This brief is offered as a contribution to current deliberations regarding Medicaid expansion and healthcare reform in the Idaho state legislature. Idaho, like many other “blue” states, did not accept the Affordable Care Act’s Medicaid expansion. As a consequence, Medicaid in Idaho, at this time, is only available to children, pregnant women, parents of children under the age of 19, disabled people and the elderly. Even within those categories not many meet the Idaho Medicaid criteria: A family of 4 must earn less than $650 / month to qualify.

Research Findings

In 2003 I conducted in-depth interviews with uninsured individuals and families in northern Idaho, south-central Illinois, Texas, Mississippi and Massachusetts. All 37 Idahoans – at the time – were in the work force, though many were struggling to maintain a level of health sufficient to allow them to continue working and caring for their families. As I wrote in Uninsured in America: Life and Death in the Land of Opportunity (University of California Press, 2015), I was struck by the “rugged Idahoans” who shared with me stories of swallowing handfuls of Ibuprofen each day in order to manage pain, using a pocketknife to shave off bone spurs from their feet, turning to friends who worked as aides at nursing homes for help bandaging wounds, and confronting medical bills of $100,000 or more in the wake of an accident or health crisis.

In 2015 I returned to Idaho and the other four states in which I had carried out research in 2003.

  • In Idaho I looked for 37 people and was able to re-interview 20 of the 37.
  • Five of the 37 were dead: all five had passed away prematurely (in their 40s, 50s or early 60s).

One of the dead, who passed away at the age of 58, had worked in the mines his entire life. He left behind a wife and children.

  • Five are now recipients of SSI or SSDI by virtue of having become too disabled to continue working.

Jane used to work at three jobs: cleaning houses, doing laundry in a nursing home, and waitressing at a café. “Eventually I cut back to just the café job because it was my social life,” she explained, “but finally I couldn’t do it anymore. I even kept working through double pneumonia because I had to pay my bills, but eventually I had to stop because of my legs – you see my feet and ankles hurt and then turned black.” When she was finally diagnosed with diabetes at a free clinic she was told that she most likely already had diabetes for seven to ten years, but it had never been diagnosed or controlled. The staff at the free clinic would give her free samples of her medication whenever they had it available, but that was not a consistent source. At age 57 Jane was granted Disability (SSDI), but then had to wait two more years to become eligible for Medicare. By 2015 was able to access care through Medicare and Medicaid, but it was too late. She now is housebound.

  • Five now receive insurance through their employers and none of the five are able to cover their dependents through their employers. According to the Idaho Department of Labor, approximately 95% of Idaho businesses employ less than 50 workers, exempting the businesses from the ACA mandate to provide health insurance.

Marla and Peter, parents of three young children, were uninsured when I met them in 2003 and remained uninsured until a year or so ago. This was challenging because Peter has a blood disorder, ulcerative colitis and glaucoma. Throughout his adult life he has worked steadily for a company that he likes and likes him, but does not provide health insurance. When their kids reached school age Marla took an office job, but it did not provide health insurance. To take care of her family’s health needs, Marla drove them to doctors all over the northern part of the state – sometimes putting hundreds of miles on the car. At each office she would accumulate a manageable bill that they tried to pay off over time. Typically, the doctor would not see them again until they fully paid the bill. Knowing they needed healthcare coverage, Marla began to work for another small business owner who agreed to pay half of their monthly health insurance premium. But the remaining half was so high that after it was deducted from her salary she ended up taking home about $5 / hour. In 2015 she moved to a job with somewhat better insurance. Her premium now is $250 / month, but the deductible is $3000 per person and there are hefty co-pays and co-insurance.

Al, a farmer in his early 60s, was embarrassed to admit to liking “Obamacare.” But he certainly has benefitted from expanded healthcare access. Diagnosed with lung cancer a number of years ago, he had not been able to obtain health insurance before the ACA because of his pre-existing condition. During those years, hospital bills were as high as $300,000 annually, leaving him in horrendous debt. Now he pays $12 / month for insurance through the Exchange and his doctor is satisfied that “there are no new tumors.”

  • Four had moved out of state, primarily in order to access healthcare in Washington or other states that have expanded Medicaid under the ACA. No one in Idaho was receiving Medicaid in 2015.

Chris and Brittany, a vivacious couple in their thirties, moved from Idaho to Washington several years ago after Chris injured his leg on a construction job and the workers compensation ran out before the surgeries he needed were completed. While Chris was out of work Brittany took a job at a restaurant in order to tide them over. With her salary they earned too much for Chris to qualify for Medicaid and get his leg fixed. But without that salary they couldn’t survive. Today, they both are healthy and productively employed in the state of Washington, where they are raising their children and waiting for the day when it will be possible for them to return home to Idaho.

