KINGSTREE - Richard Goodman won't be getting a South Carolina Medicaid card.
He may have qualified for one if the state chose to expand the low-income health insurance program under the Affordable Care Act. In fact, he's already enrolled in a New York Medicaid plan because he lives in Rochester part-time.
That means a trip to the hospital in New York is covered by Medicaid, but a trip to Williamsburg Regional Hospital in rural Kingstree costs him more than $400 - more money than he can afford to pay.
"When I come here, they say, 'We can't take your plan because it's in another state,'" he said.
Medicaid eligibility rules in South Carolina have long been stricter than the rules in New York and that won't change anytime soon. This state has rejected the option to expand Medicaid eligibility this year under Obamacare. About half of all states in the country aren't expanding their Medicaid programs either.
So instead of Medicaid, Goodman, a 61-year-old former assembly worker who suffers from chronic allergies and high blood pressure, has been enrolled in the Williamsburg Regional Hospital's Healthy Outcomes Plan - part of South Carolina's larger, statewide alternative to the Affordable Care Act's Medicaid expansion.
The Healthy Outcomes Plan is designed to keep Goodman and 49 other Williamsburg County residents out of the emergency room and connect them with less-expensive, more efficient community resources to meet their health care needs.
"There's a big difference between health and health care and there's a big difference between health care and health insurance," said South Carolina Medicaid Director Tony Keck, an opponent of expanding Medicaid eligibility under the Affordable Care Act.
"What we're doing is reaching out to people like (Goodman) that have high needs," he said. "We are providing the services for him. It's not through Obamacare, but it's through a completely different financing mechanism that's focused on finding the people of highest need."
Williamsburg Regional Hospital was recognized by the South Carolina Medicaid agency on Friday as the first in the state to successfully enroll 100 percent of its target population - all 50 patients - into the Healthy Outcomes Plan.
"These patients have used the emergency rooms over and over again to manage their chronic illnesses," said Sharon Poston, CEO of Williamsburg Regional Hospital. "Emergency rooms are not designed to manage chronic illness. Emergency rooms are for emergencies, as we all know."
Although the Healthy Outcomes Plan does not provide these patients with health insurance and does not cover their health care costs in case of an emergency, Goodman said he hasn't needed to visit the ER since he became enrolled.
"I'm able to come and see the doctor," he said - and it doesn't cost him anything.
But the Healthy Outcomes Plan is more than simply directing patients to the most appropriate health care providers. It's also about saving the state money.
Hospitals in South Carolina were required to submit a Healthy Outcomes Plan to the state Medicaid agency last year to preserve 100 percent of their share of Disproportionate Share Hospital payments.
These are funds that the agency uses to reimburse hospitals for part of the uncompensated care that they deliver to poor, uninsured patients. If fewer uninsured patients land in emergency rooms, it could ultimately save the state government millions of dollars.
"This is a giant step in the right direction," Poston said.
Keck acknowledged that it's taken Williamsburg Regional Hospital significant "ingenuity" to enroll these 50 patients into its Healthy Outcomes Plan.
"They've gone out and found the people who really, really need our help," he said. "That's who, if we're spending taxpayer money, for instance, that's who we should be looking for. We should be looking for people who most need our help."
Reach Lauren Sausser at 937-5598.
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