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Falling through cracks if states don't expand Medicaid

Ami Vitale for NBC News

Derek Anderson, sitting next to his wife Erica, takes medication every day following a bone marrow transplant to treat his leukemia. He's been on Medicare since he lost his job and his insurance. The couple hopes to qualify for Medicaid in 2014.

Derek Anderson never imagined he'd wind up on welfare. At 36, he has a college degree, a solid background in sales and three kids under the age of 7. He's also recovering from leukemia and since he lost his job and his employer-sponsored insurance, he’s been on Medicare, the federal health insurance plan for the disabled and elderly.

Anderson, who now relies on Social Security disability payments for income while he tries to get back on his feet, worries about whether he can get a job with health insurance. If he starts working, he'll lose eligibility for Social Security and Medicare -- but he and his wife, Erica, would likely be eligible for Medicaid if his home state, Montana, expands it as called for under the 2010 health reform law and offers it to low-income adults. However, their future is now unclear after the Supreme Court said states can opt out of the expansion.

He says he's worked hard to pay all his medical bills and says opponents of health care reform have overlooked people like him, who are not seeking a free ride. “I have a college degree. I had a job. When something like this hits you, [people like me] have no idea how the welfare system works because they never needed it,” Anderson said in a telephone interview.

Anderson was working in copier sales when he was diagnosed with leukemia in 2008. It quickly became clear he needed a bone marrow transplant -- a grueling procedure that requires chemotherapy to kill off a patient’s own bone marrow and then an infusion of new bone marrow. He estimates it cost his employer’s private insurance plan $500,000 for the 2009 transplant, and he’s run up tens of thousands in charges since then for care that includes strong immune-supressing drugs that he still takes while the new bone marrow slowly takes over.

When Anderson’s grandmother died, he and Erica moved with their three children, now aged 6, 5 and 4, from Seattle to her home in Butte, Mont. He had taken short-term disability at his sales job but he maxed it out and when it became clear he would not be well enough to return to work any time soon, he resigned.

Erica Anderson is winging the summer without health insurance at all, and just hoping she doesn’t get sick. The 28-year-old will be covered when she starts taking college classes again in the fall, but the school insurance plan doesn’t cover family. She worked for a while but quit to take care of her ailing husband and children and to take classes in the hope of getting a better job.

"Getting a job for insurance is a dead end. We don’t want to get stuck in that dead-end cycle,” Erica Anderson says.

The children are covered by "Healthy Montana Kids," the state’s version of the federal-state Children’s Health Insurance Program.

One of the main goals of the 2010 Patient Protection and Affordable Care Act was to extend health insurance starting in 2014 to 32 million people who currently are not covered. A big part of this was to be through expanding Medicaid, the state-federal health insurance plan for the poor.  Most states now use Medicaid to cover pregnant women and children but exclude childless adults, in part because they lack the budget to cover more people.

The law required states to extend Medicaid to people earning up to 133 percent of the federal poverty level, or about $14,800 for single people and $31,000 for a family of four. The federal government calculated this would add at least 16 million people to Medicaid.  

But the Supreme Court ruled in June that the federal government cannot make the states do this. It must be optional. Immediately, several Republican governors said they’d be opting out, including Louisiana’s Bobby Jindal, South Carolina’s Nikki Haley, Rick Scott of Florida and Rick Perry of Texas. Others are on the fence, including Gov. Bob McDonnell of Virginia, the chairman of the Republican Governors Association; Gov. Scott Walker of Wisconsin; and even some Democrats such as Montana Gov. Brian Schweitzer.

The law provides for the federal government to pay for every new Medicaid enrollee added under the extension, but the states will have to start kicking in a small percentage after a few years. Governors of many states say they’ll have to slash education or other programs, or raise taxes, to cover this. Many governors are also worried that people who didn’t know they have been eligible for Medicaid and possibly other state programs will seek it out because of the publicity and outreach that would surround an expansion.

Supporters of reform say that’s no reason for states to balk.

“Just because we do a terrible job of enrolling people doesn’t mean we have an excuse,” said Dr. Stuart Hamilton, founder and Chief Executive Officer of the Eau Claire Cooperative Health Centers in Columbia, S.C., which provide low-cost medical care on a sliding fee scale. “For three years South Carolina is going to get those individuals paid for at 100 percent. So it would cost us absolutely nothing.”