 Policy Recommendations

  • Senate Bill No. 1204, an act that proposes expanding Medicaid eligibility to persons under age 65 whose modified adjusted gross income is one hundred thirty-three percent (133%) of the federal poverty level or below, is an excellent first step towards allowing all Idahoans access to appropriate healthcare services and thus the ability to maintain better health.
    • Those with incomes below 133% of the federal poverty level cannot afford to pay for appropriate medical services. As a consequence, their health deteriorates and/or they amass medical bills that eventually are passed on to the counties or the state.
    • Idaho hospitals and clinics, for the most part, already accept Medicaid payments. Thus, the infrastructure is in place and implementation of this expansion should not involve additional costs or bureaucratic complications.
  • The proposed Primary Care Access Program (PCAP) is unlikely to substantially improve access to healthcare for Idaho’s low income residents.
    • While primary care is the core of any healthcare system, the reality of today’s complex medical world is that primary care visits alone are rarely sufficient for diagnosing or treating serious illness. For primary care providers it is frustrating not to have the capacity to send patients for tests, procedures or specialist care. Patients will find themselves in the frightening position of being told by a primary care provider that they need certain treatments but that the primary care program does not cover them.
    • There is no evidence that access to primary care alone, without parallel access to other medical services, improves the health of populations.
    • According to the published description, “The program requires payment for services on a sliding scale fee, which encourages greater personal responsibility for the patient’s own health.” Given that this program is aimed at people with very low incomes, it is more likely that fees will function as deterrents to care rather than as encouragement of personal responsibility.
    • In my research in Idaho I have never spoken with a single individual who can afford healthcare but irresponsibly chooses not to seek it. The most common reasons for not seeking care are: lack of insurance, deductibles that are too high to meet, lack of transportation to healthcare centers, inability to take off time from work during clinic hours.
    • By limiting access to healthcare to specific health centers, this proposal fails to address the needs of many Idahoans who do not live near any of the specified health centers.

 

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Acknowledgments: In addition to the uninsured and formerly uninsured individuals whom I interviewed, I spoke with Terri Sterling, ICAN; Charlotte Ash, Snake River Community Clinic; Ken Whitney, Jr., Mayor of Troy; Dr. Richard Thurston, St Maries Volunteer Clinic; Donald Duffy, Panhandle Health District; Moriah Nelson, Idaho Primary Care Association; Pam McBride, Clearwater Valley Hospital, Orofino; Ashley Piaskowski, Heritage Health, Coeur d’Alene; Dr. Ted Epperly, Idaho Healthcare Coalition and Family Medicine Residency of Idaho; Stephen Weeg, Board Chair, Idaho Health Insurance Exchange. I thank all of these people for taking the time to share their expertise with me. All opinions and errors are my own.

 

Contact Information: Susan Sered, PhD; Department of Sociology, Suffolk University; 73 Tremont Street, Boston MA 02108

Email: ssered@suffolk.edu

For more on this research see Health is Where the Home Is   Health Insurance Roulette: The House Always Wins   The State(s) of the Affordable Care Act     

ACArally

A decade ago I traveled to the Mississippi Delta, Texas’s Rio Grande Valley, the rust belt of Illinois, the mountains of northern Idaho and the cities of eastern Massachusetts in order to learn how uninsured Americans manage (or don’t manage) their health and healthcare in diverse circumstances. This spring and summer I returned to these communities to seek out the same individuals and families I’d met ten years ago. I wanted to hear how they’ve fared in the wake of the Affordable Care Act.

It is clear to me that June 23, 2015’s Supreme Court ruling in King v. Burwell is good news for millions of middle-class Americans living in states whose leaders chose not to set up insurance marketplaces (“exchanges”). People in those states will not lose their insurance subsidies because the federal rather than the state government facilitates the exchange.

The states impacted by King v. Burwell are, however, mostly the same ones impacted by the 2012 Supreme Court ruling (NFIB v. Sebelius) which allowed states to opt out of the ACAs Medicaid expansion. Lower income people in those states will continue to fall into the coverage gap — the no man’s land for people who earn too little to qualify for subsidized insurance through the exchange but who do not qualify for Medicaid in their home states. In some of those states only extremely poor parents and children are eligible for Medicaid, leaving large numbers of people who are childless or near elderly or poor but not destitute unable to access healthcare.

