By Kristy Chambers
With the U.S. Supreme Court ruling that the whole of the Patient Protection and Affordable Care Act is constitutional, each state is left to decide if they are going to participate in the Medicaid expansion provision of the law. So who is eligible for Utah's current Medicaid program and what would a Medicaid expansion mean?
Currently in Utah, to get Medicaid health insurance a single person must make less than $16,700 a year (this is an average of all the Medicaid programs) and meet certain categorical criteria. For example, you must be poor and have a child living with you or be poor and permanently disabled for longer than one year. Even living in extreme poverty, such as those who are homeless, does not automatically qualify one for Medicaid.
At Fourth Street Clinic, a nonprofit health care provider that serves only those who are homeless, 98 percent of patients make less than $10,000 a year, but only 17-22 percent on average have Medicaid health insurance.
Should Utah choose to participate in the 2014 Medicaid expansion, the ACA legislates that all categorical criteria be eliminated, giving everyone who is poor the chance to be insured. By allowing access to health care, these newly insured will have the ability to manage their care outside the emergency medical systems. Acknowledging that this would open the door to more participants and costs, the ACA's carrot is that Utah will not have to pay a penny for new enrollees for the first two years. After 2016, Utah will have to kick in 10 percent of the total Medicaid program costs a significant decrease from the current 30 percent.
What will be said is that Utah cannot afford the expansion, that Medicaid costs are already too high, and more people enrolled in the program will mean that money will be taken away from schools, roads and economic development investments.
However, at Fourth Street Clinic we see first hand the inefficiencies and high costs of care for people cut off from insurance and a regular source of primary care. We argue that the Medicaid expansion is a real opportunity to not only keep poor communities healthy, but to provide an effective means of cost containment within the Medicaid system.
To illustrate, in October 2011, Fourth Street Clinic was contacted by an area hospital case manager about a terminal, uninsured homeless man who presented at the ER. We arranged for him to be sent to Fourth Street, where he clearly stated that he was ready to die. To get him into a hospice facility, he needed insurance, so Fourth Street worked with the Utah Department of Workforce Services to apply him for Medicaid Compassionate Care.
While his application was processed, he began his final stages of death at the emergency shelter. In the end, the application process proved longer than he had days left to live, and in April of 2012, 911 was called and he died after seven days in the intensive-care unit. Not only were his end-of-life wishes not respected, but Medicaid automatically covered the month that included his date of death. The hospital can also apply to the Utah Medical Review Board to recoup his other ER admissions for the three months prior to his date of death.
If he had had Medicaid when he needed it, he not only could have died with dignity, but all the unwanted crisis and immense expense could have been avoided.
Considering this is only one of many examples, it becomes clear that the practice of controlling costs by keeping people uninsured is a false premise. What is cheaper, more humane and actually works to keep people out of poverty is access to health insurance and care, which the Medicaid expansion provides with little investment from the state.
Kristy Chambers is executive director of Fourth Street Clinic, serving homeless men, women and children in Salt Lake City.