New data released Tuesday by federal health officials in advance of the decision showed that Florida, which enrolled the most people in Obamacare, also stands to lose the most.

Those Floridians received an average subsidy of $294 a month in March to reduce their premiums, according to the . Among those Floridians, nearly 1 million also received financial aid from the government to reduce their out-of-pocket costs, such as co-payments, co-insurance and deductibles.

Leah Barber-Heinz, chief executive of Florida CHAIN, a nonprofit consumer health advocate in favor of the health law, said the Sunshine State risks more than financial assistance for low- and moderate-income residents to buy health insurance.

“Lives are at stake when the courts rule on cases like King v. Burwell,’’ she said in a written statement. “When a million people lose their health insurance, some of them will face dire consequences.”

A total of 34 states, including Florida, rely entirely on the federal insurance exchange and risk losing subsidies if the Supreme Court rules against the health law. Through March, those states enrolled a total of about 7.3 million Americans, of which 6.4 million receive an average government subsidy of $272 a month to lower their premiums.

• Total Enrollment: 1,415,981
• Enrolled With Advanced Premium Tax Credit: 1,324,516
• Percentage of Enrollment With APTC: 93.5 percent
• Enrolled With Cost-Sharing Reduction Subsidy: 998,137
• Percentage of Enrollment With CSR: 70.5 percent
• Average APTC in Fla. Through March 31: $294
• Average APTC in Fla. Through Dec. 31, 2014: $280

Source: The U.S. Department of Health and Human Services

The data released by the Department of Health and Human Services reported that an estimated 10.2 million Americans, including about 2.9 million who enrolled through state-based exchanges, had paid for their Obamacare health plans as of March 31.

That’s a reduction from the total 11.7 million sign-ups reported earlier this year. Still, HHS Secretary Sylvia Burwell said in a written statement that the insurance exchanges are “working.’’

“We’ve seen a historic reduction in the uninsured and consumers are finding the coverage they need at a price they can afford,’’ Burwell said.

Critics of the health law, however, insist Obamacare is not working.

Andres Malave, a spokesman for the Florida chapter of Americans for Prosperity, a conservative group that opposes the ACA, accused the Obama administration of creating uncertainty and angst among Floridians.

“It’s legitimate anxiety that the Affordable Care Act has caused,” Malave said. “And it’s forcing Floridians to unfortunately have to live in a world where they are unsure of how their coverage is going to be affected because the president’s administration decided that a big government solution was better for Floridians instead of allowing the free market to operate.”

Of the 10.2 million Americans with effective coverage in March, 85 percent or about 8.7 million were receiving subsidies.

In Florida, about 1.4 million residents were enrolled in and paying for health plans through March 31, according to the data, and more than 93 percent — or about 1.3 million people — were receiving a government subsidy to help pay for the insurance. Florida had the second-highest rate of consumers, after Mississippi, who received financial aid to pay for their premiums in March.

According to federal , Florida residents who received a government subsidy to make their health plan more affordable paid an average premium of $82 in February — well below the national average of $101 a month.

If the Supreme Court ends subsidies, Floridians receiving financial aid would face an average premium increase of 359 percent, according to by the Kaiser Family Foundation, a nonprofit health policy research group. (KHN is an editorially independent program of the foundation.)

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The Florida Senate has proposed a plan — the Florida Health Insurance Affordability Exchange Program, or FHIX — that would accept federal funds under the Affordable Care Act to establish a state-run private insurance exchange for low-income residents.

An estimated 850,000 uninsured Floridians would be newly eligible for coverage under the plan, though they would be required to work or to attend school, and to pay monthly premiums.

But House leaders and Gov. Rick Scott oppose any Medicaid expansion because they say they don’t trust the federal government to keep its promise to pay for covering more Floridians.

have overcome political opposition to Medicaid expansion and adopted plans to bring government-subsidized coverage to more of their low-income residents: 28 states and the District of Columbia, as of April. Expansion is under discussion in Missouri, Montana, Utah, Alaska and Tennessee.

Those caught in an insurance gap in Florida earn too much to receive Medicaid, but not enough to qualify for subsidies to buy a plan through the federal marketplace. at how these Floridians are coping and what other states are doing to close the gap.

• Medicaid Expands In Other States, But Not Florida

Nearly all of the expansion states — 24 of 28 — have simply removed categorical exclusions, opening Medicaid to a much broader group of low-income adults, including those without dependent children or disabilities, as set forth in the health law. They also raised the income eligibility.

Five states have obtained a special waiver from the federal Centers for Medicare and Medicaid Services, or CMS, to allow them more freedom in how they expand Medicaid.

Most recently, Indiana became the 28th state — and the 10th with a Republican governor — to receive approval for an expansion plan. It’s called the Healthy Indiana Plan, which covers an estimated 350,000 people.

Indiana’s plan, which took effect in February, includes elements that hadn’t been approved in other states. Among the key provisions: no retroactive eligibility and barring some recipients from re-enrolling in coverage for six months if they are dropped for unpaid premiums.

Indiana also received approval to charge higher co-payments for non-emergency use of the emergency room.

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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.

“Work is fun if you like the job,’’ Louis said, recalling years-long friendships with co-workers and customers. “And my job, I loved it.”

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 — and her best chance at getting health insurance.

Since then, Louis has learned what it’s like to depend on , the one that’s supposed to catch residents before they hit bottom.

Those caught in an insurance gap in Florida earn too much to receive Medicaid, but not enough to qualify for subsidies to buy a plan through the federal marketplace. at how these Floridians are coping and what other states are doing to close the gap.

• Relying On The Health Care Safety Net

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 — 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.

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On the days when she feels good, when her elbows and knees aren’t stiff for hours and the bones in her feet don’t radiate near-crippling pain, Isabel Betancourt may skip the regimen of injections and pills that stop her immune system from destroying the cartilage and bone in her joints.

Missing her weekly injection of Enbrel and daily doses of other prescription drugs means Betancourt is risking the deformed joints and damaged organs that can come with rheumatoid arthritis.

The trade-off may not be worth it, Betancourt acknowledges, but it is sometimes necessary when you fall into a murky place in Florida’s healthcare system that policy analysts call the coverage gap because no government insurance program bridges it.

Rationing her medication makes a one-month supply last two months or longer. With prescriptions that can cost more than $5,000 a month without insurance, she has learned to get by.

“You find loopholes,’’ said Betancourt, 31, diagnosed with juvenile rheumatoid arthritis, an autoimmune disease with no cure, when she was in eighth grade.

Betancourt, now a part-time Florida International University employee and full-time student, is one of about 850,000 Floridians and , a no-man’s-land carved out by a 2012 U.S. Supreme Court decision on the Affordable Care Act, known as Obamacare.

Those caught in an insurance gap in Florida earn too much to receive Medicaid, but not enough to qualify for subsidies to buy a plan through the federal marketplace. at how these Floridians are coping and what other states are doing to close the gap.

• 850,000 Floridians Stuck In Health Care Limbo — And No Solution In Sight

For two years, Florida’s Legislature — meeting once again in Tallahassee this month — has refused to close the gap for people like Betancourt, turning down federal money to expand the Medicaid program to include her. Gov. Rick Scott has said he plans to sue the federal government, accusing the Obama administration of attempting to force expansion on Florida.

