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TWIN FALLS • Because Idaho has not expanded Medicaid, the bills of some poor people who get into accidents or have health emergencies are covered under a decades-old system where county taxpayers pick up the first $11,000 and the state Catastrophic Health Care Program pays the remainder.

Beneficiaries have to pay some of the cost back, to the extent they can, and counties lien people’s property and require monthly payments. The repayments, though, don’t come close to covering the cost of the program.

Twin Falls County has a contract with St. Luke’s that caps the county’s payments to St. Luke’s at $1 million a year, refunding to the county anything paid to St. Luke’s above that amount. The county has budgeted $3.4 million total for indigent care this year, which represents about 8 percent of the total county budget.

So how does the system work?

The Number of Cases

CAT fund spending has been dropping, from $35 million in 2011 to just $22 million budgeted for the upcoming year, which state officials have credited to people enrolling in the state exchange. Looking at the local numbers for just the past two-and-a-half years, the picture is more muddled, and some counties saw spikes in applications and spending in the 2015 fiscal year. Minidoka County, for example, approved 55 applications in 2014 and 63 in 2015, while Gooding County saw a spike from 41 in 2014 to 62 in 2015 but has only approved 19 applications so far this year.

Excluding Lincoln and Cassia counties, which reported their numbers in a slightly different format that makes an apples-to-apples comparison difficult, and Jerome County, which didn’t respond to a records requests, the other five Magic Valley counties approved 528 medical assistance cases in the 2014 fiscal year, 519 in 2015 and have approved 256 so far this year. The counties’ fiscal year goes through September. By far, the biggest chunk come from Twin Falls County, which approved 405 applications for medical assistance in the 2014 fiscal year, 369 in 2015 and 204 so far this year.

Decline Started in 2010

Cases started to drop in 2010, when the federal government began to enroll people in the Pre-existing Condition Insurance Plan as a stopgap between the passage of the Affordable Care Act and the plans in the exchanges taking effect in 2014, said Minidoka County Clerk Patty Temple and Twin Falls County Commissioner Terry Kramer.

After that, Kramer said, some people who might have applied for indigent assistance otherwise got their health care covered through the state exchange. Also, the state Department of Health and Welfare started to screen assistance applicants to see if they are eligible for Medicaid. According to the state’s numbers, 10 percent of applicants for assistance ended up qualifying for Medicaid in the second half of 2015.

Despite this, Kramer said, costs haven’t dropped much, because medical expenses have gone up and the county has been seeing more mental-health cases. Looking at just the local portion, Twin Falls County taxpayers paid $2.2 million in the 2014 fiscal year, $1.7 million in 2015, and $907,000 so far this year, which puts the county on track to spend a bit less than what was budgeted if the number of applications doesn’t spike.

The Number of Uninsured Has Dropped

According to U.S. Census Bureau data, 13.6 percent of Idahoans were uninsured in 2014, compared to 23.6 percent in 2010. Enroll America, a group that works to enroll more people in Affordable Care Act insurance, estimated the percentage of uninsured in Idaho was 17.9 percent in 2013 and 11.8 percent in 2015.

There were more than 102,000 people enrolled in the state exchange in February, according to a news release from Your Health Idaho. Also, even though Idaho hasn’t expanded Medicaid eligibility, enrollment in that program spiked a few years ago, with 25,000 more people signing up between September 2013 and January 2015. It has stabilized now, and was at almost 289,000 in January 2016.

Even though the number of uninsured has dropped, the number of indigent care cases has stayed pretty stable, said Mike Rawdan, senior director of revenue cycle at St. Luke’s Health System. He thinks this is because the group of people who typically receive county and state help with their bills tend to be poorer than the people who are getting signed up for the exchange.

“I think that’s the biggest challenge when you’re trying to compare these populations,” he said.

It’s Still Higher in Idaho

That 13.6 percent uninsured in 2014 was the 11th-highest rate of uninsured residents out of the 50 states plus Washington, D.C., Texas was highest at 19 percent, Massachusetts lowest at 3.3 percent. The national average was 11.7 percent.

