Politicians’ ACA stance depends on how close they are to the point of service

Since July 2014, George Masi has served as president and CEO of Harris Health System, a $1.4 billion publicly owned safety net system based in Houston serving Harris County, Texas, with three hospitals and 47 sites. It also has an affiliated Medicaid health plan called Community Health Choice with more than 300,000 members. It was recently reported that Texas Gov. Greg Abbott got miffed at the leaders of Harris Health and its health plan because the plan’s CEO was publicly pushing for Medicaid expansion while the state was negotiating with the Obama administration for renewal of its big Medicaid waiver. Masi previously served as the system’s executive vice president and chief operating officer. Before that, he served as a career officer with the Army Medical Department, heading Winn Army Hospital at Fort Stewart, Ga. Modern Healthcare reporter Virgil Dickson recently spoke with Masi about the politics of Medicaid expansion, his system’s recent tightening of its charity-care policy, and the prospects for renewal of the Medicaid waiver. This is an edited transcript.

“I have not seen much traction at all at the state level to expand Medicaid.”

Modern Healthcare: How is open enrollment under the Affordable Care Act going?

George Masi: It’s very early. At Harris Health, we have several hundred trained facilitators in place at our eligibility centers, clinics and hospitals to facilitate this process for patients who are interested in moving to the exchanges. So we’re optimistic.

MH: Are you seeing a softening from state leaders toward the Affordable Care Act, or is there still a lot of opposition?

Masi: When you get close to the point of service, the

municipality or the neighborhood, irrespective of political affiliation, the case is so compelling to take advantage of the law in terms of increasing healthcare access and reducing the local tax burden that you see increasing traction locally. At the state level, when you get further removed from the realities of day-to-day access to care, it becomes much more abstract and ideological. I have not seen much traction at all at the state level to expand Medicaid.

MH: What are you seeing in terms of the trend of uninsured people coming into your facilities?

Masi: Here in Harris County, we have the largest number of uninsured of any major metropolitan county in the country. Of about 4.7 million residents, upwards of 900,000 individuals are still without insurance. A large portion is the cohort that would be eligible for Medicaid expansion who do not have access to that program (because Texas has not expanded Medicaid).

Patients who have not had access to insurance are becoming ever more knowledgeable about their insurance options. This is through a lot of education and navigating. Slowly but surely, we’re seeing greater traction.

MH: What is Harris Health’s policy on providing charity care to people who are eligible for subsidized exchange coverage but have not enrolled?

Masi: We’ve made some dramatic changes in the last several months. We worked with our board to change the federal poverty level access point for charitable care, from 200% of poverty to 150%. Above 150% of poverty, you’re considered a self-pay patient. You can still be seen at Harris Health, but you would have to make payment for the care that you receive.

Nineteen thousand of our patients no longer qualify under those criteria, out of 325,000 patients we serve on a routine basis. For those who are eligible for the exchanges, we offer assistance to facilitate that enrollment process for them.

MH: Why was that change made?

Masi: First, everyone on the board is very supportive of the Affordable Care Act. It was clear that by maintaining the charitycare policy at 200% of poverty, we were subverting the intent of the Affordable Care Act, which was to make insurance available for those who would qualify.

Second, by moving 19,000 patients from charity care into insurance, my health system benefits from having patients who are insured. The revenue is very important to us. At

Harris Health, 60% of our patients have been designated as charity-care patients, 9% Medicare, 22% Medicaid, and 5% commercial.

That payer mix is unsustainable. By moving patients into an insurance program, we calculated that for the coming year, we would gain about $20 million in additional revenue that we could put into expanding services.

MH: What has been the impact of undocumented individuals on your system, since that’s a large population in Texas?

Masi: It’s been significant. About 20% of our patients are undocumented. Out of our annual budget of $1.4 billion, about $200 million of that, as best we can track it, are dollars allocated to care that we provide to individuals who are not eligible for health insurance. Most of that is the undocumented.

MH: Are undocumented people with an income over 150% of poverty still eligible for charity care, since they can’t buy coverage on the exchange?

Masi: Our board instituted a program that we term My Harris Health. It’s for patients between 150% and 200% of poverty who don’t have access to the exchange. They can sign up for our program and are required to make means-based financial contributions to their healthcare bill.

Those payments are similar to what a patient would pay for an exchange plan. We did that to maintain symmetry between those who are eligible for the exchange and those who are not.

MH: If an undocumented person decides not to participate in this program, what happens?

Masi: If you decide not to sign up for either the exchange or My Harris Health, you’re categorized as a self-pay patient. You will not be able to get a routine appointment.

Of course, everybody has access to the emergency center, as always. But as a self-pay patient, you will not have access to routine care.

MH: What impact has Texas’ federal Delivery System Reform Incentive Payment Program waiver had on Harris Health?

Masi: The five-year DSRIP waiver is basically to expand access to primary care and behavioral health, and to decompress emergency rooms.

The federal government provided substantial resources for organizations to take advantage of that opportunity. At Harris Health, we did that in dramatic fashion.

We’ve opened seven new clinics, generating 150,000 new patient appointments. We’ve also embedded behavioral health services in all of our outpatient clinics, generating multiple thousands of visits for behavioral health issues.

If the waiver is not renewed or extended, the impact would be profound for us and for this community, because we’ve expanded services and increased access to care, which is wonderful.

We’re cautiously optimistic the waiver will be extended.

Whether it would be renewed for the full five years, that’s more problematic because of the political dynamic of tension between Texas and HHS (over the state’s refusal to expand Medicaid).