In South Florida, where the problem is particularly acute because it is home to the greatest number of uninsured people in the state, the Miami Herald found residents in the gap piecing together their own — largely inadequate — healthcare “systems.”

They use , visit community health centers when they can afford the discounted prices and, if all else fails, wind up in a hospital emergency room that can result in crushing debt.

They cut pills in half, borrow money or cash in retirement funds for co-payments, and wait months or even a year to see a doctor. It’s an exhausting and haphazard way to get medical care, especially when people are at their most vulnerable — when they’re sick.

The coverage gap was never supposed to exist under the health law. Medicaid expansion was going to bridge the gap between the poorest Americans and those who made enough to qualify for government-subsidized plans. But the Supreme Court’s decision to make Medicaid expansion optional meant that Florida and 21 other mostly Republican-led states chose not to expand the state-federal insurance program for the poor.

For two years, people in the gap like Betancourt have been caught in a conundrum: not poor enough for Medicaid, but not earning enough to qualify for Obamacare tax credits to make health insurance more affordable.

Many people don’t know they fall into the gap until they apply for a subsidized Obamacare plan. And what they find out makes no sense, say enrollment counselors. People who make more than they do are qualifying for government subsidized plans, but those who have less aren’t eligible for any help.

He hasn’t seen a doctor in seven years. When he came down with a skin condition that caused sunburn-like pain and muscle tightness, he consulted the Internet for self-diagnosis, popping vitamins, changing his diet and taking Benadryl in case it was an allergy.

“It was scary,’’ he said. “Normally you go to the doctor when something like that happens.”

Cuervo, now living in Medley, began a full-time sales job in March, which he expects will make him eligible for a subsidy to buy an Obamacare plan next year.

Standoff in Florida

Like so many thousands of others, Cuervo is also waiting to see what the Legislature will do — if anything. Although federal health officials say 11 million more Americans are covered by Medicaid this year than in 2013, Florida lawmakers seem no closer to a solution for those in the gap.

The debate — once a partisan issue — is now dividing Republicans, who control the House, Senate and governor’s seat.

Florida Sen. René Garcia, a Republican whose district includes a Hialeah ZIP code with the nation’s highest enrollment for Obamacare plans, is one of the chief drivers of the Senate’s proposal to accept federal funding for Medicaid expansion in Florida. House leaders and the governor oppose any Medicaid expansion, saying they do not trust the federal government to continue funding into the future.

But Garcia said it’s hard to deny the need when it’s in your own district.

“It’s very heavy on my heart,’’ he said, “because you see families who are having difficulties accessing the system because of the lack of insurance. I’ve seen women with breast cancer, and men with different types of conditions who will get treated at the emergency room. They get treated and stabilized — and then they’re sent home. They’re sent home with no medication, no treatment plan, no follow-up care. And they come to me trying to help them access the system.’’

For Betancourt, it doesn’t make sense that those who earn more would be allowed subsidies to help pay for their coverage while those who earn less have nothing in Florida. “If there’s people who are earning more than me, who have a little more breathing room than I have financially,’’ she said, “why are they getting help and I’m not?’’

She has spent years and countless hours trying to come up with ways to get the healthcare she needs, sometimes paying insurance premiums with her tax returns or retirement savings, other times discovering a government program or manufacturer’s discount, always fearful that the program will end or money will run out. And she has worked or gone to school — or both — the entire time.

She received Medicaid as a child, but became ineligible when she turned 20 in 2003. By then, she had begun working as a part-time cashier for the City of Hialeah. The pay was low, Betancourt said, but it provided access to health insurance — until she was laid off in April 2010.

She wanted to aim higher, and decided to finish her degree at FIU while working part-time. She qualified for COBRA through her previous job until November 2011, paying monthly premiums that ran as high as $381. She paid those bills with temporary unemployment benefits, and by cashing out her retirement plan savings.

Then she went uninsured for five months — a scary time, she said, when she worried constantly about a health crisis — until she heard about the Pre-Existing Condition Insurance Plan or PCIP, a temporary program created under Obamacare to offer immediate help to those denied coverage due to an existing illness.

When premiums rose to $281 in November 2013, she could no longer afford even that plan. She went uninsured again, this time with medical bills she couldn’t pay. In March 2014, when she likely would have qualified for Medicaid if Florida had expanded its program, Betancourt signed up for a private Humana plan financed by her tax refund. That plan was canceled in October 2014 after three missed payments.

Vicious circle

Each time Betancourt went without insurance, she skipped doctor’s visits and medication, which led to more sick days, smaller paychecks — and less money to pay for a new health plan.

Last month, in March, Betancourt tried again, using her income tax return to buy a plan from Humana through the ACA exchange, though this time the plan has lower premiums because it is a bronze level that requires her to pay 40 percent of costs.

The premiums are $192 a month, which adds up to about 25 percent of her yearly income. Obamacare defines employer-provided coverage as affordable if the employee’s contribution is less than 9.5 percent of annual income. Betancourt pays more than 2 1/2 times that rate — without help from her employer or the government.

Though she lives with her father, and her aunt pays for her FIU tuition for a bachelor’s degree in broadcast journalism, Betancourt said she still has student loans. And she’s on her own for every other expense, from books to medication.

Some weeks, those expenses amount to more than she can pay.

On March 20, for instance, she received a bi-weekly paycheck of $361.45, after taxes, for 46 hours of work. But her white 2009 Toyota Corolla needed a new alternator, engine belt and radiator cap, which cost about $350. That left her with a little over $11 to stretch over two weeks.

With her next paycheck, Betancourt had to be sure she could cover the April premium for her Humana plan, and her monthly car insurance bill of $155.

She wouldn’t dream of asking her father to help. He already works two jobs.

“I’m too old to be asking dad,’’ she said. “I can’t be running to dad when he’s already spread thin.’’

Like Betancourt, more than half of the uninsured Floridians who would qualify for Medicaid under expansion are working, according to Families USA, a nonprofit that advocates for broadening health coverage under Obamacare.

And many are working in minimum-wage service jobs essential to the state, according to Cathy Kauffman, enrollment director for Families USA and the former director of Oregon’s Medicaid program for children.

“So much of the economy in Florida is tourism,’’ she said, “and so many people working in that industry fall into the gap.”

‘Everybody needs insurance’

There are others, though, employed in jobs that many would assume pay middle-class wages, who also fall into the gap.

, 38, is a paralegal. A single mother, she lives with her four young children in Palmetto Bay, in southern Miami-Dade.

Her children are covered by Florida KidCare, the state’s Medicaid program for kids. But Corr is uninsured. To qualify for Medicaid, she would have to earn less than $9,943 a year. She earns $24,000.

When she applied for an Obamacare plan in March at the Doris Ison Community Health Center in Cutler Bay — where she had taken her 7-month-old son, Santos, for a check-up — an enrollment counselor told Corr that she needed to earn about $28,000 a year to qualify for a subsidy.

When she talks about the risk of an unexpected illness that could send the family tumbling into debt or leave her children without their only caregiver, Corr wipes away tears.

“This is not like season tickets to the Dolphins,’’ she said. “I mean, this is health insurance. What kind of country are we? Everybody needs insurance.”

For Betancourt, who has already had two major surgeries to replace joints decimated by rheumatoid arthritis, the fear of financial ruin or needing care she can’t afford hasn’t lessened during her two years in the gap.

