Rural clinics help those caught in coverage gap
Published: Sunday, August 17, 2014 at 6:01 a.m.
Last Modified: Saturday, August 16, 2014 at 9:48 p.m.
Surrounded by pasture and large homesteads off a country stretch of State Road 235 south of Brooker, the Alachua County Organization for Rural Needs (ACORN) Clinic seems to be in the middle of nowhere.
But for ACORN, a nonprofit health clinic that has served low-income, small town and rural residents for four decades, the middle of nowhere is the middle of everywhere.
Connected by a short covered walkway, the medical and dental clinics on site draw patients from 18 counties, the vast majority coming from Alachua, Bradford and Union.
Wednesday morning, the parking lot was filled with vehicles, and both clinics were buzzing with activity. Patients had come from Fort White, Starke, Hampton, Gainesville and other areas of North Central Florida, some driving more than 45 minutes to find medical or dental care they can afford.
At ACORN, 65 percent of the 3,000 patients who come to the clinics each year have no coverage through Medicare, Medicaid or private insurance, said Candice King, the clinic’s executive director. The patients cover their own costs out of pocket on a sliding fee scale that takes into account their income.
At a time when the Affordable Care Act was supposed to significantly boost the number of people with health care insurance, safety-net clinics like ACORN remain crowded with uninsured patients who fall in the coverage gap between Medicaid and private insurance available under the ACA.
“What we in the safety net are seeing is that since the state of Florida did not expand Medicaid, there are those who are poor who continue to not have access to coverage,” King said. “They make too much for Medicaid and are too poor to qualify for subsidies under the Affordable Care Act. So we in the safety net remain very full. There are always going to be people who slip through the cracks.”
Lacking health care coverage and the ability to cover costs out of pocket, people often put off their health problems for years, said Dr. Bob Thoburn, a volunteer rheumatologist at ACORN. The person’s untreated or undiagnosed condition then grows worse over time, Thoburn said, until the person eventually ends up in the emergency room, where costs for care are far more expensive, adding to the burden on patients and taxpayers.
Standing along a short block of storefronts in the southwest corner of the county, the University of Florida College of Nursing’s Archer Family Health Care clinic also continues to see a large number of patients who fall through the coverage gap, said Denise Schentrup, the facility’s clinical director.
The Archer clinic sees about 1,900 patients a year, and 40 percent have no coverage.
Argentina Montilla, who lives in Levy County just outside Archer, is one of them. Self-employed with her own cleaning business, Montilla said she applied for Medicaid and didn’t meet the eligibility requirements because the state did not expand the program to low-income adults. She also did not make enough to qualify for subsidies and get insurance through the ACA.
“I am in limbo now because I don’t have any insurance,” she said. “Charity care is my only option for health care.”
Her situation is not unique. In a study released in May, the Henry J. Kaiser Family Foundation said that the decision of lawmakers in two dozen states, including Florida, to reject the Medicaid expansion had a “disproportionate effect on coverage options for uninsured individuals in rural areas.”
Two-thirds of the uninsured rural residents in the country live in those 24 states that rejected the Medicaid expansion. Looking at Medicaid eligibility and federal poverty-level criteria, those rural areas have more low- to moderate-income residents and more blue-collar workers with jobs that might not offer health benefits, the study said.
Compared with metropolitan areas, they also had a moderately higher percentage — 17 percent to 14 percent — of nonelderly residents in households without either a full-time or part-time worker.
Florida’s decision not to expand Medicaid and these individuals’ financial constraints combine for a situation where “uninsured rural individuals may have fewer affordable coverage options moving forward,” the study said.
Staff at ACORN and the Archer Family clinic noted that Alachua County did have one program that could have filled the coverage gap — the CHOICES health care program for the working uninsured. But CHOICES went away at the end of 2013, just as coverage under the ACA was about to start.
Shirley Poindexter, a former CHOICES recipient and ACORN patient, said CHOICES and the clinic combined to “save my life” during years of serious health issues. While ACORN offers sliding scale fees based on a patient’s income, Poindexter said even reduced payments pose a burden compared with the amount she paid through CHOICES.
Currently, Poindexter has another common obstacle to accessing health care in rural areas — a lack of transportation. Her car broke down months back, and in these sparsely to moderately populated rural areas, there is no bus to get to an appointment.
While the Legislature did not implement the Medicaid expansion that might have helped rural residents get health care coverage, state lawmakers did pump money into the region’s safety-net clinics during the most recent session.
This year’s budget includes a combined $750,000 to allow four safety clinics, including ACORN, Archer Family Health Care and the UF College of Medicine’s Mobile Outreach Clinic, to restore programs eliminated or cut back during the recession. They include clinical pharmacy and mental health counseling programs.