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Nearly 14,000 low-income people in the Roanoke Valley would be eligible for government-paid health insurance if Virginia decides to expand the program with federal funds.
MATT GENTRY | The Roanoke Times
Lois Casto serves a meal to a customer while working for Virginia Tech Dining Services in Dietrick Dining Hall on the campus in Blacksburg. There are six people in Casto’s household, and she does not have health insurance, but she is not eligible for Medicaid.
MATT GENTRY | The Roanoke Times
Even though Lois Casto’s $18,000-a-year job at a college cafeteria puts her well below the federal poverty guideline for the household of six people she supports, she does not qualify for Medicaid.
JOEL HAWKSLEY | The Roanoke Times
Marion Macauley-Cintron is unemployed, and her only income is the $72 a month she gets in food stamps. She worked all her life before losing her job as a home caregiver in January, and paid taxes, but does not qualify for Medicaid.
JOEL HAWKSLEY | The Roanoke Times
“It hurts," said Marion Macauley-Cintron, talking about asking for help. "It hurts very much because I have worked all my life. And it hurts that I have paid taxes all of this time and it’s nothing that anybody can do to help me.”
Sunday, June 16, 2013
Lois Casto takes home $1,260 a month from her job serving students at a Virginia Tech dining hall, hardly enough to feed her family of six.
Unable to afford health insurance, she gets most of her care from a free clinic. But in some times of sickness, she says, “I’ll just ride it out.”
She does not qualify for Medicaid.
* * *
In the small white frame house where Kyle Fields is going blind and his wife, Lois, frets about surgery she’s had to put off, the money usually runs out by the end of each month.
The Salem couple worked 90 years between them — she as a seamstress and nursing aide, he in a garment factory — for the $1,730 a month they draw from Social Security. It’s not enough for the medical bills, and by the end of the month the Fieldses subsist on bologna sandwiches and beans.
They do not qualify for Medicaid, either.
* * *
Marion Macauley-Cintron can’t find a job. Even though she worked most of her life in Roanoke as a home caregiver and nursing aide, no one seems to want to hire a 61-year-old, she says. Money is so tight that Macauley-Cintron has to skimp on her medication for high blood pressure, which is driven even higher by the fear of becoming homeless.
She does not qualify for Medicaid, either.
* * *
Casto, the Fieldses and Macauley-Cintron are among an estimated 376,000 to 400,000 people in Virginia who would benefit from a proposed expansion of Medicaid, the government insurance program for the poor and disabled.
The Patient Protection and Affordable Care Act, a sweeping overhaul of the nation’s health care system championed by President Barack Obama and passed by Congress three years ago, calls for expanding Medicaid to cover uninsured people who make up to 138 percent of the federal poverty guideline.
That’s $15,856 for an individual, $32,499 for a family of four.
Many of the potential beneficiaries are the working poor. They might be the cashiers on the other side of a fast-food counter, the laborers at one of the Roanoke Valley’s many warehouses or the migrant workers harvesting apples or tobacco.
“Health care is a human necessity, and there’s no question that the cost of health insurance is well beyond what the people who would qualify for Medicaid could actually afford,” said Jim Lindsay, a member of the health care committee of Virginia Organizing, a citizens advocacy group pushing for the expansion.
However, when the U.S. Supreme Court upheld the law last summer, it ruled that states cannot be forced to go along with the Medicaid expansion. Since then, according to the National Conference of State Legislatures, 21 states have decided to expand their programs, which are funded by both state and federal tax dollars.
Virginia is on the fence. A two-year budget approved by the General Assembly in March allows for the expansion, but only if major improvements are made to the program.
As part of the budget bill, lawmakers created a commission that will oversee the reforms and, ultimately, decide whether to proceed. The panel is scheduled to meet for the first time Monday in Richmond. A decision is expected by year’s end.
Broadening the eligibility requirements for Medicaid is but one part of the Affordable Care Act, which has been phased in gradually since 2010.