Though doctors have advised her to have her left shoulder replaced, Betancourt said she would have to go into debt to cover the $6,000 deductible for the surgery — assuming she can continue to afford her current plan. So she’s going to do what she has done for years: hang on and hope.

“All my life,” she said, “insurance companies have said no.”

Miami Herald staff writer Chabeli Herrera contributed to this report. “Falling into the Gap” was written 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’s Annenberg School for Communication and Journalism.

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The financial impact would be felt most acutely by so-called “safety net” hospitals statewide, and in Miami-Dade, particularly by the taxpayer-owned Jackson Health System, according to Florida Legal, which estimated that Jackson could lose more than $570 million a year.

Other Miami-Dade hospitals, including University of Miami Hospital and Mount Sinai Medical Center, could lose as much as a combined $60 million a year, according to the report, while hospitals in Broward, Palm Beach and Monroe counties stand to lose more than $500 million in annual federal funding.

But if state legislators were to accept the government’s offer to spend about $5 billion a year to expand Medicaid to an estimated 760,000 more Floridians, the new revenue would more than offset the anticipated loss of federal funding for hospitals that treat many uninsured patients, Florida Legal reports.

Given that Miami-Dade is home to the state’s largest numbers of uninsured residents, the local public healthcare safety net risks serious damage without Medicaid expansion, said Charlotte Cassel, an attorney with Florida Legal and a co-author of the report.

“Miami-Dade cannot afford [for Florida] not to expand Medicaid,” she said. “It will be a crisis.”

Florida Legal’s report found that Miami-Dade is home to more than 160,000 residents who fall into the so-called “coverage gap,” which means they are not eligible for Medicaid and they do not earn enough income to qualify for government financial aid to buy private health insurance on the ACA exchange.

Miriam Harmatz, a senior attorney with Florida Legal and a co-author of the report, said Florida has an estimated 760,000 residents in the coverage gap who will not have access to health insurance even with ACA reforms.

“The Legislature has a chance to address that,” she said.

The anticipated funding cuts reported by Florida Legal derive from a series of agreements between Florida and the federal government, and the intent of President Barack Obama’s healthcare reform law, which had anticipated that more Americans would have access to insurance under the ACA, reducing the amount of uncompensated care delivered by hospitals.

The healthcare law calls for gradual reductions in certain payments known as Disproportionate Share Hospital (DSH) program funds. In 2014, Florida hospitals will receive almost $240 million in DSH funding, which the state then distributes according to a formula.

But the biggest loss stems from a July 2014 agreement between Florida and the Centers for Medicare and Medicaid Services, which administers the healthcare programs on the federal level.

That agreement calls for the elimination of about $1.8 billion a year in statewide funding through the Low Income Pool program (LIP) starting on June 30, 2015.

The federal funding cuts are scheduled to occur regardless of the Florida Legislature’s actions on Medicaid, according to Florida Legal’s report. For Medicaid expansion to occur in Florida, the legislature would have to approve a Medicaid expansion bill and Gov. Rick Scott, a Republican, would have to sign it.

Florida Democrats and some Senate Republicans have said the state ought to accept the federal money to expand the program, including Sen. Rene Garcia, a Miami-Dade Republican.

At a meeting of Miami-Dade commissioners Nov. 5, Garcia stumped for Medicaid expansion, repeatedly calling it “a game changer” for the state.

“There’s about $50 [billion] to $66 billion waiting to coming into this state,” he said, referring to a 10-year estimate of the federal government’s pledge to never pay less than 90 percent of the cost of adding more Floridians to Medicaid.

Then he laid down the gauntlet: “If the feds continue down this path” of eliminating DSH and LIP funding, Garcia told the commission, “Jackson will be out about $500 million. So you all are going to have to come up with that money.”

As Miami-Dade’s public hospital system, Jackson relies on a balance of local, state and federal funding to operate the $1.6-billion-a-year system of hospitals, community clinics and physician offices.

This year, Jackson administrators estimate that Miami-Dade will contribute about $370 million in local property and sales tax support.

According to Florida Legal, Jackson will receive about $570 million in LIP funds this year and about $75 million in DSH funds.

Carlos Migoya, chief executive officer for Jackson Health, said the nonprofit hospital system is looking at “statewide level” solutions to make up the funding if the federal government ends the programs.

Migoya said Medicaid expansion is “one of our very top priorities,” but that Jackson would also explore “other funding opportunities’’ to pay for care of the uninsured and indigent if the DSH and LIP programs end.

Still, Medicaid expansion will not help Jackson with a chunk of its uncompensated care — the amount spent to care for undocumented immigrants.

Jackson’s total costs for providing medical services to the undocumented in the year ending Sept. 30, 2014 was about $47.6 million. Jackson’s total costs for uncompensated care in the same time period was $485 million.

State Medicaid administrators, hospital representatives and others have been meeting with CMS officials in an effort to persuade the federal government to extend the LIP program beyond June.

Mark Knight, chief financial officer for Jackson, said that is among the hospital system’s preferred paths.

“Right now, we are supporting a revised LIP program,” Knight said, noting that California and Texas officials have negotiated continued federal support for the care of uninsured patients.

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But even though at least eight hospitals provided the service — which could range from a hip replacement to reattachment of a foot — no two hospitals were paid the same amount.

The average payment varied widely — from $12,644 at Memorial Hospital West in Pembroke Pines up to $37,622 at Doctors Hospital in Coral Gables. Even among hospitals next door to each other, the average payment was significantly different: $29,978 at University of Miami Hospital but $13,475 at Jackson Memorial Hospital across the street.

The numbers, provided by AvMed, offer some insight into Miami-Dade’s employee health benefits . But healthcare experts and hospital administrators say that because they are averaged payments, they also obscure details that would allow the county to truly understand and manage its labor healthcare costs.

“From an employer perspective, it would be difficult to look at these numbers and figure out exactly what is going on,” said Steven Ullmann, director of health policy at the University of Miami business school.

As the county negotiates with labor unions over proposed changes to employee health insurance — potentially requiring a biweekly premium for employees who currently pay none and increasing premiums for others — healthcare price transparency has become increasingly critical for the county and its workers.

But like many employers across the country, Miami-Dade the prices their own insurance plan administrators negotiate with healthcare providers, even when they’re self-insured, like the county, and the claims are paid with taxpayer dollars.

AvMed won’t divulge the rates on the grounds that they’re proprietary and confidential. That means Miami-Dade officials never get to see precisely how the insurance company spends more than $400 million a year to pay healthcare claims for nearly 60,000 employees, retirees and dependents.

Instead, in response to a public records from Miami-Dade’s labor unions, AvMed produced charts showing the top 10 medical services by spending, and the average payment for those services — including joint replacement — at some hospitals.

But Ullmann noted there’s no indication in AvMed’s figures about case complexity, which could explain why one hospital received a higher average payment than another for the same procedure.

Nor do the averages indicate whether the payment includes the physician’s services and other related expenses, he said. Perhaps more importantly, there’s no indication of quality of care — a factor that drives patient choice and helps determine the value of healthcare.

“The bottom line,” Ullmann said, “is even when you have numbers, it’s difficult to get transparency — transparency to really see what the numbers mean.”

