Inside a bus, East Texans get the health care they can’t afford or find anywhere else

Shelly Huffman meets with a nurse practitioner at a mobile health clinic in Kirbyville on Oct. 17. The mobile unit provided affordable care to Huffman, who doesn’t have health insurance coverage. (Credit: Callaghan O'Hare for The Texas Tribune)

KIRBYVILLE — When Shelly Huffman stepped onto a 40-foot bus on Monday afternoon, she wasn’t looking for public transportation. She needed a checkup.

The 52-year-old had recently been diagnosed with depression and high blood pressure, which runs in her family. Without health insurance, Huffman could no longer afford to see a doctor to help manage her hypertension.

This mobile medical unit, parked behind a community center in the rural East Texas town of Kirbyville, had become a lifesaver.

“I like the people here, and it’s affordable care,” Huffman said. Her white T-shirt read “I love pickup trucks and rock and roll.”

Inside the mobile bus — equipped with medical supplies such as gloves, tourniquets and blood pressure monitors — a nurse practitioner named Anita Drake greeted Huffman. Between the standard questions about Huffman’s physical and mental health, Drake — or “Miss Anita” as her patients and coworkers fondly call her — and Huffman shared jokes and laughs.

Anita Drake, a nurse practitioner, conducts an appointment with Shelly Huffman at a mobile health clinic in Kirbyville on Oct. 17. (Credit: Callaghan O'Hare for The Texas Tribune)

Mobile health units like this one, operated by the TAN Healthcare clinic, have emerged as an effective method to provide lifesaving care to hard-to-reach patients. With the highest uninsured rate in the nation — more than double the national average — Texas is home to thousands of underserved, economically disadvantaged patients in need of medical care. And with an increasing number of rural hospitals closing down, access to care is limited in Texas’ 172 rural counties.

As a federally qualified health center, TAN Healthcare receives federal funding and serves an underserved population. The clinic has brick-and-mortar sites in Beaumont and Orange and operates the mobile bus unit three days a week, providing preventive health care to outlying areas of East Texas, many of which have no hospital of their own.

At TAN, uninsured patients like Huffman pay for their health care according to a sliding scale based on their family’s income level and size. Huffman pays $25 for each visit, a nominal fee compared to the minimum of $80 she forked over at a nearby clinic. And she pays the same amount regardless of how many labs or tests are done — or how long her visit takes.

Whereas most doctors’ offices book appointments every 15 minutes, TAN schedules patients every 30 minutes. Appointments with Drake routinely run longer.

The clinic sometimes loses money on those longer appointments, said Dena Hughes, CEO of TAN Healthcare. “But that’s why we’re a nonprofit,” she said. “We’re not supposed to be making tons of money — we’re supposed to be putting money back into the system.”

Melissa Forward, a medical assistant, walks toward a mobile health unit that operates three days a week, providing preventive health care to outlying areas of East Texas. Kirbyville is one of hundreds of towns in Texas where access to health care is limited. (Credit: Callaghan O'Hare for The Texas Tribune)

Rural counties struggle for health access

Kirbyville occupies 2.4 square miles in the southern half of Jasper County, a heavily forested region known as the Big Thicket. Originally a railroad terminus, the 2,000-person town is now a common stopping point for visitors of one of the three nearby lakes.

The town is one of hundreds in Texas where access to health care is limited. Over the past two decades, dozens of rural hospitals have shuttered, unable to keep up with the rising costs of health care and dwindling rural populations.

Since 2005, 24 rural hospitals have closed in Texas, the highest number in the nation.

Kirbyville has no hospital of its own, and while the nearby Christus Southeast Texas Jasper Memorial Hospital remains, it did recently close down its obstetrical unit and suspend orthopedic surgeries.

Now, 28% of counties in Texas have no hospital, forcing residents to drive farther away to access both preventive and emergency care at a time when gas prices are surging. Statewide, there’s a significant shortage of primary care physicians. Only four Texas counties — Fort Bend, Williamson, Rockwall, and Callahan — meet the federal benchmark of having at least one primary care physician for every 3,500 residents.

“You have [hospitals] that come and go and can’t sustain themselves,” Hughes said. “We are building up this expectation and this energy around feeling better, and that’s a big deal.”

Texas is one of 12 states in the country that has not expanded access to Medicaid under the Affordable Care Act, which would allow Texas to offer government-funded health care to adults with incomes under 138% of the federal poverty line.

Instead, adults in Texas must have dependents or a disability to be eligible for Medicaid, regardless of how low their incomes are. And the eligibility requirements are so stringent that a family of three with an annual household income of $4,000 pre-taxes would not qualify for Medicaid. As a result, 1 in 5 Texas residents is uninsured. An estimated 1.7 million additional Texans would qualify for Medicaid if the state were to expand eligibility.

This wide coverage gap coupled with limited access to doctors has created poor health outcomes in rural Texas. The ten Texas counties with the worst health outcomes, according to a study by the University of Wisconsin Health Institute, are all rural.

Much of the patient population in rural communities has chronic illnesses like diabetes or hypertension, and they have delayed getting care or never had consistent care.

“Some of our patients haven’t been seen in five to seven years,” said Lyndon Hallmark, manager of TAN Healthcare’s mobile unit. “And they come in saying, ‘I’ve had a headache for three years,’ and their blood pressure is almost in the stroke zone.”

Dena Hughes, the CEO of TAN Healthcare, in Kirbyville on Oct. 17. “We’re not supposed to be making tons of money — we’re supposed to be putting money back into the system,” Hughes said of the clinic’s nonprofit economic model. (Credit: Callaghan O'Hare for The Texas Tribune)

Providing compassionate care

After about 45 minutes with her care team, Huffman left the mobile unit feeling pleased. Her blood pressure, once elevated, was back within a normal range. Several months of diligently taking her daily medications had paid off.

“It was just perfect,” Huffman said.

“I just love it at the clinic,” Huffman said the day after her appointment. “The people are so nice and caring, and the nurse, she takes her time and listens and checks everything.”

TAN prides itself on providing compassionate care to a population that sometimes distrusts the medical community.

“We are more personal than a normal doctor’s office,” said Y’londa Attaway, a registered nurse who works in the mobile clinic. “We don’t see as many patients, but we take the time to listen.”

Attaway said some patients don’t like going to other doctors in town because they feel like they aren’t being heard.

After visiting TAN Healthcare as a patient, Lyndon Hallmark started working the clinic’s front desk and more recently took over its mobile unit. (Credit: Callaghan O'Hare for The Texas Tribune)

Often, patients make appointments at the mobile clinic simply because they want someone to talk to, Hughes said. Many struggle with mental health disorders such as anxiety and depression. The nurses at the mobile unit said they are in some cases the only providers patients trust.

Hallmark and his team greet visitors with hugs, not handshakes. Patients call providers by first name and talk to them about their families. When a patient calls the mobile unit, they don’t hear an automated message. Instead, a health practitioner answers the phone. And once a patient enters the bus, they are never rushed out.

Between patients, Hallmark stepped outside in the community center’s parking lot to smoke a cigarette. “This is how I keep going,” he joked.

Hallmark first came to TAN as a patient. He loved it so much that he started working the front desk and more recently took over the mobile unit.

“We don’t have that white-lab-coat, starched-shirt, clinical environment mentality,” Hallmark said. “Our staff here is approachable and down to earth.”

He’s not sure what is feasible given the limited financial resources, but he has big dreams for TAN. He wants to see the clinic add an imaging center for patients who need X-rays or CT scans and hopes to see OBGYN also become a part of their regular services.