Charity, CHIP, Medicaid and the Community

By Glenn Robinson

Each year, thousands of Texas patients must rely on charity care to receive the medical services they need. Hospital charity care means no payment is expected for the services the hospital provides, which means that patients who qualify for such care typically receive no hospital bill and are not subject to collection efforts.

While Texas may lag far behind other states when it comes to number of residents who have health insurance coverage, it was the first state to establish a required level of community benefit for non-profit hospitals in exchange for state tax exemption.

This community benefit requirement means that Texas not-for-profit hospitals must spend four percent of expenses on charity care, and a total of five percent overall on charitable activities.

While exact criteria to receive hospital charity care may vary, generally patients who receive care at a non-profit hospital may apply for complete or discounted charity care if they are either financially indigent – meaning they are uninsured or underinsured with an income at or below 200 percent of the federal poverty level; or are medically indigent – meaning their medical or hospital bills exceed a certain percentage of their annual income after payment by insurers, leaving them unable to pay the remaining bill.

A hospital’s total uncompensated care is the sum of its charity care provided and uncollectable patient debt. Since 2000, U.S. hospitals have provided more than $538 billion in uncompensated care.

Funding for Medicaid and the Children’s Health Insurance Program recently have been the topic of a lot of hot political talk in Congress, so let’s take a closer look at these two government-administered health insurance programs.

Medicaid covers about one in five Americans. It reaches many low-income children, adults, seniors, and people with disabilities.

In Texas, children, the disabled, and seniors represent 90 percent of those covered by Medicaid. The remaining 10 percent are working-age adults – three-quarters of whom are employed, but do not earn enough to afford health insurance or do not work for an employer offering insurance.

Medicaid is the nation’s major source of long-term care financing, which is particularly important in supporting seniors and helping relieve the care burden that often falls on families. It also provides benefits for people with disabilities who are unable to find or afford other coverage.

The Children’s Health Insurance Program, or CHIP, is low-cost health coverage for children of families who earn too much money to qualify for Medicaid.

Medicaid, together with CHIP, has resulted in improved access to care for children and helped bring the uninsured rate for children to record lows. Children with Medicaid or CHIP have greater access to care than uninsured children and comparable access to children with employer-sponsored insurance.

But enrollment in Medicaid and CHIP have positive impacts on children and families beyond improving access to health care services. These programs may provide financial protection for families who have very little otherwise.

When we talk about a changing approach to healthcare in this country, many people’s minds immediately go to what is going on in Washington regarding healthcare policy – or perhaps some of the latest and greatest treatment technologies.

These are indeed important, impactful facets of the changing healthcare landscape, but perhaps even more impactful is the shifting mindset of many hospitals and healthcare organizations who are now focusing on overall community wellbeing.

Central to these efforts are innovative and effective community partnerships. Through community partnerships, hospitals and health systems seek out new and nontraditional partners to improve both health and overall quality of life in the communities they serve – regardless of the ethnic, racial, socioeconomic or physical circumstances that make up a community.

These non-traditional partners for hospitals may include police and fire departments, food banks and grocery stores, community recreation centers, churches, and local non-profits addressing issues such as housing and education.

The esteemed Robert Wood Johnson Foundation believes hospital-community partnerships are indispensable when it comes to building what it calls a “Culture of Health.” While often viewed as non-traditional, these partnerships make good sense because good health is dependent on far more than the medical care available to a community. A safe environment and dependable access to healthy foods are essential to the cause, as are a range of other factors.

These partnerships have the potential to reshape communities and change lives. And in the end, isn’t changing lives for the better what great healthcare is all about?

This report, and other episodes, are available at KWBU.org


Glenn Robinson is the President of Baylor Scott & White Medical Center – Hillcrest. He has over 30 years experience in hospital and health care management, and currently serves on several Boards associated with the Texas Hospital Association and the American Hospital Association. In addition, Glenn is Past-Chair and an active member of the Greater Waco Chamber of Commerce, and serves on the Prosper Waco Board.

