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Arkansas's working poor are hoping the state says yes to expansion 

Melissa Farrell was at the end of her rope several years ago, battling a drug addiction and unable to find a job. Along with her two children, she checked herself into Our House, a Little Rock shelter that provides housing and job training. Today, she has a job and an apartment, and she's been clean for more than two years.

"I still live one day at a time," she told me when I visited her recently in her east Little Rock apartment. "I crossed a lot of barriers. Not everybody gets to do what I've done. It's by the grace of God."

When I asked her what prompted her to turn her life around, her son Kaleb happened to come in the room and joined her on the couch. "There's one," she said. "Where's the other?" Her daughter Zadie came in and sat down next to them.

Farrell put her arms around her children. "That's why we had to do better," she said.

With little education and a felony arrest in her background, it wasn't easy, but she was willing to work. While at Our House, she got her high-school diploma and got her conviction expunged. Initially unable to find a job, she started working through a paid internship program at Our House that features on-the-job training to gain work experience. The stipend was $500 a month. In an unusual turn, she convinced Our House to hire her to work a weekend shift as shelter supervisor at minimum wage, on top of her internship. She would eagerly volunteer to cover for folks and pick up extra hours, thankful for the opportunity to work. She still can't believe "the blessings that God gave me there at that place."

But once she started working, Farrell lost her health care because her income was almost three times too high to qualify for Medicaid in Arkansas. How much did she make that first year that booted her off the rolls? Around $9,000.

"I try to be self-sufficient," she said. "You're damned if you do, damned if you don't."

Arkansas has the second stingiest Medicaid program in the nation, and many low-income parents find themselves in a position like Farrell's: uninsured and too poor to purchase their own health insurance or health care but not poor enough to qualify for Medicaid in the state. Farrell had knee surgery while she still had coverage but lost it before she could start her physical therapy. She paid for one visit out of pocket. "They had some compassionate people that tried to teach me what to do at home," she said. "But I probably need physical therapy."

Nowadays she works just under 40 hours a week in a supervisory role at a residential rehab center. She makes $8 an hour and gets no benefits. Paying the bills and providing for two kids, she doesn't have money left over for private insurance. "There's no way," she said. "I'm doing good to get by."

She avoids seeking any sort of medical care because of cost concerns. If she ever had a major health issue, "I'd just have to go to the emergency room. And then they tell you to follow up with your primary care physician. But I can't afford that."

Farrell, a working mother of two struggling to make ends meet, is the sort of person who stands to gain health insurance if the Arkansas legislature is willing to accept federal money to expand coverage. (Arkansas already offers insurance to children in poverty, through the ARKids program.) I asked what it would mean to her. "Wow," she said. "It would take a lot of stress off of me to start with. I'm 44 years old and I have little kids to get grown. It's hard to plan the future with the uncertainty." She told me she worries about not being able to have routine checkups. And she worries about what would happen if she had a medical problem that she couldn't afford to treat. "I could be right back where I started."

Health care reform in general, and Medicaid expansion in particular, is a complicated issue. There are a lot of moving parts. A lot of numbers, a lot of projections. Policy wonks trade charts and graphs and fight over solutions. It can get confusing, and you'd be forgiven for throwing up your hands.

But it's important to remember that this is an issue that has a real impact on real people, people like Farrell. One in four Arkansans between the ages of 19 and 64 does not have health insurance. There are honest disagreements about the best way to address that, or even whether to address it at all. Nothing you read about Melissa, or anyone else among the more than 200,000 people that would gain coverage under expansion, can resolve any of that. But surely our debate on this issue will be wiser if we hear their stories.

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Rep. John Burris (R-Harrison) recently tweeted, "The debate about expansion is not about working poor." The truth is more complicated.

Yes, unemployed adults without income would gain coverage if the state opted for Medicaid expansion. But there are tens of thousands of working Arkansans in the coverage gap between the stingy eligibility lines in the current Medicaid program and the 100 percent federal poverty line (above which folks will be eligible for subsidized insurance on the healthcare exchange even if the state doesn't expand). People like Farrell. People like Charles Lott, whose family of four lives on an income of $23,000 a year.

"Everyone I've talked to on the subject, unless they've gone through it themselves, they don't understand what the Medicaid situation in Arkansas is," Lott said. "It's wonderful that we have ARKids that covers kids. But we have such a lacking Medicaid program other than that."

Let's take a look at just who qualifies now for Medicaid in Arkansas. There are a few nuances not fully elaborated here, but the following paints the general picture for non-disabled, non-pregnant adults.

First off, childless adults, no matter how poor, are not currently eligible for Medicaid in the state. If you're an individual without kids and no income, or make less than $11,000, there will be no coverage if the state turns down expansion.

For parents, if you make more than 17 percent of federal poverty level (FPL), your income is too high to qualify. For a family of two, that's 17 percent of $15,510, or around $2,600 a year. For a family of four, that's 17 percent of $23,550, or $4,000.