Texas, one of the states that did not expand Medicaid, has a federally facilitated marketplace. During my return trip to the Rio Grande Valley, I was able to locate 18 of the 26 individuals and families (all adults) I’d met a decade ago. At the time, all were uninsured. Fourteen of the 18 are now insured – a figure that, on the face of it, looks encouraging.

However, of the 14 who are insured, 5 now are covered by Medicare via Disability (as a consequence of becoming sufficiently disabled to qualify for SSI or SSDI). In other words, a third of the newly insured people are covered because their health deteriorated to a the point in which they no longer are able to work. One person is covered by Medicare because she is over 65. Two people have Medicaid but only as a supplement to Medicare; no one qualified for Medicaid as their primary insurance.

All 4 of the uninsured people fall into the coverage gap – when they applied for insurance on the exchange they found that their incomes are too low to qualify for subsidies. The experiences of the Martinez family (a pseudonym) are typical. Maria works full-time in a food service job that provides health insurance for her but requires a bi-weekly payment of $250 to cover her children. Her bi-weekly income is $500, so she had to turn down the coverage. Her husband, Enrique, is a truck driver whose employer does not offer insurance but he earns too little to qualify for a subsidized premium on the exchange. For a short time their youngest child was eligible for Medicaid (CHIP), but then Enrique’s income went up (marginally) and she no longer qualified. In 2013 Enrique spoke with an ACA enrollment specialist who helped him apply for an exemption from the penalty for not having insurance. In 2014 he forgot to re-apply and had to pay $190 in fines ($95 for himself and $95 for their 21 year old child.) In the meantime, he takes medication for high blood pressure when the border with Mexico is safe enough for him to cross over and buy pills there. I make no claim to extraordinary prophetic powers, but my guess is that in another five years he will join the ranks of disabled Texans.

That leaves 5 who are insured via the exchange and 5 now insured through employers – certainly a step up from when I first met them. However, all 10 of these Texans are unhappy with their insurance, for the most part because of high deductibles and co-pays. Rosa, an energetic and articulate middle-aged woman, is reimbursed by her employer for part of the cost of the premium she purchased through the exchange. Because of her low salary she chose a “bronze” plan with a low monthly premium (all that she could afford) but a $4500 annual deductible and $1000 co-pay for hospitalization. With a history of tumors in her breast and kidney, she needs scans that she cannot afford even with insurance. I fear that she too, will join the growing ranks of Americans who are disabled.

Shortly after the Supreme Court’s ruling on the ACA, President Obama spoke from the Rose Garden celebrating our national declaration that health care is a right, not a privilege. Now the challenge is to turn that declaration into reality on the ground – even in states whose leaders would rather thumb their noses at the feds than allow residents of their state to access the care that they need in order to remain healthy.

For more on health insurance read  Health Insurance Roulette: The House Always Wins

For more on the original research in the five states read  Uninsured in America: Life and Death in the Land of Opportunity

 

 

sickleave

feature image via Cody Glenn, The Daily Journal

Francesca, a woman I have come to know during the past seven years, has tried hard to rebuild her life after fleeing an abusive marriage, overuse of pain medication, homelessness and a stint in prison. She popped into my mind this week when I read an article about Maria Fernandez who died of exhaustion. Working more than eighty hours a week at minimum wage jobs in fast food chains, she sat down in her car to take a nap between shifts. A gas container tipped over and Maria never woke up.

With a prison record, Francesca can barely find one job, let alone the four that Maria juggled. But she certainly understands what Maria was going through at Dunkin Donuts. A couple of years ago Francesca was hired at a Boston-area Dunkin Donuts where she worked erratic, long shifts at the whim of the manager. She rarely knew ahead of time when she’d be called into work, or for how many hours. After a few weeks she found herself in pain — bone spurs in her foot had been exacerbated by the long hours standing on her feet. Her manager told her that if she took off time or reduced her shifts he would let her go. Fortunate to be a recipient of Massachusetts’ generous health insurance coverage, she went to her doctor who gave her an orthopedic boot to wear at work. Unfortunately, the boot caused her to trip at work and she was fired on the spot.

Paid Sick Leave

In a mid-term election cycle that resulted in few reasons for young, sick, poor or vulnerable Americans to look forward to positive changes in their circumstances, there was at least one bright light. Massachusetts voters (yes, the same folks who voted in Republican Charlie Baker for governor) approved a ballot measure in support of the country’s most robust requirements for providing paid sick leave to workers. The new Massachusetts law entitles people to earn up to 40 hours of paid sick time each year if they work for businesses with 11 or more employees; staff at smaller companies would earn 40 hours of annual unpaid sick time. Sick leave could also be used to care for a sick child, spouse, or parent.

