Shekana Seymour-Green needed her gallbladder removed, but had no health insurance and couldn't afford to pay for the surgery.

Month after month, she wound up in the emergency room at St. Francis Hospital in West Ashley with gallstones - a dozen times last year - doubled over, throwing up, unable to manage her pain with medication.

"That's what I used as my primary care," said Seymour-Green, 30, of North Charleston. "It just got worse over time. That's pretty much what my main issue was. It was always my gallstones."

She owes Roper St. Francis Healthcare $20,000 for those ER visits, but, as a full-time student, can't pay her medical bills. In December, when she received a letter from the hospital system explaining that she may be eligible for a free primary care program, she didn't bother opening it.

"I'm going to be honest, I thought it was another bill from Roper St. Francis and I just threw it to the side," she said.

The Affordable Act Care offered a glimmer of hope last fall, but Seymour-Green quickly realized she couldn't afford the monthly health insurance premiums. She didn't qualify for a Medicaid card either because South Carolina, and most other Southern states, chose not to loosen eligibility rules for the low-income health insurance program with federal funds available through the new health care law.

"I tried to do the Obamacare, but it's too expensive for me," she said.

Seymour-Green is one of an estimated 194,000 South Carolinians who fall into the Affordable Care Act coverage gap - she's too poor to qualify for a tax credit to lower the cost of private insurance and doesn't fit the criteria for Medicaid.

The law meant to cover everyone below the poverty level with Medicaid, eliminating the need to provide them private insurance subsidies, but the Supreme Court ruled in 2012 that states don't have to expand Medicaid if they don't want to.

While some states expanded their programs even though it's not mandatory, many, including South Carolina, did not. The court ruling didn't change the way the subsidies for private insurance are distributed, either. Those tax credits are still only available for customers who earn between 100 percent and 400 percent of the federal poverty level.

So an estimated 4.8 million Americans, including Seymour-Green, who live in "non-expansion" states and fall below the poverty threshold, are essentially shut out of options. That's why she kept showing up at the ER.

"I spoke to one of my aunts and she told me there are agencies out there in the community, doctors in the community that will help you," she said. "I was like, 'Nah, ain't nobody going to help me for free.'"

But her aunt was right. That letter Seymour-Green tossed aside in December encouraged her to apply for a program called Access Health. It cost her nothing to sign up and once she enrolled in the program in early February, she qualified for free primary care appointments and, even better, for free gallbladder surgery at Mount Pleasant Hospital.

"I paid for none of it," she said. "They didn't treat me any differently than a person who had insurance."

Access Health isn't a new program, but Anne Sass, grants director for Roper St. Francis Healthcare, explained that a new statewide initiative called the Healthy Outcomes Plan recently "put it on steroids."

Last fall, every hospital in the state wrote their own Healthy Outcomes Plan to keep uninsured patients with chronic conditions, like diabetes or hypertension, out of the ER. These patients, who often can't afford to pay their own bills, cost hospitals and the government the most money. Every year, South Carolina spends nearly $500 million - a combination of federal and state money - reimbursing hospitals for providing uncompensated care.

Hospitals were not mandated by the Legislature to participate in the project. The state doesn't directly cover the cost of this new free care to the Healthy Outcomes Plan patients - for example, Roper St. Francis had to write off Seymore-Green's $2,800 gallbladder surgery as charity care. But each hospital needed to brainstorm a plan to preserve their full share of funding distributed by the state Medicaid agency and they all received a 2.75 percent Medicaid reimbursement increase as an extra incentive.

Roper St. Francis teamed up with Medical University Hospital and East Cooper Medical Center on a joint Healthy Outcomes Plan. The hospitals are leveraging the existing Access Health model to connect frequent ER patients to less expensive health care resources in the community.

Unlike the Affordable Care Act Medicaid expansion, which would have made more than 300,000 residents in this state eligible for insurance, the criteria for patients to qualify for the Healthy Outcomes Plan is stricter. They must be uninsured, must have made several trips to the emergency room, and must have some chronic condition. The Medicaid agency expects hospitals to enroll only 8,500 patients statewide.

This year, hospitals were paid simply for participating - it didn't matter how many patients they managed to enroll in the Healthy Outcomes Plan. Next year, the rules will change.

"We will tie it more to the actual level of enrollment," said Medicaid Director Tony Keck.

Meanwhile, hospitals are awaiting further clarification from Keck's office.

Roper St. Francis, Medical University Hospital and East Cooper Medical Center already exceeded their Healthy Outcomes Plan goal this year by enrolling more than more than 1,200 patients in Access Health. They don't know if the state agency will make them find more patients next year or how exactly future success will be measured.

The legislation also specifies that hospitals must to connect their Healthy Outcomes Plan patients with a primary care "home" within 60 days of enrollment. Sass, who spoke at a conference in Boston about the project last week, contends that expectation isn't reasonable.

"There's not the (primary care) capacity in our community to be able to do that," she said.

That makes Seymour-Green one of the lucky patients.

She still must figure out how to settle that $20,000 hospital debt, and her Access Health card isn't technically insurance, but her bill of health has vastly improved since her gallbladder surgery and she calls the program "a blessing."

"Because I had the operation, I can continue on living."

Reach Lauren Sausser at 937-5598.