If Miami-Dade knew the contracted rates that AvMed has negotiated with hospitals for specific medical services, Ullmann said, county officials would be better equipped to manage healthcare costs by steering employees to lower-priced providers or by leaving some facilities out of the network.

But Jim Repp, vice president of sales and marketing for AvMed, said in a written statement that “without question” the averages can help the county control its healthcare costs.

“The data we provide our self-funded clients allows them to analyze and understand utilization patterns,’’ Repp said. “They then work with us to modify the existing plan design as an opportunity to lower the overall incurred costs the following year.”

Indeed, while AvMed will not divulge exact healthcare prices, Miami-Dade officials could use some of the aggregated data to lower costs in the long run, said Sal Barbera, a veteran hospital administrator who now teaches healthcare administration at Florida International University.

For instance, he noted, Miami-Dade spent nearly $2.6 million in 2013 on a medical service called “operating room procedures for obesity,” which could range from gastric bypass surgery to stomach repair.

It was the single most costly medical service to the county’s plan last year. But Miami-Dade administrators could try to lower those costs, Barbera said, if they “look at ways they could start attacking these particular diagnoses, and maybe minimizing the cost for these diagnoses by doing something proactively to avoid them.”

But Martha Baker, president of SEIU Local 1991, the union representing doctors and nurses at the county-owned Jackson Health System, said Miami-Dade’s health plan manager has hardly begun to explore the potential savings of such programs.

“AvMed hasn’t come through on a real wellness program,” Baker said. “AvMed hasn’t come through in managing chronic diseases. … There’s a lot of money to be saved in healthcare in Miami-Dade. Encourage employees to walk more.”

Corey Miller, and AvMed spokesman, said wellness and disease management programs can be implemented in the future at the county’s direction, and its expense.

But price variation among hospitals remains an unexplored well of potential savings.

AvMed’s charts show a difference in average payments for the same medical services when they’re performed at Jackson compared to other hospitals. For example, childbirth by Cesarean section ranged from $8,075 to $9,751 in the data, while Jackson’s average was $3,708.

An AvMed representative speaking at the county’s labor healthcare committee meeting in April said variations in payments can be attributed to the facility, the complexity of the individual procedure, and contract negotiations.

“Why Baptist [Health South Florida] charges more than Jackson … that’s a very individual question for each facility, and each negotiation,’’ Patricia Nelson, AvMed’s regional head of strategic accounts, said at the meeting.

Duane Fitch, a healthcare consultant for SEIU 1991, said the average payment of $15,513 to all other hospitals for an overnight patient admission — versus the average payment to Jackson of $9,380 — indicates that “some providers are receiving two, three, four times the amount that Jackson is receiving for the same services.”

“It just seems like a wasted opportunity,” he said, “not to explore this pricing variance.”

But comparing average payments doesn’t offer employers enough information to make changes, said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network for South Broward County.

Sacco said averages do not reveal which hospital’s patients may have needed more intensive and expensive treatment.

“You have to be apples to apples,” when comparing treatment costs, he said.

To be sure, Sacco said, some price variance among hospitals can be attributed to contract negotiations with insurers.

“I think our contracting people do a better job than, historically, Jackson has been able to accomplish,” he said.

Part of a hospital system’s advantage also comes from regional dominance. Like Memorial Healthcare, which has six hospitals across South Broward, Baptist Health has seven hospitals and dozens of outpatient and urgent care centers across South Miami-Dade and parts of Monroe — the type of presence that bestows “must have” status on hospital systems when they negotiate rates with insurers, said Barbera, the FIU expert.

“It would be very difficult for any third-party payer in Miami to have a plan and not offer Baptist,” Barbera said.

Karen Godfrey, Baptist Health’s corporate vice president for revenue management, said she could not address the hospital system’s negotiations with health insurance companies. She said Baptist Health focuses on providing “value” — not just the lowest price.

“As an employer,’’ she said, “I think I would want to understand what is the holistic picture in terms of what that provider brings to the table and brings to the community. … It’s a central piece of Baptist Health’s strategy to focus on prevention and wellness, and by doing so to control costs.’’

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A few weeks later, Lorimer received a bill in the mail from Fishermen’s Community Hospital, showing the charge for the CT scan: $9,165.21.

“I was kind of blindsided by this,’’ said Lorimer, 67. “I thought the charge was a mistake.’’

Lorimer didn’t have to pay Fishermen’s full charge, though. Because he’s on Medicare, Lorimer was responsible for only a portion of the bill, and his share came to $1,456.36, which the hospital recently recalculated to $1,817.55 after adding a physician’s fee.

“Had I been a better health care buyer,’’ Lorimer said from his other home in St. Paul, Minn., “I would have probably checked around. But I was in a lot of pain. So I went over to the hospital.’’

Lorimer, like many health care consumers, didn’t give much thought to the cost of his medical service before receiving it, nor was he inclined to research it while in pain.

But that may have to change. Increasingly, individual consumers with health insurance are feeling financial pressure to be more careful shoppers as employers and insurers pass along a greater burden of costs through higher deductibles, co-payments and co-insurance rates.

Placing more financial responsibility on patients for their health care also may change costly behaviors left over from the days when generous health insurance plans shielded consumers from the true cost of medical care, health care experts say.

“There’s more interest in what folks are paying,’’ said Bruce Rueben, president of the Florida Hospital Association, which has launched a committee to study healthcare price transparency and the ways hospitals can communicate costs to consumers.

“The very fact that people were insulated from the cost of care because it was the insurance company paying for it … gave people less incentive to be asking those questions,’’ Rueben said. “Now that they are, we’re certainly trying to respond.’’

Health care prices can be , though, and the contracted rates between insurers and hospitals or physicians are considered proprietary.

Yet the price a consumer pays for a medical procedure can vary significantly from one hospital or doctor to the next — often with little difference in quality. And those price differences can add up, especially for so-called “consumer-directed” plans with co-insurance, which requires consumers to pay a percentage of medical costs.

If a CT scan costs $9,000 at one medical facility but much less at another, a consumer could save on out-of-pocket costs by knowing which provider has the lower price.

Consumers trying to lower their healthcare costs do have some help in the marketplace — but most aren’t using the tools available.

Cigna, the health insurance company, offers an Internet-based transparency tool that shows plan members price information on the 200 most common procedures, which make up about 70 percent of the company’s medical claims, said Mark Slitt, a spokesman.

“People really like cost transparency,’’ Slitt said, “and having quality information as part of their choice.’’

But some studies show that only a very small percentage of consumers use these tools, which are offered by a number of insurance companies, when planning a medical service, said Joe Smith, a physician and engineer who chairs the board of West Health Policy Center, a Washington, D.C.-based nonprofit that studies healthcare reform.

“Maybe 98 percent of those who are covered have access to some sort of price transparency tool, which appear to be used about 2 percent of the time,’’ Smith said.

Power of Price: A glossary of healthcare terms

As if health care pricing wasn’t complex enough, try talking about it without running into some conversation-stopping jargon. Words that mean one thing to the rest of the English-speaking world can mean something completely different in health care — like a “charge” that isn’t the same as the price.

