Who Deserves Health Care? 

“What’s the good word?” Fourth Street Clinic physician assistant Joel Hunt asks Calvin Davis in the lobby of the Sunrise Metro public-housing complex. The sun streaming into the lobby on this early January morning belies the record-breaking cold afflicting Salt Lake City just beyond the window.

“There’s not,” Davis says softly, a gray ponytail peeking out from behind his baseball cap as he rolls down blood-soaked socks to reveal legs covered with scabs and sores from recent falls while he was drunk.

Hunt snaps on a pair of blue rubber gloves. While other residents of Sunrise mill around, Hunt, who provides primary care, case management and friendship to the homeless and indigent, goes to work.

Hunt says the 52-year-old Navajo is the poster child for Medicaid expansion, the optional element in the Affordable Care Act—aka Obamacare—that, come January 2014, Utah can choose to embrace.

If Davis had had Medicaid, Hunt says, he would have gone to a care or nursing facility to recuperate after recent falls, rather than being released back onto the streets by a hospital. Without Medicaid, no one would take him. “It would definitely serve all the Calvins out there,” says Davis’ case manager at the Metro, Nils Abramson.

In a gentle voice tinged with sadness, Davis says his mother, his father and three brothers all died from alcoholism. “I’m tired of …” he adds, then drifts into silence.

Davis worked in construction all his life until, “somewhere along the line, alcohol became a problem,” Hunt says. “He is compelled to drink. I don’t know if sobriety is possible on his own account.” Davis had Medicaid for eight months, then lost it because he failed to make a review appointment with the Department of Workforce Services, which oversees eligibility.

In just the past 12 months, Davis went to the emergency room at LDS Hospital 21 times. He has had “multiple, multiple hospitalizations, ER visits,” Hunt says. “It’s crazy, the cost.”

Hunt’s next patient at Metro is Jay Gibson, who doesn’t qualify for Medicaid. A former Denny’s short-order cook and seven-year veteran of the streets, 41-year-old Gibson has been at the Sunrise Metro for two months.

His arm trembles from alcohol withdrawal as Hunt asks him, “Do you feel there’s any hope?” Gibson says he tries to calm his anxiety by going outside, then, in the early hours, drank a bottle of vodka someone gave him “so I could get through my anxiety attack.”

Gibson doesn’t qualify for Medicaid because, he says, “I’m an able body, I can work.” But Hunt says the condition of Gibson’s teeth means that customer service—the most accessible employment for someone like Gibson—is not a possibility. Hunt believes Gibson, whom he describes as being where Davis was 10 years ago, “genuinely does not want to drink,” but “there’s no safety net of basic insurance to provide continual health care.” With expansion, Hunt says, Gibson would get that care.

Hunt and his assistant, Leticia Vasquez, load up their bags, bundle up against the cold and head out to the street to drive to Sugar House to search for a man with schizophrenia whose “invisible buddies” made him leave housing after just two days of being under a roof for the first time in several years. “When you’re taking care of people, money always gets in the way—money and time,” Hunt says. “That’s where expanding Medicaid comes in.”

Salt Lake County’s head of behavioral health, Pat Fleming, predicts expanding Medicaid will be the No. 1 topic in the legislative session this year. Public behavioral health, which includes substance-abuse and mental-health issues, is currently the responsibility of the counties through federal block grants, state and county funding and the behavioral-health portion of Medicaid. Fleming cites two benefits of expanding Medicaid: On-demand substance-abuse treatment and the early identification of mental illness. The latter might well “have changed the trajectory of something like the Newtown school massacre.” Rather than putting armed officers in schools, “we need school nurses, mental-health experts working with families, who, through expansion, are getting services earlier.”

Utah is at a crossroads. The expansion of Medicaid could help shoulder the burdens of not only those who struggle with substance abuse and mental-health issues, but also the working poor, people who have declared medical bankruptcy and those juggling multiple part-time jobs without insurance. If expansion is adopted, non-disabled individuals without children who earn less than $14,856 annually could get Medicaid for the first time. That amount is 133 percent of the 2012 Federal Poverty Level, the salary baseline from where the feds measure poverty.

But, argue lawmakers, expanding Medicaid could have the potential to bankrupt the state.