Other major provisions that will kick in Jan. 1, 2014, include setting up market exchanges for people to purchase insurance at subsidized rates if they are too well-off for Medicaid but still struggle financially; requiring employers with more than 50 full-time staffers to offer insurance or face financial penalties; and the so-called “individual mandate,” which directs nearly every American citizen to have insurance of some kind.
It’s all part of a highly complex system with interconnected parts — a system that would be compromised if Virginia does not expand Medicaid, advocates say.
“I think it’s one of the most critical parts of the law,” Lindsay said. “The idea that we would leave the lowest-income Virginians behind as we make health care more accessible … is absurd. It’s unjust, and it’s immoral.”
Too well-off for Medicaid
Lois Fields is worried.
She’d postponed surgery to clear her left carotid artery, hoping to prevent a repeat of a mild stroke. A $73,000 bill from an operation last year on her right carotid still hangs over her head, and she still doesn’t understand why Medicare, which covers large parts of seniors’ bills, isn’t paying.
She would like to make a doctor’s appointment for her husband, Kyle, 77, who moves around their single-story house by touch since his eyesight is fading.
Her diabetes medicine — two shots a day — is running out.
“I just had to call and cancel a doctor’s appointment because I can’t pay,” she said late last month. “I only have $5 in the bank. I won’t get my check until next week.”
That would be the $850 she gets from Social Security for the five decades she worked as a nursing aide and seamstress.
It means she is too well-off to get Medicaid.
A couple with disabilities getting more than $12,400 a year makes too much money to qualify for Medicaid in Virginia. The Fieldses draw $20,760 a year in Social Security benefits.
In fact, Virginia has some of the strictest rules in the nation on who can get Medicaid. About 9 percent of Virginians are covered by the program; only North Dakota has a smaller percentage. The national average is 16.5 percent.
Unlike Medicare, the taxpayer-funded health insurance program for senior citizens, Medicaid is administered by state governments. As a result, eligibility guidelines vary from state to state.
In Virginia, children in low-income families and indigent pregnant women have an easier time getting coverage. A far smaller number of the disabled, the elderly and parents with children younger than 18 qualify for help with their medical bills.
Census data show that just under 14,000 people in the Roanoke region have no insurance but could get Medicaid if Virginia agrees to expand coverage. They account for about half the area’s uninsured. There are already about 32,000 area residents on Medicaid.
The results of an expansion would be dramatic: A mother with two children who earns more than $4,700 a year makes too much to receive Medicaid for herself, although her children would be covered. The cutoff point would be moved up to $26,950 under the expansion.
Alabama and Indiana are the only other states with such low caps.
A person with disabilities earning more than $9,200 a year is too well-off to get Medicaid in Virginia. Unlike most states, Virginia does not use Social Security’s eligibility standards for assisting people with disabilities.
Childless adults currently aren’t entitled to Medicaid no matter how poor they are, although they are covered in several other states. They would be covered under the expansion if they make up to 138 percent of the federal poverty level.
Red tape, red ink
Virginia’s Medicaid program costs about $7 billion a year, half of which comes from the state and half from the federal government.
Concerns about pumping even more taxpayer money into a system plagued with inefficiencies is a key argument made by opponents of Medicaid expansion.
The Affordable Care Act calls for the federal government to pay the full cost of covering the additional beneficiaries for the first three years, starting in 2014.
After that, the share of federal funding would gradually decrease to 90 percent by 2020. The cost of insuring those already covered would remain a 50-50 split between state and federal dollars.
Where some see an influx of federal funds for the needy, others see nothing but red tape and red ink.
“Advocates for Medicaid expansion have misleadingly claimed … that it’s ‘free’ federal money,” Speaker of the House of Delegates Bill Howell, R-Stafford County, said earlier this spring. “I have been around long enough to know there is no such thing as free money from the federal government, and no such thing as a bigger program that costs less and works better.”
Citing the huge federal budget deficit, many Republicans have expressed fears that the money will run out with Virginia left holding the bag.
“Our country is slowly drowning in a sea of red ink,” said state Sen. Bill Stanley, R-Franklin County. “Expanding the Medicaid program in Virginia on a promise from the federal government to continually subsidize the program would certainly be foolhardy.”