To help clarify, here’s a glossary of common terms in the world of health care finance:

• All-payer claims database: A state-run database that tracks what insurers and other payers actually shell out for health care services from different hospitals and providers. Florida’s Agency for Health Care Administration was denied a budget request of $5 million to develop a database last spring.
• Charge: The price a health care provider says it is owed for a service; not necessarily what it expects to receive. Insurance companies negotiate with providers for cheaper rates than the listed charge. People who are uninsured may be billed for the whole charge — but even then, the amount is frequently negotiable. Appears as the amount billed column on an explanation of benefits.
• Chargemaster: A hospital’s list of charges for common procedures. These lists are different from the list of rates negotiated by each insurer. Starting in October, the Affordable Care Act requires hospitals make charges available to the public. Many hospitals plan to satisfy this requirement with the chargemaster.
• Contracted rate: The price an insurer and provider have agreed upon for a particular service — usually lower than the charge. This is also known as the reimbursement or negotiated rate. On an explanation of benefits, it appears as the amount paid by the insurer.
• Copay: The standard price paid by an insured patient for a covered service or medication. This is in addition to what the insurance company will pay on behalf of the patient.
• Cost adjustment: The difference between the charge and the contracted rate. It’s sometimes presented to health insurance customers as savings.
• Deductible: The amount a patient must pay for covered health care before the insurance company picks up the rest of the tab.
• Explanation of benefits (EOB): A statement from an insurance provider detailing how it covered a patient’s health care. EOBs typically include details like a description of the service and its billing code, the amount the provider charged, the amount the insurer paid (the contracted rate), and what the patient owes. It looks so much like a bill that some insurance companies write, “this is not a bill,” on the statement.
• Premium: The monthly price you pay for health insurance. It is separate from the deductible and copay.
• Medicaid: Health insurance for people with disabilities and low-income individuals and families. It’s managed at a state level with federal oversight and it’s funded with federal and state money.
• Medicare: Federally run health insurance, mostly for people over 65.
• Self-Insured: When an employer takes on the risk of insuring its employees and pays their health care claims. Self-insured employers, like Miami-Dade County, frequently hire an insurance company to manage the claims process and negotiate rates with providers on the employer’s behalf.

Compiled by Sammy Mack

Cigna’s transparency tool allows plan members to search by medical service and provides them with a range of providers and an estimate of their prices. But Cigna does not reveal the underlying rates that the insurance company has negotiated with those providers, nor does the insurer’s tool show the rates that other insurers have negotiated with the same providers — the sort of insight that would empower consumers to comparison shop.

“They all want you to be informed,’’ Linda Quick, president of the South Florida Hospital and Healthcare Association, said about insurer transparency tools. “They just only want you to have their information.’’

Lorimer, the part-time resident of the Florida Keys, would not have had to look far for information that may have saved him more than $1,000 on his share of the CT scan from Fishermen’s.

He intends to pay the bill, “but I will pay it under protest,” Lorimer said. “The whole system is very opaque. There’s no question about that. But there are prices available.”

About a mile away from the hospital, an independent imaging center named Homestead Diagnostic Center advertises a CT scan starting at $275 and topping out at about $350 when a contrasting dye is included.

Tomas Gonzalez, the owner of Homestead Diagnostic, said he makes “a nice profit” with his rates. And he’s well aware that hospitals charge higher prices for the same services.

“Running a hospital is a lot more expensive than me running a diagnostic center,’’ he said.

But Gonzalez was taken aback by the charge from Fishermen’s — even after acknowledging that the hospital has the only CT scanner in Marathon. At his facility, patients who need x-rays, ultrasounds and digital mammograms are seen on site. Those who need CT scans and MRIs are bused for free to the company’s main facility in Homestead, an 80-mile trip that might not be worth it for someone in pain.

Still, Gonzalez said, “$9,000 for a CT scan? Come on. It’s outrageous. It really is. I’m in business to make money, but not like that.’’

Hal Leftwich, chief executive of Fishermen’s, said part of the reason for the hospital’s high charge is that the facility is certified by Medicare as a so-called “critical access hospital,’’ a designation typically assigned to rural hospitals that are far from other medical facilities.

The designation requires around-the-clock emergency care capability, and care for the uninsured, adding considerable costs for Fishermen’s, Leftwich said.

Medicare reimburses critical access hospitals on a cost basis, instead of a fixed rate like most urban hospitals receive. For Lorimer’s CT scan, Medicare paid $673.85, after adjusting the charge.

Leftwich declined to discuss Lorimer’s hospital visit or his bill, citing patient privacy laws. But he said he had “some knowledge” of the charge, and that the amount represented two CT scans — one performed with a contrast dye, and one without the dye.

“There’s basically two CTs being done there,’’ Leftwich said.

He explained that Fishermen’s compares its prices with other hospitals in South Florida for similar services, and that their prices “are very similar,” for the services involved.

“What we’ve tried to do,’’ Leftwich said, “is keep our pricing to be below the market leaders. But because we’re in such a rural-type area with low [patient] volumes, of course, we can’t be the lowest price, either.’’

Maintaining a CT scanner can be expensive. Leftwich said the hospital pays for a $90,000 annual service contract, among other costs.

“That $90,000 will get amortized over fewer studies here because there are fewer people,’’ Leftwich said.

Advocates for health care pricing reform call the practice of factoring operating costs into the price of a particular service “cross-subsidizing,’’ and some say it’s disingenuous of hospital administrators and unfair to the community that has to foot the bill.

Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, a Connecticut-based nonprofit, said hospitals blend their costs precisely because healthcare prices are shrouded in secrecy.

“The reality is today people can do this because there is no price transparency,’’ he said. “So you have all this cross-subsidization that goes on at hospitals that leads to high prices. They say it’s high because of all these additional expenses that we have to cover. Yes you do, but those ought to be covered in an open forum about the explicit need to subsidize them.

“It’s either done by taxpayer money so everyone pays a price,’’ de Brantes said, “or you close it down. But that’s your community’s decision. It shouldn’t be up to the hospital administrator.’’

Leftwich said Fishermen’s has developed ways to reduce costs, particularly for those patients who are willing to pay their own way.

“We may not match $350,’’ he said, referring to Homestead Diagnostic, “but we’ll come pretty close if they’re willing to pull out the credit card and pay right there.’’

That’s how one Hollywood resident who asked the Herald not to use his name because of privacy concerns, paid for his hernia operation at Imperial Point Hospital in Fort Lauderdale this summer.

The 52-year old, self-employed man has not carried health insurance since about 2012, saying he got fed up with the confusion and complexity of the cost for his healthcare.

“I found dealing with insurance and the bills and trying to obtain a clear itemized bill from the guy who is sending us the bill was very difficult,’’ he said.

Prior to his surgery, the marine industry worker contacted friends who work as insurance claims adjusters, and they helped him to identify national averages for a hernia operation, and negotiated on his behalf with the physicians and hospital.

The negotiated prices for the outpatient surgery: $125 for the initial doctor’s visit, $1,000 for the surgeon, $1,000 for the anesthetist and $2,753 in hospital fees.

“I was expecting something in the region of $15,000 to $20,000,’’ he said.

Instead, he paid around $5,000 total for his surgery — in advance, on his credit card.

That’s about the same amount as his deductible when he had health insurance, he said, minus the paperwork and confusion.

“What’s the point of having insurance,’’ he said, “if at the end of the day I’m going to pay more? I would far prefer to accept my own risk and pay for it than to have insurance and have them turn everything around and turn it into a deductible.’’

