For the 25 years that Michael J. Jones had health insurance, he avoided Parkland Memorial Hospital "like the plague."

But the 49-year-old Irving resident changed his mind after he lost his coverage and suffered a ruptured appendix. He showed up in Parkland's emergency room Monday, bent over in pain so severe he was dragging his right leg.

"Within 30 minutes, I saw a doctor, got some pain medication and was admitted," he recalled. "This is a good hospital. I would come back here again."

Parkland will need that kind of patient loyalty to survive the changes coming to the nation's health care system.

Health insurance changes, which President Barack Obama signed into law last week, could end up costing Parkland many of its current patients as they gain access to public or private coverage.

It's not clear how many Parkland patients would flee to private doctors and hospitals if given the chance. But it could be a substantial loss.

An estimated 32 million Americans will leave the ranks of the uninsured by 2014, when the new law becomes fully effective.

In Texas, at least half of the state's 6.1 million uninsured residents may get coverage through the mandate. Either they will be able to get private health insurance through an employer, buy it themselves or qualify for coverage in the state's expanded Medicaid program.

"If this program cuts the uninsured population in half in Texas, this would be a huge victory," said Dr. Ron Anderson, Parkland's president and chief executive.

But Anderson also is preparing for the uncertainty of what will happen at Parkland, a tax-subsidized public hospital that has served Dallas County's indigent and uninsured since 1894.

Last year, county taxpayers kicked in $426 million to support the hospital. The money helped care for 257,000 patients, of whom 181,000 were uninsured, the hospital said.

One of them was Lupe Villarreal, a 62-year-old Grand Prairie woman who said she would love the chance to leave Parkland's care.

"I would go to Baylor," said the cancer survivor, a Parkland patient for 10 years. "I don't like all the doctors here. They don't believe you when you tell them your symptoms."

A dozen other patients – all interviewed at Parkland this week – said they'd stick with the county hospital.

"I like the doctors here," said Myrtha Sneed, a 63-year-old Dallas woman. "I don't have to wait longer here than I would at any other clinic."

Parkland will have to wait to find out how many patients will seek care elsewhere. But a significant loss could force the county's lone public hospital to compete with private doctors and hospitals.

No one can say for sure, but health experts seem to agree that Parkland is more likely to experience a change in patient population than not.

"Parkland needs to pay attention to patient satisfaction," suggested Larry S. Gage, president of the National Association of Public Hospitals and Health Systems, which represents 140 public systems in the U.S.

"A large number of patients who come to Parkland are going to have insurance" in the near future, he predicted.

"Certainly, Parkland and other public hospitals are hoping to keep some of those patients by providing high-quality services. But that's a challenge."

Parkland officials don't seem too worried about competing with private hospital systems in Dallas-Fort Worth – even though some hospitals resemble fancy hotels more than health care facilities.

"Competition for the loyalty of the patients is a good thing," said Anderson, who has headed Parkland since 1982.

He stressed that he has never opposed any reform plan that would allow Parkland's patients a choice of medical providers.

"We ought to create situations where people have options, and they don't have to stand in lines at the public hospital," he said.

"I also believe that public hospitals that are attentive to their patients and act as their advocates will do fine."

Parkland officials believe they will have a competitive edge with the construction of a $1.3 billion replacement hospital, which gets under way this fall.

The planned 17-story, state-of-the-art facility is slated for completion in 2014, about the time health insurance becomes accessible to most Americans.

"We are going ahead with plans to build the hospital that voters want us to build," Anderson said . "Our board considers this a wonderful coincidence."

Probably the first impact of expanded insurance coverage will be felt in Parkland's emergency room. Most uninsured people, who have little access to private physicians, often seek basic medical care from emergency rooms.

The new coverage rules are expected to discourage that habit.

"Health insurance plans and managed care design their deductibles so that it costs more to go to the emergency room than to a private doctor," said W. Stephen Love, president and chief executive of the Dallas-Fort Worth Hospital Council, which represents 73 local hospitals.

"Many people access Parkland through their emergency room because they have no primary care doctors," he noted. "Now, they're going to have primary care doctors."

But it's uncertain if there will be enough primary care doctors, including internists, family practitioners and pediatricians, to accommodate the newly insured patients moving into the private sector.

"We do not have enough primary care doctors now, and they're struggling financially," said Michael Darrouzet, executive vice president and chief executive of the Dallas County Medical Society, which represents local physicians.

Any increase in the number of primary care doctors would depend on the government's reimbursement rates for Medicare and Medicaid services, which also serve as the basis for private insurance rates, he said.

If the payments were enough, more physicians would choose to practice primary care, instead of higher-paying specialties such as surgery and orthopedics, Darrouzet said.

Even if insured patients choose to abandon Parkland, the hospital would hang on to several patient groups.

For instance, the federal insurance mandate does not cover illegal immigrants, and Parkland has a long history of caring for them.

The hospital says it doesn't know the portion of its patient load such immigrants comprise.

A 2004 study of the hospital's operations estimated that 20 percent of Parkland's uncompensated care was for illegal immigrants. In 2008, the hospital amassed $523 million in uncompensated care.

Anderson said he did not believe that the 20 percent share for immigrants was accurate, but he did not offer a substitute.

"Civilized societies take care of people inside their borders," he said. "They do not let them die in the streets."

But Anderson vowed that Parkland would not be a hospital primarily serving immigrants and other patients who had nowhere else to go.

"We want to be the hospital of choice," he said, "and not the hospital of last resort."

In 2009, Dallas County's public hospital had:

685 available beds

$922 million operating budget

$426 million in taxpayer contributions

41,364 admitted patients

14,872 babies delivered

9,375 employees

983,820 clinic visits

108,717 emergency room visits

SOURCE: Dallas County Health & Hospital System

Some of the changes in public programs under the health care overhaul:

•Medicaid will be expanded to cover all people under age 65 with incomes up to 133 percent of the federal poverty level ($14,404 for an individual and $29,327 for a family of four in 2009) based on modified adjusted gross income.

•This expansion will create a uniform minimum Medicaid eligibility threshold across states and will eliminate a limitation that prohibits most adults without dependent children from enrolling in the program today (though as under current law, undocumented immigrants will not be eligible for Medicaid).

•Eligibility for Medicaid and the Children's Health Insurance Program (CHIP) will continue at their current levels until 2019.

•People with incomes above 133 percent of the poverty level who do not have access to employer- sponsored insurance will be able to get coverage through newly created state health insurance exchanges.

•The federal government will provide 100 percent funding for the costs of those who become newly eligible for Medicaid for years 2014 through 2016, 95 percent for 2017, 94 percent for 2018, 93 percent funding for 2019 and 90 percent for 2020 and later.

•States that have already expanded adult eligibility to 100 percent of the poverty level will receive a phased-in increase in the federal medical assistance percentage for nonpregnant childless adults.

•Medicaid payments to primary-care doctors will be increased to 100 percent of Medicare payment rates in 2013 and 2014 with 100 percent federal financing.

SOURCE: Kaiser Family Foundation