"We've reached out to 22,000 of our patients," said Marian Morrow, Parkland's patient financial service manager, in the crowded enrollment office.
In 2012, Parkland provided $685 million in uncompensated care for its mostly uninsured patient population and for those who are underinsured. Yet under the Affordable Care Act, the hospital could still find itself in the red next year.
"About a third of our revenue comes from federal payments," said Ted Shaw, Parkland's interim chief financial officer. "If we don't have those revenues, we can't fund the programs they support."
Under the ACA, federal payments to hospitals will be cut starting in 2014 on the expectation that more of their patients will be covered by insurance. That may be the case in states that have opted for the Medicaid expansion program, which extends Medicaid coverage for individuals and families earning up to 138 percent of the federal poverty level, roughly $15,856 for a single adult and $26,951 for a family of three.
Texas is among two dozen Republican-led states that have rejected Medicaid expansion, after the Supreme Court ruled that the Obama administration could not force states to adopt the program.
"By not expanding Medicaid, I estimate that it is costing Parkland about $30 million a year, starting next year," said Shaw, due to lower federal reimbursement and the likelihood the hospital will continue to see patients who don't earn enough to pay for insurance.
A study by the nonpartisan Commonwealth Fund estimates that by 2022, taxpayers and providers in states that opt out of Medicaid expansion will lose out on billions in federal funding.
(Read more: Oklahoma lawsuit to derail Obamacare?)
The researchers calculated the move would cost Texas more than $9.2 billion. Florida, where Dade County has the nation's highest rate of uninsured patients, would see a net loss of $5 billion by not adopting Medicaid expansion.
Obamacare plan limitations
For patients who would otherwise qualify for the Medicaid expansion coverage, the lowest-priced plans on HealthCare.gov could still prove costly, even with federal subsidies that in some cases fully cover the cost of monthly premiums.
Private physicians like Dr. Roger Khetan worry that many of those low-premium plans will leave patients underinsured, because they come with high out-of-pocket costs for things like lab tests and MRI screenings.
"Once you give them their preventive care, if there's an abnormal lab, an abnormal finding, what is the follow up?" Khetan asked. "Is it going to be covered by that insurance company?"
(Read more: Fixed Obamacare site still not secure, says hacker)
At the Mission East Dallas clinic in nearby Mesquite, staffers have been helping their mostly uninsured patients learn how to enroll in Obamacare plans, but they have found that the most affordable plans on the exchange don't include the clinic in their networks.
The clinic is now lobbying the insurers to be included in the plans that its patients are most likely to choose.
"We are trying to get enrolled into those networks, so we'll be able to take care of the patients," said Dr. Chris Berry, a family physician at Mission East Dallas.
Berry admits this is not traditionally the way doctors' offices work.
"This is a unique moment where we haven't had to think that way before," he said.
Obamacare: Not a federal health program?
Parkland Memorial was studying a way to help its patients maintain their Obamacare coverage, by providing premium assistance to those who may have trouble making their insurance payments. It is something the hospital has done in the past with patients covered under COBRA plans.
"When patients come in and their insurance is lapsed, ... if we pay the premium for them then we actually get paid for delivering care, which tends to be more expensive than just paying the premiums.," said Parkland's Shaw. "So we recover costs that way."
They can't pay patient costs for federal health programs like Medicare. But while the Affordable Care Act is considered President Barack Obama's signature initiative, Obamacare plans are not considered a strictly federal health program.
Health and Human Services Secretary Kathleen Sebelius has determined that Obamacare plans sold on the health insurance exchanges should be treated like private plans. As a result, the plans do not fall under government health program anti-kickback statutes, which bar financial incentives to patients.
Yet, last month HHS officials strongly discouraged hospitals from trying to pay their patients' premiums, saying it could create an uneven playing field among providers, warning that the health department would take action against such payments. Parkland has since abandoned its premium-support plan.
Some health policy legal experts say hospitals can legally make a case for allowing the payments, despite the health department's determination.
"The secretary has said they're not subject to the statute. The statute requires a willing and knowing violation, " explained Kevin McAnaney, a health policy attorney who worked in the Office of Counsel to the Inspector General during the Clinton and Bush administrations.
"It's hard to understand how a violation could be knowing and willful if the secretary has told you it doesn't apply," he said.
Ironically, Obamacare gives hospitals in Medicaid expansion states an advantage over facilities in states that have opted out. In those states, a hospital that treats a patient who is uninsured but would otherwise qualify for Medicaid expansion, could sign the patient up for temporary Medicaid coverage and get reimbursed.
