Get to know some of those affected most by Florida's Medicaid expansion debate

Published Feb. 25, 2013

The tea party governor now says he wants to expand Medicaid. The Republican Legislature isn't as sure.

Hanging in the balance? Access to health care for 1 million or more poor Floridians. Billions of dollars in federal money. The state budget, which — already — pumps $21 billion a year into care. Florida's Medicaid system today serves more than 3 million people, about one in every six Floridians.

The decision whether to expand the system by a full third will be made by men and women in suits in Tallahassee's mural-filled chambers this spring.

But the impact is elsewhere, in children's hospitals in Tampa and Miami, in doctors' offices in New Port Richey and in the home of a woman who recently lost her full-time teaching job.

ST. PETERSBURG — Nancy Fraze quit waitressing last year after a letter from the government led her to this conclusion:

Her two children, especially her chronically ill son, are better off if she doesn't work.

Fraze, a single mother, said she was making about $12,000 a year and receiving about $650 a month in child support. But last year, the state said she was making too much money to keep the children's Medicaid coverage.

Get insurance through her employer? Fraze, who has always worked in the service industry, doesn't get those kinds of jobs. Pay for care out of pocket? Not a chance — her 16-year-old son, Dustin, racks up about $1,400 a month in medications for allergies and asthma so severe he has been hospitalized several times. The shots he gets are costlier, one of them $4,300 per injection.

"I want to work," said Fraze, 38. "But basically I'm in this situation."

So she made her calculation. Dustin and his 13-year-old sister, Morgan, can get Medicaid coverage as long as the annual household income remains under $19,000, the cut-off for children in a family of three in Florida. She said there's a safety net program for Dustin since he requires so much care, but her daughter would have nothing if the family lost Medicaid.

Every week, Dustin has to sign in at All Children's Hospital Outpatient Care Center, immediately head for an exam room — he could have an allergic reaction sitting in the carpeted waiting room — and roll up his sleeve for allergy shots or injections of his expensive asthma medication, Xolair.

His mother said the services covered by Medicaid have kept Dustin alive since he first began having reactions at age 2. "If it wasn't for Medicaid," Fraze said, "Dustin wouldn't be here."

Fraze counts herself lucky in some regards. She and her children live rent-free in her father's home. Her boyfriend pays her power bill and car loan. Child support covers the basics for the kids.

But she doesn't have the health coverage that her children do. Fraze's income is still too high to receive regular Medicaid for herself. Because she's poor but not poor enough, the state enrolled her in Florida's Medically Needy Program, which functions like an emergency Medicaid program.

Depending on their income, these patients owe a certain amount of money before Medicaid kicks in. When Fraze was working, her share of medical costs was as high as $700, she said. Now, it's $7.

The program can be a huge help, such as when Fraze had to have a hysterectomy last year.

But she said finding a doctor who will take Medicaid cost-share patients is even harder than finding ones who'll take regular Medicaid. Without a regular primary care physician, her option is also the most expensive one — the hospital emergency room.

That's where she ended up last weekend after breaking her ankle while playing basketball with her daughter.

Jodie Tillman, Tuimes Staff Writer. Times researcher John Martin contributed to this report.

HAWTHORNE — This was not how she envisioned her 60s.

Jean Vincent dreamed of turning her five-bedroom home into a bed and breakfast. She painted murals on walls, created mosaics on floors and let her imagination guide the interior decorating. There is a "garden" room, a "bamboo" room and a "canopy" room.

In 2010, Vincent lost her full-time job teaching in Citra, north of Ocala. Her mother became sick with cancer and needed around-the-clock care before dying in August. Then, doctors began prescribing Vincent costly medications to treat osteoporosis and early-onset diabetes.

"I started getting a little behind with my mortgage," said Vincent, 61. "All of a sudden, I found out I had to have an emergency retina eye surgery."

Today, Vincent is searching for roommates to move into her home and help pay the bills. She begs Gainesville's Sante Fe Community College and City College to schedule her for as many classes as she can handle as an adjunct geography professor; this semester's four is the most she has ever had.

But her biggest worry? Not having comprehensive health care.

Vincent —who is too young for Medicare — is enrolled in CHOICES, a health services program the Alachua County government created for the uninsured. It covers preventative care like her flu shots and helps with her drug therapy. But if Vincent ever got so sick she needed to go to the hospital, she'd be on her own.

Under current Florida law, adults with no dependents are not eligible to participate in Medicaid no matter how little they make. Vincent's four children are all grown, which means even as her income has dwindled she can't become eligible for the health insurance program run jointly by the federal and state governments.

If Florida decides to expand the Medicaid system, people in Vincent's position for the first time could be covered.

The expansion would allow any single adult making about $16,000 a year eligible for Medicaid.

