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Exterior view of the Barnes-Jewish Center for Outpatient Health building on the Barnes-Jewish Hospital campus in St. Louis on Tuesday, March 6, 2012. Photo by Johnny Andrews,

Stephen Maxwell had struggled for years with a bad back, but what he felt in December was something new.

A pop, pop, pop in his spine left Maxwell, 45, in constant, inescapable pain that’s made it impossible for him to work or even get a full night’s sleep.

Doctors told him that his condition will only get worse without surgery. But instead of getting into an operating room, Maxwell has been stuck in the reclining chair in his Kansas City apartment.

In January, Truman Medical Center, the hospital he has relied on for care, rolled back its financial assistance program. Truman used to provide free or discounted care for uninsured people making up to 400 percent of the federal poverty level — $46,680 for an individual. Now, only those making less than 200 percent qualify for the help. The change was intended to motivate people to sign up for health insurance plans through the Affordable Care Act.

Maxwell didn’t get the message in time. His income from supervising sheltered workshop clients at the Rehabilitation Institute of Kansas City is just under $25,000. That used to qualify him for a generous discount from Truman. But it puts him about $1,450 above the new limit for assistance.

“Now they told me I make too much money,” Maxwell said. He said Truman wanted a five-figure down payment before he gets back surgery. “If I had $10,000 or $15,000 lying around, don’t you think I’d have health insurance? I don’t even have a bank account anymore.”

Other low-income patients may be in for the same surprise. Hospitals across the country are rethinking their financial assistance policies now that the Affordable Care Act is making insurance available to more people.

Most states, although not Kansas or Missouri, have expanded their Medicaid programs through the ACA to cover more people with low incomes. And many people with incomes up to 400 percent of the poverty level qualify for premium subsidies on private insurance plans offered through the ACA’s exchanges.

“Hospitals are really struggling with prioritizing who should get financial aid and what it should be. How do they help the people who need help the most without discouraging people from getting insurance?” said Melinda Hatton, general counsel of the American Hospital Association.

It’s not clear yet how many hospitals already have made their financial assistance policies stricter, but examples have been cropping up across the country.

Locally, the nonprofit St. Luke’s Health System now is providing financial assistance to patients with incomes up to 300 percent of poverty, rather than 400 percent as it did before.

BJC HealthCare, which includes Barnes Jewish-Hospital in St. Louis and 11 other hospitals in Missouri and Illinois, also has lowered its maximum income for assistance from 400 percent to 300 percent of poverty. And the nonprofit hospital system has started requiring all patients, even those below the poverty line, to pay something toward their care.

Patients at the Southern New Hampshire Medical Center, near the Massachusetts state line, used to get free or discounted care if they had incomes up to 225 percent of the poverty level. Beginning this year, most patients qualify only if they make less than 100 percent of the poverty level, which is $11,670 for an individual.

Some critics say hospitals may be overestimating the ACA’s benefits when they change their financial assistance policies.

“There seems to be a sense among hospitals that ‘We don’t feel responsible anymore. There are other ways to pay for your care. We’ll wipe our hands of it,’” said Erin Fuse Brown, who has studied hospital financial assistance policies as a law professor at Georgia State University’s Center for Law, Health and Society.

“They can feel OK about it. ‘This person should have gotten an ACA plan.’ The reality is a lot more complicated.”

Even with the ACA’s subsidies, not everyone will be able to afford health insurance, Brown said. And those who do enroll in plans may find that the deductibles and co-payments make their insurance too expensive to use.

“It doesn’t mean everyone has meaningful access to health care,” Brown said.

Hospitals also say the ACA is making things complicated for them.

When the ACA was being developed, the nation’s hospitals agreed to accept tighter reins on Medicare spending. While hospitals would receive less in the future from Medicare, their bottom lines would still balance out because formerly uninsured patients would have coverage through Medicaid or exchange plans.

In Colorado, which expanded its Medicaid program and encouraged people to enroll in exchange plans, hospitals saw their Medicaid volumes jump during the first three months of this year, as more people gained coverage. Meanwhile, charity care at Colorado hospitals dropped by an average of 36 percent. And in Washington, another state that embraced the ACA, total charity care provided by hospitals declined by nearly $154 million during the first half of 2013.

But in states like Missouri and Kansas, that hasn’t happened. Political opposition has stopped Medicaid expansion and dampened enrollment in the ACA insurance plans. Meanwhile, the changes in Medicare are going ahead.

“We are at the front side of some very difficult times for hospitals if we don’t make some changes,” said Dave Dillon of the Missouri Hospital Association. “They’re under tremendous financial pressure.”

So far, hospitals have been changing their financial assistance policies to motivate enrollment in health plans, not as a way to save money, Dillon said.

“It is a nudge in the direction of doing the right thing,” he said. “We’ve been saying for decades that having insurance is a good thing. You want to have it to insulate yourself from something catastrophic.”

But even as the economy has improved, Missouri hospitals have seen their charity care costs skyrocket, from $482 million in 2011 to $681 million last year. That trend could lead more hospitals to change their assistance policies.

“If things get more difficult, then the pressure will be on more hospitals to do this,” Dillon said. “There’s a true consequence to us of people who choose to roll the dice and not get insured.”

Hospitals that have put new restrictions on financial assistance say the limits haven’t affected many patients. The St. Luke’s system estimated fewer than 40 patients have been affected.

At BJC HealthCare, the estimate comes in at fewer than 3 percent of patients.

“We have not seen a cost savings yet,” spokeswoman June Fowler said. “But the goal was not to save money. The goal was to encourage members of the community to enroll in health insurance.”

The same has been true at Truman Medical Center. The number affected by the policy change “is not that large” and the effect on revenues not significant, spokesman Shane Kovac said.

“It’s just an incentive,” Kovac said. “It was merely that you’re eligible for insurance and it’s really better for you to be insured.”

Maxwell said he wants to be insured, but money and circumstances have gotten in the way.

After taxes and child support payments, he takes home less than $1,000 each month, he said, and can’t afford the premiums for his employer’s health insurance plan.

Maxwell said he doesn’t own a computer. His mother, who does have one, tried enrolling him in an ACA exchange plan. But like millions of other people, she couldn’t get on the bug-ridden website.

“The next thing you know, the deadline was up,” he said.

Maxwell hasn’t been able to work since June. He used to spend most of his time on his feet. Now, he spends his time sitting, wincing each time he tries to shift to a less uncomfortable position.

Maxwell spoke recently to a caseworker with MetroCare of Greater Kansas City, a nonprofit organization that finds specialists, such as surgeons, who volunteer to treat uninsured patients. “She said it’s a very long waiting list.”