"It would be enormously better if we were part of Medicaid expansion," said Mission East's Berry.
Berry expects most states now opting out of expansion will eventually take up the program over the next couple of years, with the federal government committing to pay 100 percent of the cost through 2016. After that, the states will have to pick up 10 percent of the cost.
"It makes perfect sense from almost any way you look at it," he said.
By Ed Kiersch
Just a week ago, skeptics were laughing at Shawn "Jay Z" Carter, wannabe sports agent.
Not any more. The New York media and sports agent rivals this year derisively dubbed Jay Z the "Rookie" after he seduced Yankees second baseman Robinson Cano away from super-agent Scott Boras. Watching him make missteps, while even lesser-known agents were cashing in on $1 billion worth of new contracts this off-season, critics scoffed that Jay Z was playing out of his league.
Then last Thursday, only hours before his nine Grammy nominations were announced, the hip hop power broker (reportedly worth $500 million) found a willing suitor for Cano in the Seattle Mariners—Nintendo owns a 55 percent controlling share of the team—and landed the player $240 million for 10 years. It's the third largest free agent contract in history.
Just a week ago, when it had leaked to the New York media that Cano wanted $310 million for 10 years, rival agents were pointing out the "Rookie's" mistakes to CNBC.
(Read more: The highest paid players in major sports)
"The key is to create mystery, speculation on who's bidding. If you don't create mystery, you lose bidders immediately," said an agent who represents a prominent Dodger player and who asked not to be named.
"The Dodgers said, 'We are not in the bidding.' You must keep things like that as quiet as possible. The best thing is to say as little as possible. No one should know what's going on. A team has to be scared that they're losing a player. ... The first mistake was letting that $310 million figure out there. Being quiet is the best and only strategy in a market that's hotter than ever."
"The perception is that it's all Jay Z's victory," said Florida sports lawyer Darren Heitner, founder of the Sports Agent Blog.
"This deal takes Cano until he's 41 years old, meaning players still have leverage," Heitner said. "I thought 10-year deals were dead. Though there's a $70 million discount off that $310 figure (that Cano wanted), it's a fantastic agreement. Ripped by the media, the deal now lets Jay Z be perceived as the able negotiator."
Jay Z and Boras did not respond to requests for comment.
The Cano deal has its flaws: He had to be moved to Seattle, a full continent away from media-charged New York, where Cano could possibly garner millions in endorsements. Still, Jay Z fulfilled his primary responsibility: He showed Cano the money. It barely matters if the Mariners were only desperate to boost their lackluster brand. The Yankees adamantly refused to agree to 10 years and objected to giving their All-Star, .300-plus hitter more than a seven-year, $175 million pact.
Jay Z certainly faced challenges with Cano. Skeptics charged that his agency, Roc Nation, failed to create enough bidders for the second baseman. Teams were scared away by media reports suggesting the 31-year-old Cano demanded $310 million for 10 years after he was lured away from Boras this year.
Jay Z, who also represents basketball's Kevin Durant and football wide receiver Victor Cruz, brashly congratulated himself earlier this year after he wooed Cano away from Boras, who still holds the records for negotiating the first- and second-most valuable baseball contracts in history, both for Yankee Alex Rodriguez.
(Read more: Holiday gifts that will make a sports lover cheer)
Dissing Boras in the song "Crown," Jay Z says, "Scott Boras, you over baby, Robinson Cano, you coming with me."
Boras countered in The Wall Street Journal, "Anyone who thinks playing the game of baseball is like being an artist knows nothing about the game. … I don't worry about others. … When your agent wears a Yankee hat, how seriously are they going to take you?"
Columnist Mike Lupica, whose New York Daily News prematurely reported that the Seattle deal was dead when Jay Z demanded 10 years, still savaged the "Rookie" outsider after the Mariners contract was done.
"In this case the dumb owner is Nintendo, usually a smart corporation," wrote Lupica. "Maybe if this thing dragged on a few more weeks, Jay Z would have delivered Cano to Japan. Or the moon."
Feeling the Cano deal bolsters the rapper's aura of "invincibility," Zack O'Malley Greenburg, the author of Jay Z bio "Empire State of Mind," told CNBC: "Athletes look up to Jay Z for his business moves. This deal only strengthens his attractiveness to other players, certainly if a guy wants headlines."
It remains unclear how aggressive Jay Z will become in luring other marquee athletes to Roc Nation. He recognizes his brand only suits a select player, and would be diminished if he pursued a plethora of athletes.
But one thing is likely. Lesser sports brokers representing elite, soon-to-be free agents are looking over their shoulders.