There was a small drawback: The physician prescribed a narcotic pain killer that cost $245 without health insurance. He stuck with ibuprofen to relieve the pain.

Overall, Smith said, he was satisfied with the quality of care he received and the price tag.

“It’s been much easier,’’ he said, “because I knew what I was going to pay.’’

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Could the committee charged with reducing Miami-Dade labor’s healthcare expenses look at the spreadsheet showing the rates that the county pays local hospitals and doctors for medical services to employees?

Healthcare Prices: Many Moving Parts Veiled By Confidentiality Agreements

“We really need to understand where the money is being spent in order to be insightful about benefit design changes,’’ said Duane Fitch, a healthcare consultant for , which represents physicians and nurses at the county-owned Jackson Health System.

But the answer to Fitch’s question at that inaugural meeting of the last March was the same response he would receive every time he repeated the question during the panel’s next six meetings through July.

Essentially, no.

“Contracts are proprietary,” said Patricia Nelson, regional head of strategic accounts for AvMed Health Plans, the county’s health benefits administrator that negotiated the payment rates for medical services for county employees. She noted that both the insurance company and the healthcare providers agree to keep such payment rates confidential.

Fitch and others who asked for the information never got to see precisely how Miami-Dade spends more than $400 million a year to pay healthcare claims for nearly 60,000 employees, retirees and dependents in the health plan.

That’s because Miami-Dade — like many employers across the country — isn’t allowed to know the prices their own insurance plan administrators negotiate with healthcare providers, even when they’re self-insured, like Miami-Dade County, and the claims are paid with taxpayer dollars.

And that means that the mayor’s healthcare committee has no more insight than the average Florida consumer on how to lower costs for their employees or themselves — frustrating everyone from union leaders to county commissioners who are trying to push down prices.

Because when county officials claim they are doing everything they can to reduce employee healthcare costs, they actually don’t know how and where the public’s money is being spent.

“You need the data in order to do the proper plan design that drives your outcomes,’’ said Miami-Dade Commissioner Juan C. Zapata, whose requests for AvMed’s contracted rates also have been rejected. “Without that, you’re just shooting in the dark, basically.’’

No Disclosure

The lack of disclosure of a most basic fact — how much does it cost? — has prompted a movement around the country toward greater price transparency, even as insurance companies and hospitals say revealing those rates will put them at a financial disadvantage with competitors.

A local hospital CEO, Steve Sonenreich of Mount Sinai Medical Center on Miami Beach, even made on WLRN-91.3 FM radio last year that he would reveal the contractual rates the hospital charges private insurers — only to learn that he was barred under the non-disclosure agreement in the contract.

Sonenreich said in a written statement this week that he believes one of the problems with pricing secrecy is that it allows large hospital systems to leverage their “geographic dominance” to run up rates on insurers, who pass on the increases to employers and consumers through higher premiums, deductibles and other costs.

“If we make health care pricing information available to consumers, particularly employers,’’ he said, “they will be able to make better decisions.’’

But the push for price transparency has had an uneven impact across the country.

Some states, such as , and , have adopted legislation that requires insurance companies and health care providers to report reimbursement rates and payments for use in what they call an “all-payer claims database” — a repository of comprehensive information on health care use and payments for all medical services by Medicaid, Medicare and commercial insurers, among others.

Florida has enacted or amended statutes and regulations more than a dozen times since 1985 requiring some level of transparency and disclosure from hospitals and physicians, but not insurers.

A state-mandated website managed by the Florida Agency for Healthcare Administration at gives consumers average and total charges for a variety of medical services by hospitals — but not specific reimbursement rates.

In the bewildering world of healthcare pricing, charges are not the same as prices — because almost every payer gets a discount on hospital charges, and usually by double-digit percentages.

While Florida’s price transparency efforts are as other states, AHCA officials did request about $5 million in annual funding this year to build and maintain an all-payer claims database. The request was ignored by state lawmakers.

By keeping prices secret, health care providers and insurers leave employers with little choice for managing their benefits costs as they go up. Most choose to shift more financial burden onto employees, said Francois de Brantes, executive director of , a Connecticut nonprofit that advocates for payment reform.

“If you’re an employer,’’ de Brantes said, “and you don’t have access to your underlying claims data, even though you’re self-insured, there’s absolutely no way for you to make decisions on benefit design — other than using the brute force of across-the-board premium increases.’’

And that’s what Miami-Dade County’s health care committee recommended in its final report: Require a biweekly premium for employees who currently pay none for single coverage in the county’s HMO plan, and increase existing premiums for those in the POS plan. Employees also will be offered a new plan with no premiums for individual coverage, but a limited choice of hospitals and doctors.

Need For Transparency

For most people with employer-provided health insurance, rising premiums are not unusual. Insured consumers across the country are shouldering more financial responsibility for their medical care through high deductibles, co-insurance rates and health savings accounts — fueling momentum for price transparency.

“The consumer is going to basically have to take responsibility for their own healthcare,’’ said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network in South Broward County, “and look not only at costs but quality outcomes, the safety metrics. All of that has to be transparent, and then they’ll have to make informed decisions.”

But translating healthcare pricing to into useful information for consumers is complicated because every patient’s experience can be different, even for similar procedures, said Linda Quick, president of the South Florida Hospital and Healthcare Association, a for regional providers.

Then there’s the variety of payers, from government programs such as Medicaid and Medicare, to private commercial insurers — all paying a different rate.

Adding to the complexity: a procedure such as a knee replacement may require that an insurer pay a number of different providers, from the lab and physician to the hospital and home health agency.

“So if the hospital told you that their cost is $27,000,’’ Quick said, “it’s still not a true representation of the cost of knee surgery, because the surgeon’s bill is going to be separate, and the anesthesiologist is going to bill separately.

“It’s very hard,’’ she said, “to make it totally transparent.”

AvMed, the county’s health insurance administrator, declined to discuss healthcare pricing with the Herald and WLRN, canceling two interviews with Jim Repp, vice president of marketing. The company also declined to discuss its management of Miami-Dade’s employee health plan while the county’s labor unions and administrators negotiate new collective bargaining agreements in the coming months.

But when Repp addressed the mayor’s health care committee in June, he said AvMed had secured average discounts of 65 percent with South Florida hospitals and physicians, helping to save the county what he estimated was about $56 million on expected claims from 2010 through 2013.

Private Sector

For employers, having access to data on actual payments would be much more useful than knowing the average discount negotiated by a plan administrator, de Brantes said.

When he worked as a program leader for General Electric Corporate Health Care Programs in the mid-1990s, de Brantes said, GE required its health plan administrator to deliver the data — or lose the company’s business.

“We would use those data constantly to figure out: What do we need to do as an employer to improve cost and quality? Where are there problems? And even to do accurate modeling of what would be the impact of, say, increasing our co-pay on ER visits,’’ de Brantes said. “How many people would that impact? And who’s going there more often? Is it people who have chronic illness, or those seeking routine service?

“You wouldn’t even know that,’’ he said, “if you didn’t have the claims data.’’

Miami-Dade could also take a from other large private employers, such as aerospace giant Boeing, and negotiate contracts directly with hospitals and other health care providers, said Joe Smith, a physician and engineer who chairs the board of , a Washington, D.C.-based nonprofit that studies healthcare reform.

