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A deep health care divide in Rick Perry’s Texas

The Lone Star State has the highest rate of uninsured residents in the nation. This has created a yawning gap between rich and poor for even basic treatment.

By Tracy Jan
Globe Staff / September 25, 2011

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HOUSTON - The cutting edge treatments and renowned doctors here at the Texas Medical Center draw Arab sheiks and former first ladies to gleaming facilities adorned with spraying fountains and aquariums. Billed as the world’s largest medical campus, the towering glass and sandstone buildings house 14 hospitals and three medical schools, spread across 14 square blocks.

But for the more than 6 million Texans without health insurance, these world-class institutions remain largely out of reach. Texas has the highest rate of uninsured people in the country - 24.6 percent - and the number of uninsured that has grown by 35 percent during Governor Rick Perry’s 11-year tenure. And here in Harris County, which includes Houston, the state’s largest city, the picture is even more troubling: One out of three people lacks insurance.

“This is ground zero in the health care disaster,’’ said Dr. Leonard Zwelling, an oncologist at The University of Texas M.D. Anderson Cancer Center. “Houston is such a rich city, with some of the best medical care in the world. . . . And yet the people without insurance have a heck of a time getting into most of these facilities because they can’t pay.’’

And what is the price Texas pays for so many without insurance? A host of health problems, researchers have found. Overall health care quality for Texas is poorer than in every other state, especially when it comes to preventive, acute, and chronic care, as well as care for diabetes, heart, and respiratory diseases, according to the 2010 report of the federal Agency for Healthcare Research and Quality.

Texas ranks third to last in the country for the percentage of adults with a regular source of medical care, according to Commonwealth Fund data on state health system performance. It places 39th among the states in the percentage of adults over 50 who receive recommended screenings such as mammograms and colonoscopies. A fifth of its pregnant women receive no prenatal care in their first trimester.

And in a state where 16.8 percent of children are uninsured, more than all but one other state, only half of Texas children have a medical provider who knows them and coordinates their care. More than a third of them have not received recommended medical and preventive care within the year, and immunization rates are low as well. Texas also ranks last in the country in the percent of children who receive needed mental health care.

Doctors recount horror stories of uninsured patients who die of treatable diseases because families delay seeking medical help or must endure long waits for appointments with specialists.

Dr. Katherine Yudeh King, a pediatrician at Ben Taub General Hospital, which serves a large uninsured population, said one of her patients, a 15-month-old boy, died from dehydration due to diarrhea because his family brought him to the hospital too late, assuming they could not afford care.

“This is the type of thing that happens in Somalia and other developing nations, not something that should happen in Houston,’’ said King, one of the founding members of Doctors for Change, a group that advocates for universal health care in Harris County.

Another uninsured patient, a 16-year-old boy, was repeatedly treated by emergency room doctors for chest pain because he did not have a primary care physician, King said. Doctors eventually discovered a tumor in his chest. The delay in care led to a more advanced cancer that was inoperable. The boy died within a year.

Other doctors tell of uninsured children dying from vaccine-preventable diseases such as influenza and hepatitis A, and patients being admitted into the emergency room for uncontrolled asthma and diabetes. Doctors here routinely see untreated infections of the ear, sinus, or tooth spreading to the brain, requiring surgery, and bone infections that result in permanent disability.

“This is an everyday occurrence,’’ said Dr. Claire Bocchini, another Houston pediatrician who specializes in infectious diseases and is president of Doctors for Change.

As underfunded as the state’s health safety net has been, conditions stand to worsen. In the last legislative session that ended in May, the state cut two thirds of the funding for women’s health clinics and underfunded Medicaid by almost $4 billion, in addition to cutting hospital reimbursements. This follows other health cuts in the Perry years.

Perry vetoed a bill in 2001 that would have expanded Medicaid services and added cancer screenings such as Pap smears to women’s health services. In 2003, Texas tightened the eligibility requirements for the Children’s Health Insurance Program, and as a result, 237,000 children were kicked off its rolls, said Garnet Coleman, a Democratic state representative from Houston who has served in the Texas Legislature for 20 years and is a member of the House Public Health Committee.

The Perry campaign declined a request to interview the governor, saying Perry would work to free states from federal mandates and empower them to come up with their own solutions.

Catherine Frazier, a campaign spokeswoman, said that because there are so many Texas children eligible for Medicaid who are not enrolled, Perry - rather than widen eligibility to more low-income families - focused on increasing funding for public awareness campaigns to encourage the neediest parents to enroll their children.

“The governor has made considerable effort throughout his tenure to make insurance more affordable so people can afford to purchase it if they choose to,’’ Frazier said. “His goal is to create an environment of independence from the government, not dependence.’’

In a recent debate, Perry said conditions would be better in Texas if the federal government had granted the state a waiver, which would have allowed it to redirect Medicaid money into subsidies for private or employer-based insurance. The Bush administration never approved the 2008 request.

The burden of the Texas health care crisis falls largely on the working poor. Most of the state’s uninsured adults have jobs and are US citizens or legal residents, according to the nonpartisan Center for Public Policy Priorities. Working adults account for nearly two out of three uninsured Texans between ages 19 and 64, though most of them make less than $25,000 a year.

An example is Joyce Jones, a 60-year-old yoga instructor earning $20,000 a year who said she cannot afford private health insurance because she has Parkinson’s disease, a preexisting condition that would increase her premiums.

