Juanita Franklin was driving through the East Texas town of Gun Barrel City a couple of years ago when she saw a new sign down the road from the Christian Life Center food pantry where she volunteers. It promised something she desperately needed: "Healthcare Access for All!"
Franklin, whose left leg is amputated below the knee and who has chronic high blood pressure and thyroid problems, is among the 18% of Texans who are trying to survive without health insurance. That's the highest state rate in the country by far and more than double the national average. The rate is even higher -- nearly 30% -- among the 6,400 residents of Gun Barrel City.
The sign Franklin saw that day -- staked in front of a former office building -- announced an effort by two local doctors to bring relief to some of those struggling Texans.
Doug Curran and Ted Mettetal have practiced medicine for 80-plus years combined, most of it in a thriving private practice in the town of Athens, about 20 miles east of Gun Barrel City. In 2019, at an age when most physicians are ready to retire, the longtime friends set out on a new venture: opening a safety-net clinic that would treat anyone, regardless of their ability to pay.
Such clinics are urgently needed because low-income Texans have less access to health care than residents of any other state.
Eligibility for Texas Medicaid -- the federal-state partnership that provides health insurance to low-income Americans -- is so restrictive that a family of three is denied coverage if it earns more than $4,000 a year. Those who do qualify may not be able to find doctors who accept the public insurance because the state's reimbursement rates are so low. A 2017 survey found that a third of Texas doctors refuse to accept new Medicaid patients.
Curran has tried for years to persuade the Republican-dominated state Legislature to address these problems. When he served as president of the Texas Medical Association from 2018 to 2019, he made it his mission to get Gov. Greg Abbott's signature on a bill to expand Medicaid coverage, a position 69% of Texans now support, according to a 2020 poll by the Episcopal Health Foundation. But Texas remains among 12 states that have refused expansion, even though the federal government would pay at least 90% of the cost.
"I basically spent a year of my life trying to convince Texas legislators that they really ought to value our people more, they ought to provide better access for all our people, especially our working poor," said Curran, who leans conservative but has grown increasingly progressive. "But our state has not had the wisdom of engaging that."
If Texas expanded Medicaid as envisioned in the 2010 Affordable Care Act, a family of three could qualify for health care coverage if it earned as much as $31,000.
In 2019, Curran and Mettetal -- along with Athens native Glen Robison, who had managed their private practice -- began planning to close at least a sliver of the health care gap themselves.
The idea was to build a network of safety-net clinics to serve a mostly rural area east of Dallas, beginning with the clinic in Gun Barrel City. They'd combine the clinics with a medical residency program to bring desperately needed new doctors into the region.
To launch the East Texas Community Clinic, or ETCC, they persuaded two local organizations to put up $200,000 in seed money. For long-term funding they set out to apply to a federal agency, the U.S. Health Resources and Services Administration, which offers millions of dollars in grants and enhanced Medicaid and Medicare reimbursements to qualified clinics in poorly served areas.
In a series of interviews with Public Health Watch over the past 13 months, Curran, Mettetal and Robison laid out what has happened in the three years since they launched their grand plan.
Much of what they had envisioned has gone as expected. The need for the clinics is certainly there. If anything, it's greater than they had imagined. And their residency program, a collaboration with the University of Texas Health Science Center in Tyler, has been even more successful than they had hoped.
Where they went wrong, Curran said, was in underestimating how hard it would be "to get a good thing done."
They had hoped to receive the federal funding relatively quickly -- by the end of 2021 -- because to them the health care needs in Texas seemed so obvious and urgent. But the bureaucracy has moved at a glacial pace.
"I thought, we're gonna do this thing and everyone will recognize the need and say 'let's absolutely help you,' but that's not what happened," Curran said.
To calm his frustrations, Curran, who is 73, likes to reflect on the story of Roald Amundsen, the Norwegian explorer who led the first successful trek to the South Pole. Amundsen succeeded because he persisted in pushing forward 20 miles each day, Curran points out, no matter how harsh the conditions.
"That's kind of how we've done this," he said.
* * *
The Gun Barrel City clinic opened at 8 a.m. on May 20, 2020. As Curran waited for the first patients to arrive, he wondered -- for a moment -- what he had gotten himself into.
"Here I am, 70 years old, starting a new adventure," he said. "You kind of ask yourself, what in God's name am I doing?"
His friend Mettetal was 69. And Robison, then 45, had left a steady job and taken a pay cut to join them. The plan may have seemed crazily ambitious to an outsider, but the three men had seen firsthand the consequences of people having to forgo care because they couldn't afford it. They felt compelled to help.