With that vote, Massachusetts joins two other states (California and Connecticut) and about a dozen municipalities. Paid sick time questions were also on the ballot in three cities in this election, and passed in all three.

It’s not hard to argue that paid sick leave is good for everyone, not just for Francesca or Maria. For parents, it means being able to take off from work to care for sick children. For consumers, it means less likelihood that the people serving your meal, ringing up your groceries or checking you in at the doctors’ office will spread germs by coming into work sick. It also means less likelihood that someone doped up on Nyquil will be at the wheel of a car or truck. Or that construction workers, bank tellers and security guards will make the kinds of illness-induced errors that can lead to roofs collapsing, money going astray, or weapons making it into public institutions. But it doesn’t end there. Paid sick leave is also good for employers: Productivity and profitability go down when workers are forced to come to work when they are sick. One study on the impact of illness on productivity estimates that businesses lose twice as much money to workers who show up at work while sick then when workers stay home due to an illness.

Tip of the Iceberg

But there are more macro reasons that the four sick leave ballot votes are a cause for elation. On a deep level, paid sick leave pushes back against a corporate culture in which workers, and especially low-wage workers, increasingly are treated as replaceable cogs in the money-making wheel.

In the best of all possible worlds (actually, in the world that the labor movements of the early twentieth century fought hard to create), employers and employees would collaborate in creating a safe working environment, a first rate product, and profits for the company and livable wages and solid benefits for the employees. In that world, the health and safety of the employee would be seen as serving not only the moral but also the financial good of the employer. Employers would understand that they could not prosper without the dedicated services of their employees. They would nurture that dedication through an occupational culture of respect and fairness, and they would do everything in their power to hold onto their employees’ services. These employers would know that it is in everyone’s interest to ensure that the workplace environment minimizes the risk of injury and thus minimizes lost workdays, and that in the case of accidents or illness employees receive the best possible medical treatment so that their return to work is expedited. These employers would also respect that their workers have lives outside of the factory or store or restaurant or office. They would understand that workers, like themselves, are also human beings living in the frail bodies. And workers, like employers, are embedded in the family and social networks of mutual obligation that provide the truest safety net when we – as all humans do – are born, give birth, become ill, age and die.

This scenario is rooted in an idealized business ethos of respect that recognizes the mutual dependency between owners and workers, and it is actualized through specific health and safety programs that employers support on both moral and business principles. Employers know that it is economically inefficient to deal with frequent turnover in their workforce so they want employees to work for them for a good long time, to improve their job skills, and to develop company loyalty. To some extent, it is irrelevant whether this goal is driven by pure altruism, by the profit motive, or by a combination of the two. Whatever the motive, in our ideal world, it wouldn’t be such a bad idea to link health care to employment or for workers to depend upon their employers to compensate them for work related injuries.

Unfortunately for American workers, however, that ideal world does not exist (at least, not outside of occasional nostalgic TV sitcoms). The current American work world is highly mobile and transient; many of the largest employers in, for example, the fast food industry, seek ways to structure employment so that workers are easily interchangeable; multi-national conglomerates neither feel loyalty towards their employees nor expect their employees to feel loyalty towards them; small businesses go under faster than they get started; and manufacturing and other business associations spend billions of dollars lobbying Congress and state legislatures to limit laws requiring and enforcing workplace safety standards.

In the real world, employees and employers often experience their relationship as more adversarial than cooperative. Rather than collaborate on a mutually beneficial social contract that balances the well being of workers with profits and productivity, employers increasingly have chosen to pursue immediate profits. Employers frequently view living wages, strong worker benefits, and safe working conditions as coming at the expense of profits. Investing in the health of employees often is seen as superfluous in an economic climate in which the growing caste of the working poor can be hired on a temporary or contingent basis, and in which plants and factories can be moved to South America or Asia — places where employers need not bother with things like paid sick leave, health insurance or worker’s compensation, labor unions, environmental regulations, or child labor laws.

What’s Next?

Successfully passing paid sick leave ballot questions in a few states and cities cannot reverse decades of policies that created the work environments in which Francesca and Maria live, and die. But it is a meaningful move pragmatically for hundreds of thousands of people, and a meaningful move symbolically in terms of collective recognition of basic human rights of workers.

So, as I write this I can, for a few minutes at least, feel a bit better about the 2014 mid-term elections. That is, until I remember that Republican leaders have made clear that one of their highest priorities will be the repeal of Obamacare, which while far too watered down for my own tastes, does require employers of large companies to offer health insurance to their employees.

You can read more about these issues in Uninsured in America: Life and Death in the Land of Opportunity by Susan Sered and Rushika Fernandopulle.