Woman stands in her living room.
Ana Yanes, 53, says the Hillsborough County Health Care Plan helped her late husband get through a medical emergency a few years ago after he lost his job-based insurance. Now she uses the coverage to work on improving her own health. Credit: Stephanie Colombini/Health News Florida

Ana Yanes was in crisis. It was 2019, and the kidney transplant her husband Daniel Torres had been living with for many years was failing. His health got so bad, Yanes says, he couldn’t work. He lost his job, and with it the employer-based medical insurance the couple depended on.

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Yanes says it came at the worst possible time.

“Everything happened so fast,” Yanes said. “I kid you not, he lost his job June 28. By July 8 he was already admitted to the hospital.”

Yanes, 53, spent days scouring the internet and making frantic phone calls to find coverage for her husband’s care. They didn’t qualify for Medicaid in Florida, but also couldn’t afford private insurance.

Then the Tampa resident came across the Hillsborough County Health Care Plan. It’s paid for by a county sales tax and offers free care to residents with low incomes who can’t access insurance.

Yanes applied and said within a week, she and her husband were covered.

“They really put him first, you know what I mean?” Yanes said. “With the time frame, we were running out of time. Everything was just coming down, and he made it. It was a blessing.”

Daniel Torres died last fall, but Yanes credits the plan for the extra years they got to spend together. Now she’s using the coverage to work on improving her own health.

“I miss him, but also now I’m focused on, ‘OK, let’s get better,’” she said.

How It Works

As one of 11 states in the U.S. that has not chosen to expand Medicaid, Florida restricts its program to children, pregnant people, caretakers of minors and some seniors and residents with disabilities. This leaves thousands of low-income residents who don’t meet the criteria struggling to access health care. 

The Hillsborough County program offers help to residents who can’t qualify for Medicaid or access other health-care benefits.

Most of the more than 13,000 people on the county plan are middle-aged adults, according to Philip Conti, Hillsborough County’s health care services manager. Many lack stable jobs and housing.

“Those socioeconomic conditions put them at a greater risk of chronic diseases, not treating what it is that they have, and also using emergency rooms as their primary care with no follow-up,” Conti said.

The goal of this plan, Conti said, is to help residents get healthy and stay healthy.

Patients choose one of four networks of local providers that include hospital systems and federally-qualified health centers. Primary and specialty care is covered as are medications and some dental and vision services — all with no premiums or copays. Members can also access fitness centers and health education classes at county facilities.

“In the name of really encouraging preventative care,” Conti said. “When we take the ability to pay off the table, we hope that people will take advantage of that and use that to improve their overall health.”

Philip Conti oversees the Hillsborough County Health Care Plan. In addition to primary and specialty services, members can access health education and fitness classes at county facilities, including the Lee Davis Neighborhood Services Center near Ybor City. Credit: Stephanie Colombini/Health News Florida

Getting the Community on Board

To qualify, people must be Hillsborough County residents. There also are income and asset limits, and the applicant cannot be eligible for any other health-care programs.

This year, Hillsborough County expanded eligibility to residents earning up to 175% of the federal poverty level. For a single-person household, that’s about $1,900 a month.

All of this is paid for with a half-cent sales tax the county has been using since the program was created in the early 1990s.

Jay Wolfson, a public health professor and senior associate dean at the University of South Florida’s Morsani College of Medicine, helped get it off the ground.

“That was an educational process, and quite frankly it took a lot of resources,” Wolfson said.

Wolfson and others who championed the plan, including late Hillsborough County Commissioner Phyllis Busansky, spent years working with businesses and elected officials to get support for the program. It wasn’t just the Hillsborough County commission they had to convince. 

They also needed the state legislature to pass a law allowing counties to impose a tax like this.

It was a tough sell at times, but Wolfson said he’s proud to see the work paid off.

“Getting the local community to buy into the value of its own citizens,” Wolfson said. “A healthy community is a productive community, it’s an economically credible community.”

