Angela Felan is sitting in the ER waiting room at O'Connor Hospital in San Jose, Calif. A blue surgical mask covers her nose and mouth, and a sweatshirt is pulled snug over her head.
She first came into the emergency room a few days ago with what she thought was bronchitis. The doctor prescribed an inhaler that cost her $56.
Felan, 31, works part time in retail and hasn't had insurance for at least a decade because she hasn't been able to afford it. "Unfortunately even not having insurance is just as expensive," she says.
Felan has heard of the state's insurance exchange, called Covered California, but she worries that coverage will still be pricey. She's unsure whether she will qualify for subsidies for private insurance because of her low income, or even Medicaid. "As far as today goes, I'm expecting another large bill from the hospital," Felan says. "Previously, when I would come in uninsured, I would get like a $200 or $300 bill for just one visit."
Some 5,000 uninsured people come into O'Connor Hospital's emergency department each year, and now it is Araceli Martinez's job to help them find coverage. She runs the Health Benefits Resource Center just down the hall from the ER. The center has beefed up staffing and hours in response to the Affordable Care Act.
Martinez says uninsured patients had few options before 2014 to pay off hefty hospital bills or enroll in health coverage. Now when they come in through the emergency room and are faced with a bill, they're saying they might be able to afford coverage.
Still, patients remain confused about the law. Half of uninsured adults who could get policies now through the health insurance marketplaces have never thought about buying insurance on their own before, and, in California, nearly half of poor adults don't know they would qualify for Medicaid. Martinez estimates that 70 percent of the uninsured patients she sees can now get coverage, if they follow up and apply.
Hospitals have extra motivation to sign up patients for insurance because they also face Medicare cuts. As for Medicaid, 26 states and the District of Columbia have opened the program up to most poor adults. That means if an uninsured patient is found eligible, hospitals can get paid retroactively for medical treatments going as far back as three months.
"I think the emergency department waiting room is one of those places where you have low-hanging fruit," says Renee Hsia, an associate professor of emergency medicine at the University of California, San Francisco. "They're not the sickest of the sick, because at least someone, the triage nurse, has deemed them stable enough to wait. And if they're waiting, they might as well be filling out some application form, or at least learning about the process."
O'Connor Hospital CEO Jim Dover doesn't expect to get a whole lot more money if more people are signed up for Medicaid. California has one of the lowest reimbursement rates in the nation. Even so, he sees it as a worthy goal.
Dover says he wants to get patients insured so they don't have to come to the ER for common problems. "Let me use this metaphor: A person is coming down the river, and they're drowning, and you jump in and pull them out. And then they come down again, and you pull them out. Next. Two. Three. Four. Five. At some point, you have to go up the river and take care of the spot where they're all falling in."
Angela Felan emerges from seeing the doctor clutching a stack of papers. The doctor told her she had a worrisome ear infection and needs antibiotics. When she came to the emergency department a few days ago, the discharge nurse didn't mention anything about new insurance options. But at the end of this visit, she says, "someone said they would give me a financial packet, and I could call the number on that and someone would go over financial options with me."
Calling later sounds good to Felan. She has spent enough time in the ER and is ready to rest. "You just want to go home and just relax and not deal with anything because your head is pounding and you just don't feel good," she says.