“Health care has enough middlemen,’’ Smith said of plan administrators. “The employers are not ignorant at this. They’re good at negotiating contracts, and can also use market power to gain information.’’

De Brantes questioned AvMed’s incentive to reduce Miami-Dade’s annual health care costs since the insurance company pays claims with the county’s money, and receives an administrative fee of $31 per employee per month — regardless of the rates it negotiates with providers.

“They don’t care because it’s not their money,’’ de Brantes said. “That’s the bottom line.’’

For 2014, AvMed’s fee is estimated to be $16 million, about 4 percent of annual claims, according to county reports.

In The Dark

Without price transparency — and a review of AvMed’s negotiated rates — there’s no way for Miami-Dade to evaluate AvMed’s job performance, said Fitch, the health care consultant to SEIU 1991.

Fitch expressed concern that AvMed could be giving preferable treatment to Baptist Health South Florida, the largest hospital system in the region and the top-paid provider in the county’s employee health plan.

AvMed is the administrator for both Baptist Health’s employee health plan and Miami-Dade’s, Fitch pointed out, creating “a perception that there is unfair dealing.’’

At a meeting of the county health care committee, Fitch asked Repp how AvMed manages to negotiate rates on behalf of Miami-Dade with a hospital system that is also AvMed’s client.

“Very delicately,’’ Repp said. “We do have clients who are also providers. We keep those two divisions of the organization separate from each other.’’

Christine Kotler, a Baptist Health spokeswoman, declined to address price variances between the system’s hospitals and others in Miami-Dade’s plan. She said Baptist Health hospitals score high marks in clinical safety and consumer satisfaction surveys.

“In discussions about cost and price,’’ she said in a written statement, “it’s important to also talk about quality.’’

Miami-Dade employees do express a preference for Baptist Health centers when using a hospital, according to analyses by Gallagher Benefits Services, a county consultant. Consequently, most of Miami-Dade’s healthcare dollars go to Baptist Health hospitals — more than $61 million in claims for 2013, Gallagher reported, well above the second-highest paid provider, the University of Miami Health System, which received $24.3 million in payments.

But county officials have lacked the specific payment rate data they need to properly evaluate plan changes that could save Miami-Dade taxpayers money, according to a Gallagher of all medical claims for the year ending June 30, 2012.

For example, the report noted that county employees have “unusually high” rates of emergency room use, likely because their copays for the service are low. But county administrators didn’t have the payment data to determine whether raising the copays to steer employees toward cheaper “urgent care” centers would save enough money to be worthwhile.

Instead of payment rates and claims data, county officials were given average costs per member, showing that Baptist Health facilities cost an average of $12,988 per overnight admission.

Baptist wasn’t the most expensive by that metric. Aventura Hospital and Medical Center, owned by Hospital Corporation of America, cost the county plan $14,975 per admission.

But Gallagher’s analysis showed that visits to Baptist ERs that year cost Miami-Dade more per encounter, an average $2,427, higher than any of the top 14 providers in the plan network.

Gallagher noted another interesting figure during recent meetings of the county health care committee.

In 2013, Miami-Dade’s plan paid Jackson Health hospitals an average of $9,380 per overnight admission. The average paid to all other hospital systems: $15,513 per patient — a difference of $6,133.

Gallagher projected that if all hospitals in the county employees’ network were paid at the same level as Jackson, Miami-Dade could have saved nearly $77 million in claims.

“We think there’s a lot of room for savings because of this price variation,” said Martha Baker, president of Jackson’s labor union for physicians and nurses.

Repp and others, including Jackson Health’s chief financial officer, Mark Knight, disputed that number.

“We don’t know the mix of the patients,” Knight said. “That $15,000 average could have been based on a bunch of really bad, train wreck patients who were in a bad motor vehicle accident and intensive care for a month. You can’t tell.”

Drawbacks

But Knight did illustrate one potential drawback for the consumer when it comes to price transparency: When Jackson officials read the Gallagher report showing the health system was being paid the lower rate in 2012, they went back to AvMed and renegotiated prices — higher.

The result? It now costs Miami-Dade more for its employees to use Jackson Health, though the plan still saves money when its members choose Jackson over a higher-priced competitor.

Unless consumers and employers know beforehand how much a medical service costs, they’ll never be able to make informed — and cost-saving — choices.

“Just like the individual needs choice,’’ said Smith, of the West Health Policy Center, “Miami-Dade County needs choice as it thinks about who it’s going to contract with. Otherwise, there’s just too much risk of hiding the ball.’’

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Private commercial insurers do not publish their payments like Medicare does, but health care experts say the prices they pay hospitals for the same procedure can vary just as much — and the reason often depends on more than just the hospital where the knee replacement was performed.

For most insured Americans, the reasons for such variance in health care prices also can include the medical condition of the patient, complications that may arise, physicians’ fees, market competition, and even who’s paying for the procedure and how.

That’s a lot of moving parts for anyone to nail down a firm price, said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network for South Broward County, Fla.

“Healthcare pricing,’’ he said, “is probably the most complex, convoluted pricing of anything that I’ve ever seen in my life.’’

One way to begin unraveling the twisted threads of healthcare pricing is to understand the difference between charge and price. Every hospital establishes a list of charges or so-called “charge masters’’ for medical services, but almost no one pays those rates.

Charges include a hospital’s costs for all services provided to a patient plus a variety of factors unique to each hospital, said Karen Godfrey, corporate vice president of revenue management for Baptist Health South Florida, the largest hospital system in the region.

Some hospitals may have higher costs due to high-intensity services, such as organ transplants, trauma centers and neonatal intensive care units. Or they may have higher mission-related expenses, such as teaching, medical research or caring for the uninsured.

“That may sound simple and straightforward,’’ Godfrey said. “It’s not. If you come in for emergency services, since we don’t know what’s wrong with you, we don’t ultimately know what the charges are going to be.’’

What the hospital collects in payment is the price, and that can range depending on the payer.

For government payers, such as Medicare and Medicaid, prices are publicly available and the rates are set, with provisions made for so-called “outlier” patients whose conditions are especially complex or severe. Typically, Medicare and Medicaid pay less than a hospital’s actual cost to provide care.

So hospitals recoup their operating losses, plus a small margin, in their contracted prices with commercial insurers, Sacco said.

When insurers and hospitals meet behind closed doors to negotiate payment rates, insurers are trading market reach and patient volumes for discounts on hospitals’ rates. Hospitals are leveraging their range of services, quality ratings — and size.

Pat Geraghty, president of Florida Blue, the state’s oldest and largest health insurance company, agreed that a hospital system’s geographic reach can be “critical” in negotiations, but said quality and customer satisfaction may matter more.

“It really matters will the service be redone because it wasn’t done as well in one setting versus another setting,’’ he said. “It really does matter that if it could be done outpatient as opposed to inpatient that we use that setting, or if someone’s disease state could be managed from home as opposed to in any setting.’’

Geraghty said healthcare payments are moving in the direction of packaged prices for episodes of care, and arrangements that hold providers more accountable for healthy patient outcomes if they want to earn higher rates.

“If the patient’s condition worsens and requires more care,’’ Geraghty said, “then the provider takes the loss financially. But if the provider manages the patient’s care efficiently, then he gets to keep the savings.’’

Right now, most hospitals are paid a daily rate or a fee per service or diagnosis group.

