Texas’ poor on outside looking in
WHILE ARKANSAS SEES ITS UNINSURED RATE PLUNGE, LONE STAR STATE STILL TOPS NATION
TEXARKANA — An invisible boundary runs down the center lane of State Line Avenue. A flick of a turn signal one way is Texas, the other way is Arkansas.
That turn matters these days. Living on one side of the street rather than the other can mean the difference between getting better or staying sick.
Erika Castaneda lives on the Arkansas side, just outside Texarkana, in a small house in the country with a faded hobby horse out front. Some days, the nerve damage in her legs from diabetes was so bad she couldn’t stand. But a doctor over at the clinic cost $75, so she put off going. Like so many around her, she was uninsured.
Until suddenly she wasn’t anymore, becoming part of a grand experiment in the time of Obamacare.
In her red state of Arkansas, where the Affordable Care Act is often cursed, lawmakers found three years ago a politically palatable way to use an underpinning of the law and expand Medicaid to cover hundreds of thousands of people without actually calling it that.
Soon, the state’s uninsured rate began to plunge — faster and more dramatically than any other in the nation except Kentucky, which it tied. In 2013, the Arkansas uninsured rate for adults was 22.5 percent. By 2015 it was 9.6 percent, according to a Gallup-Healthways Well-Being Index.
People in Arkansas began to go to the doctor more because they could.
Cheryl Nunn lives up the road on the Texas side, a place where lawmakers won’t consider expanding Medicaid.
As a nurse, she knew that taking the nine steps from bedroom to kitchen in her narrow trailer should not leave her collapsed against a table struggling to breathe. But she would pull herself up and head for the door anyway.
“I am the only breadwinner,” she thought. “If I don’t work, we don’t eat.”
Her husband, Jimmy, 56, is disabled after a heart attack. Without insurance, the medical bills were already stacked tall. She promised herself a checkup soon at the clinic a few miles away in Texarkana, by coincidence the same one Castaneda uses.
Then came the day in July when her breath turned ragged and her calf swelled so much she could not roll up her pant leg. Her daughter drove her to the emergency room, where tests found a potentially fatal blood clot had traveled to her lungs. She had undiagnosed heart disease, too. The doctor worried for her life. She worried about the money. She checked herself out the next day.
A month later, the 51-year-old was back, this time by ambulance after blacking out at work.
“It was scary for me,” remembered Dr. James Miller, the second-year resident who treated her. “I can only imagine how scary it was for her.”
This is what being uninsured can look like in Texas. The latest estimate is that 4.6 million people, the most in the nation, dwell on that dangerous cliff, put there, in part, by politics, kept there by the whim of geography. Insurance alone does not guar- antee good health. But often, as Diane Rowland, executive vice president for the national Kaiser Family Foundation, explained, “it is the key to the door.”
Such a door opened in Arkansas.
Once home to some of the highest rates of stroke, heart disease and lung problems in the country, Arkansas appears to be getting healthier. The poor go to the doctor sooner. They go to the emergency room less. They manage chronic conditions better.
The exact opposite is happening in Texas, a recent Harvard University public health study reveals. For instance, three years ago, about 8 percent of poor Texans used the emergency room as their doctor. In 2014, it was 10 percent. Last year, it was 11.3 percent.
“The ER is the last place in the world you want to send someone who doesn’t have an emergency. It’s expensive; there is no continuity of care, no follow-up,” said Dr. Joe Thompson, director of the nonpartisan Arkansas Center for Health Improvements, a Little Rock-based health policy center.
The Arkansas turnaround grew out of the 2012 U.S. Supreme Court ruling on the ACAthat said each state could decide whether to expand Medicaid. Texas said no; Arkansas said maybe.
With a Democrat in the governor’s mansion and a Republican majority in the Legislature, a customized version of Medicaid expansion was negotiated with federal authorities to develop what they called the “Private Option.”
