KY Free Surgery Program Retools for Underinsured

Even as healthcare reform has expanded insurance rolls, high-deductible health plans have rendered care unaffordable for many. The Surgery on Sunday program, created for uninsured patients, is retooling for the underinsured.

For all its problems, the Patient Protection and Affordable Care Act has made health insurance accessible for millions of Americans, and that is a good thing.

To make that coverage affordable, however, many bare-bones plans have very high deductibles. A family of four earning $30,000 will likely pay deductibles of several thousand dollars before coverage kicks in. The result has been the creation of a new class of patients that one observer has aptly called the "functionally un-insured."

These underinsured people are apt to avoid medical care because of the justifiable fear that they can't afford it. In fact, it is widely understood that one reason why medical cost growth has slowed of late is that high-deductible plans have made care unaffordable.

With that in mind, it would not be unreasonable to suggest that these high-deductible plans are designed more to protect the healthcare sector than patients. If a family of four making $30,000 accrues a $10,000 medical debt, it might as well be $100,000 for them. They'll never pay it off.

These newly underinsured have forced some charity care organizations to change the way they do business.

For the last 10 years, Lexington, KY-based Surgery on Sunday has provided about $10 million worth of free outpatient surgeries for more than 7,500 uninsured people who were too poor to pay for their own care. When the PPACA/Obamacare expanded insurance to thousands of working poor people in Kentucky, they became ineligible for charity care under the SOS criteria, even though their need persisted.

"It's really created a mess for us," says Andrew Moore, MD, a Lexington-based plastic surgeon who is the founder of SOS. "Prior to this, looking back maybe a year and a half or two years ago, we had a waiting list of about 1,500 people. We thought that was dangerous. People were waiting too long. So we expanded the program and got two other hospitals involved so we could do it twice a month instead of once a month so we could whittle down the numbers."

"When Obamacare came on the scene, our criteria for taking care of people was you could not have insurance and you had to be at the poverty level. So, by early last fall we had no or very few people on the waiting list. They all had insurance and didn't meet our criteria."

The backlog of 1,500 patients all but disappeared. Moore says that only about 40 people are on the waiting list. Until recently, SOS was considering expanding to other ambulatory surgery sites and recruiting more volunteers to meet the demand. Now, the program will cut back services to once every other month.

"There is no sense in having people open the doors with 80 volunteers to take care of three or four patients," Moore says. "We'll do it every other month until we can get the numbers back up."

Unintended consequences

Shouldn't we celebrate the fact that fewer people need charity care? That's just the problem. The need is still there, but the PPACA made these underinsured people ineligible for charity care, even though they can't afford to meet the deductible. So they go untreated.

"The problem is the insurance they are selling in our state," Moore says. "They are selling policies that are pretty hard to afford even at a discounted rate. These folks are paying $300 a month and they are at poverty level. That is a lot of money. The second thing is they have huge deductibles. The individual deductible will be $6,000 and for a family that is $13,000. That is no insurance. You are never going to use that because you can't meet the deductible."

SOS is adjusting its eligibility criteria to see if that will alleviate the problem.

"When we looked at that, we were doing 200% of poverty so we went to 250%," Moore says. "This is our first attempt. We may adjust it more. Then we said if their deductible was 10% of their income, we would treat them for free. We just started that and we are spreading word across the state that this is the new criteria. We will probably take a look at this in two or three months and see how that's affected it, and if we need to lower that even further to capture people who need our help."

"I hope somebody puts us out of business, but I don't think that Obamacare does it," Moore says. "In our state it has changed from an uninsured population to an underinsured population. I read that by a wide margin most bankruptcies are healthcare-related, either for people who have no insurance or who are underinsured. That tells you it's fairly expensive, and somehow we have to get ahold of the cost to make it more affordable for people."

Societal good and bad

Let's be clear: Expanding health insurance coverage to millions of people is a net positive for society. The PPACA should not be too harshly criticized for creating a new class of underinsured people, because that is still preferable to what we had before.

That doesn't mean that improvements can't be made that will make access to healthcare more affordable to these underinsured. After all, underinsured people, like the uninsured, will delay seeking care until it becomes too critical—and expensive—to ignore. That defeats one of the oft-stated goals of the PPACA and the wellness movement: to treat people early and in the least-expensive, most efficient environment.

Can society respond? Healthcare "really is out of the reach for a lot of our population," Moore says, "and if we can't do this as a nation, we have to do this as individuals to help these people along."