The early morning caller to Dr. Sarah Hershman’s personal cellphone was a patient.
Dr. Hershman, who works at a public health clinic in Nampa, Idaho, isn’t supposed to give out her private number. But she has been sharing it with some patients who she knows have no other recourse, telling them, “You really need to be able to contact me.”
Sophia Perez, 28, whose family has no health insurance, spoke in a frightened voice. Her husband, John, had been welding, she told Dr. Hershman, when he felt a hot sting on his eyeball. Could it have been hit by a metal shard? They could not afford a visit to a hospital emergency room.
Dr. Hershman asked careful questions and slipped him into the clinic’s packed Saturday roster.
Full Circle Health, where Dr. Hershman practices family medicine, has long been a last-hope safety net in the American health system. It is one of 1,400 networks known as federally qualified health centers with thousands of sites that receive federal funds to care for patients regardless of their ability to pay.
Now their caseloads are growing, even as revenues are falling. With cuts to Medicaid mounting and the cost of Obamacare insurance plans soaring, the clinic’s doctors and counselors are going to new lengths to patch together care for people with complex medical issues who are underinsured and uninsured.
Dr. Hershman and her colleagues have been spending hours providing unpaid care, emailing advice, calling after hours. They forage for cheaper but sometimes less effective medicines and spend weeks adjusting doses to make them as effective as possible. They negotiate with specialists to accept patients and offer to perform the work-up exams and follow-ups themselves.
Idaho has been one of the most aggressive states to slash Medicaid rolls over the past few years, affecting patients as well as clinics like Full Circle’s, which rely heavily on those funds to stay solvent. Now pressures on patients as well as clinics are about to become even worse, not only in the state but also throughout the country.
As harvest season for sugar beets, onions and potatoes winds down here, two ominous events loom on the calendar.
The annual enrollment period for Your Health Idaho, the state’s Obamacare marketplace, began on Oct. 15, but the generous government subsidies that helped make plans affordable are no longer available because Congress declined to renew them. Like many people, Mrs. Perez, whose job at an orthodontist practice includes filing insurance claims for patients yet cannot wrangle health care for her husband and 2-year-old, found that even the cheapest plan was out of reach. “It was all so overwhelming,” she said with tears in her eyes during her half-hour lunch break.
And come January, many patients covered by Medicaid — whose incomes are well under the state’s limits — may lose coverage. On New Year’s Day, new work requirements for eligibility, enacted as part of President Trump’s sweeping domestic policy bill, begin across the country. Idaho’s rules are among the nation’s most stringent.
Anxious Preparations
At 8 a.m., Debbie Lehnert, a community health worker at the clinic, replenished a filing cabinet drawer with patient stress busters for the day: Bubble wrap for popping and Little Debbie Swiss rolls, the primal ones with chocolate cake, cream filling and fudge coating.
Ms. Lehnert’s responsibilities include connecting distressed patients with emergency health coverage and support services.
For weeks, she and her peers in public health clinics across the state have been under a weighty new burden: The rapidly approaching Medicaid work rules. Community health workers have been convening regularly in videoconferences to puzzle through the rules, discussing patient hypotheticals that none of them can answer with certainty.
Starting in January, Idaho patients will have to show documentation that they have worked or volunteered at least 80 hours a month for the previous three months. (Most states will require one month.) Reauthorization for the program will double in frequency, from the traditional yearly review to every six months. The requirements are expected to eventually reduce Medicaid rolls nationwide by five million people, the Congressional Budget Office estimates.
One of Ms. Lehnert’s most urgent tasks right now is to alert patients. She dialed the next one on her bottomless list. The young man, who can’t get his diabetes under control, had qualified for Medicaid after he lost his job at the post office for using too many sick days. Now his reauthorization date coincides with the start of the new work rules.
“I just wanted to see where you are in that process, if there’s anything I can do to help with that?” Ms. Lehnert said, gently prodding. “January is just around the corner.”
Given the man’s bleak health, it is unlikely he will be able to produce three pay stubs in time. Ms. Lehnert said that with the clinic’s records about his chronic diabetes, they could collaborate to seek an initial medical exemption.
“My hope is that would give you time to focus on getting better and finding employment, so that the second determination in six months would be easier,” she said.
“OK, yeah,” he replied dully.
Ms. Lehnert suggested they meet to attack the paperwork together. Or do a three-way call with a state assistant. Or he could file online, where, studies show, procedural errors, such as computer mistakes and confusion over directions, are the biggest reasons for lost coverage.
“OK, yeah,” he said.
“So which would you like to choose?” she pressed.
He chose online.
After they hung up, Ms. Lehnert buried her head in her hands.
