This story originally appeared in the June 30 edition of the weekly LINK Reader. To get these stories first, subscribe at linknky.com/subscribe.
Covington resident Jake Caldwell is 31.
He also has a chronic liver disease.
If he’d gone to a doctor sooner, it might not have gotten this far. But what else could he do? Because he didn’t have health insurance or a way to pay for care out of pocket, he avoided going to the doctor for years.
“You just kind of let things go that you shouldn’t let go,” he said. “There were a few times where I had obviously broken a bone, like in my hand or my foot, and I was just like, ‘Fine, I’ll walk it off, I’ll let it go, because I can’t afford to pay the bill.’ ”
Like Caldwell, 276,000 Kentuckians are without health insurance. Fear over the cost of health care and misunderstandings about eligibility are leading factors, according to a survey of uninsured individuals by the Urban Institute, a Washington, D.C.-based think tank focused on economic and social policy research.
The rate of uninsured is highest for young adults between age 19 and 34. Caldwell, like many in that situation, was young and relatively healthy.
Or so he thought.
“For a while, it was touch-and-go,” Caldwell said. “I had liver issues, but I didn’t want to see a specialist because I knew that was going to cost me.”
He eventually ended up going to the emergency room and was told he had a form of hepatitis brought on by fatty liver and was instructed to lose weight.
He did try to lose the weight but did not seek out any additional care.
“I let it go too long, and now it’s cirrhosis,” he said.
Two years ago Caldwell, at the urging of his family, found help on KYNECT, the state portal for health care assistance and program information. He is now covered under Medicaid.
What are the options for people who can’t afford care?
For low-income Kentuckians struggling to find affordable health care coverage, Medicaid and the state’s program for children, KCHIP, might be the answer.
Qualification for Medicaid and other programs is based on the federal poverty level. For a family of four in 2023, the level is $30,000 a year before taxes. To qualify for Medicaid, the family’s income can be up to 138% of that level, or $41,400. In certain circumstances, such as pregnancy, the program allows for an annual income of up to 200% of the poverty line.
Those whose incomes are too high to qualify for Medicaid, but who do not have private or employer-provided insurance, may apply for coverage through the state’s qualified health plans.
Qualified health plans are the health insurance plans available through a marketplace (known as the exchange) created through the Affordable Care Act, also known as the ACA. The plans are “qualified” because they meet the requirements for insurance outlined in the ACA.
The plans must provide “minimal essential coverage,” including preventive services, at no extra cost to consumers. Examples of preventive care services include annual physicals and wellness visits, mammograms and other cancer screenings, and vaccines. Plans also must meet certain established limits on cost-sharing. In other words, the plans are limited in how much they can charge consumers for deductibles, copays, out-of-pocket maximums and other costs.
Individuals are eligible to enroll in a qualified health plan if they are residents of Kentucky or intend to reside in the state, if they are not incarcerated and if they are a citizen or national of the U.S. or a non-citizen who is lawfully present in the U.S.
“Right now, about 1.7 million Kentuckians receive their health care coverage through Medicaid. So, that’s starting to be about one in three,” said Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services. “That does not include the other 75,000 that get help through a qualified health plan. We’re sure that there are more eligible out there. … For the qualified health plans, folks qualify for a much higher percentage of their income, and they can get some help paying for that coverage.”
Depending on income and family size, those covered through a qualified health plan also might be eligible for premium tax credits that can be applied in advance to lower monthly premiums. Income-based aid also might be available to reduce costs for copayments, coinsurance and deductibles.
The state’s health care website, KYNECT (kynect.ky.gov), is designed as a one-stop shop for Kentuckians seeking information on health care coverage and other benefits.
Online information was available before the pandemic, Friedlander said, but the number of people using the KYNECT site grew exponentially during that period. According to Gov. Andy Beshear’s office, the portal had 1.8 million visitors between October 2020 and October 2021, a 180% increase over the daily average for the period between January and September 2020.
Friedlander said his department found that the increase in online traffic cut way down on wait lines in its service offices. In turn, it made the whole process easier, leading to a jump in the number of people who have signed up, he said. People can also visit a Department of Community Based Services office in person. There’s one in each county.
The pandemic offered other lessons, Friedlander said.
“What I hope we’ve learned is that whatever is impacting one of us in the community impacts everybody in the community,” he said. “So, I don’t want people to feel like they can’t access services that they’re eligible for or support that they’re eligible for. It helps everybody when we use all the support we can give.
“And I think that makes us better as people, better as communities, better as families. It’s really important for folks to know that. When you see somebody else who is getting support, know that that’s helping your community, too.”
