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Over the past two years, Arkansas has seen the country's largest decline in its per capita number of uninsured residents. In mid-2013, according to a Gallup poll, 22.5 percent of adults in Arkansas were uninsured, the nation's second-highest rate after Texas. In mid-2015, Gallup found that only 9.1 percent of Arkansans over age 18 still lacked health insurance. That's a 60 percent drop.
The majority of those folks haven't had their lives saved by their new coverage. For most people, the immediate value of insurance is in peace of mind, access to exams and routine doctor visits. Still, sooner or later, they'll need their insurance for something serious, because sooner or later, almost everybody does.
Then there are those Arkansans for whom getting insurance — for the first time ever, in many cases — has genuinely transformed their lives. It's meant cancer screenings that have caught tumors while they were still manageable. It's meant necessary surgeries and treatment for mental illness. It's meant an end to rationing essential medication for asthma or arthritis or multiple sclerosis or hundreds of other ailments with sky-high prescription drug costs. That's why our Arkansan of the Year for 2015 isn't any one person, but the estimated 300,000 citizens in this state who have gained health insurance since 2013.
The ongoing sea change is the result of the Affordable Care Act. Or call it Obamacare, if you prefer. In addition to an array of other reforms, mandates and incentives, the 2010 law created two distinct means of helping Americans get insurance. First, for lower- to middle-income people, it made available a sliding scale of subsidies (in the form of tax credits) to help defray the cost of buying private insurance on a newly created marketplace, or exchange. Second, for individuals at the bottom of the income ladder, it expanded eligibility for Medicaid.
In 2012, the U.S. Supreme Court said that states, which administer Medicaid programs, had the power to reject this second piece if they wished. Eager to take a stand against Obamacare, every Southern state did just that, with two exceptions: Arkansas and Kentucky (which has seen the nation's second highest drop in the uninsured). Thanks to former Democratic Gov. Mike Beebe and a group of pragmatic Republicans in the state legislature, the Arkansas Medicaid expansion was authorized in 2013. The state took a novel approach, using the federal money to buy private insurance policies for most beneficiaries rather than covering them with Medicaid directly. The private option, as the policy became known, was the subject of rancorous fights among Arkansas Republicans in 2013 and again in 2014, when the legislature reauthorized its funding by the narrowest of margins.
In 2015, though, the reauthorization passed easily, and it now seems likely it's here to stay. Republican Gov. Asa Hutchinson may not have approved the Medicaid expansion if he had been sitting in the governor's office in 2013, but he's inherited the private option and now wants to keep it in place. Taking away insurance from hundreds of thousands of Arkansans would be politically treacherous, to put it mildly. Also, shutting down the flow of federal Medicaid dollars would blow a hole in the state budget: According to a consultant hired by the legislature, the private option will save Arkansas $438 million between 2017 and 2021, on net.
Hutchinson wants to make the private option more conservative, with more cost sharing from beneficiaries and punitive measures if people don't make their co-pays. (He's also striving to rebrand things: It's not "the private option" anymore, but "Arkansas Works.") Last summer, his administration kicked tens of thousands of people off their insurance as part of an error-ridden and unnecessarily harsh process to redetermine eligibility.
Such changes matter, and the Times will continue to follow them in detail in the coming months. However, it's equally important to step back from the policy machinery and take a look at the larger triumph: Piece by piece, bit by bit, lower income Arkansans are gaining access to health care. Here are a few of their stories.
Anita Bacon grew up on a dairy farm in the Appalachian foothills of the northeast corner of Alabama, 23 miles from the Tennessee line. That may be why she and her husband, Cory, decided on a whim to settle down in Madison County while passing through Arkansas nine years ago.
"Basically, God brought us here," the 40-year-old mother of one said recently. "Led to come and led to stay. My husband fell in love with the place, and how can you not? Right in the middle of the Ozark Mountains and you've got a creek running through your property."
He worked as a carpenter, she cleaned houses, and six years ago they opened a restaurant called Backwoods BBQ, in the remote hamlet of St. Paul, pop. 113.