By Diana Olick
While 203,000 jobs added to the U.S. economy in November is welcome news, it will push interest rates higher—specifically, residential mortgage rates. Those rising rates, along with tighter underwriting and fast-rising home prices, are pushing borrowers away from larger lenders.
"If you're buying a house, our advice is to find a local lender that's reputable," said Eric Egenhoefer, president of Waterstone Mortgage, a subsidiary of Milwaukee-based WaterStone Bank, an independent with reported assets of more than $1.6 billion. "An independent company in general is more nimble, can get to a closing faster and provides better service."
An increasing number of borrowers are doing precisely that.
Smaller bank and nonbank lenders' share of the mortgage market rose to 60 percent in the third quarter, versus 39 percent in 2009, according to Inside Mortgage Finance. Those outside of the top 25 largest lenders rose to 35 percent of the market from 13 percent in 2009.
What's more, the big banks are pulling out in a big way—just five of the top 20 single-family mortgage originators in 2006 remain active in the market, according to a recent Fannie Mae report.
"If Wells Fargo wanted to gain market share, they would," said Brian Simon, chief operating officer at New Penn Financial, a nonbank lender owned by specialty finance firm Shellpoint Partners.
Wells Fargo, the largest lender in the U.S. with a 22 percent market share, has changed its website to make the experience for consumers more like one they would have with a smaller bank.
"The lending space for Wells Fargo mortgage feels much more like a local community bank than a giant bank with a call center," said Franklin Codel, head of Wells' mortgage production, in a September interview. "Most consumers are looking for a personal relationship with someone who can help them through the process and not just looking for the lowest rate if it doesn't come with a reasonable amount of service."
But with refinance volume down more than 60 percent from a year ago, the company has laid off hundreds of workers, as have other large lenders. In addition, historically low rates and higher fees charged by Fannie Mae and Freddie Mac are squeezing lending margins, so big banks are focusing on more lucrative businesses.
"Even though the big guys came back, they never came back the way they were in the Countrywide days," said Guy Cecala, CEO and publisher of Inside Mortgage Finance. "They never got aggressive on the prices, so it was very easy for Acme community bank to compete."
(Read more: Mortgage rates on the rise again)
Small lenders are not only competing but becoming more aggressive.
"There are a lot of opportunities in play," said Simon at New Penn, speaking this week from the Mortgage Bankers Association's Independent Mortgage Bankers Conference in Miami. He said he has been talking to smaller colleagues with the aim of making acquisitions.
"There is a lot of angst in general," he said. "When there's angst, there's opportunity for guys like me to make a pitch for why New Penn is a great place for people or groups to work."
But smaller and community lenders are not necessarily going to offer the absolutely lowest rates, especially for savvy online rate seekers—most of whom are looking to refinance a home, which generally requires less hand-holding than a purchase.
(Read more: Why mortgage rates are taking a holiday)
Brian Del Terzo shopped online when he was buying his first home outside Minneapolis but ended up on a call list getting dozens of offers and rates. Instead, he went with a local lender, Waterstone.
"It seemed easier because I can get in touch with the loan officer more easily," he said. "There is not as much red tape, especially if something unusual pops up."
Though Del Terzo acknowledged that he may not be getting the lowest rate possible, he said he would happily trade that for better service.
"At the end of the day if I'm getting the home for the price I want, and the mortgage process is smooth, and I'm getting a rate that's fair, I'm completely satisfied," he said.
Small-to-midsize local banks—many of them publicly traded companies—were hit hard during the credit crash, with hundreds going out of business. But recent increases in their mortgage business are helping to boost balance sheets. Nonbank lenders, which often compete online, are also seeing big gains, and more of them are going public to raise more cash.
While new mortgage regulations going into effect next year may throw another wrench into the already tight lending landscape, smaller lenders seem poised to profit. Fewer loan products may be available today than during the housing boom, but borrowers have a growing number of options for getting a loan—and new competition among more lenders can't hurt.
By Jeff Cox
Fiscally distressed governments across the country may have gotten a troubling blueprint this week for getting out of their respective messes.
In allowing Detroit to move ahead with its planned bankruptcy filing, federal Judge Steven Rhodes sent a message to municipal bondholders that their investments are not risk-free and in fact could suffer dramatic losses
Bond pros are worried about the implications.
"If they allow Detroit (general obligation) bondholders to be impaired significantly, this could cause in Michigan and maybe also municipalities across the country their GO bondholders to have the perception that this could happen anywhere," said Patrick Stoffel, municipal bond analyst at Wells Fargo.
