As Florida lawmakers far away in the state capital struggle to break their stalemate over Medicaid expansion, sees the bus bench advertising 鈥淥bamacare鈥 near her Miami home as a reminder of a broken promise: that the Affordable Care Act would help her get the medical care she needs to return to work.
Louis, 57, has been unemployed since fall of 2013. Before then, the mother of three worked for Burger King for nearly 25 years, preparing and serving breakfast and lunch to Miami customers.
Dr. Annelys Hernandez, left, checks out Cynthia Louis in Florida International University鈥檚 Mobile Health Center. (Photo by Peter Andrew Bosch/Miami Herald)
鈥淲ork is fun if you like the job,鈥欌 Louis said, recalling years-long friendships with co-workers and customers. 鈥淎nd my job, I loved it.鈥
When she fell ill at the store on Biscayne Boulevard and Northeast 91st Street in Miami Shores, vomiting and unable to stand from the pain in her legs, Louis could not return to work, losing her job 鈥 and her best chance at getting health insurance.
Since then, Louis has learned what it鈥檚 like to depend on , the one that鈥檚 supposed to catch residents before they hit bottom.
Although at times in the past she had been covered by private insurance through her employer, she no longer had that option. And she discovered that while more than 1.5 million Floridians now have insurance through the Affordable Care Act, she falls into a category of healthcare have-nots called the coverage gap.
Too poor to qualify for financial aid to make insurance more affordable under the health law commonly known as Obamacare, Louis and some under Medicaid 鈥 if the state had chosen to expand the program as provided under the ACA.
But legislators in Florida, like those , have chosen to keep Medicaid open only to strict categories: poor children, and adults who are disabled, pregnant or parents with dependents earning no more than $5,500 a year for a household of two.
For Louis, life in the gap means any healthcare she gets will be up to her. And that means the safety net: free clinics, community health centers and public hospitals.
In the year-and-a-half since she lost her job, Louis has found she can usually get in to see a family doctor within weeks of seeking an appointment. And she qualifies for discounts on doctor鈥檚 visits, medical tests and prescription drugs through a charity care program at Jackson Health System, Miami-Dade鈥檚 public hospital.
But with no income, discounted care often means deferred or neglected care.
In mid-March, Louis learned first-hand the value 鈥 and the problems 鈥 of the safety net.
A viral infection had settled in her lungs. She wanted to visit her family doctor at the Jessie Trice Community Health Center in Brownsville. But she didn鈥檛 have $25 for the co-payment, and instead turned to a free clinic run by Florida International University鈥檚 Herbert Wertheim College of Medicine as part of the NeighborhoodHELP program.
The program offers low-income Miami-Dade residents free visits with a family doctor aboard a mobile clinic, along with counseling from a psychiatrist and other social services in exchange for patients鈥 allowing students to work with them.
The mobile clinic, a blue bus with the FIU logo on it, stops every Tuesday in the parking lot of the Pentecostal Tabernacle Church in Miami Gardens, an area of Miami-Dade with a high rate of uninsured residents.
Inside one of the narrow clinic鈥檚 two exam rooms last month, Louis met with Fred Anderson, a family physician and FIU assistant professor who helps run the fleet of three mobile clinics.
Anderson, who has been seeing Louis for about a year, asked if she had yet to get the X-rays of her hips and hands ordered by doctors during previous visits.
鈥淣ot yet,鈥欌 Louis said.
Her X-ray referral, she said, had been sent to an imaging center in Coral Gables that charged twice the amount it would cost at Jackson Memorial Hospital 鈥 $40 鈥 with her charity care card.
Louis said she had been calling the imaging center every day to have her referral forwarded to Jackson, and she had yet to hear back.
But the referral wasn鈥檛 her only obstacle. Louis also did not have the money for the co-payment because, she said, she often must choose between paying for her healthcare and buying soap and deodorant.
Without the X-rays, Anderson was unable to work on Louis鈥 chronic pain. He prescribed her an antibiotic for the viral infection, telling her she can get a two-week supply for free at a local supermarket. He also has prescribed anti-inflammatories for her pain. But he wants her to see a specialist, a rheumatologist, which means another co-pay she probably can鈥檛 afford.
鈥淚 would love to have all the X-rays,鈥欌 Anderson said. 鈥淭hat would probably shed a little more light on what鈥檚 going on with her diffuse muscle aches and joint pains. But those are also the reasons that we wanted her to be seen by a rheumatologist, to get a second opinion.鈥欌
Anderson said he first wrote the referral for Louis to see the specialist at Jackson Memorial about a year ago. Confused, she went to an orthopedist instead.
Louis said the orthopedist told her to take Aleve for her pain. 鈥淏ut Aleve wasn鈥檛 doing me no good,鈥欌 she said.
Since then, Louis has been waiting to see a rheumatologist whom she hopes can chart a course of treatment to get her back to where she wants to be: taking pride in her work.
She鈥檚 not giving up. But, she said, 鈥淭his here is driving me crazy, sitting around the house.鈥欌
Hospital charity care, even at a publicly-funded facility like Jackson, isn鈥檛 always the answer for people in the gap.
Louis is enrolled in Jackson鈥檚 program, which provides discounted medical care to all uninsured Miami-Dade residents with no other options for insurance. Coverage is on a sliding scale; those with the lowest incomes receive the greatest benefits.
Louis qualifies for the most generous classification at Jackson, the J02, which is for those living below the poverty level of $11,770 a year for an individual.