But by that point, Bacon's health had started to fail, with one ominous diagnosis arriving after another. First she discovered she had rheumatoid arthritis, then ulcerative colitis, a severe autoimmune disorder of the gastrointestinal tract, akin to Crohn's disease.
"The insurance plans that my husband and I looked at were well above our budget," Bacon said. "Between working, buying our own food and paying our own way, we lived week to week with hardly any savings, like most Americans."
A few years ago, a free clinic in Fayetteville discovered precancerous polyps in her colon, news that demanded further tests of her gastrointestinal tract. The clinic performed a lower GI series — a diagnostic exam of the large intestine — but Bacon and her husband had to pay out of pocket for the upper GI series.
"You had to give them $800 down," she recalled. "And, you know, it's just something to me when someone is bleeding on the inside and they're saying, 'You got to give me $800 first.' You got to go and try to make that money, and try to eat Pepcid and Tums and Pepto-Bismol, and you're vomiting, and you can't even hold down water. And ... you go to the ER to get hydrated. And you get a $1,500 bill. It's a circus.
"I begged and made payments and got a lot of threatening letters. I ate less and tried to work a little more."
Even so, when Bacon was told she would be eligible for Medicaid, she was reluctant to enroll. "I was dead set against it. I was!" she said with a chuckle. "I'd heard all this bad stuff. But then when I researched it myself ... I had to weigh it at that point."
Karen Reynolds, a nurse practitioner who runs a clinic in Elkins and who is Bacon's primary care provider, helped to convince her otherwise. "Karen does a notch above to help," Bacon said. "She's taken her own time to help me — to help me find medication, to find referrals." The free clinic in Fayetteville also encouraged her. "The doctors were like, 'You need it. There ain't no shame in it. You've worked your whole life.' "
Which was true, she realized. "I've had to work dairy farming seven days a week for 10 years. I started out when I was 15 years old. I've worked my whole life and I've paid in, you know? And I've never walked on a line of trying to have any help. I just wasn't brought up that way. You work two jobs if you couldn't make it. ... I watched my daddy work three jobs and die with hardly nothing. ... And that's hard to swallow, you know?
"Life is tough. You shell out all your money, and you go through days of excruciating pain to try to make it, and all the doctors want to do is give you a prescription and move on. ... Pain pills and antibiotics and all that. ... They won't do any testing on you unless you have insurance."
Bacon signed up for Medicaid a year ago, in January 2015. (Because of her chronic conditions, she was routed into the traditional Medicaid program, rather than a private plan.)
"I know people have different opinions [on the health care law]," she said, "but the insurance overall has been a blessing to me and my husband. ... I was just able to have an upper and lower GI done. I had to have an ultrasound done on my stomach. I've had some procedures done that I would never have had done before." Between illness and various losses in her family life, Bacon has struggled with depression and anxiety; fortunately, the insurance pays for mental health care. "I've been able to get help for that, too."
It's the drug coverage, though, that's made the biggest difference. Before she got insured, she said, "the prescriptions for the rheumatoid arthritis — at Harp's [Pharmacy] they'd run me a tab. ... It's the only way we could do it. It was $200 a month, and I could only buy five pills at a time. Then I'd skip two days and go buy five more. I did that a lot, and I cried a lot. But we got through it.
"I think we went through the bad to get here. And everything ain't just great and dandy and dandelions growing, you know, but I'm grateful. I am. ... You may not have everything you want, but you have everything you need."
Along with the prescriptions and procedures, Bacon says, she tries hard to lead a healthy lifestyle to manage her conditions. "You walk and juice and you do all these things to try to get better. ... I try to keep myself at a weight that's easier on my joints and stuff. So I'm very aware of my part in this whole ordeal."
"It's been a hard road," she said, her voice breaking slightly. "I didn't even have to take a Tylenol till I was 23 years old. I was never sick. I worked hard."
She has no doubt the insurance has been a great help , but she's still not sure what to make of the bitter political debate around health care reform, which seems so disconnected from the reality of her day-to-day struggle.