St. Elizabeth’s layered approach
St. Elizabeth Healthcare has a number of programs to help patients who are uninsured, those who are insured but have trouble paying out-of-pocket costs or those finding themselves struggling financially due to a medical emergency or issue.
The hospital takes a layered approach, said Tony Helton, vice president of the Revenue Cycle Department at St. Elizabeth. First and foremost is patient confidentiality when it comes to finances, he said.
“Let’s say they come through the emergency room, and they have no insurance,” Helton said. “First off, the clinical team has no idea that they are uninsured. An external group reviews all of our uninsured patients to see if potentially they’re eligible for Medicaid.”
He was clear to note that providers and health care staff at St. Elizabeth do not know who is insured and who is not. Research has shown that patients’ fears about stigma and lower quality of care associated with Medicaid and similar public health coverage are not unfounded.
In 2022, the Urban Institute interviewed Medicaid and uninsured patients and reported that about 8 percent of respondents reported experiencing unfair treatment or judgment either because of their health insurance type alone or in combination with other factors in a clinic setting. A report by the Tulane School of Public Health and Tropical Medicine in 2021 noted that physicians can and do refuse patients based on financial factors. The researchers found primary care physicians offered Medicaid patients 27.6% fewer appointments than privately insured patients.
Helton and his staff identify and reach out to uninsured patients, many of whom are unaware that they may qualify for Medicaid or other forms of assistance. He said he is proud of how many patients and their families have been helped.
“If you look at the past 13 months, our average conversion rate from self-pay to Medicaid is about 60%,” Helton said. “Then you go into the other 40% – what about them? We have a basic five-tiered program. We have a financial assistance program that is based on your income level and how that equates to the federal poverty guidelines. If you’re at 200% of the federal poverty guideline, you’ll get 100% assistance.”
In other words, if your income is twice the federal poverty guideline or less, you pay nothing.
Patients who do have insurance also might be eligible for that same financial assistance program based on their income, Helton said.
Mike Yadav, system director for the department, put it into numbers. Through its financial assistance program, the portion owed by the patient (after insurance) would be cut in half for those who make between 200% and 300% of the federal poverty line. For those whose incomes are higher, up to four times the poverty line, the program would cover a quarter of the patient portion of the cost of care.
“So the point is that up to $120,000 for a family of four making that income, they can still get a significant discount,” Yadav added.
For patients admitted to the hospital, Helton listed more options.
“We have an uninsured discount, which is an automatic 40%,” Yadav said. “Then we have the catastrophic discount program, which basically says we will not charge you a bill that is more than 20% of your annual income, and that’s something you can take and pay over years.”
The health care system also has a hardship committee for special situations.
“We would ask them just to simply write us a letter and tell us your story,” Helton said. “The hardship committee is made up of people from finance, but also pastoral care, our compliance area … and also the clinical sites. Many times, it’s a ‘Yes, in order for this family to move forward, they need some type of relief.’ ”
The challenge for St. Elizabeth has been to ensure patients know help is available.
“That’s where we have an extensive outreach to communicate to patients that this financial systems policy is out there,” Helton said. “So when you receive your statement from us, it’s on there. On the back of the statement is the application, which you can fill out and begin the process.”
In addition to that, he noted, information is available through Mychart, the patient portal, as well as the website.
Yadav said he takes advantage of every opportunity to go out into the community and spread the word. He’s a frequent exhibitor at area health fairs and community events. He recently initiated a program with the Boone County Public Library to offer outreach about assistance to seniors in the community.
St. Elizabeth Physicians, the clinic side of the health care system, provides a similar financial assistance program. It is similar to that of the hospital, but limits may be different because clinic patients are not facing the potentially catastrophic bills that can mount up in a hospital stay, Yadav said.
Other options are available in Northern Kentucky
HealthPoint Family Care is a nonprofit primary care clinic group whose Northern Kentucky locations include Florence, Newport and Covington, as well as several school-based care centers across the region.
“In 1972, Northern Kentucky Family Health Centers was incorporated as a nonprofit focusing on primary care for patients with unmet needs,” said Sally Jordan, chief executive officer.
Now called HealthPoint, its clinics take a whole-patient approach, providing adult and pediatric medical, dental, mental health, substance abuse treatment, obstetrics and gynecology and vision services. They serve people with traditional insurance as well as those who may be on assistance programs.
“HealthPoint focuses on access,” Jordan said. “Access is sometimes an issue for the entire community, regardless of income. For example, mental health. Wait times and affordable mental health services are an issue for this region even for those with insurance coverage. HealthPoint addresses that by staffing with five psychiatrists and 13 other providers, including psychiatric nurse practitioners and counselors. And offers same-day appointments.”