Wolfson suspects it would be even harder to start a program like this in today’s political and economic climate, but believes it’s possible. He hopes other communities use Hillsborough County as a model for similar initiatives.

Some advocates in Florida are continuing their calls to expand Medicaid, energized by South Dakotans’ recent vote to do so. Hillsborough County officials say they don’t know what would become of the county plan if that happened, but say they’re committed to investing in the health of their residents.

Why Aren’t More People Enrolled?

For now, their goal is to get more people enrolled in the program. The county has enough money to serve thousands more residents than the 13,000 or so it currently serves. Even after raising the income limit to qualify for the health plan this year, not enough people are taking advantage.

“No one in this county should go without health care,” said Philip Conti. “If they do need health care they can come to us and we’ll, you know, we’ll help them through it.”

But a lot of people don’t even know the plan exists. Hillsborough County’s population has grown dramatically since the program launched, with many people moving to the area from out of state. Conti also suspects some are wary of government programs.

Ana Yanes admits she was skeptical when she initially heard about the county-run program, assuming bureaucratic red tape would drag out the sign-up process. Now, as a satisfied member of more than three years, she says she spreads the word whenever she can.

Sometimes she encounters friends and family who are struggling financially but are overwhelmed by the idea of applying. Signing up for health care involves research, pulling documents together and navigating online application portals or phone lines. That requires time and energy that Yanes says some people don’t feel they have.

“So I think they’re just more focused on keeping a roof over their shoulders right now than worrying about medical insurance. Does that make sense?” she said.

Cassandra Blaylock (left) frequently does community outreach to spread the word about the health care plan and help people get signed up. Credit: Stephanie Colombini/Health News Florida

Expanding Outreach

County officials say they get that, and say that’s why they’ve shifted their strategy in the last couple years.

Instead of relying on people to find out about the plan through referrals from health providers or online searches, staff such as Cassandra Blaylock are also going out into the community to recruit members. And they’re doing more to help applicants overcome digital barriers, like needing a computer or tech savvy.

Blaylock, the education and outreach manager for the county’s health care services department, explained she uses ZIP code data to identify areas in need and plans her outreach around that. She visits churches, neighborhood meetings, job fairs and other events, and partners with community groups who already have relationships with residents.

Since there is no specific enrollment period, Blaylock and her colleagues will often bring tablets to get people registered on the spot.

“I just try to show them in the field that it’s simple,” Blaylock said. “It’s simple. It goes step by step, and once people get the hang of it, then they’re pretty good.”

She was flying solo on a recent Saturday morning at an event the county hosted at its community center in Ruskin. Many attendees came for free food and entertainment, but Blaylock hoped some would leave one step closer to accessing health care.

She engaged with folks about the health plan as they passed by her table, answering questions and handing out pamphlets. Blaylock directed people who needed hands-on assistance to representatives from the Family Health Care Foundation and Hispanic Services Council, some of the organizations the county works with to assist with signups.

One woman she spoke with at the fair, Linda Stuart, already had health insurance. But she was interested in the plan for her son, who is in his 20s and who Stuart says hasn’t felt the urgency to seek out coverage.

“And that’s why I’m kind of, as Mommy, trying to motivate him,” Stuart said. “Coming here and getting this information will give me a better point to jump off to help him.”

Interactions like that are why county health workers say the outreach is worth it, and they hope it will translate to higher enrollment numbers. Philip Conti said he’d like to see the plan get up to 18,000 members.

“At the end of the day, I think we have to get a little bit more targeted to the communities,” Conti said. “We have to get a little bit deeper into the communities where we think people would benefit from this, and we have to do things to gain their trust.”

This story is part of“The Holdouts,” a reporting collaborative focused on the 11 states that have yet to expand Medicaid, which the Affordable Care Act authorized in 2010. The collaborative is a project of Public Health Watch.