Advocates for payment reform argue that under the fee-for-service system, hospitals and other providers have an incentive to over-treat because they’re reimbursed by procedure.

But when consumers know the prices for some services across all providers, they’re more likely to comparison shop — according to a recent published in the journal Health Affairs that found publishing MRI prices led to lower patient costs and reduced price variation.

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Through Jackson’s charity care program, Samuel said, she was paying about $70 to see a nephrologist each month, $50 for routine blood tests and $22 a month for four prescriptions. But in June, Samuel failed to renew her membership in the Jackson program – and that’s when the trouble began.

She had an appointment for a blood test and kept it, at the suggestion of a Jackson financial assistance counselor, because her renewal application was being processed.

A few days later, Samuel got a bill for the blood test: $1,640. She couldn’t pay it. She stopped going to the doctor and refilling prescriptions. “I can’t see the doctor,” Samuel said in early August, “unless I have the money to pay them.”

Samuel, 50, said Jackson officials did not re-enroll her in the charity care program in June because – despite providing utility bills, paycheck stubs, a property tax receipt and bank statements – she did not produce signed, notarized affidavits from one of her adult sons, and from family friends in St. Kitts, attesting that they have provided her with financial support in the past.

Demanding onerous paperwork from low-income applicants is just one way that Jackson has barred eligible Miami-Dade residents from accessing the charity care program, according to administrative complaints filed this week with the Internal Revenue Service and the U.S. Department of Health and Human Services.

The complaints lodged by Florida Legal Services and the National Health Law Program, nonprofit groups that provide civil legal help to the indigent, allege that Jackson fails to meet new requirements for nonprofit hospitals under the Affordable Care Act and other laws.

The groups say Jackson has not widely publicized its charity care program as required under the health law and has put up eligibility barriers such as “unduly burdensome verification requirements.”

The complaints also say Jackson subjected uninsured patients to harsh debt-collection tactics without telling them about financial assistance, and the hospital system had failed to produce a required “community health needs assessment” to help Jackson design a charity care program.

Miriam Harmatz, a health law attorney with Florida Legal Services, said Samuel could not afford to pay $25 a page to produce the notarized affidavits Jackson wanted – documentation that Harmatz calls excessive, since state and federal officials don’t request such records from people who apply for Medicaid or a subsidized health plan under the ACA.

“It bothers us that this is how they’re treating people,” Harmatz said. “We don’t think Jackson is taking the necessary steps to ensure that people really have access.”

As a county resident who meets low-income criteria, Samuel should qualify for charity care from Jackson, Harmatz said, noting that the public hospital system with a mission to treat Miami-Dade’s uninsured and indigent receives more than $350 million a year in local property and sales taxes.

Jackson offers charity care on a sliding scale, with residents who earn less than the federal poverty level receiving the most generous benefits, such as free primary care visits and nominal copayments for prescription drugs.

After Florida Legal’s intervention in Samuel’s case, Jackson officials rescheduled a financial-assistance interview – approving her for the charity care program on Aug. 19 without requiring the notarized affidavits, Samuel said.

“I went to the doctor yesterday,” Samuel said last week, noting that she qualified for the neediest category. “It’s actually cheaper than the one I had first.” She has not received a second bill for the $1,640 blood test.

Jackson officials declined to comment on Samuel’s case. But Myriam Torres, vice president of revenue cycle management, said “no special treatment” was given to any applicant, including Samuel.

“Maybe circumstances for that patient changed from last time to this time,” Torres said, “and now the attestation is no longer needed.”

Jackson officials say they request notarized affidavits to safeguard taxpayer funds, though Samuel said the hospital system had not requested the documents in 2013.

“We’re not denying care,” said Mark Knight, Jackson’s chief financial officer. “We’re merely asking for validation of what [applicants] are telling us.”

Jackson officials said 29,176 individuals are enrolled in charity care. Knight said that in 2013 the program cost the hospital system $365 million for 212,294 separate medical encounters, ranging from emergency room care to doctors’ visits and outpatient surgeries.

Knight said Jackson has an obligation to screen uninsured residents for eligibility in Medicaid or other public-assistance programs, such as the Cuban Haitian Entrant Program.

“We have to ensure that those people don’t have any other available venues,” Knight said.

Jackson aggressively screens all uninsured patients for some form of coverage, he added. In 2013, hospital system counselors converted 29,746 previously uninsured patients to Medicaid. So far this year, Jackson has converted 22,950 uninsured patients to Medicaid.

Knight said county residents typically have to wait three weeks to meet with a counselor and apply for charity care, but that applicants can schedule a doctor’s visit or other care while waiting for the financial-assessment interview.

However, Samuel’s experience suggests that those patients also risk incurring debt if their applications are denied.

“They get these really   high bills,” Harmatz said. “They don’t know what for. . . and they don’t go back. They feel it’s just going to create more medical debt.”

Still, Knight noted, “Billing the patient doesn’t always mean they’re paying it.”

As for the complaints that Jackson has failed to widely publicize its charity care program, including eligibility criteria and debt-collection policies – by not posting the information online, neglecting to post signs in emergency rooms, and failing to insert notices in debt-collection letters – Knight said that the information is available by request.

“We are looking to post those policies online,” he said. “There’s not any concerted effort [not to publicize the information]. It’s just that we haven’t historically done that.”

Matt Pinzur, a Jackson spokesman, disputed the allegation that the program is not widely publicized, given that Jackson treats more uninsured patients than any hospital in the state.

While the health law requires that nonprofit hospitals make their written charity care policies widely available, it does not specify the criteria hospitals must use to determine eligibility for care.

Nor does it offer any guidance on a fundamental question that many safety-net hospitals like Jackson struggle with every day: Are some patients unable to pay, or just unwilling?

That’s not an easy question to answer, said Rick Gundling, a vice president of the Healthcare Financial Management Association, which represents healthcare finance workers.

Gundling noted that safety-net hospitals have to balance a community’s health needs with their resources and mission.

“There’s far more demand than they have resources to do,” he said. “So they’re always trying to figure out the right balance.”

Jackson serves a community with the state’s greatest number of uninsured residents: The U.S. Census estimates that about 744,000 people, or about 34 percent of Miami-Dade’s population, lacked health insurance in 2011.

And while the debut of the ACA’s health insurance exchanges in January provided almost a million Floridians with coverage – federal officials have not provided county-level breakdowns of enrollment – advocates for low-income residents say the need is still great, and probably much greater than Jackson alone can meet.

Samuel, a night-shift custodian at Miami Dade College, is one of an estimated 800,000 Floridians, including about 165,000 in Miami-Dade, who remain uninsured in the so-called “coverage gap” because their annual income is too low to qualify for government help buying a plan under the ACA – and they are ineligible for Medicaid, the federal-state healthcare program for the poor.

Harmatz acknowledges that there is a scenario under which Florida Legal’s complaints would “go away,” but it’s not something under Jackson’s control – expansion of Medicaid eligibility to cover all Floridians, including childless adults currently excluded from the program.

The Florida Legislature has refused to expand Medicaid, though, turning down an estimated $66 billion in federal funding over the next decade.

“If the Florida Legislature would just accept federal funding and provide healthcare coverage for low income adults,” Harmatz said, “then these problems would be wonderfully diminished. All these people would be covered.”

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