Retirement didn't suit the doctors, anyway. They relished the joys and pace of small-town medicine: delivering a baby in the morning, stitching up a wound in the afternoon, making a house call after work.
"When you're used to going 90 miles an hour, you kind of go stir crazy," Mettetal said.
Robison had the technical skills to run day-to-day operations and navigate the clinic toward steady, long-term funding. The doctors had state and local connections that could help them patch together start-up funds and resources.
A group of physicians from their former private practice in Athens agreed to buy the 1,900-square-foot Gun Barrel City building and lease it to them. They used an economic-development loan to gut the old accounting office and create four small exam rooms.
The Dallas-based Ginger Murchison Foundation, whose namesake had deep ties to Henderson County, where ETCC is based, and Ardent Health, a privately owned company that operates health care facilities in Texas and other states, donated the $200,000 in seed money. A third funder -- the East Texas Medical Center Foundation -- stepped up after Curran drove one of its board members, a neurosurgeon and old friend, to Waco to visit a safety-net clinic similar to what ETCC was hoping to build. "So much in life, it's not what you know, it's who you know," Curran said.
To save money, Curran and Mettetal worked without pay, on alternate days, six days a week. The clinic's doors were open 10 hours on weekdays, six hours on Saturdays.
"We've never read anything in the Bible that talks about retirement," said Mettetal, who, like Curran, grew up in rural Arkansas. The two met in medical school at the University of Arkansas, where they were both members of the Baptist Student Union. They still worship together at the First Baptist Church in Athens.
The Gun Barrel City clinic offered all the services that a private family practice would -- preventive screenings, chronic-disease management, immunizations, lab work, prenatal care, child wellness checkups. They used some of their precious start-up money to bring in a pediatrician, Alice Splinter, two times a week.
But there was one big difference between this clinic and their old practice. Patients paid only what they could afford, even if that meant they couldn't pay anything at all. Everyone was welcome.
Patients rolled in slowly at first, maybe a dozen a day.
But word quickly spread, and within a couple of weeks the clinic was booked. Some people traveled hours for the chance to see a doctor.
"It was like instantly, we had a full schedule, we were seeing patients left and right," said Colby Estrada, the front-desk receptionist.
Estrada, 22, had always known that plenty of locals couldn't afford health care. Her own father, a rancher, doesn't have medical insurance. But she was shocked by the number of people who came through the door. It wasn't uncommon for 80 to pass through in a single day.
Many had been forced to delay treatment for so long that their ailments had become more costly and complex to treat.
One woman had postponed surgery for an abdominal tumor because she had lost her job and health insurance. Some people had been living with untreated diabetes. Others were on the cusp of kidney failure. The doctors rarely went a week without seeing someone who lived in a car.
"It was mind-blowing," Estrada said. "It's just amazing to see us help everybody."
Estrada's father, Emilio, now comes to ETCC for care. So does her mother, Debra, who works a mile down the road at the local WIC office, which serves low-income women and children. Debra sends her WIC clients there, too.
"It's so great to be able to say that right down the road there's a clinic that's sliding-scale, they don't turn anyone away," she said.
The doctors had always known Texans were suffering because they couldn't afford health care. But seeing the reality of the unmet needs was unsettling.
"You delude yourself into thinking it's not that bad," Curran said. "It's pretty bad."
Juanita Franklin, 58, the woman who had seen the clinic's sign on her way to volunteer at church, was among the clinic's first patients. She and her husband, Kevin, had spent eight years trying to find consistent care for his prostate cancer.
In 2019, when Kevin became too sick to work, he finally qualified for Social Security disability benefits and Medicare. But when his new benefits were added to their household income, Franklin lost the disability assistance that had made her eligible for Texas Medicaid. She's been uninsured ever since.
"It was very scary," she said. "I didn't know what else to do but pray."
Franklin now considers ETCC her medical home.
* * *
While Curran and Mettetal were treating the first patients, Robison was running the business side of the clinic. They couldn't survive on donations. They needed the steady stream of funding that the Health Resources and Services Administration offers clinics deemed "federally qualified health centers," or FQHCs.
Becoming an FQHC is such a grueling process that many groups hire consultants to do the paperwork for them. To save money, Robison took on the job himself.
The clinic had to be up and running six months before he could even submit an application. During that period, it had to abide by strict FQHC rules to prove it was worthy of the special designation. It couldn't refuse care to anyone. It had to make its services easily accessible. And most of the people on its board of directors had to be patients at the clinic.