HealthPoint is a federally qualified health center, or FQHC, an outpatient clinic qualified for specific reimbursement under Medicare and Medicaid, as well as federal grant funding.
Federally qualified health centers are part of the federal Health Resources and Services Administration program and receive government funding to provide care to people who have low income, even those who are experiencing homelessness. They offer a sliding scale for fees based on income.
“But FQHCs operate much like any private- or hospital-owned practice in that most of the revenue comes from billing insurance,” Jordan said. “All patients, even those with insurance, who meet federal poverty guidelines qualify for a discount. The discount varies based on household size and income.”
Faith Community Pharmacy’s unique approach
Doctor visits and hospital stays are two parts of the trifecta of medical costs. The third is the skyrocketing cost of prescription drugs. The U.S. Centers for Disease Control and Prevention (CDC) reports that more than 9 million people skipped or skimped on their prescriptions last year because they could not afford them.
Aaron Broomall, executive director of Faith Community Pharmacy, has seen this first-hand.
“Literally every day, we have people come in here and tell stories of husbands and wives who are both diabetic,” he said. “They could afford $50 for insulin for the month. They would buy that much, and then they would share it. Every day it happens.”
Faith Community Pharmacy provides free prescription medications to people living in Northern Kentucky who are under 300 percent of the federal poverty line. It defines Northern Kentucky broadly, serving 13 counties, Broomall said.
While many of its patients are on Medicaid or Medicare, the organization helps those with insurance, too, as long as they meet the financial threshold.
“There are many people who can’t afford $2 or $5 for a copay,” Broomall said. “Our average patient is receiving nine different medications from us. Seven dollars sounds pretty affordable for copays. And, it is, but if you have nine of them, that’s $63. Our average patient has a household income of less than $24,000 a year. Those stacked on top of each other can become very, very difficult.”
The pharmacy was started in 2002. While always a separate entity, it partnered with St. Vincent DePaul in Crestview Hills until moving into its own building in Florence. Last year it made another move, to 601 Washington Ave. in Newport.
The pharmacy sees about 1,000 patients each year and gives away 24,000 90-day prescriptions valued at more than $4 million, Broomall said.
“Our average patient has three different chronic disease states, which isn’t unusual, and we work with the diseases that typically disproportionately impact the poor – diabetes, cardiovascular, respiratory, COPD (chronic obstructive pulmonary disease), mental health issues, gastrointestinal,” Broomall said. “Those are really the core ones that we treat. … If you have COPD or asthma, it’s likely you’re going to have a cardiovascular illness that goes along with it. So many of those things go hand in hand.”
The pharmacy usually provides a 90-day supply and works with patients to ensure they get what they need going forward. It uses a high-touch philosophy – pharmacists get to know patients and work with them to manage their diseases. Patients are welcome and encouraged to come in person if they can, but the pharmacy also provides medication by mail for those who cannot come in, Broomall said.
Funding for the pharmacy comes from a variety of sources.
“A lot of our medications come from an organization called Americares,” he said. “Americares is a clearinghouse of overstock and short-dated products (meaning they’re approaching their expiration date) that manufacturers have. They donate them to Americares, and then Americares distributes free of charge to free and charitable clinics across the country.”
The pharmacy also partners with pharmaceutical company Eli Lilly for free injectable diabetes medications.
“We are Eli Lilly’s second-largest free distributor of their medications in the United States,” Broomall said.
Rounding it out are grants and partnerships with other drug companies, as well as partnerships with St. Elizabeth and the Boone, Kenton and Campbell county fiscal courts. The rest comes from private donors and fundraisers, such as the annual Time to Celebrate fundraiser held in October.
“What we see is patients in their first year in our program see a 60% reduction in ER visits and a 70% reduction in hospitalizations,” Broomall said. “So what’s happening is, before they come to us, they’re rationing or not taking medicine, which means their disease state isn’t properly being cared for. So they’re going to the hospital, they’re utilizing a whole lot of very expensive resources.
“And the best way to avoid that is just ensure they can get the medication they need. And we’re lucky enough that we get to do that here. We’re pretty unique. There aren’t a ton of charitable pharmacies across the United States. We are by far the largest in Kentucky. Northern Kentucky is pretty lucky to have a resource like this.”
Don’t put it off
The number of uninsured Americans has dropped significantly over the past decade. According to the CDC, 46 million people had no insurance in 2011. That number dropped to 28 million by 2021, even after the economic downturn during the pandemic. Health care experts across the board credit greater access through the Affordable Care Act and the expansion of Medicaid and related programs.
