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ALBION — Because she's not working at the moment, Dannielle Ryals has Medicaid coverage that will allow her to get surgery for a disease that has afflicted her since she was young.

The Albion woman wants to go back to work, and her boss is holding her job open for now, but when she does she will probably lose her coverage. She can't keep it if she makes more than $650 a month, she said, and she pulls in a little more than $1,000 a month at a gas station and convenience store in Albion.

So Ryals expects to be back in the "Medicaid gap" after her surgery and return to work.

Adults who don't qualify for Medicaid but whose incomes are too low to get tax credits to buy health insurance on the state exchanges originally were expected to get Medicaid coverage under the Affordable Care Act. But in 2012 the U.S. Supreme Court struck down the ACA's mandate that all states expand Medicaid coverage to everyone making up to 138 percent of the poverty level; that left it up to the states whether to expand the program, and Idaho hasn't.

Like others around Idaho, Ryals is waiting and hoping.

A majority of people in the "gap" are employed but with lower-paying jobs that don't provide coverage, in industries like restaurants, construction and child care, according to a presentation the pro-expansion group Idaho Voices for Children provided to lawmakers in August. An estimated 78,000 adults statewide fall into this group, including an estimated 724 in Cassia County (almost 6 percent of the county's adults) and 976 in Minidoka County (8.5 percent).

Ryals has endometriosis, a condition where tissue that is supposed to grow inside the uterus grows outside of it, and she needs surgery periodically to treat it. After getting passed to several doctors — one thought the underlying problem was a bowel issue — she is now waiting for her surgery.

Ryals has three children. Her husband is looking for work, but he has health problems of his own — high blood pressure and arthritis. He has worked in farming and construction, but having to take time off due to his health has been a consistent problem, Ryals said. One of his last employers, who was also their landlord, docked his pay when he went to the doctor.

"He'd take hours off his final paycheck," Ryals said. "It was basically a punishment for being sick."

The family gets food stamps, but the allotment went down from $648 to $576 a month last time they re-certified, because at the time they had income coming in. That isn't the case now, though.

"For the most part, I've been decreasing my meals, and thankfully the kids are at school during the week, so that helps," Ryals said.

She started a GoFundMe page in late November to raise money to keep the electricity on and to buy firewood to heat their home. Her usual supplier, who sold the family wood at $100 a cord, ran out, and she faces paying $200 to $250 a cord now.

"I don't know what we're going to do for Christmas if I don't get back to work soon," she said.

Idaho lawmakers have debated for several years whether to expand Medicaid, do something else, or do nothing. Generally speaking, Democratic lawmakers have favored expanding Medicaid. Republicans have opposed it for a variety of reasons, including concerns about growing the federal debt, or how much it could cost the state in the future, or opposition to asking taxpayers to pay for other adults' health care.

Gov. C.L. "Butch" Otter put forth a state-funded primary care plan at the beginning of the 2016 session, but it died in the Legislature, with critics from the right concerned about the cost and about creating a new social program, and critics from the left supportive of Medicaid expansion instead, which would have provided more coverage. A plan to apply for a Medicaid expansion waiver from the federal government, which would let the state implement a state-designed program with federal funds, came out toward the end of the session but died when the Senate and House deadlocked.

What the state is going to, or could, do now is even more uncertain after the November election. President-elect Donald Trump has vowed to repeal and replace the ACA, a goal of congressional Republicans for years. While it is unclear what exactly would replace it if they succeed in this, there is a good chance Medicaid expansion, at least in the form it was being discussed during the Obama presidency, wouldn't be an option anymore. Traditional Medicaid could end up looking quite different; Trump and House Speaker Paul Ryan have proposed giving Medicaid money to states as a block grant.

Toni Lawson, vice president of government relations for the Idaho Hospital Association, suspects repealing the ACA is going to be harder than people think, given how many other states have already expanded Medicaid. She said she hopes whatever Idaho does, it’s something coordinated that encourages collaboration between providers, rather than “piecemealing small programs” in a way that makes a future comprehensive solution more difficult.

“The truth of the matter is, regardless of the outcome of the election, we still have thousands of Idahoans who can’t afford coverage and we need to find a way to deal with that,” she said.

A group of Idaho lawmakers who studied the issue over the interim wrapped up in late November by recommending "a policy to provide health care of some kind to the gap population should be enacted by the 2017 Legislature." But it decided against including much more specific recommendations on how this should look.

The work group did recommend that, if the Legislature opts to expand Medicaid, it should include a sunset clause if federal policy changes, and that any state-funded solution should include a primary and preventive care component and be paid for out of the state's general fund and the Millennium Fund.

Lawson said she's glad the lawmakers on the working group now know more about the issue, but she is worried the Legislature could pass something that addresses just primary care, which wouldn’t cover things such as surgeries and injuries.

“One concern we have (is) there seem to be a number of legislators who think that by simply addressing primary care, we will have solved the coverage issue,” Lawson said. “And that just, unfortunately, will still leave people in a coverage gap who are vulnerable to life’s happenings.”

The IHA is one of the organizations that is part of the Close the Gap coalition that has lobbied for Medicaid expansion. The group put out a statement in late November saying it is still committed to ensuring health coverage to those who lack it.

"Moving forward, Close the Gap will monitor and evaluate well-intentioned proposals and remain focused on gaining affordable, comprehensive coverage options for all Idahoans," the group said in a release.

Like everyone, Ryals doesn't know what will happen. Trump, she noted, has said he would repeal Obamacare and reduce other social programs. Ryals said she has no problem with restricting welfare benefits — she believes people ought to work for what they have — but there should be something for people who have chronic conditions, or who work but can't get coverage.

Ryals said even having just primary care coverage would help her, because she would be able to monitor her condition more consistently and reduce the likelihood of ending up in the emergency room with a massive bill.

"Keeping an eye on something, you're less likely to have surgery," she said. "You're more likely to have a better way of life if you can see your doctor regularly."

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