Health Care Divides in America

Across the State Line

Bluefield, Virginia and Bluefield, West Virginia: They share the same name and for most residents, crossing the state line for work, errands, and appointments is a regular part of everyday life. While it can be easy to lose track of what side of the state line you’re on, for low-income adults without health insurance, one of the key differences is the differing decisions made by the Legislatures in West Virginia and Virginia regarding whether to expand Medicaid through the Affordable Care Act. 

Joanna Sampson, 44, lives in Bluefield, Virginia, about a 15 minute drive from the Mercer Charitable Clinic in Bluefield, West Virginia. The Mercer Charitable Clinic, which also has sites in Beckley and Hinton, provides free primary care and prescription drugs and connections to specialty services to people living on both sides of the state line.

West Virginia is among the 27 states and the District of Columbia that have opted to expand their Medicaid programs to all individuals under 138 percent of the federal poverty level (about $33,000 a year for a family of four). While Virginia Gov. Terry McAuliffe has tried to expand Medicaid in his state, it has not yet happened.

Joanna Sampson, 44, lives in Bluefield, Virginia.

Sampson has several serious health conditions and has been a regular patient at the Mercer Clinic for “many, many years.” She works full time as a nursing assistant at a home health agency based in Princeton, West Virginia. She helps seniors to meet their basic needs including bathing, grooming, and eating.

“If it weren’t for this place I don’t know what I’d do,” Sampson said.

While her employer offers health insurance at $90 a month, she says she “had to decline it because I can’t afford it. It’s just too much.” She considered moving across the state line to West Virginia so that she could enroll in Medicaid, but “I can’t afford that. Danged if I do, danged if I don’t. The state of Virginia needs it. And any other states that don’t have it, they need it too….Everybody needs healthcare. It’s just getting it, finding it, keeping it at a level people can afford it. You know you have got people that are either okay to eat or okay to pay for healthcare insurance and it shouldn’t be that way, it really shouldn’t.”

Sampson isn’t the only one in her family to experience a myriad of health conditions with limited options for care. Both of her parents died in their 50s from heart attacks and congestive heart failure. “I’ve had a heart attack, my older brother had a heart attack, my baby brother put an end to that but he does have high cholesterol…Heart disease runs in the family, cancer runs in the family, diabetes runs in the family. Both of my grandmothers passed away from complications from diabetes. Me and my older sister have diabetes.” She has been visiting the clinic more often in the past three to four years as her health has declined. The clinic provides her with free access to her medications, both oral and insulin, which she would otherwise be unable to afford.

Mercer County Clinic CEO, Jeff Graham.

Patients at the Mercer clinic must provide proof of household income demonstrating that they are at or below two times the federal poverty level, or $47,700 for a family of four. The clinic is able to keep costs low through the use of volunteer providers, donated equipment and prescription drugs, and a strong relationship with the local hospital for referrals for specialty services. According to the clinic’s CEO Jeff Graham, “If you’re trying to understand a free clinic, you can’t exist without community resources.”

The 10 free clinics in West Virginia expect to serve nearly 60,000 patients in 2014. Thanks to the state’s decision to expand Medicaid, most of the free clinics in West Virginia have started billing Medicaid for the services they provide to those with coverage. This will hopefully help to improve their bottom line while allowing the clinics to continue to serve the patients that have come to them as a regular source of care for years and sometimes for decades. The 10 clinics in West Virginia are among the 1,200 free or charitable clinics that serve about six million patients around the country, according to the National Association of Free and Charitable Clinics.

Everett Catron, 58, goes by Jack. He lives in Virginia and learned about the Mercer clinic through word of mouth. He is well aware that he makes “too little money to qualify for Obamacare.” But,” he adds, “I make too much money to qualify for Medicaid.”

Everett Catron, 58, goes by Jack. He lives in Virginia and learned about the Mercer clinic through word of mouth.

While he could get insurance through his employer, “they would be taking out one hundred something out of my paycheck a week – and I can’t afford that.” He is very impressed with the care he gets at the Mercer Charitable Clinic for his Type II diabetes.

Both Sampson and Catron have siblings living on the other side of the border who have enrolled in Medicaid and are now seeing health care providers for the first time. Catron considered moving to West Virginia to benefit from expanded Medicaid, too, but said his family doesn’t want to make the move. “I wish they would. I like Virginia and living in Virginia too, but I’m a West Virginia mountain man and always will be.”

Before the Affordable Care Act, 17 percent of West Virginia residents were uninsured. Since the expansion of Medicaid, the rate has dropped to less than 7 percent. (WV Gazette). As of July 2014, more than 132,000 (almost 93 percent of the total eligible) low-income West Virginians had gained coverage through the Medicaid expansion approved by Gov. Earl Ray Tomblin. Nearly 26,000 additional previously uninsured people were able to enroll in subsidized private insurance plans. And about 18,000 young adults were allowed to remain covered by their parents’ policies until age 26. Combined, that’s 176,000 West Virginians who have gained health insurance since the implementation of the Affordable Care Act.

One of the reasons for this dramatic boost in the rates of insurance in West Virginia is that before the Affordable Care Act, West Virginia had one of the most restricted Medicaid policies in the country. Low-income and pregnant women were able to enroll in health insurance coverage through Medicaid or the Children’s Health Insurance Program (CHIP), but low-income parents were only eligible for Medicaid if they made less than 35 percent of the federal poverty level (a shockingly low $8,300 for a family of four) and adults without children were ineligible at any income level.

Virginia also had a limited definition of who qualified for Medicaid before the enactment of the Affordable Care Act, but its lack of action to expand Medicaid has meant that few Virginians have gained coverage this year. Up to 400,000 Virginians, many of them employed, would gain coverage if Virginia decided to expand Medicaid. Until that time, they remain in what is known as the coverage gap – they cannot afford to purchase private health insurance through the exchanges and cannot receive subsidies to make it more affordable and yet they make too much or are otherwise ineligible for Medicaid.