At the heart of all those conversations is one issue: Is access to health care a right? State Speaker of the House Rebecca Lockhart, R-Provo, a former nurse, argues that the U.S. Congress failed to address that issue with the Affordable Care Act, and while acknowledging she doesn’t know if it is a right or not, she wishes Utah “would have that discussion. The problem is they’re tough questions, there are difficult emotions wrapped up in them. It’s people’s lives, for goodness’ sake.”

Indeed, weeks later, Calvin Davis was dead.

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HIGH STAKES
Medicaid is a federal-state partnership. The federal government pays 70 percent and the state pays 30 percent of coverage for certain low-income and moderate-income citizens who fall within categories such as pregnant women, the disabled and children. Medicaid provides them immediate access to health care. On Jan. 1, 2014, Medicaid expansion goes into effect with “a new income methodology,” says the Utah Department of Health’s deputy director of Medicaid, Nathan Checketts. Essentially, that switches Medicaid from being category-driven to poverty-driven.

For the first three years, the federal government will pay 100 percent of the cost of insuring low-income nondisabled adults without children who are currently excluded from Medicaid. Over the following seven years, the federal government’s portion will drop, eventually falling to 90 percent.

A 2011 fact sheet by the Utah Coalition of Religious Communities estimated that while the adoption of full Medicaid expansion would cost the state about $1 million a month more, it would bring $25 million a month of federal income to Utah’s health-care providers. That, in turn, would lead to hundreds of new jobs.

Utah has not yet decided to expand Medicaid—and there’s no deadline for when it has to. Utah can embrace expansion, walk away or sit on the sidelines while the first three years of 100 percent funded expansion dwindle away. Legislators struggle to believe the federal government, stumbling from one financial crisis to the next, will keep its commitment to paying so much money to open up Medicaid to an additional 145,000 Utahns.

“It’s not like the federal government is flush with cash,” says Rep. Jim Dunnigan, R-Taylorsville, chair of last year’s legislative health-system-reform task force. If Utah expands Medicaid, once that benefit has been provided, “it’s very difficult to take it away,” potentially leaving Utah to pick up the bill if the federal government defaults on its commitment.

Dunnigan recalls Medicaid accounting for 10 percent of the state’s budget 10 years ago, when he was first elected. Now, it’s at 20 percent, he says, “and growing. It’s demanding money that could be going for other things such as education, corrections, transportation ... fill in the blank.”

Salt Lake County estimates that 23 percent of Utah’s population currently earns less than 139 percent of the Federal Poverty Level. An adult earning $14,856 annually would become eligible for Medicaid through expansion, as would a family of four earning less than $23,050. Salt Lake County says Medicaid would extend coverage to 44,000 additional county residents, half of whom are currently eligible but not enrolled, the other half newly eligible.

The uninsured can end up costing taxpayers a lot of money, particularly when it comes to mentally ill individuals without insurance who end up in the jail, the University of Utah Neurological Center [UNI] or the ER. Valley Mental Health’s chief executive, Gary Larcenaire, says a visit to any of those “can run from $1,500 to $5,000 an episode.” In 2012 alone, a record of the Salt Lake City Police Department’s call log shows officers responding to 905 calls of “mentally ill” individuals citywide.

The problem with such uncompensated care is not only that the costs eventually work their way to the taxpayer through increased premiums, but that when those uninsured individuals are released from “a high level of care” back to the street, “they run out of their medication supply and recycle back to the jail, UNI, the ER or the morgue,” says Larcenaire. If expansion were to occur, then those individuals could be placed “into regular, proactive, well-designed care, which would keep them at the lowest level of the medical-care continuum possible. Right now, many of those people are getting health care, but it’s from the most expensive end, i.e., jail,” Larcenaire says.

While Salt Lake County, which recently endorsed expanding Medicaid, has $1.2 million annually to fund uninsured behavioral health care, it’s a finite sum that usually runs out before the end of the year, Larcenaire says. Without expanding Medicaid, “there isn’t enough money to treat everyone,” he says.

Shawn McMillan, chief executive of First Step House, a substance-abuse-treatment provider, argues that if fiscally conservative legislators “don’t think the tax base can support it, they won’t support it. ... If we’re able to show costs being offset, it will make sense to them.” The stakes are high, he says. “With Medicaid expansion, 93 percent of the 300 individuals we serve each year will become eligible because they make less than $14,500.”

