Just after midnight on January 1, 2011, Jason Villareal and his wife were driving home from a church service when they were hit head-on by a drunk driver. The damage was massive.
"My wife broke her right foot. I was knocked unconscious. I had a shattered right foot, heel and a broken left arm. My ribs were all broken, displaced and my aorta had came out of my heart. It had severed," he says.
Doctors had to resuscitate him twice at Ben Taub Hospital, Villareal says. "I was in ICU for 20 days. I had nine surgeries. I was out of work for a year." He had to use a walker to get around.
Fortunately, he was a longtime employee of his company, which produces lift equipment. "I was disabled and left with a deformity in my right leg and right foot. They still wanted me to come back. They gave me a lot of accommodations; they understood. If I had to leave early or come in late, it didn't bother them." And equally fortunately, he had health insurance.
But then another company bought out his employer. "I got laid off November 30 of 2012." And because it was the end of the month, on the day his job was terminated, he also lost health insurance coverage on the spot.
"I was thinking, 'Man, I still see my doctors regularly.' It was almost two years since the accident. I was seeing my orthopedic doctor and my vascular doctor. I was on new medications because of everything, the stent in my heart, blood thinners. Doctor visits were a must."
He'd been seeing a doctor at Kelsey--Seybold. "All of a sudden, a $20 co-pay turned into a $300 doctor visit, which all came out of my pocket, and I just couldn't see her anymore." She advised him to apply for Social Security disability -- which he did but says he's still waiting on a final ruling a year later -- so he can't go back.
A friend of a friend told him about the San José Clinic on Fannin in midtown Houston, which serves low-income patients. And he immediately encountered a problem -- Villareal's past income was way too high. "I had to explain to them what had happened to me, and I don't have any more medication; I'm running out." He calls being accepted into the program "a miracle."
Last year, just as the Affordable Care Act was shifting into gear, the Houston Press visited the San José Clinic, whose President and CEO, Paule Anne Lewis, was concerned, in part, that some of the clinic's donors might curtail their giving, thinking that with the arrival of the ACA, there would no longer be a need for a San José. She predicted there still would be "tens of thousands of people who are uninsured."
A year later, there had to be things that changed, right? Had to be a decline in the number of patients San José was seeing since health care had been opened up to so many more people. Right?
"Our patient population has not changed," Lewis says. "What we're finding for us at San José Clinic is as we thought; without the expansion of Medicaid in Texas, there are so many people left uninsured or uninsurable."
'When did it become socially acceptable for a physician to say no to a patient because they had no money?" asks Dr. Pedro Greer, recipient of a MacArthur "Genius" Fellowship and associate dean of community engagement at the Florida International University College of Medicine.
In October, Greer was keynote speaker at the clinic's fall speaker series luncheon, and while he had a receptive audience there, that probably isn't the case everywhere he talks. A provocateur with a quick ability to turn a phrase, Greer celebrates the "spectacular" volunteer physicians at San José and elsewhere but makes it clear he thinks too many physicians and medical institutions have lost their way.
"If emergency rooms were not forced by law not to refuse patients, what would they do? How does that fit into their bottom line?"
"We're supposed to be a profession that takes care of people without prejudice. The example I give to medical students is that when you apply to medical school, you never say, 'I want to make a lot of money.' You say you want to make people better or society better. You take a white-coat ceremony in which there's there's actually the words 'social justice.' When you go on the wards, the first person who lets you put in an IV or do a lumbar puncture is generally not the CEO of a multinational corporation but an indigent patient," he says.
"Two-thirds of a student's cost for medical education is supplemented by public funding and you take an oath when you graduate," he says. But despite this and all the medical school training doctors receive, something happens "between that and going into practice," Greer says.
"It's not like we doctors don't make a great living. With all due respect, if you have a really nice sports car, you can help the poor even quicker," Greer says.
Lewis says that 60 percent of San José's patients are at or below the federal poverty level, which means they don't make enough money to get subsidies to help them pay for medical insurance. Some, but not all, would be covered if Gov. Rick Perry had agreed to expand the state's role in Medicaid; Texas is one of 14 states that has declined to do so. The clinic's clientele also includes undocumented immigrants, who don't qualify for government programs.
"We still have this huge coverage gap," Lewis says, explaining that many of the working poor did go to the marketplace but realized the deductibles and out-of-pocket costs were just too much. Her conclusion: "If you couldn't afford it [health insurance] before, you probably can't afford it now."