"That could increase borrowing costs for municipalities and issuers," he added. "It could cause prices of GO bonds to be affected in the market, and so there are some possible wide-ranging implications from this Detroit bankruptcy."
Stoffel cautions that municipal bankruptcies are messy, costly and have wide-ranging after-effects, so he doesn't see Rhodes' ruling—if upheld—to lead necessarily to a rash of other cities filing.
However, for investors in governments teetering on bankruptcy, the implications could be substantial.
"Municipalities that have gone through bankruptcies before have not gone about impairing bondholders necessarily as a means to solve their fiscal problems," he said. "This is much different than what we've seen before. I could see there being some impact on the municipal market generally speaking more so than we've seen in other bankruptcies."
The Detroit case could get messier yet.
Rhodes indicated some unease over whether the city did enough to negotiate with its creditors, possibly providing appeals ground for bondholders.
Richard Larkin, director of credit analysis at HJ Sims, said the situation over the long run actually could discourage other municipalities from seeking bankruptcy protection.
"If this is the future for Detroit, it doesn't necessarily set the tone for the future for other state and local governments; Detroit has yet to feel the fiscal pain of being treated as a pariah by the municipal bond market over the long term," Larkin said in an analysis for clients.
"Speculators and hedge fund managers may profit from (debtor-in-possession) financings for now, but how accepting will the municipal bond market be after the exit from bankruptcy and bondholders get 'stiffed' for lending to the city when it was in need?" he added. "In particular, if I was a bondholder that bought Detroit's pension obligation bonds a few years back, I would be enraged and insulted at how they are going to be treated in bankruptcy."
There was little immediate reaction from the municipal market as investors waited to see what the long-term effects would be.
The Pimco Intermediate Municipal Bond exchange-traded fund lost a bit of ground Wednesday and is down 4.1 percent for the year, underperforming the Barclays Municipal Bond Index, which is off 2.3 percent. The past three months, though, have been positive for the muni market.
As for Detroit, Larkin has long held that the the city does not need to go the bankruptcy route. In August, he listed 10 misconceptions about its financial status along with recommendations on what it could do to recover.
However, he believes Tuesday's decisions set the city on a dangerous path.
"While there have been changes in the makeup of the municipal bond market in recent years," he said, "I don't believe that those changes have enough permanency to assure Detroit that they will be able to borrow long-term in the future, as we know they will need to do if they seriously want to repair their infrastructure and eliminate the blight that is poisoning this once-thriving metropolis."
With the crucial holiday shopping season here, the Apple name is losing its luster in the face of a more diverse market of tablets and smartphones, a tech analyst told CNBC on Monday.
In an interview on "Squawk on the Street," Colin Gillis, a senior technology analyst with BGC Partners, said the Apple brand needs some good news now that competitors have narrowed the gap between their flagship devices. He said he's looking toward a long-awaited deal—perhaps in mid-December—with China Mobile to stimulate the company's outlook.
Under the potential deal, Apple would distribute its new line of iPhones on the Chinese Mobile network, the world's largest wireless carrier.
"There's very few catalysts left in the name," Gillis said of Apple. "I'm looking toward the China Mobile news. ... I think most of the good news is out in the name."
Gillis said his company forecasts more than 25 million iPads selling this year, which he called a "great number" but cautioned that it could let down investors if Apple doesn't exceed that threshold.
"It's following the same path as the iPhone," Gillis said. "The only smartphone was the iPhone and the competition slowly caught it. It's the same thing in the tablet marketplace. The only tablet was an iPad and then Amazon is going to get a little traction."
Apple made headlines this weekend when it acquired PrimeSense, an Israeli chip-developer whose 3-D machine vision technology was used in Microsoft's Kinect devices. Israel media said the deal cost about $350 million, which Gillis called a "drop in the bucket."
(Read more: Apple acquires 3-D chip developer PrimeSense)
Gillis said Apple was "behind the curve" when it came to motion sensing, which he predicted was becoming a bigger part of the home living room. He said Apple should be more "inquisitive" going forward and put more cash into work toward innovation rather than dividends, for example.
"They're lacking in payments," Gillis said. "They're lacking in advertising. There are a lot of areas where they're weak [that] they could grow in. They can go up and down the stack a little more."
Last month, Apple posted better-than-expected earnings during its fourth-quarter, but disappointed investors on its forecast of future earnings. During the earnings call, Apple CEO Tim Cook predicted an "iPad Christmas."
Despite his bearish stance on Apple's outlook, Gillis said his in-house research showed Apple products still remained high on many people's Christmas lists.
"That being said, I'm going to buy one," Gillis said. "My kid only wants an iPad this Christmas."
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