On the matter, Vincent has become an activist. She joined with patient rights group Florida CHAIN and traveled to Tallahassee to lobby lawmakers.

"When I gave my testimony, that's all I wanted them to do was see there were people out there that weren't just trying to take advantage of the system," she said.

This summer, she expects to only be assigned one class at Sante Fe. That will provide about $2,000 for her to live on for three months. Meanwhile, her retirement dreams are put on hold.

"I always wanted to be creative, but I had four kids to raise, then I had my mom," she said. "And now I'm trying to survive."

By Tia Mitchell, Times/Herald Tallahassee Bureau

NEW PORT RICHEY — Dr. Saurinkumar Shah has a complicated relationship with Medicaid.

On one hand, it is his bread and butter. He estimates that 70 to 80 percent of the patients at his single-doctor family practice, Trinity Family Health Care, are on Medicaid.

He takes pride in treating entire families, along with the elderly. He says he can meet just about all of their medical needs, anything from routine checkups to common illnesses. It's the type of work that pays the bills but won't make him a millionaire.

"I am very well satisfied," he said. "I am sleeping at night time."

When he was a little boy in India, his grandmother told him that he would become a doctor. He has been passionate about pursuing medicine ever since.

But being a Medicaid doctor is often-times a pain.

"To deal with Medicaid is not easy," Shah said. "Medicaid has its own rules and it has its own problems."

For example, Shah only gets paid for services rendered to Medicaid patients. However, he has been assigned hundreds of people that never come in, not even for a checkup. Meanwhile, the government caps the number of Medicaid patients he is allowed to treat.

He would like to hire a nurse practitioner to assist him but can't afford it. Instead, Shah employs three medical assistants to run the office and help tend to patients.

In Pasco County, sometimes he has difficulty finding specialists who are willing to treat Medicaid patients with serious ailments. Recently, he had to ask a doctor in Tampa as a personal favor to perform a biopsy on a Medicaid recipient with oral cancer.

The Affordable Care Act does have a provision designed to make Medicaid more lucrative for doctors. As of Jan. 1, states are supposed to pay primary care physicians the same amount they pay doctors who participate in Medicare, the government health care program for seniors.

"That is what I've heard, but I have not seen it," Shah said.

Even so, money is not his main complaint. It's the abuse Shah sees. For every patient that he feels is truly needy of government assistance, there are two that are bilking the system.

Shah believes Medicaid should require more accountability from those it serves.

"Make patients responsible," he said. "Don't think this is a freebie in the name of the poor."

For example, patients are supposed to pay $2 co-pays per visit. Many of them balk at that cost and refuse to ante up. There are no repercussions.

There should be education programs, Shah says, that urge Medicaid recipients to wait to see primary care physicians instead of rushing to the emergency room when they're not feeling well. The government should cut off those who are taking advantage.

He believes the purpose for Medicaid is noble. But what is actually happening, the "big, black hole" as Shah calls it, can be far from that.

By Tia Mitchell, Times/Herald Tallahassee Bureau

MIAMI — Erika Vila, a nurse at Miami Children's Hospital, says expanding Medicaid in Florida means she might see more of her young patients grow up to have children of their own.

That's her hope as nursing director of the hospital's cardiac program, where patients range from premature babies to adults. Those with the most serious heart defects usually wind up in the high-risk clinic, where many, mostly children, rely exclusively on Medicaid to pay for multiple surgeries and round-the-clock specialized care.

"The care they provide the children is very special and unique," said Vila. "It's a different and therapeutic environment."

Indeed, Miami Children's Hospital last year served more than 345,000 patients, with 66 percent using Medicaid, the state-federal health care program for the poor. The percentage of Medicaid patients in three intensive care units — cardiac, neonatal and pediatric — is higher at 70 percent.

"We're proponents of access to care," said Vila, who joined the hospital two years ago. "These kids really do need more than the normal follow-up."

Without Medicaid, low-income families struggle to pay for their children's medical bills, while hospitals struggle to absorb costs for necessary care.

Miami Children's aims to serve all children, Vila said, but making up the difference puts a strain on the hospital's resources.

The hospital would welcome an expansion of Medicaid but would especially like to see an increase in the percentage of Medicaid expenditures for children, Vila said.

For Vila, the positive impact of Medicaid was on display earlier this month when the hospital held its annual cardiac program reunion, bringing together cardiac patients and their surgeons, nurses and ICU docs. The event drew more than 150 former cardiac patients who were treated as children. Many of them came with their new families and children. Years ago, she said, only the wealthiest patients would have had access to such life-saving care.

"It is just amazing to see children that probably would not have maybe survived in other hospitals," she said.

By Erin Jester, Miami Herald