“I truly feel like this is a calling, and I won’t do anything else,” she said, giving her dark curls an emphatic shake. “But these days, I’ve never hated doing my job more.”
Working, but Earning Too Much
It was just after 6 p.m. on a Thursday, but the buzzy restaurant was already slammed with people waiting for tables. Amid the kitchen chaos, Oscar Casarez, 37, a line cook and a patient at the Nampa clinic, kept his head down, juggling grill times and rhythmically seasoning burgers, steaks and salmon.
Just over a year ago, Mr. Casarez, lightheaded and gasping, drove himself to a hospital in septic shock. He was placed in a medically induced coma. By the time he was discharged nearly four weeks later, his employer had replaced him, leaving him uninsured as well as unemployed.
To cover Mr. Casarez’s six-figure bill, the hospital helped him get emergency Medicaid, which carried him through countless clinic visits, scans, blood transfusions and medications as well as hospital stays each time his newly diagnosed severe ulcerative colitis flared up.
Yet he managed to secure line-cook shifts. In May, he was booted off Medicaid because he started earning too much.
He works at two restaurants; neither offers health insurance. But his health problems continue: He also has a blood clot in his liver.
To help, Dr. Amanda Aman, his primary care doctor at the Nampa clinic, has been coordinating with a local gastroenterologist so she can monitor him at the clinic for lower fees than the specialist would charge. Case managers at the clinic scrounged for less expensive medication. After determining that the only drug that quells his colitis attacks requires an out-of-pocket monthly cost of more than $14,000, they helped enroll him in a special program that will provide the drug free for a year.
Still, given his precarious health, Mr. Casarez knows he needs insurance. His only option is to buy a plan on the state’s Obamacare marketplace.
He will likely have to select the most bare-bones policy, which has monthly premiums of about $310 and a deductible of $10,000. The plan doesn’t even cover his gastroenterologist.
At most, when he works 10 straight days of double shifts (to get an entire weekend with his 9-year-old son), Mr. Casarez can earn $3,800 a month. Rent takes a $1,400 chunk; then there are utilities, car payments, gas, child support, food, toiletries.
It comes down to this, he said: He can pay bills and insurance by working overtime at two jobs, almost guaranteeing a slow, steady death march. Or he can work fewer hours and get on Medicaid but have no money for housing and bills.
“I feel like I’m damned if I do and damned if I don’t,” he said.
‘Medicaid Tears’
Late one afternoon, Dr. Ty Waters, the tattooed director of Full Circle’s Nampa South clinic, unfurled himself into a chair in Ms. Lehnert’s office. He mused sarcastically about getting teardrops tattooed down one cheekbone, prison gang style, to signal the fights he gets into on behalf of his patients. He would nickname the tattoos his “Medicaid tears.”
Recently, a manual laborer without insurance injured his leg but held off coming in for weeks, wary of racking up a flurry of the clinic’s income-adjusted fees. When at last he limped in, Dr. Waters, who suspected that the man had torn his anterior cruciate ligament, treated him free of charge, put him in a stabilizing brace so he could return to work and coordinated with an orthopedist who would see him without requiring an expensive M.R.I.
“Our patients are basically people who are already struggling, who lose coverage and then get penalized for asking for help,” Dr. Waters said.
Dr. Hershman, who teaches family medicine to residents at the clinic, poked her head into Ms. Lehnert’s office, rubbing her face wearily. Every week, she allows a battered woman to sit in a clinic room for as long as she needs because the woman feels safe there. Dr. Hershman bills only a few dollars for the visit. It’s hardly conventional health care, she said, “but it’s that nexus of what we can do to improve their social situation and, therefore, their health outcomes.”
Her eyes glistened. “I love my patients, and I want to show up every day and be the person that they need,” she said. “Because even though this job is hard, being them is so, so much harder.”
(Dr. Hershman knows personally what it’s like to face crushing medical debt: After being treated for cancer recently, she discovered that her insurance doesn’t cover fertility preservation procedures. In addition, she owes $450,000 for her medical education.)
Too many times, Dr. Hershman said, she has sat with deathly ill patients who are nonetheless consumed with worries about cost, anxious about burdening their survivors with medical bills.
She treated a 59-year-old tech writer with a chronic gastrointestinal bleed that had turned life-threatening: Normal hemoglobin levels for men range between 13.5 and 17.5; his was 3.5. Or, as she put it: “He literally had no blood in the tank. I don’t know how his brain was functioning.”
She felt strongly that he needed to be hospitalized in intensive care because he required emergency surgery and, likely, a stay of five days. Chatting him up about his adored grandbaby, she almost got him to agree.
But then he dug in and, however reluctantly, refused. Her notes from that visit read: “Pt. doesn’t want to be here because of financial situation. Working to get insurance with open enrollment but has limited means.”