But it鈥檚 not free. For each service that Anderson recommended, Louis will have to cover a $40 co-payment.
Even though she鈥檚 sure she can borrow the money from one of her adult children or a friend, the co-pay is only the first hurdle. Then there鈥檚 actually getting the services.
The X-ray referral that went to the higher priced clinic in Coral Gables still hadn鈥檛 gotten her the procedure at Jackson, a month after doctors prescribed it. Her appointment is in June.
The rheumatologist is taking even longer. Louis said she booked that appointment in January, and was told she can see the doctor in July.
鈥淭he waiting is tearing me down,鈥欌 Louis said. 鈥淚f I can find out what鈥檚 going on 鈥 all of us can get together and see where we go from there. But when you don鈥檛 know, that鈥檚 a big problem.鈥
While she waits, Louis fights the fatigue that feels as though it comes as much from her illness as from her healthcare limbo. She dreads the moments when hopelessness creeps up.
鈥淚 pray,鈥欌 she said, 鈥渁nd that helps. It helps a lot.鈥欌
While Louis prays, her doctors wrestle with their own dissatisfaction over the pace of her care.
鈥淚 do not feel satisfied with how we鈥檝e been able to really get her on her feet,鈥欌 Anderson said. 鈥淪he still has significant limitations, let alone medical uncertainty that she鈥檇 really like to have resolved so that she can start to really plan her treatment.
鈥淚f she had access to a full insurance program,鈥欌 he said, 鈥渟he would not have to wait six months or a year.鈥欌
Ed O鈥橠ell, a spokesman for Jackson Health System, couldn鈥檛 directly address Louis鈥 case because of privacy concerns. But he said the wait to see a specialist at Jackson can run five to six months or as little as two weeks.
鈥淚t depends on the specialties,鈥欌 he said. Urology, pulmonary and ear, nose and throat specialties have the longest waits, he said, because the clinics are only available four hours once a week since they are used for teaching or academics.
Jackson鈥檚 charity care program is the largest in Miami-Dade, offering discounted care to an estimated 40,000 uninsured county residents in 2014, O鈥橠ell said.
That鈥檚 not only people in the coverage gap. Jackson officials estimate about 6,200 of those charity care patients in 2014 were undocumented immigrants, who do not qualify for any benefits under Obamacare.
Resources to care for the uninsured are scarce, even for Jackson, which this year will receive about $370 million in local sales and property taxes to help fund its mission to care for all county residents regardless of their ability to pay.
Still, some patient advocates say Jackson鈥檚 charity care program is not enough to meet the medical needs of an estimated 140,000 low-income residents who fall into the coverage gap in Miami-Dade.
With co-payments for the poorest qualified patients at $6.50 for prescription drugs, $40 for an emergency room visit or $100 a day for outpatient procedures, Jackson鈥檚 program is not a replacement for Medicaid, said Miriam Harmatz, an attorney for Florida Legal Services, a nonprofit that provides legal aid to low-income residents.
鈥淚t鈥檚 not real coverage,鈥欌 Harmatz said. 鈥淭hat is very different from having an insurance card, a Medicaid card, where you would get those services with very minimal co-pays.鈥欌
For eligible beneficiaries who earn less than poverty level, Medicaid charges a maximum co-payment of $4 for outpatient services, and a flat fee of $75 for hospitalization. Preferred drugs are capped at $4.
Harmatz added that Medicaid expansion also would mean hospitals and doctors would be paid for services now provided for free or at low cost to patients in the coverage gap 鈥 perhaps allowing those healthcare providers to hire more doctors and improve care.
It鈥檚 not just patients like Louis who are frustrated by long waits in the safety net. Doctors are, too, especially knowing that their patients might qualify for Medicaid under expansion.
鈥淧eople are losing out. Their health is being affected,鈥欌 said Katherine Chung-Bridges, a family doctor who counts Louis among her patients at the Jessie Trice center, a community health center with federal funding where patients pay on a sliding scale.
鈥淵ou鈥檙e trying to get studies done. You鈥檙e ordering labs. You鈥檙e trying to get tests done, and the patient has to pay out-of-pocket for those tests,鈥欌 she said. 鈥淎nd then the patient might have to decide, am I going to be able to eat dinner today or am I going to get this test done? Those are decisions that people shouldn鈥檛 have to make.鈥
Despite the barriers to her healthcare, Louis is more fortunate that many in the coverage gap.
Even with the long waits and co-payments she often can鈥檛 afford, Louis said she feels fortunate to have the safety net. But she also knows that she would qualify for a far superior form of coverage 鈥 Medicaid 鈥 if Florida legislators were to open the program to nearly all of the state鈥檚 low-income adults.
That鈥檚 why the Obamacare ad on the bus bench near her home leaves Louis feeling cheated.
鈥淚 look at it all the time,鈥欌 Louis said, on a drive to visit her mother in Miami. 鈥 鈥極bamacare. You can get Obamacare. You ain鈥檛 gotta be working.鈥 That鈥檚 what it was all at first. Then you get there, and people say, 鈥榊ou鈥檝e got to have some kind of income.鈥 That鈥檚 not what you all said in the beginning.鈥
鈥淔alling into the Gap鈥 was reported with the help of the Dennis A. Hunt Fund for Health Journalism, administered by the California Endowment Health Journalism Fellowships at the University of Southern California鈥檚 Annenberg School for Communication and Journalism. WLRN-Miami Herald News reporter Wilson Sayre contributed to this report.