A'lana Marmel had insurance.
It was a last resort policy — one that might not help a ton with routine doctor visits, but would keep the single mother of two afloat if an emergency struck. Catastrophic insurance, as brokers call it.
Then Marmel needed surgery. It could wait. So she did. A year later, she had her medically necessary but not time-sensitive surgery — an ovarian mass found to be benign once removed — after Medicaid expansion took effect in Idaho this January.
"I ended up having to basically wait," Marmel recalled recently. At a screening before the surgery, she found out the mass had grown more complex.
"My feeling is that if Medicaid expansion had happened sooner, it would've been less problematic for me in terms of a medical issue," she said.
The struggle of delayed care leading to costlier and worse conditions rings true for many of roughly 94,000 Idahoans, many of them working poor, who are now covered by Medicaid expansion.
The Affordable Care Act originally envisioned that every state would expand Medicaid coverage to everyone making up to 138% of the poverty level, but a 2012 U.S. Supreme Court ruling made that optional. Many Republican-run states, including Idaho, chose not to expand coverage. This left a group of adults in a "Medicaid gap" where they were too poor to qualify for federal tax credits to buy insurance on the Your Health Idaho state exchange but didn't qualify for any other government health care programs.
What to do about this was, for several years, one of the most hotly debated issues in Idaho politics. The Legislature, which is about 80% Republican, rejected both expansion and a couple of halfway proposals to give some coverage to people in the gap offered by former Gov. C.L. "Butch" Otter. In 2018, the group Reclaim Idaho spearheaded a ballot initiative to expand Medicaid that passed with 61% of the vote.
However, the cost of Medicaid expansion, which is paid 90% by the federal government and 10% by the state, is coming in much higher than expected. This will create a headache for lawmakers who must decide next year how to pay for a program that will cost the state tens of millions more than they originally thought, and has provided some vindication to conservatives such as Rep. Barbara Ehardt, R-Idaho Falls, who warned before expansion that it would cost more than projected, pointing to the experience of other states.
“My other concern was, because of what’s happening in other states, the very people for whom Medicaid was originally designed were having their services not just scaled back but completely removed to accommodate this expansion for people, including people who were capable of working but chose not to, and that’s just what I thought was systematically unfair,” Ehardt said.
Ehardt said lawmakers need to control costs moving forward and earmark a revenue stream for Mediciad expansion so they don’t have to scramble for funding every year.
“I definitely feel that it needs to be a dedicated source,” she said.
Higher per-patient spending appears to be driving costs. There were 94,000 people enrolled in expanded Medicaid in November, just a few percent higher than the 91,000 the actuarial firm Milliman Inc. projected in 2018. But many of those people were uninsured for a long time and are now finally accessing care for conditions that have worsened due to lack of affordable preventive care.
"I think there has always been a kind of acknowledgment that the Medicaid expansion population might have pent-up demand," said Alex Adams, head of the state's Division of Financial Management.
'I didn't know'
Mariana Pablo, who helps patients wade through the insurance world, has seen this pent-up need. For the past two years, she has been the outreach and enrollment manager at the Community Family Clinic in Idaho Falls, a federally certified clinic that lets uninsured patients pay their bills on a sliding fee scale according to their income.
Winter 2019 was busy for Pablo. As January approached, she and other clinic staff prepared. They pored over income records for patients, determined who might qualify for Medicaid now and called around. Some patients knew about Medicaid expansion and were already getting their applications together. Others were confused.
"'Oh, you know what? I already applied, and I didn't qualify,'" Pablo recalled them saying. She would then explain the new income cutoffs and offer to help them apply.
Jorge Avalos, 50, didn't know. Ten years ago, things didn't go anywhere near as planned. He knew he had high blood pressure. But he began losing weight fast. Uninsured, he went into the clinic anyway, only to find out his thyroid was hyperactive.
"It was probably because I didn't see my doctor often enough," he said.
Weeks later, he fell off a machine at the farm he worked at.
Avalos hasn't been able to work since. He was later diagnosed with diabetes. His sister helped with rent and some bills, but the medical bills continued to pile up and prescriptions became harder to fill.
"I didn't know what to do," Avalos said. "There was nothing to do at home other than stay home. It was long days. So, my life did totally change 360 degrees."
He's on a monthly payment plan to repay his hospital bills while he tries to get Social Security assistance.
When he visited the clinic for blood work in January, staff told him he might qualify for Medicaid now. It took a few months as the clinic and others coped with the pandemic creeping into Idaho. Pablo did a three-way call helping him enroll in Medicaid in June.