In deciding not to expand Medicaid, Virginia loses out on $4.4 million dollars in federal funding every day which amounts to more than $1 billion since January 1st of this year.

Until Virginia is able to expand coverage, the free clinics like the Mercer Charitable Clinic continue to treat thousands of patients with nowhere else to go. Most of Mercer’s patients, like Sampson and Catron, are among the working poor. Beth Pritchett has been a family nurse practitioner at the Mercer clinic since September 1990 when the clinic opened its doors. “Our patients are concerned with paying their rent, putting food on the table, and helping their kids; so their health comes very near last.” Most work full time and some hold two or three jobs but are still unable to afford rent and other basic necessities in one of the more affordable places to live in the country. “I have patients that work in dietary, nursing homes. I have a patient who works full time at the quarry, he comes and he’s covered in dust. Another patient works at Walmart full time. They offer health insurance but when it’s $800 per month, they can’t afford it working at Walmart.” Employment opportunities in the area are limited, so many job opportunities are at convenience stores and fast food restaurants.

While they recognize that their health is extremely important, “For our patients…lack of insurance is one of their fewest problems. Poverty, isolation, low education level…Many of them have a third grade education and can’t read.” New patients who visit the clinic typically have not had any health care, including preventative care, for a long time, often years or decades. Pritchett said, “We have patients who walk in with blood pressure of 220/180. I mean that is not at all unusual. A good percentage of our patients have insulin dependent diabetes with many complications. We have people walk in with congestive heart failure. So they have a myriad of problems, not just one problem. Very rarely do we see somebody who comes in with a sore throat or a rash, we just don’t see that….We have patients who just found our clinic and have been taking their insulin every other day or every two days. They stretch out their medicine to make it last.”

Low-income Americans lacking access to health care face a vicious cycle. People cannot work if they don’t have their health. And yet many people are working several jobs to get by and the stress of poverty and making ends meet means that they cannot always get the health care they need. According to Pritchett, “And you know, denying people health care, and they have high blood pressure, and then they have a stroke, and they’re unable to continue working, and they end up in intensive care without insurance; well who pays for that?  I mean we all pay in the long run. That saying that no man is an island is certainly true when it comes to health care.”

The providers at the Mercer Charitable Clinic are deeply committed to the work they do. While many free clinics rely on volunteer providers, most of the staff at the Mercer Charitable Clinic are paid. While they know they could make more elsewhere, they are driven to serve a population in need. Pritchett said, “Well, I can tell you that I’ve been offered much more lucrative positions, and, as you can tell, I feel very passionate about this…This is the reason why I became a nurse practitioner.”

The different decisions made by Virginia and West Virginia regarding Medicaid expansion have resulted in two different worlds regarding how the clinic treats its patients.

According to Pritchett, “when patients have Medicaid we can refer them to a specialist because some doctors will take Medicaid. We have an orthopedist in town who actually takes Medicaid; we have an endocrinologist who will take Medicaid. So when we need that type of support and they need that referral, Medicaid is the magic word.”

In the United States today,  health care is a privilege for those wealthy and lucky enough to afford it, not a right as it is in nearly all other industrialized nations in the world. In America’s extraordinarily complex heath care system, over 40 million people are uninsured and millions more people have inadequate health care coverage with high deductibles and copayments. In terms of life expectancy, infant mortality and other health outcomes, the United States lags behind almost every other advanced country in the world. Despite this unimpressive record, the U.S. spends almost twice as much per person on health care as any other nation. As a result of an incredibly complicated, wasteful, bureaucratic, and profit-driven system, the U.S. spends 17 percent of its gross domestic product – approximately $2.7 trillion annually – on health care and yet tens of millions remain uninsured.

And what’s so important about health insurance?

A 2009 study published in the American Journal of Public Health found that nearly 45,000 people die a year because they do not have health insurance, including more than 2,200 veterans. Many of these deaths could have been prevented if people were able to have their health condition diagnosed or get the care they needed before it was too late. There are people who do not get to a doctor or end up in the hospital when their once preventable condition has become fatal. In fact, at least 7,000 people are expected to die unnecessarily in those states that have chosen not to expand Medicaid.

And yet it is clear that a health insurance card alone does not ensure access to care. Many parts of the country face a severe and growing shortage of health care providers, especially providers who accept Medicaid. Many private practices cap the number of Medicaid patients they will see. This presents serious challenges in ensuring that people can see a provider when they need one as Medicaid expands in West Virginia, and hopefully, in time, in Virginia too.

Those who are low income tend to have poorer health overall than the general population, including more complex health care needs. Many low to middle income people who are buying private insurance with the help of subsidies from the exchanges will soon find that the out of pocket costs associated with the plans they have chosen may continue to make health care unaffordable. And even with insurance, many critical health care services are not included, such as adult dental and vision services, case management, and health education.

While many leaders of free clinics say they wish there was no longer a need for their services and that they could close their doors, even in states expanding Medicaid, there will remain a sizeable uninsured population. Even after full implementation of the Affordable Care Act, 30 million people will remain uninsured. As a result, according to Patricia Rouse Pope, Executive Director of the West Virginia Association of Free Clinics, “the need for free and charitable clinics, which provide the uninsured with access to preventive, primary, and specialty care, will remain.” Allowing the states to determine whether they will expand their Medicaid program has meant that many states that were already performing poorly on measures of health care access, costs, and outcomes are slipping further and further behind, widening the divide between neighbors in towns like Bluefield, WV and Bluefield, VA.