With a part-time job that pays about $10,000 a year and no health benefits, Jacqueline Samuel of Miami has relied on Jackson Health System, the county’s public hospital network, to manage her chronic kidney disease at reduced rates since last year.
Through Jackson’s charity care program, Samuel said, she was paying about $70 to see a nephrologist each month, $50 for routine blood tests and $22 a month for four prescriptions. But in June, Samuel failed to renew her membership in the Jackson program – and that’s when the trouble began.
She had an appointment for a blood test and kept it, at the suggestion of a Jackson financial assistance counselor, because her renewal application was being processed.
A few days later, Samuel got a bill for the blood test: $1,640. She couldn’t pay it. She stopped going to the doctor and refilling prescriptions. “I can’t see the doctor,” Samuel said in early August, “unless I have the money to pay them.”
Samuel, 50, said Jackson officials did not re-enroll her in the charity care program in June because – despite providing utility bills, paycheck stubs, a property tax receipt and bank statements – she did not produce signed, notarized affidavits from one of her adult sons, and from family friends in St. Kitts, attesting that they have provided her with financial support in the past.
Demanding onerous paperwork from low-income applicants is just one way that Jackson has barred eligible Miami-Dade residents from accessing the charity care program, according to administrative complaints filed this week with the Internal Revenue Service and the U.S. Department of Health and Human Services.
The complaints lodged by Florida Legal Services and the National Health Law Program, nonprofit groups that provide civil legal help to the indigent, allege that Jackson fails to meet new requirements for nonprofit hospitals under the Affordable Care Act and other laws.
The groups say Jackson has not widely publicized its charity care program as required under the health law and has put up eligibility barriers such as “unduly burdensome verification requirements.”
The complaints also say Jackson subjected uninsured patients to harsh debt-collection tactics without telling them about financial assistance, and the hospital system had failed to produce a required “community health needs assessment” to help Jackson design a charity care program.
Miriam Harmatz, a health law attorney with Florida Legal Services, said Samuel could not afford to pay $25 a page to produce the notarized affidavits Jackson wanted – documentation that Harmatz calls excessive, since state and federal officials don’t request such records from people who apply for Medicaid or a subsidized health plan under the ACA.
“It bothers us that this is how they’re treating people,” Harmatz said. “We don’t think Jackson is taking the necessary steps to ensure that people really have access.”
As a county resident who meets low-income criteria, Samuel should qualify for charity care from Jackson, Harmatz said, noting that the public hospital system with a mission to treat Miami-Dade’s uninsured and indigent receives more than $350 million a year in local property and sales taxes.
Jackson offers charity care on a sliding scale, with residents who earn less than the federal poverty level receiving the most generous benefits, such as free primary care visits and nominal copayments for prescription drugs.
After Florida Legal’s intervention in Samuel’s case, Jackson officials rescheduled a financial-assistance interview – approving her for the charity care program on Aug. 19 without requiring the notarized affidavits, Samuel said.
“I went to the doctor yesterday,” Samuel said last week, noting that she qualified for the neediest category. “It’s actually cheaper than the one I had first.” She has not received a second bill for the $1,640 blood test.
Jackson officials declined to comment on Samuel’s case. But Myriam Torres, vice president of revenue cycle management, said “no special treatment” was given to any applicant, including Samuel.
“Maybe circumstances for that patient changed from last time to this time,” Torres said, “and now the attestation is no longer needed.”
Jackson officials say they request notarized affidavits to safeguard taxpayer funds, though Samuel said the hospital system had not requested the documents in 2013.
“We’re not denying care,” said Mark Knight, Jackson’s chief financial officer. “We’re merely asking for validation of what [applicants] are telling us.”
Jackson officials said 29,176 individuals are enrolled in charity care. Knight said that in 2013 the program cost the hospital system $365 million for 212,294 separate medical encounters, ranging from emergency room care to doctors’ visits and outpatient surgeries.
Knight said Jackson has an obligation to screen uninsured residents for eligibility in Medicaid or other public-assistance programs, such as the Cuban Haitian Entrant Program.
“We have to ensure that those people don’t have any other available venues,” Knight said.
Jackson aggressively screens all uninsured patients for some form of coverage, he added. In 2013, hospital system counselors converted 29,746 previously uninsured patients to Medicaid. So far this year, Jackson has converted 22,950 uninsured patients to Medicaid.
Knight said county residents typically have to wait three weeks to meet with a counselor and apply for charity care, but that applicants can schedule a doctor’s visit or other care while waiting for the financial-assessment interview.
However, Samuel’s experience suggests that those patients also risk incurring debt if their applications are denied.
“They get these really high bills,” Harmatz said. “They don’t know what for. . . and they don’t go back. They feel it’s just going to create more medical debt.”
Still, Knight noted, “Billing the patient doesn’t always mean they’re paying it.”
As for the complaints that Jackson has failed to widely publicize its charity care program, including eligibility criteria and debt-collection policies – by not posting the information online, neglecting to post signs in emergency rooms, and failing to insert notices in debt-collection letters – Knight said that the information is available by request.
“We are looking to post those policies online,” he said. “There’s not any concerted effort [not to publicize the information]. It’s just that we haven’t historically done that.”
Matt Pinzur, a Jackson spokesman, disputed the allegation that the program is not widely publicized, given that Jackson treats more uninsured patients than any hospital in the state.
While the health law requires that nonprofit hospitals make their written charity care policies widely available, it does not specify the criteria hospitals must use to determine eligibility for care.
Nor does it offer any guidance on a fundamental question that many safety-net hospitals like Jackson struggle with every day: Are some patients unable to pay, or just unwilling?
That’s not an easy question to answer, said Rick Gundling, a vice president of the Healthcare Financial Management Association, which represents healthcare finance workers.
Gundling noted that safety-net hospitals have to balance a community’s health needs with their resources and mission.
“There’s far more demand than they have resources to do,” he said. “So they’re always trying to figure out the right balance.”
Jackson serves a community with the state’s greatest number of uninsured residents: The U.S. Census estimates that about 744,000 people, or about 34 percent of Miami-Dade’s population, lacked health insurance in 2011.
And while the debut of the ACA’s health insurance exchanges in January provided almost a million Floridians with coverage – federal officials have not provided county-level breakdowns of enrollment – advocates for low-income residents say the need is still great, and probably much greater than Jackson alone can meet.
Samuel, a night-shift custodian at Miami Dade College, is one of an estimated 800,000 Floridians, including about 165,000 in Miami-Dade, who remain uninsured in the so-called “coverage gap” because their annual income is too low to qualify for government help buying a plan under the ACA – and they are ineligible for Medicaid, the federal-state healthcare program for the poor.
Harmatz acknowledges that there is a scenario under which Florida Legal’s complaints would “go away,” but it’s not something under Jackson’s control – expansion of Medicaid eligibility to cover all Floridians, including childless adults currently excluded from the program.
The Florida Legislature has refused to expand Medicaid, though, turning down an estimated $66 billion in federal funding over the next decade.
“If the Florida Legislature would just accept federal funding and provide healthcare coverage for low income adults,” Harmatz said, “then these problems would be wonderfully diminished. All these people would be covered.”