Republican gubernatorial candidate Ken Cuccinelli, who highlights his record as attorney general in prosecuting Medicaid abuse, also opposes expansion.
“Medicaid is the fastest-growing and most out-of-control part of the Virginia General Fund Budget, and it’s filled with waste, fraud and abuse. We are also struggling mightily to retain doctors in Virginia’s Medicaid program,” Cuccinelli campaign spokeswoman Anna Nix said.
Impoverished and unqualified
While politicians quarrel about billions of Medicaid dollars, Lois Casto gets not one cent.
Even though her $18,000-a-year job at a college cafeteria puts her well below the federal poverty guideline for the household of six people she supports, Casto does not qualify for the program.
She is considered a childless adult, even though she has two daughters, because both are older than 18.
In reality, Casto is the breadwinner of a Christiansburg household that includes three children, ages 12, 8 and 7. They are the children of her 29-year-old daughter, who lives with her. Casto’s husband suffered a heart attack 12 years ago and is unable to work.
“I don’t know,” Casto says when asked how she supports a family of six on such a meager income. “With God’s help.”
Medicaid covers the medical costs for Casto’s daughter and her three grandchildren. Food stamps help, as does a HUD subsidy on her rent.
But when it comes to medical treatment for Casto’s diabetes and her husband’s bad heart, they must go to the Free Clinic of the New River Valley.
“Without them,” Casto said, “I don’t know where I would be.”
McAuliffe: Expand Medicaid
If Medicaid were expanded and every eligible Virginian — people like Casto — signed up, the estimated costs would be $2.2 billion in the first year.
Washington would pick up that cost in its entirety. The bill would rise to $3 billion by 2022, at which point the state would pay 10 percent.
The net cost, though, would likely be lower. One reason is that the state expects only about 60 percent of the roughly 400,000 Virginians who might be eligible to actually sign up.
Another factor reducing the net cost of expansion is that there should be savings, in part from other initiatives of the Affordable Care Act and in part because the state wouldn’t need to pay teaching hospitals quite as much to subsidize care for the indigent. That bill now runs about $100 million a year.
Other savings could come because private insurance premiums — including the premiums the state pays to cover its employees — would no longer have to make up for the bills that hospitals and doctors can’t collect from the uninsured.
Estimates for the savings to the state government on employees’ health care range from $17 million to $42 million a year.
In addition, many people now treated at state mental hospitals or through community services boards entirely through state or local taxes could shift to the Medicaid system, with that cost funded almost entirely by the federal government.
Foreshadowing an issue in his upcoming race with Cuccinelli for governor, Democratic candidate Terry McAuliffe favors expansion, calling it “the right thing to do.”
He said expanding Medicaid would generate as many as 33,000 health care jobs and would reduce costs for people who already have insurance by encouraging those who are now uninsured to get care earlier, when it is less costly.
Having worked all her life, Marion Macauley-Cintron is accustomed to buying things.
But after recently purchasing a pair of black dress shoes from Cato for $19, she took them back for a refund after picking up a similar pair at a yard sale for $1.50.
It’s just one of the lifestyle adjustments she’s been forced to make after losing her $42,000-a-year job as a home caregiver.
Until January, Macauley-Cintron was working up to 60 hours a week providing care to the elderly and ill in their homes. Her blood pressure medicine made her drowsy, she said, and one day she fell asleep on the couch of a patient’s home.
When the patient’s family reported that to her employer, Macauley-Citron was fired, rendering her ineligible for unemployment benefits.
She’s been looking for a job ever since.
“I will scrub floors; it doesn’t matter to me,” she said. “I just want to work.”
A diabetic, Macauley-Cintron is on medication to keep her blood pressure under control. Instead of taking three pills a day the way she should, she takes one or two every other day to cut costs.
“I need to do all the things the doctor wants me to do, but I’m not doing it because I don’t want to make another bill,” she said.
Most of the cost of Macauley-Cintron’s health care is covered by Carilion Clinic. As as a nonprofit health care system, Carilion provides free or discounted care to the poor.
But all too often, that treatment comes only after the uninsured show up in the emergency room, where care is the most expensive.