If Utah doesn’t take on expansion, he says, “we risk losing the opportunity to have an impact on a standing social problem that has been perplexing the United States for 40 years: access to substance-abuse treatment on demand. If an individual requires assistance, they have to get in line, and this would be an end to that.”

An apartment became available in Sunrise Metro for Gibson only after its occupant died. “I just wish someone didn’t have to pass away for me to get in,” he says.

“The average age for death of a homeless person is around 48 years old,” Hunt says. “Their causes of death are virtually the same as you’d find in any insured clinic: heart disease, lung disease. Granted, it’s exacerbated by substance abuse.” But so many of those deaths, he believes, could be averted with care provided through Medicaid expansion.

Gibson says he’d tell the politicians, in whose hands this decision lies, “Take a look around you. There’s people dying from this, from neglect,” then adds, in a voice full of disbelief, “real people, real people.”

MIRROR, MIRROR
Medicaid was signed into law by former President Lyndon B. Johnson in 1965, evolving from providing health-care access to welfare recipients to covering “needy” categories within the low-income population, as well as long-term care for the elderly and the disabled. One key category excluded from Medicaid is nondisabled adults without children, something expansion would dramatically change.

Because each state has some control over how and to whom Medicaid is administered, it can mirror a state’s political and cultural values. That’s particularly true in Utah, where many in the state Legislature view health care as an individual’s responsibility, with volunteer care provided by local wardhouses or parishes meeting the needs of the low-income and indigent. Nathan Checketts notes some other states have provided Medicaid to every child, citizen or not—as Illinois did, until the recession forced it to retrench.

Whether frugal or mean, Utah has kept Medicaid available “at the federal minimum,” meaning “the lowest income levels that are allowed.” It’s also one of only three states that still enforces that applicants pass an asset test, which checks that applicants don’t have too much money in the bank—more than $2,000 for an individual or $3,000 for a couple—or an extra car. ACA will remove the asset test in 2014.

Utah, says Sen. Allen Christensen, R-North Ogden, is a state dedicated to the idea of self-reliance. “We take pride in ourselves,” he says. Taking “a handout” like the expansion is “not something that’s in our genetic makeup.”

Medicaid is a lightning rod for Republican legislators’ dislike of federal government and what many see as entitlement programs. Lockhart says Medicaid “is a so-called partnership between states and federal government. ... That usually means the federal government tells us what to do and how we do it, and we pay for it. When we want to change, we have to ask permission, a ‘mother may I,’ if you will. Many times, we are told no.”

THE RIGHT TO VIAGRA
While there are “hundreds of nuances” to the arguments surrounding Medicaid expansion, says Rep. Dean Sanpei, R-Provo, the heart of legislative resistance is the fiscal concern. Sen. Christensen is chair of the social-services appropriation committee. Salt Lake County and treatment providers, he says, “simply look at the humanitarian side—‘All those who need it, let’s give it to them.’” But, he asks, “up to what point? Where do we draw the line?”

He sees the prospect of the federal government offering millions of dollars to Utah to expand Medicaid as akin to a dealer pushing addictive drugs. “How long can we rely on this drug before it eats you alive?”

At the same time, however, Christensen admits he’s torn. He’s not willing “to provide another entitlement program to people who are largely responsible and capable of finding alternative ways [to make a living].” But, as a pediatric dentist who sees children on CHIP, he recognizes that “there will be a lot of people who could have received benefits who won’t have that opportunity, and that hurts my humanitarian side. It’s nice to give everyone what they need.”

Lockhart says Medicaid is a fact of life, but nevertheless expresses frustration that when she was a nurse, while she did see people who needed Medicaid, she also saw “individuals who were abusing it.”

That’s a complaint Damien Trujillo heard firsthand when he testified to a legislative health-care reform task force about the importance of expanding Medicaid. He felt the legislators “were sick of people leaning on the resources and taking advantage of them, using that as a crutch. It does happen, people do milk the system all the time.”

The uninsured 34-year-old has turned his life around after a brief spell in prison and a long wait getting county-funded substance-abuse treatment. He’s now attending Salt Lake Community College. He says the possibility of getting Medicaid through the expansion is tantalizing. “How perfect would that be, to be able to go to the doctor when you’re sick? I never had that opportunity—only when I was in prison and you could go to the doctor. It cost $4.”