Every expert interviewed for this story had a similar piece of advice for those who are uninsured or struggling to afford their medical bills, premiums and copays: Don’t put it off. The sooner you seek care, the better it will be for your health, your finances and for the community.
“Don’t let the fear of cost prevent you from getting the care you need. Never put off the recommendations that the physician makes. Because at that point, that is the best time to seek treatment. That’s when it’s least expensive. That’s when you have time to plan,” Helton said.
As for Caldwell, did having health care coverage through Medicaid give him peace of mind?
“Sure,” he said. “I started taking way better care of myself because I knew things would be getting covered.”
For a long time, he said, like so many in his situation, he just hoped and held on.
“You can hope things don’t go bad, you can hope things get better, but that can only get you so far before you actually need to take some action for yourself,” Caldwell said. “And that’s what the doctors help me do now. So, definitely, my best piece of advice would be to just look for help. It’s out there.”
Finding care when you have nothing
Although the number of people who are uninsured has dropped dramatically in recent years thanks to available programs, it is difficult to get help if you have no income, are experiencing homelessness or are undocumented.
For people and families experiencing homelessness, medical services are spotty, but there is help available. Here are a few resources in our area that have some medical outreach or can help people find additional health resources:
· The Emergency Shelter of Northern Kentucky partners with the University of Kentucky College of Medicine to provide a health care clinic for people experiencing homelessness in Covington one or two days a week. The clinic is located at 436 W. 13th St. in Covington. For more information, visit emergencyshelternky.org, email info@esnky.org or call 859-291-4555.
· St. Paul’s Healthcare Mission, at 7 Court St. in Newport, provides free health screenings, medication assistance and help with finding health insurance. Services are offered on Wednesdays from 5:30 to 7:30 p.m. For more information, visit stpaulsnewport.org or call 859-581-7640.
· As part of its Open Door mobile outreach services to people who are experiencing homelessness in our area, Welcome House has a medical care van that stops at local libraries and other sites in Northern Kentucky counties, bringing care to the homeless population. The facility also partners with St. Elizabeth to provide medical respite care. For more information, visit welcomehouseky.org or its Facebook page “WelcomeHouseKY.”
· Esperanzo Latino Center of Northern Kentucky does not provide health services, but it provides Spanish-speaking resources and people to help immigrants and others whose first language is Spanish navigate systems and find support and services. Visit esperanzanky.org or call 859-261-0862.
· Kentucky Refugee Ministries has an office in Covington. It helps connect refugees in our area to a variety of resources, including both physical and mental health help. The office is located at 321 W. 12th St. in Covington. For more information, visit kyrm.org or call 859-547-5571.
· RefugeeConnect is located across the river in Cincinnati, but it provides services to help refugees on both sides of the river, including help finding health care. In fact, social work students at Northern Kentucky University have raised more than $6,000 to support the organization’s work. Find information on the RefugeeConnect Facebook page, visit refugeeconnect.org or call 513-304-1994 to get connected.
Health care resources in Northern Kentucky
KYNECT (kynect.ky.gov)
Kentucky’s health care portal is the best place to start to find health care assistance. The portal also provides links to what are called “kynectors,” individuals trained to assist in finding health care coverage. Call 1-855-459-6328 (855-4kynect).
Faith Community Pharmacy (faithcommunitypharmacy.org)
The pharmacy provides free 90-day supplies of insulin and other medicines. Its pharmacists work directly with patients to help them with care. It is located at 601 Washington Ave., Newport. Call 859-426-7837.
HealthPoint Family Care (healthpointfc.org)
HealthPoint clinics are located in Covington, Florence and Newport. A federally qualified health center, its clinics provide a range of care, including primary care, dental, mental health, obstetrics and gynecology, substance abuse and pediatrics. Call 859-655-6100.
Northern Kentucky Community Action Commission (nkcac.org)
The Northern Kentucky Community Action Commission provides “kynectors” in seven Northern Kentucky counties to assist Kentuckians in finding health care. You can find the list on its site under Family Services/Health Care Enrollment. The organization is located at 717 Madison Ave., Covington. Call 859-581-6607.
St. Elizabeth Healthcare (stelizabeth.com)
St. Elizabeth Healthcare provides several financial assistance programs. Counselors can help patients find insurance coverage or assistance. For financial assistance programs, call 859-301-9090.
St. Elizabeth Physicians (stelizabethphysicians.com)
The St. Elizabeth Physicians provides its own financial assistance programs. Call 859-344-5555.