Arkansas took the money earmarked to expand Medicaid and instead bought private insurance for the poor off the ACA-mandated exchange. The controversial measure found bipartisan support because it touted a free-market sensibility to soothe objections against expanding entitlements.
“Regardless of what you think of the Affordable Care Act, there was a duty to pull together to do what was responsible, to do what was in the best interest of their constituents,” said Dr. Dan Rahn, chancellor at the University of Arkansas for Medical Services, which operates a network of clinics for low-income people like the one where Nunn and Castaneda go.
Today, more than 300,000 in a state of just under 3 million get their insurance under the law. The path has never been smooth politically, as conservatives continue to be skeptical of promises it will not explode the state budget. Still, the law survived a challenge earlier this year but retooled.
The new version, backed by Republican Gov. Asa Hutchinson and approved last week by U.S. Health and Human Secretary Sylvia Burwell, is called “Arkansas Works.” It encourages the unemployed to look for work and some enrollees to contribute toward premiums so they will be more involved in their own health.
The election of Donald Trump — who carried both Texas and Arkansas handily — throws into question what happens in Arkansas and the 30 other states that expanded Medicaid to millions of Americans.
The president-elect and his administration picks have signaled a preference for block grants to states for access to health care for the poor instead of the existing federal funding system. The current way could be among the first casualties in the march to dismantle the Affordable Care Act.
A block-grant system typically returns more power to individual states and allows them to decide criteria for low-income programs.
But “it could perpetuate the disparities,” Rowland cautioned.
There already are different levels of federal funding to states, depending on whether they expanded Medicaid. If that continued unchanged, states like Texas could start out behind, Rowland said. States also might set widely different rules on coverage.
In Arkansas, Hutchinson’s press office said the governor is hopeful the Trump administration will allow “Arkansas Works” to stand.
“This is long ball,” said Rahn, a proponent who urges patience. “Everyone deserves the opportunity for a healthy life. You can’t get there until everyone is under the tent.”
When the little white card arrived in the mail, Erika Castaneda had no idea what it was. It said Blue Cross and Blue Shield of Arkansas. She almost threw it away.
She had been uninsured so long, she didn’t know what being covered looked like.
The 35-year-old works in collections. Her husband has a landscaping business. Together, they bring in about $3,000 a month but too often skate near the edge of poverty.
She always made sure her four kids had insurance through ARKids First, the state’s program for low-income children, even when she and her husband were without. Diabetes runs in her family. She has it; her sister does, too. Complications from the disease claimed her mother at age 62.
Castaneda brushes at the tears that gather, a mix of sadness and fear that she was on the same path.
“When are you going to come in for you?” Dr. Cheryl Verma, a family doctor at the University of Arkansas for Medical Services clinic, asked when Castaneda used to bring in her mother and father for checkups.
“I’ll come in when I have the money,” Castaneda promised and then disappeared.
In these parts, 1 in 5 people live in poverty. They go to the emergency room when things get bad and walk out with a week’s worth of medicine. After that, they begin to ration. Or borrow pills from friends. Or just do without.
In fall 2014, Castaneda was renewing her kids’ enrollment and asked if there was anything for her. It was a joke. She had applied for Arkansas Medicaid before but was always turned down.
The woman behind the counter said there was something new.
Yeah, right, Castaneda thought, filling out the paperwork anyway.
Then came the call that she was approved, followed by the card. She didn’t believe any of it up to the moment she handed over the card at the clinic.
“That will be $8,” the receptionist said as she collected the co-payment.
“Dang, this feels good,” Castaneda thought, tucking away the rest of the crumpled bills she had brought just in case.
Back at Castaneda’s house on a recent night, the kids are sprawled across couches, watching sports with the sound turned down, doing homework, shoveling in a dinner of noodles, beans and eggs with green salsa.
“I eat a lot of salads,” Castaneda said, watching. She is trying to eat healthier. She plays with her kids more. She takes her seven prescriptions a day without fail.
