In Accomack, Virginia's health insurance wasteland, Medicaid expansion may offer lifeline

Ann Lewis lost feeling in her hands and feet, and the numbness was spreading. When she could no longer urinate, she finally decided to go to the hospital.

As she lay in bed in the hospital last November, her mind became fixated on something other than her rapidly deteriorating health.

"All I could do was cry," Lewis recalled. "I thought, 'What am I doing to do? I can't afford all this.' That's the first thing I thought of."

Decision on whether to expand Medicaid eligibility

When Virginia state senators gather this coming week for a special session, one of the biggest issues they will face is whether to expand Medicaid eligibility to cover up to 400,000 more low-income residents like Lewis.

The House easily approved a budget in April that broadens Medicaid's availability. The measure faces more resistance in the Senate, where Republicans hold a narrow 21-19 margin over Democrats.

If Virginia becomes the 33rd state to expand Medicaid under the federal Affordable Care Act, few places would be as transformed as much as Lewis' home of Accomack County.

Newly released Census figures show that its 17.9 percent uninsured rate among people under the age of 65 is the highest in the state. Statewide, it's 9.9 percent.

Health officials attribute Accomack's spotty insurance coverage to high unemployment, a dearth of employer-sponsored coverage, rising premiums and pervasive poverty that thwarts people from buying it on their own.

By any account, expanding Medicaid would almost certainly lower the uninsured rate.

Accomack and Somerset County, its neighbor across the state line in Maryland, have similar populations. After the Obama-era health legislation's insurance exchange became available in 2014, Accomack's uninsured rate dropped 3 percentage points. In Somerset, where the exchange was accompanied by Medicaid's expansion, the rate fell by 6 percentage points.

“Your community is a perfect example of how irrational things play out based on where you live whether you get quality, affordable health care," said Michael Cassidy, president of the Richmond-based Commonwealth Institute for Fiscal Analysis.

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'Right mad over it'

Therein lies the perverse irony behind Lewis' plight.

When the 53-year-old nursing assistant suddenly fell gravely ill, an ambulance transported her across the state line — from Riverside Shore Memorial Hospital in Onancock to Peninsula Regional Medical Center in Salisbury.

The Parksley woman could take advantage of Maryland's health care but not its more-generous insurance program. Ultimately, she said, the hospital wrote off her $85,000 bill as "charity care."

Doctors performed emergency surgery to rebuild three bulging vertebrae at the base of her neck. They recommended an extensive stay at a rehabilitation facility after her discharge. Since Lewis couldn't afford the care, she went home instead.

Her former employer, a home health-care company, picked up the tab to cover seven physical therapy visits. Afterward, she was on her own.

"Once they left, this is it," said Lewis, who still wears a neck brace and relies on a walker for longer trips by foot. "They left me with a program of exercises, and I try to do them as I can."

Although she is unemployed and has no income, Lewis likely wouldn't qualify for Virginia's restrictive Medicaid program. She has applied several times and been turned down just as many, she said.

"Frustrated with the way things are with Medicaid isn't even the word," she said. "I am right mad over it."

What are the cost considerations?

Virginia's Medicaid program leaves two key groups on the outside looking in: families who are slightly above the federal poverty level and destitute adults who aren't raising children.

The Medicaid expansion legislation would increase the upper income threshold to 138 percent of the poverty level and make adults eligible, regardless of whether they have kids at home.

The federal government has vowed to pick up at least 90 percent of the expansion's expense. Traditional Medicaid is split 50-50 between state and federal governments.

Still, several lawmakers are concerned about the long-term costs of expansion, particularly since Medicaid accounts for such a large share of the state budget.

“That is the stumbling block," said Delegate Robert Bloxom, a Republican who represents the Eastern Shore. "We’ve been historically against it because it is a huge budget item. Medicaid’s been expanding at a rate faster — in the '80s it was 5 percent of the budget and now it’s 20 percent of our budget — so expanding that program is risky.”

Despite those concerns, Bloxom crossed the aisle to support the expansion legislation. After the Republican-controlled Congress failed to "repeal and replace" the Affordable Care Act in Washington last year, the Eastern Shore lawmaker realized the law was here to stay.

“You campaign against the program for four years and the federal government won’t change it," Bloxom said. "At some point you say you have to live with it.”

Virginia's expansion proposal is laden with provisions aimed at making it more palatable to conservatives, including a "kill switch" if the federal share falls below 90 percent. The latest bill also includes the toughest work requirements yet.

That part of the bill bothers Lewis.

She can't raise her right arm above her head. She can't do the dishes without taking a break or two. There's no way she can return to nursing anytime soon, she said. And she doesn't have the skills to do anything else.

"I could maybe do a desk job because I can type, but to get a desk job I don't have the training," Lewis said. "So to receive that training, I would have to go back to college. I can't afford to do that."

Gov. Ralph Northam, an Accomack native and Democrat, is putting pressure on lawmakers to pass the expansion, saying he will include a traditional Medicaid plan in a budget amendment if the legislature fails to act.

The Senate is set to reconvene on May 14. Lawmakers must approve a budget by July 1 to head off a government shutdown.

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If Medicaid availability expands, Bloxom is sure of at least one thing: It won't be a magic pill that solves Accomack's insurance woes.

In the 6th Senate District — which includes the Eastern Shore and portions of Hampton Roads — up to 10,000 people stand to gain insurance under the expansion, according to the Commonwealth Institute.

People who earn too much to qualify for Medicaid, though, are struggling to afford insurance premiums, particularly those on the state health exchanges, Bloxom said.

Anthem, the insurance company that operates the Eastern Shore's exchange, announced a 54 percent average premium increase for 2018. The vast majority of recipients get a subsidy to defer much of the premium's price tag.

But costs keep rising, Bloxom said.

“Is this fair?" he asked. "We’re getting ready to subsidize a portion of the working poor and the people right above them — the small businesses and people on the single-payer system who don’t get subsidies — are going to have worse insurance.”

Improving health

The expansion's supporters argue that Virginia has failed to collect more than $10 billion in funding over the years by refusing the federal government's offer.

"It’s no different than the state drawing down federal defense dollars or federal transportation dollars," Cassidy said.

One place that could use some of that money: the Eastern Shore Rural Health System, which operates five medical offices and four dentist offices in Accomack and Northampton.

Before the state health exchange took effect in 2014, about two out of five patients receiving care at the health system were uninsured, CEO Nancy Stern said. To stay financially afloat, the nonprofit sought other sources of revenue, such as a drug-screening venture.

After the exchange, the number of uninsured patients plummeted to just one in four patients, she said. Since then, however, the decrease has leveled off amid the premium rise.

The Medicaid expansion would allow people to get care on a more consistent basis, Stern said. That could help people get and stay healthy, particularly those with chronic diseases such as diabetes.

"By expanding Medicaid in Virginia, I can’t give you a number, but I’m certain this will have a positive effect on the uninsured population that is within the qualified poverty guidelines," she said.

For her part, Lewis looks forward to the day when she can walk into a doctor's office with an insurance card instead of an empty wallet.

Her message to lawmakers: "Just do it."

"I have worked for 23, 24 years in the health-care field," she added. "I've seen older folks make a choice between food, rent or medicine, and it isn't right."

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On Twitter @Jeremy_Cox

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