San José Clinic can't meet all the need that arrives at its doors. Applicants are screened for eligibility just as Villareal was. Sometimes they don't realize they have some state or federal coverage, and San José helps them navigate the system. The clinic doesn't see many children, but it does "get them on the path to coverage," Lewis says. In 2013, she says, the clinic helped about 20 percent of the people who came to them sign up with other providers.
Part of the Archdiocese of Galveston-Houston, San José Clinic pays rent to the CHRISTUS Health System ($1 a year) but is not part of it. Operating under rules of the Roman Catholic Church (no abortion referrals or birth control), it is looking to expand beyond its eye clinic, dental offices, pharmacy, radiology department and examining rooms. Most of its services are provided by volunteers from the medical field, and there's one full-time physician. Most clinic patients are women, and the three most common conditions are high blood pressure, obesity and diabetes. Payments are on a sliding scale, with no charge for lab visits, and dental visits (which are not covered for anyone under the Affordable Care Act) are set at about $100.
Lewis wishes San José could do more things in-house; it still can't do procedures such as colonoscopies or biopsies. "It's difficult to find the resources for our patients. Where do we send them to get help?" The clinic needs more dentists and could use more volunteers of all types.
As Greer sees it: "Improving the health of a nation starts with the health of the individual. We do a thing called triage. We take the ones who are the sickest. Those are the first ones we see because those are the priority. Unfortunately, those that are the sickest in our society are also the poorest. And those tend to be the last ones we see."
It's almost mind-boggling that not just in Houston or Texas but across the country, there are large parts of the population whose lives haven't been changed in any way by the Affordable Care Act. It might as well be an ongoing program on Mars as far as they're concerned.
Although its patient numbers haven't dwindled, San José has made some strides in the past year, Lewis says. It's making more inroads into preventative medicine, tackling the borderline overweight before they become obese. "We're trying to catch people before they cross over into that chronic disease state. Our statistics on diabetes got better."
San José has taken on a partnership with the Houston Food Bank, bringing fresh produce to the clinic. It has intensified its nutrition counseling, although perhaps the best thing it did there was to move classes from Tuesdays to Saturdays. "It doubled, almost tripled our attendance," Lewis says.
The clinic is hoping for at least some alternative approach to added state funding for health in the next Legislature, pointing to the model in Florida, whose legislature pulled $4.5 million from state funds to support charity care clinics, Lewis says.
Greer's mission is to spread the word that physicians and other medical people need to recall what they are supposed to be all about.
"The whole thing is working together -- collaboration -- something which I defined earlier as an unnatural act committed by non-consenting adults," Greer says. "The problem in health care is very simple. Doctors, medical institutions, hospitals, we're like dogs. We pee and this is our area. Don't come into my area and I won't come into your area. The real cost of disease in our country has to do with social and public policies."
Asked if he supports the Affordable Care Act, Greer answers quickly. "I support it. How can somebody say, 'I'm not for having people having coverage'? Forget the details."
Before he was in management at the rigging company, Jason Villareal was a welder. He was not some homeless guy, someone who wasn't productive, someone who didn't contribute to society, to his family.
He was a man who had a most unfortunate thing happen to him. We can shake our heads and step away, or stop and consider that we still haven't put enough health-care coverage safeguards in place to stop a really bad day from turning into years of trauma.
After he lost his job, Jason Villareal was able to get interviews at several places, but says they never called him back. No one ever told him so, but he thinks his obvious disability may have scared them away.
He goes in on weekly visits with Dr. Sherri Onyiego at San José, where they regularly try out new medications. "When I got out of the hospital, they told me I was back to being a diabetic. So we've been working with that."
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He can handle the sliding-scale payments, but doesn't know what he would have done if San José hadn't accepted him. "I was already out of medication. I already exhausted my 401k." The young woman who hit them "didn't have good enough insurance. There was nothing to sue for."
He has improved to where he can ride a stationary bike and with the help of a cane "walk about a block, maybe two and come back home and it's lights out." One doctor has told him there is definitely more surgery in his future.
He's hoping to get the Social Security disability money coming in so he can move on. He's only 43 years old, and doesn't quite know what he's going to do with the rest of his life -- only that he needs to come up with a plan to make it all work.
After all, he says: "I still have the hospital district calling me for my 20 percent."