If Arkansas chooses not to expand, people above 100 percent of the federal poverty level would be eligible for subsidized, low-premium insurance on the healthcare exchange. If you're a parent anywhere in between 17 and 100 percent — like Farrell and Lott — you're out of luck.

One of the most frustrating aspects of the current system is that parents are actually discouraged from working and trying to better their situation. Rick Wells makes $8 an hour working in a retail store to support his 13-year-old son and his fiancee, who is pregnant. Unable to afford private insurance but above the income line for Medicaid, he believes that the current system "essentially says, unless I'm going for welfare, I can't have medical coverage. It's either stop working and be a lazy schmuck or you won't have any medical coverage at all. I find this ridiculous. I'm trying to support my family and do things right.

"It's not like I'm trying to live off the system ... the system tries to direct me to be a welfare case. It's actually forcing me to go in that direction. I don't want to be that type of person. I try to avoid any government help as much as I possibly can. We're talking health here."

Wells has multiple reccurring health problems that have hospitalized him in the past, but said that seeking care "is not an option. I cannot seek medical help unless it's an emergency. Making enough money to support myself and my family is complicated enough, let alone things like medical bills."

"We're worried, that's an understatement," he said. "I can't explain to you my stress level every day. If something happens to me, if I'm going to be able to afford it, if I'm going to lose everything."

Like Wells, Charles Lott knows that fear. Around five years ago, complications from his wife's diabetes led to multiple hospitalizations. She was unable to work. Because of her medical situation, they were desperate to maintain insurance, and tried to keep up with premiums they couldn't afford. Out-of-pocket costs came on top of that. They tried to keep up with medical bills with credit cards, but eventually they couldn't make ends meet and had to file for bankruptcy.

They've gotten back on their feet, but what would happen if a medical problem cropped up for Lott, who is uninsured? "I don't know," he said. "We've talked about it. There's not a whole lot of options."

I asked Lott what he would tell lawmakers trying to decide what to do about expansion. "If you're getting federal funding," he said, "if you have the chance to take tax money that has been paid in by higher-income states to assist you in paying for costs for health care for the citizens in your state, which is lower-income, than saying no means you're condemning them to have medical problems that aren't being treated. It doesn't seem appropriate."

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Claudia Reynolds-LeBlanc has only one kidney, which she says has made her uninsurable since she was a little girl. "I can't be touched by an insurance company with a 10-foot pole," she said. She's periodically had coverage if she was working for a company that provided it to all employees, but she now works a retail job part-time because she is assisting in the education of her son, who has a neurological disorder and is unable to attend a traditional school.

"I have to dedicate a lot of time to him," she said. "Being a single parent, it limits what you can do in order to take care of your child."

The Affordable Care Act's reforms will keep insurance companies from discriminating against people like Reynolds-LeBlanc with pre-existing conditions, but she'll still likely fall in the coverage gap if Arkansas doesn't go forward with expansion.

She hasn't been to a doctor in years, and says she feels like she's "playing a gamble game." Back in 2000, she suffered major system organ failure due to sepsis and her organs are now stuck together by scar tissue. Pain is a daily struggle, and she should be under a doctor's care.

"I can't overemphasize how difficult it is for a person to need to see a doctor and they can't afford to get there," she said. If she has further health problems that demand attention, she said, "I'd be up a creek without a paddle, and do a lot of praying."

She worries that her son will find himself in the same trap. He's already had a surgery for his rare disorder, a brain malformation, when he was a young boy. He may need another operation in the future. "From a mother's perspective — he is on ARKids, but what happens when he turns 19? I think he's going to have the academic scores to go to college. But then if he has to have surgery and he doesn't have medical coverage."

Reynolds-LeBlanc said she would consider trying to move to another state that offered coverage expansion if Arkansas fails to. "I just can't see staying in a state if they can't take care of their people," she said. "It's the moral thing to do."

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Melissa Farrell is hoping to go to school to become a drug counselor and help folks in the same situation that she has managed to struggle out of.

Several times she mentioned the slogan of recovery: "one day at a time." She's tough — you can see right away the dogged resolve that allowed her to buck the odds and build a life for herself. She's matter-of-fact in tone, but quick to smile. Her kids are polite, quiet at first but they warmed up quickly. Who knows what's to come, but spend a little time with the Farrells and you can't help but feel hopeful. You can't help but feel inspired.

The legislature is giving signals that it's more open to expansion now that the feds have given the state the option of doing it via private insurance companies on the healthcare exchange. Premiums would be paid by the government. Farrell told me that it didn't make any difference to her whether it was private coverage or public coverage, she was just hoping for something.

"You'd have a lot healthier people that could live a little longer," she said. "Everybody needs to see a doctor, especially at my age." Laughing, she added, "But I quit smoking cigarettes and I quit doing drugs and I quit drinking, so that gives me a little bit more leeway."

"You worry, 'what would I do if I get sick?' " she said. "It would take the worries away."

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