And It’s Even Higher in the Magic Valley

Jerome and Minidoka counties had the third and fourth-highest rates of uninsured in the state according to Enroll America’s 2015 data, at 17 percent and 16 percent of all residents, respectively. Hispanic men aged 18 to 34 have the highest uninsured rates — 26 percent of them lacked health insurance in Idaho in 2015 — which could factor into this. Every county in the Magic Valley except for Blaine, where 10 percent of residents were uninsured, has an uninsured rate higher than the state average — 16 percent in Gooding and Lincoln counties, 15 percent in Twin Falls and Cassia counties and 14 percent in Camas County.

Who Gets Indigent Assistance?

Not everyone who applies. From July 1, 2014, to today, Cassia County approved 30 percent of applications for medical assistance. In 2014, Minidoka County approved 45 percent of applications, Gooding County approved 28 percent and Blaine County approved 36 percent. So far this year, those three counties have approved 40 percent, 30 percent, and 32 percent of applications, respectively.

Most people who get help, Kramer said, fall into the “Medicaid gap,” where they don’t qualify for Medicaid but make less than the poverty level, the threshold to qualify for tax credits to buy insurance on the exchange.

“We do have a few people who, through their own decision, have chosen not to get insurance, wanted to play the game,” Kramer said. “But a majority of those people don’t have the income where they would qualify for the subsidies.”

Counties looks at someone’s income and assets and also take into account what they might need for food, lodging, transportation and other basic needs before deciding to grant an application, and the counties ask for documentation of expenses when appropriate. An application is granted if, after all this is taken into account, a person wouldn’t be able to pay for their treatment costs within five years, Kramer said.

The process can take a long time, Rawdan said, and generally starts when a patient comes in and, they find out, can’t pay their bills. The health care providers then talk about a patient’s options with them, and he said county assistance is supposed to be the option of last resort.

Some people get rejected because they don’t meet the income criteria, but many, Rawdan said, are turned down because the county or state doesn’t agree with the hospital that a procedure was medically necessary. In those cases, the hospital sometimes pays if the patient can’t.

“The vast majority (of them) would fall under the guidelines of financial charity care,” Rawdan said.

What Kind of Problems Do They Have?

Kramer said they fall into two main categories — a smaller group who need one-time help with something like a broken leg, a car accident or a gall bladder problem, and a larger one with ongoing problems such as mental-health issues, alcohol or drug abuse, or chronic conditions like diabetes, heart disease or cancer.

“You have the chronic illness person who will have case after case after case that we see,” he said.

One solution Kramer has mulled for the long-term cases is for the county to buy them insurance. But, he said, this would require a change in state law.

“There would have to be a change in the indigent law that would allow us to first rate patients based on health care needs and then create a threshold,” he said.

Rawdan said many patients who end up getting government help come into the system by going to the emergency room. Many then need surgery for something and then inpatient care. Cancer patients also commonly end up receiving either charity from the hospital or county aid, Rawdan said.

“Those treatment plans are very, very expensive,” he said.

What Do They Pay?

“I don’t think the general public realizes that this is not a free ride,” Kramer said.

For example, someone with an outstanding indigent fund bill can’t sell their house or buy a new one without permission, because the county puts a lien on it.

“It’s an intrusive kind of a situation for these people,” Kramer said. “It is not free.”

Twin Falls County requires a minimum repayment of $25 a month, even for people who have absolutely no assets or money, on the off-chance that they hit the lottery or get an inheritance. People who can pay but don’t can be sent to collections, unless they negotiate or show extenuating circumstances.

A few years ago, Twin Falls County instituted a program where people who owe money voluntarily give up half their federal income tax return, said Commissioner Leon Mills, which has boosted the amount people are paying back. In 2015, the county received $673,374 in repayments from indigent assistance beneficiaries and sent another $299,377 in repayments on to the state, county Clerk Kristina Glascock said. As of Friday, the county had gotten $233,158 in repayments this year and sent another $134,143 back to the state.

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