"I don't know if everything is right or wrong about this situation. You can't even really talk about this to people, 'cause they'll start arguing with you. ... But, I think, I can jump in there and say, 'If you need help, this is what I did.' It's tough when you're a person with no insurance.
"But, I'd rather have no insurance and be healthy, to be honest with you."
On Jan. 25, 2012, George Coleman lay in bed in his North Little Rock home, preparing himself for death.
He was in the grip of an asthma attack, but that in itself was nothing new. Coleman said his chronic respiratory problems date back to the 16 years he spent working at a now-shuttered plant in North Little Rock called Chicopee Inc., where his regular duties included sweeping out the ventilation system on an industrial oven. What made this time different was that he'd run out of medicine: To clear his lungs, Coleman depends on Symbicort, a prescription inhaler that can cost over $300 for a month's supply. He'd been out for several weeks at that point.
"When you don't have any oxygen in your body, you can't even move. You're froze. You're paralyzed," Coleman said. "I had pretty much accepted the fact that my time on this earth wasn't long.
"I'm a spiritual person, and I asked God for just enough time for me to make my will out. Give me the opportunity to tell my mama I love her just one more time. It felt like at that moment I was given that extra measure of strength to get up and go work enough to buy this medicine. But I thought it was over. I did."
For a decade and a half, Coleman, now 55, has made his living driving a cab. He went without insurance for years, paying for medication out-of-pocket, but it was a tenuous situation. "I was just showing up enough to pay for the cab and make a little money to buy medicine," he recalled; he relied on his savings to pay other living expenses. "It was becoming difficult to even get a doctor to respond to my phone calls when I needed a prescription filled."
In 2013, Coleman managed to get insured through his employer. Coverage was dropped, but around the same time, in January 2014, the private option kicked in. Coleman was one of the first in line to sign up.
"I think it's the greatest thing since sliced bread. It's probably saved my life, to be honest with you," he said.
Opponents of the Affordable Care Act often caricature Obamacare beneficiaries as idle welfare recipients in search of a handout. Coleman's story shows that narrative isn't just wrong-headed — in many cases, it's exactly backward. Access to health care can allow people to work who otherwise would have been driven out of the labor force by illness.
"My spirits lifted up because I felt like I would be able to still be part of the working class. It's in my blood to work," Coleman said. "I have been working since I was 11 years old. I grew up in the heart of Lonoke County, on a farm on [Highway] 232. ... I chopped cotton, I baled hay, I hauled wood for four different families in the wintertime. I washed cars, raked leaves, cut grass. ... My parents picked the check up and used it to support the family."
Health insurance wasn't an option back then. "My daddy was paid $90 a week and my mama was paid $15 a week. There were six of us in that house, plus my mom and my dad. My daddy, he didn't get past grade school, and neither did my mother. ... It's not that we're not hard-working people, but the system hadn't progressed or advanced enough so that families like mine could be covered. There was no way in the world my father could have covered us on $90 a week.
"I've never been fired from a job, and I've had some real tough jobs in my life. ... I've been working for 44 years, and my body is beginning to show the wear and tear of working. And you know, I love this country as much as anybody, and I'm as proud of this country as much as anybody, but ... to live in a country where I have to choose between living and dying, because my medicine is too expensive to afford? To me, it's just troubling. Disturbing. I don't understand how people don't want other people to be treated like they want to be treated."
Three days after that asthma attack in 2012, on Jan. 28, Coleman's youngest grandson was born. "If someone had told me I had four more years to live right then? Man, I would've done anything ... . Thank God for this medicine." The past four years, he said, "were probably the best of my life." He's since been able to resume full-time work.
Lately, he's facing a new wrinkle. Coleman's insurance carrier, BlueCross BlueShield, says it will no longer pay for Symbicort. Though BCBS will cover a similar asthma drug called Advair, Coleman is worried that it won't work as well. "They've switched medicines before, and they don't act the same," he said. "I've got enough [Symbicort] to last me for about another three months." Before that supply runs out, he's looking into switching carriers; the thought of facing another asthma attack without his trusted medication is too grim.
