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When you can't afford to go to the emergency room: Michigan families and Medicaid

Kate Wells
Michigan Radio

For a lot of uninsured families in Michigan, this is a big week.

Lawmakers in Lansing are sloooowly moving ahead with expanding the state’s Medicaid program.

That would give another 470,000 Michiganders coverage.

So who exactly are we talking about here?

The morning I meet Jen and Todd Nagle, we have no clue the day will end with Todd being rushed to the doctor for chest pains.

He seems fine when we slide into a corner booth at the Farmer’s Café Restaurant in Carleton.

Todd is a pizza delivery man. Jen is a laid-off teacher. They both have college degrees. Now, Jen is substitute teaching whenever she can, and working odd jobs to fill in the gaps.

"I've worked at a gas station, construction sites. You know, McDonald's won't even call me back."

“I’ve worked at a gas station. Midnight (shifts). We’ve cleaned AT&T stores, overnights. I’ve pushed a broom at construction sites. I have my own small business sewing, doing alterations. You know, McDonald’s won’t even call me back,” she says.

Together, the couple says they made about $13,000 after taxes last year.

And what are they doing for health insurance?

“Nothing,” says Jen. “In terms of hospitalization, we got nothing. If I get hit by a bus, we’re screwed.”

What’s especially painful for Jen is that she knows one way she would be covered immediately: if she gets pregnant. The subject makes her eyes well up. 

“The only way I could be on Medicaid is if I’m pregnant. And we can’t afford having a child right now. And that…breaks my heart."

“And we can’t afford having a child right now," she says. "And that breaks my heart because I was hoping that we’d be able to start a family by now.”

The big picture

There are some 470,000 thousand people like the Nagles in Michigan right now.

And all of them could be covered if Michigan’s lawmakers raise the income cap on Medicaid just a little bit.

That would raise the income eligibility cutoff for a family of four from $23,000 a year to $31,000 a year. And it would expand to cover childless adults, like the Nagles.

Now, this was never supposed to even be a choice for states -- not if the Obama administration had their way. 

They wrote the Affordable Care Act so that all states had to expand Medicaid. They envisioned a bigger safety net for low-income families. Then anyone still making too much to qualify for Medicaid could potentially get help paying for insurance on the new healthcare exchange. 

That was the idea, anyway. But when the Supreme Court ruled that the Affordable Care Act -- also known as "Obamacare" -- is constitutional, they also said the federal government could not require states to expand Medicaid.

So now, it’s a state-by-state choice.

Lansing finally finds a compromise … maybe?

Clearly, the term “Medicaid expansion” is now politically synonymous with “Obamacare.”

Democrats love it. Republicans don’t. Same old battle lines.

Except Gov. Rick Snyder, a Republican, came out in strong support of expanding Medicaid.

He says it’s a common-sense move: the more people Medicaid covers, the fewer unpaid hospital and emergency room bills, which contribute to higher insurance premiums.

In the last few weeks before their summer break, it looks like Republicans in the Michigan House of Representatives are willing to play ball. But they have a few conditions.

Let’s play “Let’s Make a Deal”

To understand why, we called up Ari Adler. He’s the press secretary for Speaker of the House Jase Bolger, R-Marshall.

Tip: if Bolger ain’t happy, ain’t nobody happy. You need this guy’s ok to get anything done in Lansing.

So the fact that he’s on board at all is big.

Press secretary Adler says on the face of it, the deal sounds great: 

“The federal government has offered to fund the expansion at 100% for the first three years.”

After that, the federal subsidy scales back to 90%. Supporters of the expansion say even at 90%, the savings Michigan will realize by avoiding expensive emergency care will outweigh what the state has to kick in for Medicaid.

But Adler says there's not a lot of trust in the feds holding up their end of the bargain.

“When you deal with the federal government, it’s always a big 'if' as to whether they’re going to fulfill that agreement. And so what we were concerned about is that after a few years, the state taxpayers would be on the hook to pay for this.”

That's why some Republicans want a parachute clause.

House Republican Condition #1: the right to ditch this popsicle joint

“We would need to have some assurance that the savings … to the state exceeds any of the cost,” says Adler.

And if that doesn't pan out, House Republicans' proposal calls for booting those 470,000 new Medicaid patients back off the rolls.

House Republican Condition #2: down the road, things are gonna change

Republicans in the House also want new Medicaid recipients to kick in their own money.

Only if they’re not disabled, of course. And only four years down the road.

So we’re talking higher co-pays, higher deductibles, etc.

Democrats don’t like this idea. They say, look, these are folks who aren’t making much money to begin with -- squeezing them on health insurance doesn’t make sense.

Now, we wait.

But what if the federal government doesn’t want to accept these conditions?

Then no deal, according to Bolger’s office. Medicaid will remain status quo.

Really, it’s anybody’s guess as to whether the federal government will go along. What if other states say, oh hey, we would also like our own conditions? Or what if the feds are worried about handing over billions of dollars to Michigan up front, knowing that the state can back out later?

Of course, this is jumping ahead. Even if the Michigan House passes the Medicaid expansion bill, it still has to be approved in the Senate. Then Gov. Snyder has to ok it. And then we wait to hear from the federal government.

And while we’re waiting …    

A few hours after the Nagles and I leave the Carleton diner, I get a text message from Jen Nagle.

“So, remember what we said about one moment being all it takes to slide into financial ruin? Todd  is having chest pains and confessed to having them for a few days now. Now they’ve gotten worse. The [low-cost] clinic is telling him to go to the ER.”

“We are hoping it’s just stress … but don’t want a $10K ER bill to tell us that.”

So they make a call: go to Monroe’s only urgent care clinic. They pay for x-rays, and the doctor tells them Todd’s cold has turned into a nasty lung infection. He might be OK with just antibiotics. So the Nagles take the drugs and go home.

They decide to forego the ER. Without insurance, they just can’t afford it.

Kate Wells is a Peabody Award-winning journalist currently covering public health. She was a 2023 Pulitzer Prize finalist for her abortion coverage.
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