Left out — health reform bypasses some immigrants, resort workers

By Katie Kerwin McCrimmon

GLENWOOD SPRINGS The young couple faced a tough choice: have their first baby in their hometown in Colorados priciest mountain resort area or travel instead to Mexico City.

Because the 23-year-old woman was uninsured and an undocumented immigrant during her pregnancy, the birth in Colorado would have cost the couple thousands of dollars out of pocket.

The womans 27-year-old husband is a U.S. citizen who grew up in Illinois, but works in Glenwood Springs, the bustling city where many service workers live about 40 miles down valley from ritzy Aspen. He gets insurance through his job, but it doesnt cover his wife and therefore excluded her pregnancy and the birth.

The young woman is one of a few hundred thousand Coloradans who could be left out as the Affordable Care Act kicks in starting on Oct. 1.

Undocumented immigrants cannot apply for any federal subsidies through health exchanges across the U.S., so many will continue to go without health care until they have an emergency. Then theyll get care in the most expensive setting a hospital emergency department. The Colorado Center on Law and Policy estimated in an April report that about 180,000 undocumented immigrants live in Colorado.

Others who need health reform the most may not get it

Resorts: most uninsured, priciest health costs

Resort communities from Aspen to Vail and Summit County have the highest number of uninsured people in the state, according to various studies including the Colorado Health Access Survey (CHAS). Conducted by the Colorado Health Institute and The Colorado Trust, the most recent CHAS survey estimates that nearly 24 percent of people in the mountain resort counties are uninsured. Thats twice as many as the number of uninsured in some counties along the Front Range, where many more workers get health insurance with their jobs.

The CHAS estimate may be low. Another recent study ranked Eagle and Garfield counties as two of the 50 worst counties in the U.S. for high numbers of uninsured. That study estimated that closer to 30 percent of workers living near swanky Vail, Beaver Creek and Aspen have no health insurance. (Click here to read Richest resort counties rank worst for health care.)

Overall in Colorado, new U.S. Census data released this week show that more than 700,000 of Colorados 5.1 million residents are uninsured, a rate of nearly 15 percent for 2011-12.

Even after Oct. 1, when Colorados health exchange is slated to open with the goal of covering more Coloradans, nothing will change for many people.

Workers who are U.S. citizens can apply for federal subsidies. But many may not qualify or may not want to pay the high cost of health insurance. In resort towns, workers often have multiple jobs in order to afford high rents, pushed up by wealthy second-home owners and tourists. Few of these jobs in the service sector come with heath insurance.

Under the exchange, health coverage guides will calculate subsidies based on income. Resort workers could appear to have high incomes that prevent them from qualifying for subsidies when in fact they may be earning just enough to cover housing expenses, food and child care.

Many may choose to pay a penalty rather than buy health insurance. Mountain resort workers also face a double whammy. While qualifying for subsidies could be tough, the rates for health plans under the exchange will be highest in resort areas. (Click here to read Rates higher in resort areas, college towns.)

For the 23-year-old pregnant woman, the only choice that made sense was to leave Glenwood Springs and return temporarily to Mexico.

Years earlier, she had entered the U.S. on a tourist visa and stayed too long. So, she wasnt here legally even though she had married a U.S. citizen. Ironically, because they were married, she also couldnt qualify for prenatal care offered through resort hospitals to single pregnant women, even those who are undocumented.

So at five months pregnant last year, the young woman went to Mexico City so she could apply for a proper visa and save money by having her baby there instead.

I needed to stay here because of work, said the husband, who asked that their names not be used.

Separated for months, the couple reunited for the birth in Mexico, then made plans to return to jobs in Garfield County.

In order to bring his wife back on a legal visa, the husband had to promise the U.S. government in writing that his wife would not apply for any taxpayer-funded services like Medicaid or the new federal rebates that will be offered through the exchange.

The birth went well and their son is now a healthy 5-month-old. The infant doesnt have health insurance yet, but as a U.S. citizen, he will be eligible and his dad plans to apply soon. The boys mother now works as a babysitter, a job that comes with no health insurance. Her prospects will change little as health reform begins to go into full effect in 2014.

We worry and try to stay healthy, the husband said.

Eventually, theyd like to have more children, but footing the bill could be impossible unless one of them gets a health plan that covers prenatal care.

Thats another thing we worry about. Were thinking of having more, but we have it on hold, the husband said.

Hes considering joining the Marines where he assumes theyd get better health coverage. Until then, he wonders why undocumented workers are left out.

Were all human beings.

Community health centers expand to cover uninsured

While many of the uninsured in Colorados mountain communities may not get coverage through the new health exchange, they have another avenue to seek care: a network of safety net clinics that are part of Colorados Community Health Centers.

At Mountain Family Health Centers, CEO Ross Brooks is committed to providing primary care immediately to any patient who walks in the door. Unlike many urban areas of Colorado, there is no waiting list to be seen at Mountain Family. For urgent matters, patients often can get in on the same day. For other appointments, providers will usually see patients within a week.

We serve all patients regardless of ability to pay, regardless of documentation status. We believe health care is a human right. TB, pregnancy and swine flu dont care about your documentation status. Its our moral job to serve them, said Brooks.

With little advertising, Mountain Family is seeing a steady spike in demand and over the last two years has opened two new clinics: one in Basalt closer to Aspen, and another that offers dental services along with medical care about 27 miles west of Glenwood Springs in Rifle. All three clinics cater to service industry workers and in Rifle, many clients work in the oil fields of western Colorado.