"There's nothing worse than not being able to breathe. Nothing. I've had broken bones, pneumonia, chest pains, back pains, toothaches, you name it — there's nothing worse. I pray to God all the time that when I die, it's not from my asthma."
For Coleman, it's a reminder that the Affordable Care Act hasn't fixed everything wrong with the U.S. health care system.
"The thing about America is — this is the one country that doesn't negotiate with [drug manufacturers] to the point where they can make sure the prices don't get out of hand," he said. Indeed, according to a 2013 New York Times report, a month's supply of Advair in the U.S. costs seven times as much as it does in France, where the government caps wholesale pharmaceutical prices.
Meanwhile, talk about rolling back Obamacare unnerves him. "I don't see how you can be the leader of the free world and not provide health care. If that's the direction our politicians want to go in, I feel like you are putting the American public at risk."
"Martin Luther King used to quote John Donne: 'No man is an island unto himself.' You know, what affects you affects me. ... I think many people are starved as far as their understanding about how mankind should try to treat mankind. We're all in this thing together. And I think this health care plan is a step in the right direction."
The average high school senior isn't too worried about insurance coverage, but for Fairfield Bay native Crystal Bles, it was a priority.
When Bles began studying welding last fall at the University of Arkansas Community College at Morrilton, she was on the verge of aging out of ARKids, the state's program covering low- to middle-income children. (ARKids is mostly paid for with federal dollars, but the funding streams are distinct from those fueling Obamacare.) While many young adults now rely on their parents' insurance to stay covered until age 26 — thanks to another change created by the Affordable Care Act — Bles' parents were uninsured.
"When I turned 18, I had to pay for certain prescriptions," Bles told the Times. "And then they sent me another letter in the mail when I turned 19, and said, hey, at this date you're kicked off of your insurance."
She "most definitely" knew she needed coverage, she said, given her chosen area of study. "In welding, people tend to get injured."
A problem arose with her application for private option coverage — Bles said she's not sure what went wrong — and she was initially denied. But in December, she sought help from the University of Arkansas for Medical Sciences. With the assistance of UAMS, she enrolled in a plan that covers her ongoing prescription needs (an inhaler, allergy medications and birth control) and also allowed her to get a minor but necessary surgery taken care of. Now recovered from surgery, she's back in school full time and has resumed working part time at the Walmart in Conway.
After graduating from Morrilton's one-year welding program this spring, Bles plans to continue studying the trade in Omaha, Neb. "I've always been kind of hands-on and artistic, and, well, I've always been told artists can't make very much money. So I figured that if I went into welding I could make a good living and still be able to do art with it — making furniture or rails, or gates, or sculpture," she said.
What would she have done without the program? "I probably would have been one of those people who would have gone without [insurance], because I really don't think I could have afforded it," she said.
One thing for Bles to consider, then: Nebraska, like 18 other states as of January 2016, has not expanded Medicaid to cover low-income adults as the Affordable Care Act envisioned. Last spring, the Nebraska legislature considered a bill that would have created a modified expansion program much like Arkansas's private option, providing insurance to some 54,000 Nebraskans. It was defeated.
For young Arkansans like Bles, the private option has already become a fact of life — a vital government service, funded by taxpayers and provided for taxpayers, just like public schools and food stamps, highways and Pell grants, law enforcement and libraries. Unlike so many other Southern and Western states that have refused to expand Medicaid, Arkansas has guaranteed that most of its young people exiting ARKids at age 19 will have access to health insurance if they can't otherwise obtain it. Assuming the Affordable Care Act remains substantially intact — itself an open question that depends on the results of this November's elections — the days in which being uninsured was the rule rather than the exception in many Arkansas communities may be coming to an end.
Sometimes there seem to be a thousand reasons to be angry, appalled or just plain saddened by Arkansas and its politics. The fact of the Medicaid expansion — or the private option, or Obamacare, or whatever one calls it — gives about 300,000 reasons to have some sense of pride in what the state, under the right circumstances, can actually accomplish.
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