Rep. Rebecca Chavez-Houck, D-Salt Lake City, sees the debate through the prism of “what potential lives, what savings can be reached? We save in the long run by investing in people. Why would we begrudge that opportunity to people to get healthy? We need to make sure we are not just looking at this discussion through initial direct costs. We have to look at it holistically.”

But such rights-driven arguments irritate Rep. Lockhart. “A right for what? To go to a physician for an antibiotic? What about Viagra? Is that a right? Should I have to pay for that for every person in society? What is society willing to pay for?”

TOO MANY STRINGS ATTACHED
Many of the legislators City Weekly spoke to say they want the federal government to provide Utah with a block grant for Medicaid without strings attached. “My wish list is that the federal government will give us flexibility,” says Rep. Dunnigan, who is sympathetic to expanding Medicaid for behavioral-health needs. “But the feds said it’s all or none. It’s just frustrating. They send down the dictate from Washington, a bill that’s one-size-fits-all. If we could do partial expansion, give us the flexibility—that would be something to look at.”

Dunnigan, an insurance executive, paints a bleak picture of the future, citing a recent newspaper article that predicted costs in the commercial-insurance marketplace would skyrocket between 30 and 100 percent because of federal health-care reform.

He cites a second article that expressed the fear that the paltry $95 federal penalty for not enrolling in insurance would mean “the young and invincible” would ignore the federal mandate to get coverage, leaving insurance carriers “afraid they get stuck with the unhealthy, that there won’t be enough healthy people” to make the system work. “[Insurance] is very likely to be unaffordable.”

Bottom line, Dunnigan says, if costs within the health-care system are not addressed, then all the Affordable Care Act is doing is “putting more people into the system, more people who are accessing a high-cost system.” Ultimately, with Medicaid only reimbursing providers a percentage of their costs, that means “everybody else will be paying for their coverage.”

That’s a perspective the Fourth Street Clinic’s medical director, Dr. Christina Gallop agrees with. “For our patients, expansion would be a very good thing, but there has to be a larger framework looking at cost-containment,” she says. “Otherwise, we could all go broke; Medicaid could eat our lunch, your lunch, everyone’s lunch.”

Lockhart says that she and her colleagues can’t ignore either side of the debate, be it the fiscal impact or the human need. But at the moment, she and others in the Republican super-majority see expanding Medicaid as “unlikely.”

“A BAD PLACE”
Fourth Street’s Hunt says the solution to ending homelessness is simple: Focus on the working poor. And if Calvin Davis and Jay Gibson symbolize Utah’s most vulnerable communities who could benefit under Medicaid expansion, Marie Maxfield speaks for many whose lives have been derailed by divorce, medical bills, unemployment or just plain bad luck.

Maxfield lives in Syracuse with her fourth husband. The 34-year-old had four children with her first husband, a former military officer, whose insurance covers their offspring. Maxfield is a passionate musician and conductor who plays in five symphonies, one of which—the volunteer Davis County Symphony—she founded. “Music is so enjoyable,” she says. “It takes my mind off my health problems a lot. It’s my medication now.”

In 1998, Maxfield was diagnosed with Crohn’s disease, an autoimmune disease that, if untreated, results in debilitating and painful ulcers in the intestines and colon. Since May 2011, when she lost her third husband’s insurance coverage after they divorced, she has been without treatment. Without insurance, the drug she needs to battle the effects of Crohn’s costs an impossible $13,000 for one IV treatment that lasts for eight weeks. Her oral medications are $600 without insurance. “That’s doable—you make it doable.”

When she applied for Medicaid, she says, she was denied because she received $1,200 a month in child support and earned between $80 and $400 a month as a Granite School District substitute teacher. Now that she has gone a year and a half without treatment, her health has worsened. She doesn’t eat well—her stomach hurts when she eats. She tears up as she describes how sitting, standing and walking all bring her pain.

When she remarried in June 2012, she thought she could finally relax. Her husband put her on his employer’s insurance plan and she started making appointments to see doctors. In July, she became very sick and, on insurance, had a picc line put in her arm. Even with coverage, it still cost $300 a day. “I haven’t been able to pay a cent on that,” she says.

In August, her husband, a 56-year-old agronomist, lost his job, sending Maxfield back to square one. She has sold most of the musical instruments she collected through her life to pay bills. “It’s hard to sell the things that mean most to you,” she says. After that, “all the things that happen remind you of the bad place you are in.”