The application also required extensive data to prove that the clinic's service area -- which stretched over three counties and included more than 47,000 low-income residents -- actually needed an FQHC.
"It's easy to understand why there's not one of these on every corner," Mettetal said.
Robison's life took on a new rhythm: Build the clinic by day, then write about it in the application that night. He said it felt a bit like walking across a bridge as it was being built.
In January 2021, Robison submitted the 234-page application.
In just seven months, the Gun Barrel City clinic had tallied roughly 7,000 patient visits, and its benefits were already being felt in the emergency room at a nearby University of Texas outpatient facility, which often serves as a safety net for people without health coverage.
Wes Knight, chief financial officer at UT Health East Texas-Athens, said that during the first year of the COVID-19 pandemic, when the ER would have expected an upturn, uninsured visits dropped about 3 percentage points.
The UT facility saw another benefit: It could refer its uninsured ER patients to Gun Barrel City for follow-up care. Curran and Mettetal think the clinic has saved the local hospital system hundreds of thousands of dollars in uncompensated care.
Robison thought details like these would prove that the clinic deserved FQHC status. People familiar with the process told him he'd probably hear back from the Health Resources and Services Administration in about 30 days -- although he figured it might be a bit longer, given that the nation was in the midst of another COVID-19 surge.
A month ticked by and there was still no word.
In March 2021, Robison sent the Health Resources and Services Administration an email asking about the status of the application.
He got the bad news in a form letter that same day.
Their application had been denied because it hadn't proved they were eligible for FQHC status. The letter didn't specify what needed to be fixed, but suggested that they apply again. Robison would have to start from scratch.
But they never considered giving up. Too many people already depended on ETCC to let it fail. In fact, they were getting ready to open a second clinic, this one in Athens. They needed the space to serve their growing list of patients and to train their first four family-medicine residents, who would be arriving that summer.
"I figured it wouldn't be the last time we'd get rejected," Curran said.
Curran and Mettetal were accustomed to the ups and downs that come with big, complicated projects. In 2010, Mettetal had founded another nonprofit, Hope Springs Water, which drills clean water wells around the world. Curran owns and helps work the ranch where he lives with his wife, Sandy, and tends more than 250 head of cattle. Both Curran and Mettetal helped start their former private practice in Athens.
They have some of their best ideas -- including ETCC and Hope Springs Water -- during their ritual, early-morning walks on a quiet road that runs past Curran's ranch and the small cemetery where he has plots for himself and his wife.
But getting the clinics on stable footing was turning out to be much more difficult than they had anticipated.
Their three core donors had committed to keep them afloat until they got through the FQHC application process, but they couldn't depend on charity forever. If they didn't qualify as an official FQHC, their plan would be unsustainable in the long term.
* * *
They opened the Athens clinic in June 2021, a couple of months after their FQHC application was rejected. It sits in the center of Athens' medical district, next door to the 127-bed University of Texas Health hospital.
"You put it right in the middle of all the health care services so that (patients) realize they get the same care that everybody else gets," Curran said.
Ardent Health, one of their primary funders, owned the medical plaza and donated the space, which had just been vacated. It was a bit of luck -- "kind of a God thing, if you will," Robison said.
The 7,000-square-foot facility was more than three times as big as the Gun Barrel City clinic, and furnishing it on a tight budget was no easy task. The previous practice had left behind some exam beds and desks, but other than that, the rooms were bare.
Robison searched everywhere for good deals. He bought an 18-foot conference table and a hutch for $400 from an attorney who was closing her office in Houston, nearly 200 miles away. He found 14 matching upholstered chairs for the waiting room -- $86 for the lot -- from a seller in Cedar Hill, 100 miles to the northwest. He roped the seats to the bed of his truck and drove them home.
"I looked like Jed Clampett," said Robison, who keeps a sign on his desk that reminds him to keep "hustlin'."
Appointments filled up fast in Athens, just as they had in Gun Barrel City. By the end of 2021, the two clinics had logged about 15,000 patient visits and had become local points of pride.
Gary Reaves, who owns a plant nursery in the nearby town of Malakoff, sometimes dropped by with lunch for the front-desk staff. His home shares a fence line with Curran's ranch.
"Athens is a very tight-knit town," Reaves said. "And a lot of it is because of people like Dr. Curran."
Reaves has been Curran's patient most of his life, first at Curran's private practice and now at ETCC. "I've been blessed that I can afford it," Reaves said. "But there's a lot of people that cannot."