South Carolina state senator Darrell Jackson, a Democrat who is also senior pastor at Bible Way Church of Atlas Road, a megachurch in Columbia, says his state will suffer if Gov. Haley doesn’t expand Medicaid. “When this legislation was crafted, it had states like South Carolina in mind,” Jackson said in a telephone interview. “We have a substantial portion of working people who cannot afford health insurance. They have to make a decision: their mortgage or health insurance, food on the table or health insurance.”

Elise Spigner is one such example. The 58-year-old stay-at-home mother sees herself as a rock for her friends and family, stepping in when someone has a stroke, caring for a disabled son. With her solidly middle-class background – she comes from a prominent South Carolina family – Spigner never thought she would rely on charity for her health care. “I was raised with a silver spoon in my mouth,” she says.

But a divorce in 1996 left her without her husband’s health insurance, and she gets medical care through one of the Eau Claire Cooperative Health Center's clinics. The non-profit’s business plan was supposed to run out in 2014, when the 2010 health reform law takes effect.  “I have been taking care of everybody else for 55 years and not taking care of me,” says Spigner, who is working to finish a nursing degree.

Dean Slade, director of grants and strategic planning at Eau Claire, makes the standard argument for extending government health insurance to as many people as possible – that it will save money in the long run. The Commonwealth Fund, which advocates for health reform, has shown in study after study that Americans spend at least twice as much per capita as the residents of other developed countries on health care, but die sooner and get lower quality care.

Slade argues that this is in no small part because tens of millions of Americans get little or no health care until they are in an acute and costly crisis, such as having a heart attack or stroke. “You have to spend money to save money, but we could significantly reduce the cost of care by just making sure that people got their medicine, that people saw their doctors regularly,” Slade says.

But opponents of the expansion say the country simply cannot afford it. Many Republicans instead support a voucher system that would help more people to buy private health insurance. “A government-run program, and a new government entitlement program — when we can't afford the ones we've got — makes absolutely no sense at a time when we’ve got over $15 trillion of debt,” Louisiana’s Jindal said earlier this month.

Advocates for reform argue that in the end, the public pays the bills when people go without regular health care and wait for an emergency to get care – and they say people struggling to make ends meet are almost certainly going to skimp on health insurance.

Chad Clayton says he’s an example. When an attack of acute pancreatitis hit him in March of last year, Clayton hadn’t yet worked the 90 days needed to qualify for employer-sponsored health insurance at his job as a meat cutter in Portland, Tenn. 

Clayton says he was taken by ambulance to a hospital where he was unconscious for 23 days after that, suffering from blood infections and multiple organ failure. Now 43, Clayton says the hospitals that treated him are likely on the hook for his bills. “My bills are about $500,000.  I can’t pay none of them,” he said. “My first hospital bill was $192,000, not including doctors. I wouldn’t even know where to begin.” Health experts agree hospitals in these cases will pass along its costs in the form of higher bills to paying customers.

Clayton said he applied for Medicare last year but was turned down.

“I think if you have worked your whole life and you have paid into Medicare and you need some temporary aid, you should be able to get it,” he said. “They don’t have no problems taking it out of your check. They sure don’t want to put it back.”

Medicaid coverage now -- and in 2014:

  • 33 states only cover parents earning less than the federal poverty level of $18,530 for a family of three in 2011. The other 17 states will only cover parents who earn less than half that. Just 9 states provide full Medicaid benefits to other adults.
  • The 2010 health care law asks states to extend this to all adults making 133 percent or less of the federal poverty level, although in reality this will be 138 percent because of wiggle room on income. Kaiser estimates that of 41.2 million adults with health insurance, 52 percent or 21.6 million of them made this much money or less.
  • Adults making between 100 percent and 138 percent of the poverty level can get federal subsidies to buy private health insurance on new health insurance exchanges that are supposed to be up and running in each state by 2014.
  • But the poorest poor – those making less than the poverty level – will not be eligible for subsidies. The health reform law presumed these people would be covered by Medicaid but they will not be if states don’t expand their programs.
    Source: Kaiser Health News

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