Jones has maxed out three of her credit cards paying for health care and has more than $30,000 in credit card debt. She is in the process of signing up for a high-deductible plan for people with preexisting conditions, made possible through the new federal health overhaul law - “Obamacare,’’ as Perry and other GOP candidates call it.

Jones now pays a copayment for a doctor’s visit at a local subsidized facility. But the wait for specialists is achingly long. She waited nearly a year for her initial appointment with a neurosurgeon, then waited four more months for an MRI.

Instead of universal health coverage, Texas relies on a county-based patchwork system to care for the poor and uninsured. Operating in the shadows of the Texas Medical Center is a web of community clinics financed by a mix of county property taxes, private philanthropy, and government grants.

The safety net includes the Harris County Hospital District, an overwhelmed system designed to serve 300,000. But more than 1 million people in the county are uninsured, so basic care - let alone specialty care - is not always easy to come by.

On the East End of Houston just six miles away from the Medical Center complex, Rigoberto Carino, a 51-year-old former taxi driver now training for his barber license, arrived at the Eastwood Health Clinic on a recent morning an hour before it was scheduled to open. Carino had an appointment for a physical, but he wanted to make sure he would be the first to be seen because the waiting room normally fills quickly.

Carino said he has lived without insurance for as long as he could remember.

“I’ve been sick but I never went to the doctor,’’ he said, seeking instead to save the money for when his three children need medical care. His youngest daughter, who is 12, is dropped from the rolls of the Children’s Health Insurance Program every few months, he said, for reasons he cannot comprehend. He and his wife, a hair stylist, must reapply.

“For years we got nothing so we pay whenever she gets sick,’’ said Carino, preferring to bring his daughter to Eastwood, where he is charged about $50 for a visit, half of what he says he would pay at a private clinic. “But here, sometimes it’s hard to get an appointment.’’

The public health clinics are merely Band-Aid solutions for Texas’s problem of the uninsured, some clinic directors say.

“Politically, it’s kind of a cheap way of making sure that people know you care for the uninsured, rather than pushing for universal health care or increasing eligibility for Medicaid,’’ said Dr. Andrea Caracostis, chief executive of Hope Clinic, a community health center tucked inside a strip mall office building in Houston’s Chinatown.

“There are a lot of gaps. Most of the time you will get your patients help, but it’s very delayed care,’’ said Dr. Charu Sawhney, an internist at the clinic.

But patients with cancer, or broken bones, can’t afford to wait.

Sawhney said four of her patients were diagnosed with breast cancer this summer, two at a late stage. While patients with insurance can usually line up an appointment with an oncologist within a week, uninsured patients may wait one to two months, she said. One uninsured woman was so scared about the cost of her treatment that she flew back home to China for a mastectomy, Sawhney said.

Nancy Saucedo, a 41 year old personal trainer who works part-time as a spa receptionist, comes to the Eastwood clinic for annual physicals as well as dental visits and mental health counseling. A few months ago she had to go to a hospital emergency room because her throat was closing and she could not breathe, due to an allergic reaction. For that visit, she was billed $7,000. The hospital calls her about twice a week to collect.

“I avoid the calls,’’ Saucedo said. “I just can’t afford to pay it.’’

More families like Carino’s would get coverage, health advocates say, if the state took full advantage of federal dollars available for medical care for the poor.

Rather than pushing to expand access to Medicaid and the Children’s Health Insurance Program, Texas has set up a host of administrative barriers for enrollment in order to tamp down state costs, they say.

“Yes, the state needs to put up a certain amount of money to get federal matching funds so not doing it is a way for the state to save money,’’ said King, the pediatrician at Ben Taub. “But it’s a very short-sighted view. We’re leaving money on the table.’’

In his presidential campaign, Perry has tried to deflect criticism by slamming Mitt Romney, his top rival for the Republican nomination, for instituting “socialized medicine’’ in Massachusetts.

Yet Texas stands to benefit more than any other state under the federal health overhaul that President Obama signed into law last year - modeled after Romney’s measures in Massachusetts, which boasts the lowest uninsured rate among the general population, as well as among children.

By 2019, about 5 million of the 6.2 million currently uninsured in Texas could be given coverage through the federal overhaul, according to Charles Begley, a professor at the University of Texas School of Public Health. Federal dollars will pick up 100 percent of the cost of Medicaid expansion for the newly eligible from 2014 to 2016, then decline to 90 percent after 2020 - meaning that Texas will get nine federal dollars for every dollar the state contributes.

Dr. Dan Stultz, executive director of the Texas Hospital Association, said that while health care reform, which he supports, would help millions of Texans, “the problem is that it’s very expensive for the state to take on that additional Medicaid expense of up to $14 billion [over five years] given their struggles now.’’

Perry vows to repeal the federal plan if he wins the White House, calling “Obamacare’’ a disastrous law that would increase costs and constitute an unprecedented federal power grab.

He estimates that the law will cost Texas $27 billion over a decade, starting 2013. Romney, who also opposes the federal law, has said he would grant waivers from it to all states.

Meanwhile, as the national debate rages, Mary Jo May, the Eastwood clinic’s chief executive, said she and other clinic directors are trying to open branches of their community health centers in the emergency rooms of local hospitals, to ease the congestion and make primary care more accessible to the uninsured.

“We’re working in a neighborhood without resources in a state without resources and a governor who doesn’t get it and doesn’t see the problem,’’ May said. “Other parts of the country have been trying to deal with the issue of the uninsured, but Perry’s just shut it down.’’

Tracy Jan can be reached at tjan@globe.com.