The Future of Medicaid in Utah - Part 3: Gaps in Services and Gaps in Coverage

Aug 1, 2012

The expansion of Medicaid as outlined in the Affordable Care Act is designed to give more people access to healthcare services. Without the expansion, a portion of the Utah’s population living on the edge of poverty may remain uninsured. But some believe that Medicaid doesn’t do enough for those who are already enrolled. In part 3 of our series, The Future of Medicaid in Utah we examine the gap in services already provided and the coverage gap that will continue to exist if Medicaid is not expanded.

One day a few years ago, Karlene Kidman didn’t feel well. She had a terrible headache and her breathing was labored. So she went the emergency room at a local hospital near her home in Layton. Karlene was worried that the pneumonia she’d had ten months before had come back. She was right.

“They said I probably needed to stay in the hospital a couple of days. And I said it doesn’t matter, PCN does not cover hospital stays at all,” said Karlene Kidman.

PCN stands for Primary Care Network, a Utah Medicaid program created in 2002. It’s designed to provide a set of health benefits to a larger pool of recipients at a lower cost to taxpayers. It covers doctor’s visits, four prescriptions a month and some trips to the emergency room, but PCN doesn’t cover hospital stays, visits with specialists other services related to catastrophic care. So Karlene was sent home from the emergency room with prescription for antibiotics. A few months later, Karlene injured her knee, but PCN wouldn’t cover a visit to a specialist or a surgery she needed. Frustrated by the limited resources of her PCN plan, she tried to explore other options.

“At that time I went to my employer and I said I really need some health insurance and so they looked up health insurance for me and my daughter and it would’ve been… the monthly premium for the insurance was more than I made a month. So there’s no way I could pay that,” Kidman said.

The best Karlene’s employer could do was give her a modest raise, but that raise put her over the eligibility limit for PCN and her enrollment in the Primary Care Network was discontinued. The raise from her non-profit employer wasn’t enough to afford private health insurance, so Karlene has lived without health coverage since 2007. If Medicaid is expanded, an estimated 50,000 additional Utahns could enroll. Income eligibility levels would rise significantly for adults with children, from 50 percent of the federal poverty level to 133 percent. Adults without children, a population that is currently not eligible for the program, could also enroll up to 133 percent of FPL or an annual income roughly 30,000 dollars for a family of four. Jason Cooke is the Medicaid policy analyst for the Utah Health Policy Project. He says expansion would finally provide coverage to a significant portion of the population.

“These are people who caught between poverty and having enough money to be able to buy coverage. The commercial market has never, never responded to that need sufficiently and they've had lots of opportunity. So there’s no choice other than leaving these people uninsured and having the problems that we currently have un-insurance in the healthcare system,” said Cooke.

But members of a conservative think tank in Utah believe government should not be involved in providing any healthcare coverage. Stan Rasmussen is with the Sutherland Institute. He says health care services for the working poor could be provided a system of privately funded free clinics, a concept Sutherland calls authentic charity care.

“And that would be a means by which primary care could be provided at a much lower cost to providers and a much, much lower cost to those who are recipients of it. Is that going to solve all of the problems? No. But we feel that an authentic charity care element is an essential component in a truly functional and effective approach to healthcare for people in the state of Utah,” said Rasmussen.

But the kind of charity care network that Rasmussen envisions doesn’t completely exist and an expanded Medicaid program could benefit some families sooner, like The Woodruff family in North Salt Lake. Chelsea Woodruff works from home taking airline customer service calls and gets some health insurance for herself and their two children, but her husband Kyle is currently unemployed they can’t afford to pay for his insurance.

“It was two hundred and fifty three dollars a month to cover me and the two children. It was going to be four hundred and fifty dollars a month to cover all of us and that difference we just couldn’t make up in our budget, there was no way to cover it,” Chelsea Woodruff said.

This family of four survives on $27,000 a year. That’s roughly 132 percent of the federal poverty level, which means if Medicaid was expanded tomorrow under the Affordable Care Act, Kyle would qualify for Medicaid, but he’s currently uninsured. Kyle has been blind his entire life. He doesn’t qualify for disability benefits through Medicaid because his blindness hasn’t stopped him from working. Last year he developed a skin infection called cellulitis while he was uninsured and paid out of pocket for his treatment. He continues to be concerned about a chronic health condition he has with kidney stones.

“The entire episode of cellulitis took a week, and that was it. And it was a nine hundred dollar week. If kidney stones happens, which… they’ve told us that I have four in my right and two in my left, so it’s not if, but when,” said Kyle Woodruff.

The Woodruff family wants to get into a situation where they have access to private health insurance that will cover their medical needs, but a rough economy and job market have hit the Woodruff’s hard. Chelsea was unemployed for more than two years and the health insurance that Kyle had at his job during that time, didn’t completely many of the chronic health problems she needed treatment for.

“When we got married, when we moved into this home we both had full-time jobs, it looked like everything was going to be fine and we filed bankruptcy last year to wipe out sixty-thousand dollars in medical debt because I was laid off for two and a half years while he was making minimum wage,” said Chelsea Woodruff.

Chelsea is so upset with the way the system works in Utah that she’s running for public office. She’s the Republican nominee in State Senate District 1 and will face Democrat Luz Robles in November. She’s concerned that insurance companies don’t work with consumers to disclose what the least expensive care options are, so that people don’t end up paying high prices for minor procedures.

“I should be able to control my own medical costs and make decisions for my own healthcare based on what I can afford,” Chelsea Woodruff said.

Utah lawmakers plan to decide in the next legislative session whether the state will move forward with an expansion of Medicaid or leave the program as it is. If nothing is done, gaps in services and coverage will still exist. People like Kyle Woodruff will continue to live day to day without coverage, hoping that a catastrophic healthcare crisis isn’t around the corner.