As the region’s safety-net hospital, “We’re going to provide the care regardless of what their income — or lack of income — is,” said Dr. Michael Jeremiah, head of Family and Community Medicine for Carilion.
But if people like Macauley-Cintron were eligible for Medicaid, Jeremiah said, they would be more likely to go a primary care physician, who would be better equipped to spot health problems early and prevent a trip to the emergency room.
That would provide some peace of mind for Macauley-Cintron, who counts her debt at about $20,000 and her only income at $72 a month in food stamps.
Asking for help is painful, she said.
“It hurts. It hurts very much because I have worked all my life. And it hurts that I have paid taxes all of this time and it’s nothing that anybody can do to help me.”
In the current debate over health care — where policy and politics seem hopelessly intertwined — some see Medicaid recipients as freeloaders, just waiting for the next government handout.
“That’s not true,” said Macauley-Cintron, who has grown frustrated with the public fray over what is both defended and derided as “Obamacare.”
“Politicians are just out for themselves and the rich man,” she said. “That’s the way I feel. I may be wrong. But nothing is telling me or showing me that I’m wrong.”
Of the five delegates on the legislation commission, three have voiced concerns about expanding Medicaid and the remaining two were members of a rules committee that killed a resolution calling for its expansion.
A majority of the panel’s five delegates, as well as a majority of the five state senators, would have to agree to an expansion.
Of the 19 states that have so far opted against expanding Medicaid, most have Republican governors or Republican-controlled legislatures.
“They’re angry, period, about Obama,” Macauley-Cintron said. “And they’re making the people of these United States suffer because of their dislike for him.
“And that is horrible.”
Costs getting passed on
While the proposed Medicaid expansion has clear repercussions for people with incomes that hover around the poverty line, it also could affect hospitals that collect billions in revenue.
Carilion Clinic, for example, could lose up to $15 million a year if Virginia decides against the expansion.
Here’s how: As part of its nonprofit mission, Carilion provides free or discounted health care to those who cannot afford it and are uninsured. In the last fiscal year, that amounted to $67 million spent on charity care.
Making more people eligible for Medicaid would reduce the charity care caseload for Carilion and other so-called safety-net hospitals.
Nationwide, hospitals will get an additional $300 billion in Medicaid reimbursements — a 23 percent increase — over the next decade with an expansion to the government insurance program, according to a study by the Urban Institute.
The catch, however, is that those revenues will be offset by cuts in other areas called for by the Affordable Care Act.
Under the new law, hospitals that treat disproportionately large numbers of Medicare and Medicaid patients will receive less in compensation payments from the government. Those cuts will happen even in states that choose not to expand Medicaid.
So while details remain unclear, Carilion could wind up absorbing the cost of continuing to treat patients who would have been covered by Medicaid, while losing up to $15 million a year it receives in disproportionate care payments.
To put that number in context, losing that much money would have erased the profit Carilion made in the last fiscal year, the first time the nonprofit hospital operated in the black since 2007.
“It’s a significant concern,” said Don Halliwill, Carilion’s chief financial officer. “It impacts Carilion, but it also has a broad impact on the business community.”
In other words, higher health care costs that might result would be passed on to employers who offer insurance plans, and in turn to the workers who are covered by them.
‘A pretty hard situation’
The Fieldses used to count themselves in the middle class.
Then Lois Fields had a heart attack and was forced to stop working as a nurse’s aide. At the time, the couple was living in Ohio, where Lois qualified for Medicaid.
About five years ago, they moved back home to Virginia. By then, Kyle was losing his sight to glaucoma and macular degeneration.
He doesn’t like to ride in cars — “I get motion sickness … it looks like things are rushing through the window at me” — but he recently accepted a ride to the social services department to ask about getting some help.
“She was real snobby,” he described the social worker. “She tossed the papers and said ‘You can fill them out if you want to, but I can tell you aren’t getting Medicaid. You make too much.’ ”
Even though some of their costs are covered by Medicare, the Fieldses still struggle to get by.
“We’re in a pretty hard situation,” Lois says.
“There’s a lot of people worse off than we are,” Kyle interjects.
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