The Act Locally Waco blog publishes posts with a connection to these aspirations for Waco. If you are interested in writing for the Act Locally Waco Blog, please email ashleyt@actlocallywaco.org for more information.

Health terms everyone needs to know: Advance Directives and Palliative Care

By Glenn Robinson

Given the complexity of today’s health care system, weighing options and making treatment decisions are difficult enough as it is.

While we are all grateful for the wonderful doctors and nurses who work long hours and go above and beyond for their patients, often it is family caregivers who are the unsung heroes of health care.

They are the ones who provide the relentless daily support for their loved ones who cannot care for themselves because of frailty, illness, injury, or disability. Their care is critical to sustaining or greatly improving life.

Being a family caregiver is the very definition of ‘labor of love.’ Spouses who act as the primary family caregiver bear an enormous burden. They routinely perform complex tasks virtually identical to what doctors or nurses perform in a clinic, such as medication management, wound care, using meters and monitors, and much more.

Making the job even more difficult is that more than half of spouses report no additional help from family or friends or home care aides, and three out of five caregivers also are members of the traditional American labor force.

And the cost of informally caring for particularly the elderly by friends and relatives in the United States? More than a half trillion dollars per year, according to one study, with Americans spending an estimated 30 billion hours annually providing care to elderly relatives and friends.

When a loved one is seriously ill – perhaps even dying – the decision-making process for the patient and his or her family becomes that much more difficult.

Too often, though, those decisions are not able to be made by the patient when the time comes. Rather, it becomes a burden that falls on a loved one – but it doesn’t have to be that way.

Advance care plans, which include advance directives, attempt to take the guesswork out of figuring out a patient’s wishes and values about end-of-life care while they are still of sound mind.

Advance directives are legal documents that establish guidelines for what treatments patients should or should not receive. They can lift the emotional burden off of loved ones responsible for making care decisions, because it is clear what the patient wants.

Both a living will and a health care power of attorney are types of advance directives. Unfortunately, a recent study found that just 29 percent of Americans had completed a living will that contained specific end-of-life care wishes, and only 33 percent had designated a health care power of attorney.

A rapidly growing field of medicine called Palliative Care is helping patients and their family members navigate the complex decision-making process surrounding serious illness and end-of-life care.

Whether it’s physical, emotional, or financial relief, Palliative Care is rapidly becoming a critical resource helping patients and families in difficult circumstances cope.

The goal of Palliative Care is to relieve a patient’s disease symptoms and minimize the side effects of treatment regardless of long-term prognosis. Palliative Care specialists often help families and patients make difficult decisions about whether to use highly aggressive therapies, and sort through treatment options – aligning them with the expectations of the patient and their family.

Additionally, palliative caregivers provide comfort care – which is spiritual, emotional, and psychological support and guidance.

The efforts of palliative caregivers are producing tangible results. Research shows that Palliative Care patients report improvement in pain or nausea, better communication with doctors and loved ones, and care that is more in line with their wishes.

Not only does not having an advanced care plan in place add burden to family members during an already stressful and emotional time, but it’s a burden on the health care system as well. The cost of care in the last week of life is 55 percent higher for those who have not had advance care planning discussions.

A Baylor Scott & White Health study showed that palliative patients and their families spend an average of $3,000 less in hospital costs than patients with similar conditions who did not receive such care, and these palliative patients often received not less, but better, care. This means having this very personal conversation is a decision that impacts all of us.


Glenn Robinson is the President of Baylor Scott & White Medical Center – Hillcrest. He has over 30 years experience in hospital and health care management, and currently serves on several Boards associated with the Texas Hospital Association and the American Hospital Association. In addition, Glenn is Past-Chair and an active member of the Greater Waco Chamber of Commerce, and serves on the Prosper Waco Board.

This report, and other episodes of “The Business of Healthcare,” are available at KWBU.org

The Act Locally Waco blog publishes posts with a connection to these aspirations for Waco. If you are interested in writing for the Act Locally Waco Blog, please email ashleyt@actlocallywaco.org for more information.