acceptance of the status quo where large numbers of the working poor do not have access to employer-based coverage resulting in limited access to comprehensive, affordable health insurance options."
David Salsberry, CFO and executive vice president of JPS, says another roadblock in Texas will be the provider network. He says he initially anticipated a significant change in patient load because their options would be greater, but if there are a limited number of physicians taking HIX patients, the impact will also be limited.
I thought, 'We're going to have a lot of patients who we may lose because they'll have more choice,' but what physicians are going to be willing to take those patients?" he says. "We have the largest family practice residency in the country, so at first I thought [we'd] run the risk [of losing patients], but now I don't think it's going to be as great."
Jacqueline Fellows is a contributing writer at HealthLeaders Media.