Michael Flores lay in his hospital bed, waiting for a lifesaving surgery that was at least 100 miles away.
Flores had been admitted to the hospital three days previously after he woke up in the middle of the night with a pain in his back. His doctors diagnosed him with an aortic dissection. Flores’ aorta, the blood vessel that pumps blood from the heart to the rest of the body, had torn, and blood was leaking in Flores’ left lung.
To live, the 55-year-old needed surgery immediately. But the closest hospitals that had the staff capable of providing the complex surgery necessary wouldn’t accept Flores as a transfer patient because he didn’t have health insurance.
Flores’ case highlights a dangerous intersection of rural health care in Texas – patients requiring complex surgery might need to transfer from their local emergency department to a larger hospital. But, if they lack insurance, that larger hospital might not take them, leaving their lives in the balance.
“This was a very dangerous situation,” said Dr. Stephanie Woolhandler, a physician and distinguished professor at the City University of New York’s Hunter College and an expert on emergency care. “Once a dissection is leaking, the person could die immediately. This is not a situation where, ‘Oh let’s wait a couple of hours, let’s wait a couple of hours more, let’s wait a day, let’s wait another day.’ That’s not acceptable because it’s an immediately life-threatening situation.”
June 19, 2018, Flores woke up in the middle of the night with a pain in his back. He stumbled to the bathroom, falling down twice from the pain.
Flores, who lives with his mom and stepfather near Palacios, woke his parents, and they drove him to the emergency room at Memorial Medical Center, the nearby 25-bed hospital in Port Lavaca. Flores was immediately admitted to the hospital, but his condition initially stumped physicians.
Dr. Paul Bunnell, Memorial’s hospitalist, worked to determine what was happening. The inner layers of Flores’ aorta had torn, and the tear was causing blood to leak into his left lung area.
An acute aortic dissection is considered an emergency medical condition – a condition which, by law, hospitals are required to treat. But an aortic dissection also requires a vascular surgeon to do the operation, meaning that Flores needed to be transferred to a larger hospital where a specialist would be able to operate on him. Memorial Medical Center, located in Calhoun County, has enough staff to care for the normal range of emergency medical conditions. But more complex or unusual situations, such as Flores’, often require a specialist who can only be found at hospitals with larger staffs.
So Bunnell and his nursing team started the transfer process, an organized routine they turn to every time a patient’s case is too complex for the medical team in Port Lavaca to handle.
But Bunnell found all three major nonprofit hospital systems in Houston – Memorial Hermann Health System, Baylor St. Luke’s Medical Center and Houston Methodist Hospital – were unwilling to take Flores as a patient because he was uninsured.
“If things were to deteriorate at our hospital with this problem, there would be really nothing we could do but give blood and medicines to support the blood pressure,” Bunnell said. “Whereas (with) a transfer into the appropriate hospital in Houston, he would go straight to surgery.”
Transfer patients exist in a nebulous area of emergency care. Legally, no hospitals are allowed to turn away patients with an emergency medical condition, like an aortic dissection. If a patient shows up at an ER with an urgent problem, or if a woman shows up in labor, hospitals are legally obligated to treat the patient, regardless of the patient’s insurance status or ability to pay for care. But patients who need to be transferred to another hospital for more sophisticated care don’t necessarily have the same protections. That leaves patients who don’t have insurance, like Flores, at risk when they need lifesaving treatment that’s not available at their local ER. While Bunnell and his colleagues tried to get a hospital to accept Flores for treatment, he was essentially at the mercy of the hospital systems’ transfer departments.
Bunnell said he and his staff have increasingly had problems getting lifesaving treatment for patients who need it, and that has become an area of concern as he and other doctors in rural Texas work to care for patients in a fractured and changing health care system. Patients in rural areas are more likely to be older, poorer and sicker, and they’re also more likely to lack health insurance. In Calhoun County, where Memorial Medical Center is, more than 23% of non-elderly adults lack insurance.
Woolhandler, a health policy expert, has authored numerous journal articles about health policy, and her research on what’s known as “patient dumping” contributed to federal protections for poor patients seeking emergency care. In the 1980s, Woolhandler documented dozens of cases of poor and uninsured patients being turned away from private hospitals, even as they required immediate attention, because they were unable to pay their bills.
But rural patients like Flores, who legally have access to immediate emergency care at their local hospital, are left at risk when they require more complicated attention. Hospitals with specialized capabilities, like a burn unit, are legally required to accept transfer patients. But when a patient has already been admitted as an inpatient, those protections are not as clear-cut.
“It’s not moral, it’s not ethical, it’s not fair to this man who could have died,” Woolhandler said. “But the prohibition against it, if it exists at all, is not enforced.”
After being rejected by Houston’s three largest nonprofit health systems, Bunnell found St. David’s HealthCare system in Austin willing to take Flores. He was transported via helicopter to Austin and went into surgery the next morning.
Flores stayed in the Austin hospital for 10 days.
More than a year later, Flores has made a full physical recovery. He is able to get discounted care through a program for indigent patients at the Jackson County Hospital in Edna, where he can afford the copay for his prescription heart medications and his regular checkups.
But the bills for his treatment have followed him. Flores’ bill totaled almost $500,000 from his stay at Memorial Medical Center to the $67,000 helicopter ride to Austin to his surgery and 10-day stay in the hospital there. Both Memorial Medical Center and St. David’s forgave Flores’ bills. But thousands more in outstanding debt has continued to follow Flores. Many of the physicians who treated Flores while he was in Austin billed him separately, and those bills have been passed on to debt collectors who regularly hound him for money he doesn’t have.
Flores gets so many phone calls from debt collectors using Austin’s 512 area code that he screens all calls from the city because he knows the conversation won’t go very far. He can’t pay the bills, he said.
The majority of Americans get their health insurance through their employers, although that’s become an increasingly difficult and expensive option for American workers. A survey released Wednesday by the Kaiser Family Foundation found that the average annual premium for employer-sponsored health insurance this year is $20,576 for family coverage. Deductibles in job-based health plans have tripled in the past decade.
As employer-sponsored health insurance gets more expensive, fewer companies are offering insurance. For those who don’t get insurance through their work, there are few options, especially in Texas. A 2012 Supreme Court decision allowed states to decide whether more citizens would be eligible for state-sponsored health insurance. Texas is one of 14 states that opted not to make more people eligible for Medicaid, meaning that childless adults under the age of 65, like Flores, have few options for accessing affordable health care.
Throughout his life, Flores has held various jobs, including positions with the IRS and the U.S. Postal Service when he lived in Austin, as well as for a real estate agency there.
Some have offered health insurance, and some haven’t. When he returned to his native Matagorda County in 2013, he moved in with his parents. He found occasional part-time work but never received any offers that came with full-time health insurance. When Flores tried to buy health insurance on the open marketplace, the copay was more than $100 a month, more than he or his family could afford.
Flores’ parents both qualify for Medicare, the government insurance program available to citizens over the age of 65. But in Texas, which is one of only 14 states that hasn’t expanded Medicaid, only a small sliver of poor adults qualify for insurance, meaning that if they’re unable to find a job that will offer insurance to them, they’ll have to go without.
The question of health care – how much it costs and who foots the bill – has roiled U.S. politics for decades. The U.S. health care system is an outlier compared to other high-income countries in the world, and in recent years the expenses have reached a tipping point for Americans with and without insurance.
But while the debate about how to reform the system roils on, patients like Flores are left at risk.
“The Houston hospitals, that’s the first thing they asked: ‘Does he have insurance?’” Flores said. “That shouldn’t be that way in an emergency, which it was. It was a life-and-death situation.”