She reapplied for Medicaid online in October 2012, but learned that because she had $3,000 in the bank, which was for her November and December house payments, she’d need to get rid of that money and their two cars to meet Utah’s asset test for Medicaid.

She found part-time work at a musical instrument store, going to schools across northern Utah where she plays with teachers and students. “It was a perfect fit for me,” but as yet has no benefits. Her last paycheck was $178. She repeats the number with a sad smile.

Now she waits to see if her most recent application for Medicaid will bear fruit, since she’s now spent her savings on the house payments. All she has is $300 in her checking account. “I’m really not getting my hopes up.” What does Medicaid exist for, she wonders, if not to help people like her? “Something’s got to work somewhere,” she says.

NO REASON TO TRUST
Davina Spotted-Elk has handled Medicaid eligibility for Fourth Street since May 2012. She’s helped 165 patients file applications since May; most are still pending. Two have died while waiting for decisions. The people she sees often display hopelessness. “They come in, and the look on their faces is, ‘I don’t know if you’re going to help me, I’ve always fallen through the cracks.’ ” She works hard to earn their trust, only to see a Medicaid denial erase that work in a moment.

The difficulties involved in applying for Medicaid for the mentally ill are all too familiar to Darcie Bakhouche, Valley Mental Health’s Medicaid outreach supervisor, who helps people at outpatient units and hospitals apply.

The Department of Workforce Services, which determines eligibility, has in recent years shifted its services online, albeit with many complaints from advocates and clients about lost documents, arbitrarily closed cases and other issues.

Many clients, when they get the paperwork to fill out, often don’t get the help they need to tackle complicated forms, including an addendum for disability, Bakhouche says. “They don’t understand there are time limits,” she says. “Most of these people don’t have calendars, they’re not able to keep appointments. If they don’t follow through, they just get denied.” A lot of her clients, she adds, “are afraid to open their mail. They come to me with stacks,” asking her to open them. By then, letters from Medicaid “have been ignored too long, so they’ve got to start over.”

ACTUAL COSTS
As the legislative session begins, behavioral-health advocates hope that a report commissioned from a Boston consultancy by the Utah Department of Health on expansion and cost-effectiveness will provide a rallying cry of savings to lead a charge in favor of expansion.

The Department of Health will take the report to Gov. Gary Herbert, who will decide whether Utah will expand Medicaid or not, albeit with significant legislative input. “He’s clearly intent on involving key legislators in the discussion,” Checketts says.

Senate President Wayne Niederhauser says he’s currently “not in favor” of expansion, but rather advocates for a “wait-and-see approach,” monitoring how other states who have said “yes” absorb the expansion and also how the federal government manages its own books. Those who have already said “yes” include conservative Arizona Gov. Jan Brewer.

While advocates and politicians went back and forth over the highly complex terrain, Calvin Davis didn’t get Medicaid. Two weeks after Hunt bandaged his legs in the lobby of the Sunrise Metro, Davis was found dead in his apartment. He had had several alcohol-related seizures in the prior weeks.

At a memorial service at Sunrise in late January, family and residents gathered to share prayers and tales about Davis’ love for his family. One resident recalled Davis asking if he could sleep in his apartment, because he had been used to having his eight brothers around “and I don’t want to be alone tonight.”

Volunteers of America’s outreach specialist, Ed Snoddy, struggled to hold back his tears before earning a laugh for recalling, “That son of a bitch, I chased him all over town for 10 years” trying to get him help and services.

A childhood friend said, “Growing up on the streets of Salt Lake City, people get addicted, things happen. It hits home when it’s family.”

The service ended with a treatment provider singing a Pacific Island song in English. When she reached the line, “our lives were touched by your warm, loving smile,” she struggled to go on.

Davis’ death bothered Jay Gibson. He knew Davis from when they were both homeless.

“I didn’t come here to pass away,” he says. But without continued access to health care, preventative care and counseling, he is fighting his alcoholism with one hand tied behind his back.

“People here, they go pretty young,” he says with a sigh.

Substance use disorder and mental-health nonprofit agencies are holding a “rally for recovery” at 11 a.m. on Feb. 12 at the Utah Capitol. Go to USARA.us or NAMIUT.org for more information.