Medicaid Stories: A Front-Line View

Medicaid helps, but getting it can be hard

Enlarge By Tim Dillon, USA TODAY Mike and Phyllis Zolotorow are among the approximately 50 million people who qualify for assistance through Medicaid. Because their son, Craig, is medically disabled, he qualifies for his own health insurance through Medicaid. By Julie Appleby USA TODAY March 15, 2007 Things started spiraling down for Phyllis and Mike Zolotorow after he severely injured his bicep and shoulder in December 2003 while working as a shipping and receiving clerk. After Mike spent a year on disability recovering from two surgeries, his employer dropped his health insurance. The couple were offered a chance to continue the employer insurance through a federal law known as COBRA, but Phyllis says it would have cost upward of $700 a month. "It was something so ridiculous, we could not afford it," she says. "We had used up most of our savings." But not long after, Mike suffered a massive heart attack, leaving the 52-year-old disabled and living on Social Security income. FIND MORE STORIES IN: Medicare | Medicaid | Craig Now, the Zolotorows are among the approximately 50 million people who qualify for assistance through Medicaid, a $313 billion-a-year federal-state program that provides health care coverage for low-income pregnant women, children, the disabled, some adults and many of the nation's nursing home residents. Despite its wide reach, the program is not an all-encompassing safety net. While the Zolotorows qualify as poor — his annual Social Security income of $11,280 puts them below this year's $13,690 federal poverty level for a couple — they earn too much to qualify for full assistance through their state's Medicaid program. They may have coverage in some months, but not others. And, because of complicated rules, they must actually go into debt before Medicaid kicks in. Because states have flexibility in designing their Medicaid programs, eligibility rules vary by state. Coverage also depends on income, family size, employment status and whether an applicant is disabled or elderly. In the past few years, with enrollment increasing and state budgets under pressure, many states cut back Medicaid eligibility. But an improving economy boosted state revenues last year and also slowed the growth of enrollment for the first time since 1999, according to an analysis by the Kaiser Family Foundation, a non-partisan research group. This year, 26 states plan to restore cuts, expand eligibility or make other changes, the report says. Still, eligibility varies widely. In eight states, working, non-disabled parents in a family of three could qualify for full Medicaid assistance with an annual income of more than $33,000, according to data gathered by the Kaiser Family Foundation. Yet, in nine other states, parents in a three-person household would be disqualified with annual incomes between $3,000 and $6,000. Rules for the disabled also vary. Single adults who never had children or have none living at home fare worst of all: Only 17 states offer coverage at all, and most provide only limited benefits to childless adults, Kaiser data show. "We do not have a safety net of health insurance coverage in this country," says Alan Weil, executive director of the National Academy for State Health Policy, non-profit, non-partisan organization of state policymakers. "Where you live, your family structure and the nature of your illness determines what it is you're going to get." A labyrinth of rules The Zolotorows illustrate the complexity of those rules. They are eligible for partial coverage from Medicare, but only in six-month increments — and only if they amass medical bills equal to 56% of their income. Here's how it works for the Zolotorows: The monthly income limit in Maryland for full assistance for a couple in their situation is $392 a month, according to documents given to the family by the Howard County Department of Social Services. Because Mike's Social Security checks total $940 a month, they must "spend down" the difference, or $528, minus an allowance of $20. For "spend down" purposes, the Zolotorows don't actually have to pay all the bills, but they must owe the money to doctors and hospitals. The amount is then multiplied by six, to get a six-month total: $3,168, or 56% of their income. Once they accumulate that debt, Medicaid kicks in. "They will cover things 100%, but only two to three months out of every six," says Phyllis, 55. "So we'll never get out of debt." She estimates they owe several thousand dollars at the moment. 'You're having the big one' Mike, who spent much of his career as an equipment manager for local baseball, soccer and basketball teams, was rushed by ambulance to the hospital in September 2005, barely able to breathe. "You're having the big one," he recalls paramedics telling him. Once at the hospital, cardiologist Martin Albornoz could not believe he was still alive. "He had the arteries of an 80-year-old," says Albornoz, who was able to put in a stent to prop open Mike's blocked artery. Later, he was transferred to another hospital, where he underwent a cardiac bypass operation last March. A few days before his heart attack, Mike was on a walk when he felt so ill, he had to call his wife to come pick him up. But, lacking insurance, he refused her pleas to go the emergency room because he knew it would be costly. The couple know how important health insurance is, as their son, Craig, was diagnosed as a toddler with a type of immune system disease which leaves him vulnerable to infections. Now 22, Craig also suffers from seizures and takes medication for high blood pressure and bipolar disorder. He developed a kind of cancer, Hodgkin's disease, at 10. Coping with the intricacies of all of Craig's illnesses led Phyllis to quit her part-time job at a florist at a Giant supermarket in 1999 to help care for him. Craig lives with his parents in their two-bedroom rented apartment and works part time as a photo technician at a CVS store. Because he is medically disabled, he qualifies for his own health insurance through Medicaid, which covers his medical visits and the seven medications he takes each day. Filing for legal separation At the time of his cancer in 1995, Craig was covered by insurance from Phyllis' job, but his medical care over the next two years tapped out the insurance plan's $250,000 lifetime cap on benefits, Phyllis says. Between her part-time job at Giant and Mike's job, the couple made too much for Craig to qualify for Medicaid. So Phyllis filed for a legal separation from her husband — and Craig then qualified for Medicaid based on her income alone. After Craig turned 19 three years ago, the couple dropped the legal separation. When Mike had his heart attack, the hospital helped him sign up for Medicaid, which covered the $64,000 hospital charge. He gets his most expensive drug, a $400-a-month heart treatment, free from the manufacturer through an assistance program. And his doctor has helped him switch to low-cost generics for many of the rest of the 12 drugs he takes each day. In about six months, the mandatory two-year waiting period for the disabled to qualify for Medicare will be up, and he will have health coverage through that federal program. The couple praise the medical care they've been given, even as they worry about the future. "It's an excellent program, if you can stay in it," says Phyllis of the state's Medicaid program. Mike's cardiologist says he treats a number of uninsured patients. "It seems that the people who need insurance are the ones who can't get it. It's most common among the working poor," Albornoz says. "They have a job, but insurance is a luxury they can't afford. Then they get sick." Mike, Albornoz says, is recovering and is now able to walk 2 miles a day. But his severe heart disease means he will never be able hold a job that requires regular physical demands. If Mike had been insured, Albornoz says, he would have been more able to afford to come in for tests and may have learned earlier that he had heart disease, before the heart attack that disabled him.