Reaves, 67, was a drummer in his high school marching band and remembers seeing a young Curran on the sidelines during football games, checking players for injuries. Years later, when Reaves' dad was diagnosed with cancer, Curran cared for him until he died. When Reaves' brother passed away last year, Curran stopped by to check on his grieving patient, friend and neighbor.
* * *
In many ways, ETCC was expanding exactly as Curran, Mettetal and Robison had hoped it would. In just over a year, they'd opened two clinics, hired three more doctors, seen thousands of patients and launched a successful residency program.
But financially, they often lived month to month. Whenever their bank accounts got perilously low, they went back to their donors with detailed progress reports -- and requests for more money.
Robison was rewriting the FQHC application with help from the Texas Association of Community Health Centers. He managed the clinics by day and worked evenings and weekends on the application. He said it was the hardest thing he'd ever done, including his four years in the Air Force.
It costs $80,000 to $100,000 a month to keep the clinics running. Their three donors fund about 75% of the operation, because about 70% of their patients either have no insurance, inadequate coverage or state Medicaid coverage, which in Texas comes with very low reimbursement rates.
The state typically pays ETCC about $28 for seeing a Medicaid patient. If it provides that same service to a privately insured patient, it can receive as much as $90.
While Robison wrestled with the FQHC application, it seemed the clinics might get a one-time shot of money from the state.
The Texas Legislature was divvying up $16 billion in federal COVID-19 relief money, and one idea was to use $200 million of it to reboot an incubator program the state had once offered to clinics that were trying to become FQHCs.
Curran traveled to Austin to lobby for the provision.
"[It] didn't seem excessive in light of the access-to-care issues that Texas has," he said. Not only was ETCC providing affordable care to thousands of uninsured Texans, it was also training young doctors who might end up staying in the rural region for good.
The Legislature passed the bill in October 2021, but it included $20 million, not $200 million, for the incubator program. Curran was still pleased. He assumed ETCC would be eligible for a big chunk of that money. They needed it to hire 10 more staff members, including another physician, medical assistants, a social worker and two full-time billers to negotiate with insurance companies, so they could capture as much revenue as possible.
But six months after the governor signed the spending bill, the Texas Department of State Health Services still hadn't opened the application process. An agency spokesperson told Public Health Watch in May it was "in the process of hiring the program staff to begin the program."
Meanwhile, ETCC was close to running out of money again.
"Glen and I just looked and we're down to our last $50,000," Curran said. "So, here we go again, we're out of money. ... It's just such a pain, you know. It's just very frustrating to have to do this when you know they're sitting on $20 million."
In a stroke of good timing, the Health Resources and Services Administration reimbursed ETCC $130,000 for uncompensated COVID-19 care the clinics had provided. It would help cover their costs for a couple of more months.
Robison had submitted their new application for FQHC status in March, and a reviewer had already been in touch, asking for a few clarifications. That was a good sign. But there was still no word about a site visit, the critical next step.
Curran and Robison went back to their donors. They got another $200,000 early this summer.
* * *
At the end of June, the state health department finally opened applications for the FQHC incubator funds. But Curran was stunned to see that applicants could ask for no more than $170,000, not the millions he had hoped for. This, he said, was "just a joke." The clinics burned through that much in a few months.
Curran immediately called longtime state Sen. Robert Nichols, a Republican whose district includes Henderson County and who helped get the incubator money included in last year's spending bill. Nichols had toured ETCC, and Curran calls him a "straight-up guy," even though the two have disagreed on issues such as Medicaid expansion.
"I've told Robert Nichols he's going to be my friend no matter what," Curran said. "That's a choice I've made. Now, I may not agree with him and we may have some strong conversation about everything before it's all over. But he'll still be my friend."
Within days, the application was pulled down from the health department's website. When it went back up about a week later, clinics that were working toward FQHC status could apply for as much as $1 million. The state health department told Public Health Watch that the change was made after the agency got "feedback from stakeholders."
Robison quickly submitted the clinic's application, and in early August he received an email granting the $1 million request. By the middle of the month, ETCC signed its contract with the state and began waiting for the first $50,000 to arrive.
* * *
Earlier this month, Curran and Robison shared ETCC's story at the annual Texas Primary Care Consortium summit in Austin. The idea was to inspire others to use their model -- combining an FQHC with a medical residency program -- to help close health care gaps in other parts of Texas.