"It was not so stressful thinking like every month that I have to come up … with enough to cover my medications," Avalos said.
The 2018 Milliman report on the costs and savings of Medicaid expansion projected it would cost the state $41.9 million this year and $44.6 million next year. The new estimates are $67 million this year and the agency's budget request for next year is $84 million, Adams said, numbers that would also increase the federal share by hundreds of millions from the report's projections of $370.1 million and $394.9 million, respectively. Gov. Brad Little will unveil his Fiscal Year 2022 budget proposal next month when the legislative session starts on Jan. 11.
"It would be premature to say what the governor's recommendation might be, but we're certainly looking at all options," Adams said.
One thing that could help is that due to the coronavirus pandemic, the federal government is paying 76% of the cost of traditional Medicaid rather than 70% as it had been before. Adams said this savings to the state could be used to cover some of the additional costs of expansion, although he said this isn't a long-term solution.
Another is that Idaho, unlike many states, is collecting more revenue than expected and has a good deal of savings despite the coronavirus pandemic. With the fiscal year less than half over (it runs from July 1 to June 30), tax revenues have already come in $170 million higher than expected, the Associated Press reported Monday.
“From my perspective, we are having higher-than-expected revenues this year in the state. However, I view that as one-time money that will be corrected in the next budget cycle,” said Sen. Dave Lent, R-Idaho Falls. “So the issue of how to fund Medicaid expansion on an ongoing basis will have to be taken up again in the Legislature. I’m hoping, as a member of the Finance Committee this year, to get more involved and help find a solution.”
Last resort help
Before Medicaid expansion, the state and counties did provide some help to uninsured people, including those in the gap, who had high medical bills due to serious accidents or catastrophic illnesses. People could apply to their county commissioners for loans to pay them, with counties covering the first $11,000 of expenses and the state's Catastrophic Health Care program, commonly called the "CAT fund," covering bills above that.
"It's a tough program because it's not like a medical provider type program that you can project the number of plans," said the state's CAT fund board Chairman Roger Christensen, who is also a Bonneville County commissioner. "This is incident-based. Somebody gets in a major accident has a major catastrophic illness — those are kind of random."
Roger Christensen looks over paperwork for indigent health care on Tuesday, Dec. 8, 2020.
One of the hopes of expansion advocates had been that these programs would no longer be necessary; the Milliman report projected abolishing them in the 2022 fiscal year. The CAT fund is requesting $8.5 million for 2022, Adams said, down from $18 million in 2018.
"We are seeing a decrease in CAT fund in the ballpark of what had originally been forecast," Adams said.
However, CAT fund payouts this fiscal year are coming in as usual, and Christensen and program director Kathryn Mooney said they expect to request more funding from the Legislature to cover this year's costs.
"We're starting to see the effects of (Medicaid expansion)," Christensen said. "It's slowing our applications down." But, he said, that hasn't hit the CAT fund since cases are typically processed eight months after they are approved.
"The number of claims at the county level (are) dropping, but the amount of the claims that go in on the CAT are going up," Christensen said. "They're a lot more expensive. A lot bigger. … It's just always been a very difficult program to project because, you know, it's kind of like a lottery."
Some local counties have seen sharp decreases in indigent health care spending. Last year in Bonneville County, before expansion took effect, 190 people applied for help with health care expenses and county commissioners approved 99 of them, costing taxpayers $541,597.47 total. From January through November 2020, just 49 people have asked Bonneville County for medical help and 24 were approved, costing a combined $114,994.69.
Teton County has shown a similar pattern — the county spent $22,000 on indigent health care in 2019 and has spent $12,523.08 in 2020 so far. Similarly, Madison County spent $49,131.26 on indigent health care during the first nine months of 2019 but $28,333.80 for the entire fiscal year running from Oct. 1, 2019 to Sept. 30, 2020.
Mooney said in a recent interview that claims for medical debt assistance since Medicaid expansion began this year tend to be people who make too much to qualify for Medicaid but choose not to pay insurance. Or, as Mooney puts it, people who "don't make enough to afford insurance" but "make too much to qualify for Medicaid."
"We are the end of the line for people," Mooney said. "And they're incurring a debt."
Some lawmakers have said counties, which are saving money as a result of expansion, should also cover some of its cost, and different proposals for how to do this have been floated, although none have made it far in the legislative process so far. Adams said he expects this to come up again during the 2021 session.
"I think that will be a big discussion heading into next year," Adams said.
Lent said he thinks such proposals have merit, but he doesn’t see them as long-term answers.
“It’s probably going to take some tax increase to cover the cost,” he said.