And sometimes, at the end of the day, she puts on music and dances around the house.
Looking back, Texas state Rep. John Zerwas, a doctor and five-term Republican from Rich-
Arkansas appears to be getting healthier. The poor go to the doctor sooner. They go to the emergency room less. They manage chronic conditions better.
mond, wonders if he was being naïve.
In spring 2013, about the time Arkansas lawmakers were forging the Private Option, Zerwas came up with HB 3791, known as the “Texas Solution.”
He said he thought he made clear he did not favor a traditional Medicaid expansion and was no fan of the ACA. He hoped to give then-Gov. Rick Perry and Texas Health and HumanService Commission leaders some direction, or maybe permission, to consider alternatives. One possibility was negotiation with the federal government to use tax revenue from premiums to tailor a program suited for Texans.
More than the humanitarian goal of helping the poor, he thought he could win over opponents with a fiscal argument. Using the federal money would help local hospital districts staggering under the weight of unreimbursed care while putting a lid on property taxes that were covering the shortfalls.
“I actually felt pretty confident about it,” he said recently.
But even a whisper of expansion was, and continues to be, radioactive.
Perry and other opponents said at the time that they would consider only a no-strings-attached block grant to fund coverage for the poor. Arlene Wohlgemuth, the now retired executive director of the conservative Texas Public Policy Foundation, derided Zerwas’ effort back then, calling it “too close to Medicaid expansion.”
She said his bill still would require Texas to meet federal Medicaid requirements, which could increase the state’s costs and deter some individuals from receiving private coverage through the health insurance exchange.
The bill died before reaching the floor.
“It was an issue that needed to be debated and let the votes fall where they may,” Zerwas said.
Any talk of resurrecting it is usually quickly silenced. Moderate Republicans have feared being targeted by conservative forces in primary challenges.
“I’ve pretty much come to real- ize it’s a lost cause,” Zerwas said.
Cheryl Nunn spreads the medical bills across her table, each one a mile marker in a run of terrible luck.
There is $12,985 for the emergency room care when her leg swelled. Then came $7,000 for the first hospital she was taken to after blacking out. The ambulance ride cost $900 followed by $1,000 more for a second ambulance to take her to a bigger hospital in Texarkana. Her four-day stay there cost $19,103.
Then there are her husband’s bills: $50,726 for the hospital and another $49,000 for the pacemaker after his heart attack in December 2014. There is another $23,000 for an air ambulance after he was severely burned in an accident changing a fuel pump in a truck.
The total is close to $165,000. She makes $35,000 a year. Her husband gets $4,104 a year in disability.
Last month, she met with a lawyer to file for bankruptcy.
“That’s not the way I do things,” she said. “I hate it, but what choice do I have?”
Last year, she had insurance for a couple of months when she worked as a licensed vocational nurse at a long-term care facility for $19 per hour. She quit to take a job as a home-health nurse that paid $22 an hour, plus mileage. There was no insurance until she accrued enough hours. When she went to the hospital the first time, she was a few hours short.
When she left the hospital, her doctor said she needed a long list of medications, none of which she could afford. He spent the better part of an afternoon calling pharmacies, pleading for deals.
“If she had health insurance, her health, her whole life would be different,” Miller said.
Nunn now works at another long-term care facility for $19 per hour. This month, she is eligible for insurance through her new job but will skip it because it takes $600 from her paycheck each month.
She considered a plan through the ACA, but even with the subsidy to lower costs, it would be $400 a month. She also thought about applying for disability, but the process takes too long.
“I can’t just stop and sit around and wait for that,” she said.
She voted for Trump because she hopes he will fix the problem. She heard about what they did over in Arkansas and wishes Texas would do something like it.
“There’s just no in-between in Texas,” she said. “It’s black or white. Apparently in Arkansas, there is gray. I guess I’m just stuck.” jenny.deam@chron.com twitter.com/jenny_deam