But even Curran, a determined optimist, says Texas' health care problems won't be solved until the state's political leaders prioritize health care for the poor. What ETCC is doing is important, but as far as statewide impact is concerned, Curran says "it's like peeing in the ocean."
"They've set up things that are hurtful to patients and that harm our state's ability to really care for our people," he said. "I think they've messed up."
Expanding Medicaid would be a big step toward helping those people.
More than 1.4 million uninsured Texans would become newly eligible for coverage if Medicaid were expanded, according to data from the Kaiser Family Foundation. In Henderson County alone, about 4,700 residents would become eligible, according to the Houston-based Episcopal Health Foundation.
Hospitals and critical-need clinics like ETCC would also benefit, because they would be reimbursed for more of the uncompensated care costs they now have to absorb. More rural hospitals have closed in Texas -- 26 since 2010 -- than in any other state, and expansion dollars could have saved at least some of them, said John Henderson, CEO of the Texas Organization of Rural and Community Hospitals.
"We say we're not going to expand Medicaid, but 38 states have and [Texans] help pay for it," Henderson said. "We're just exporting our health care dollars to expansion states."
Texas' resistance to broader coverage has left billions of federal dollars on the table.
The Perryman Group, a Waco-based firm that provides economic analysis, estimates that after a decade of Medicaid expansion Texas would reap net economic benefits of more than $319 billion.
"There's a huge body of evidence out there that the state actually would make money off of it," said Ray Perryman, the group's founder, "so it's a fiscally responsible thing to do."
Perryman described the high number of uninsured Texans as "a human tragedy with profound consequences."
Last year, state Rep. Lyle Larson, a Republican from the San Antonio area, authored a bill that would have put Medicaid expansion on the ballot, so voters could decide the issue. But it never got out of committee. When Democrats later proposed a state budget amendment to expand Medicaid, Larson was the lone Republican to vote with them.
"We've limited our access to health care because of political decisions," Larson told Public Health Watch. "I think it's the most fiscally irresponsible thing that you can do for the people that you represent."
Beto O'Rourke, the Democrat who's running for governor in November, has made Medicaid expansion a campaign promise. He calls it a "commonsense, fiscally responsible thing" to do and the "best shot" at turning around Texas' health care access problems.
Abbott, who is running for a third term as governor, doesn't mention Medicaid expansion on his campaign site, except to tout his record of opposing "ObamaCare." In 2018, Abbott led an unsuccessful lawsuit to overturn the Affordable Care Act and in the past has described Medicaid expansion as "coercive" and "wrong for Texas." Two emails to his campaign, asking for Abbott's current position on Medicaid expansion, haven't been answered.
* * *
While lawmakers argue, Curran, Mettetal and Robison are pushing ahead with their plans to make sure people in their patch of northeast Texas have access to health care.
Over the summer, they moved the Gun Barrel City clinic into a bigger building about a mile down the road. It has 12 exam rooms and can accommodate as many as 120 patients a day. An expensive-looking, stone-and-wood bench dominates the waiting room, the latest proof of Robison's knack for finding a bargain. He got it for $300 from someone in Dallas and drove it home in a U-Haul along with other good finds.
By the end of 2023, they hope to open a third clinic in an empty church in Athens. Another group of local doctors -- a different one this time -- plans to buy the 7,900-square foot building and lease it to ETCC. The added space will allow them to serve more patients and meet the needs of their growing residency program, which now has eight doctors in training.
Curran and Mettetal still see patients two or three days a week, clocking nine-hour shifts. They recently started taking small salaries, to help prove to the Health Resources and Services Administration that ETCC can sustain itself in the real world, where doctors get paid.
When they aren't in the clinic, they're often out with Robison, trying to persuade people to support their effort in any way they can. They've raised about $1.8 million in donations since 2019. As of last week, none of the state incubator or FQHC money had arrived.
On Friday, Robison got an email from the Health Resources and Services Administration, saying it was ready to schedule the FQHC site visit they'd been waiting for. But, like everything else in the application process, it wouldn't happen fast. The dates the agency suggested aren't until March 2023, six months away.
To keep things running smoothly through the winter, Robison is getting ready to ask ETCC's three primary funders for another $500,000. The clinics are on track for about 25,000 patient visits this year, 10,000 more than they saw in 2021.
This story is part of The Holdouts, a reporting collaborative focused on the 12 states that have yet to expand Medicaid, which the Affordable Care Act authorized in 2010. The collaborative is a project of Public Health Watch.
This article was originally published by Public Health Watch, a nonprofit investigative news organization. Find out more at publichealthwatch.org.