Mountain Family has a fourth clinic in Blackhawk on the eastern side of the Continental Divide that was its first clinic. Prior to the 1990s, there were no community health centers in western Colorado, Brooks said. Mountain Family saw a need, expanded west, opened the Glenwood clinic in 1999 and has seen demand climb from about 8,700 individual patients in 2008 to more than 13,000 anticipated this year.

Expansion will continue. Mountain Family is negotiating to open a new clinic in Edwards close to Beaver Creek in Eagle County.

We know theres high demand. We intend to try to meet that demand, Brooks said. I havent totally pooh-poohed the health insurance exchange. But, I think that for a decent number of people, its going to be unaffordable and many people are going to take the penalty.

That could be the case for Rosie Aguilar, who is considering opting out.

Aguilar is well educated on health issues. She used to be a medical assistant at Mountain Family and now works for a neurologist in the area. Her employer offered health coverage, but Aguilar declined since it would have cost her about $600 per paycheck to cover her family. Her husband is a chef at a restaurant and also runs a catering business. He has no insurance through his job.

Aguilar recently brought her 4-year-old daughter, Arianna, to Mountain Family for a check-up. She pays out of pocket for her visits based on her income. While there, Aguilar shared her views on purchasing health insurance.

I have been researching it a little bit, said Aguilar.

Its still iffy. Im not 100 percent sure if we are going to pick up a plan. There are high deductibles and co-pays, Aguilar said. For my well-child checkup, I was able to pay out of pocket. I dont have any health insurance or dental or vision. But it seems cheaper to pay out of pocket. When you dont have pre-existing conditions and youre healthy, insurance is just a little overrated.

Aguilar likes the cost calculator on the Connect for Health Colorado website, but sees insurance as out of reach for her family.

We pay high prices for everything here. Were renters. Food costs are high and child care is up there as well, she said. I cant afford to take something out of my paycheck thats as big as car insurance, which we have to have.

Some of Aspens ski bums also may take a pass.

A man named Scott, who preferred not to give his last name, visited Mountain Family recently to see his nurse practitioner. Hes a big supporter of Obamacare and wishes that Congress had gone even further by creating a single payer system. Now 57, and in the midst of a transitioning between careers, Scotts not sure hell be able to afford any health coverage. Like many residents in this area, he hadnt yet heard of Connect for Health.

Scott came to Aspen back in the 1970s and except for some adventures out of the country, hes lived in the area ever since. Trained in economics, hes done everything from finance to custom woodworking and construction.

He says hes been lucky with his health. But about 7 months ago, he hurt his knee when a couple of dogs wrapped their leashes around his leg and he took an awkward fall. He thinks he might have torn a ligament, but hasnt had an X-ray or an MRI yet.

As wonderful and as loving as they are at this place (Mountain Family) they cant do anything major. Im not covered for specialty care, he said.

He said the inequities in the Roaring Fork Valley make it very difficult for workers.

We have such an impoverished labor base working for the top 1 percenters, he said.

Scott worries that the young ski bums coming to Aspen today will skip buying health insurance and will get into trouble that they cant afford.

The people who came in the 70s were an educated group who could afford to take care of ourselves, Scott said. Everybody could afford their own shenanigans.

Medicaid expansion may boost coverage more than exchange

Throughout the Mountain Family network of clinics, as of last year, about 46 percent of patients were uninsured. That means they pay for their care out of pocket. Depending on income, a visit can cost as little as $10 or as much as $120. Similar services at private practices in the Roaring Fork Valley can cost up to three times as much.

About 19 percent of Mountain Family patients had private health insurance last year and 25 percent had Medicaid, the public health insurance program for low-income people. The rest either were older people who qualified for Medicare or children who receive coverage through the Childrens Health Plan.

With so much anticipation of changes coming in 2014, CEO Ross Brooks doesnt expect a major increase in the percentage of patients who will have private insurance. He has joined a consortium of groups in Eagle, Garfield and Pitkin counties who are working together to offer outreach to patients. And Mountain Family will provide space to health coverage guides who will help enroll people in the health plans through the exchange.

Still, Brooks is projecting that the number of patients with private health insurance will grow only a bit from 19 percent in 2012 to 24 percent in 2014.

Health coverage guides will sit right next to financial counselors who can enroll people in Medicaid. Thanks to Colorados decision to expand Medicaid to many more low-income adults, Brooks is anticipating that the percentage of Mountain Family patients who qualify for Medicaid will jump from 25 percent last year to 35 percent next year.

It turns out that the biggest impact of health reform in this area could come from Medicaid expansion, not from the creation of the new health exchange.

While many private doctors will no longer take new patients who have Medicaid or Medicare, reimbursements from the government are critical to Mountain Family while caring for low-income workers is central to its mission.

Its a delicate balance to have almost half your patients be low-income, self-insured people, Brooks said.

In order to survive, the clinics must rely on philanthropy along with government payers.

Valley View Hospital donates 10,000 square feet of space for the Glenwood clinic, while Aspen Valley provides space for the much smaller clinic in Basalt, which doubles as a hospital urgent care clinic at night.

In Rifle, Mountain Family had to pay for its new clinic there which proudly boasts 5 dental chairs. But specialists at Rifles hospital are providing some discounted consultations with patients who have cancer or other diseases that require specialty care.

Mountain Family is boosting its in-house behavioral health care and is participating in a pilot program that aims to change the way providers get paid. That system rewards providers for keeping patients well rather than for coming in when theyre sick.

For now, however, fee-for-service is the model that governs reimbursements, so providers have to hustle to see at least 20 patients a day.

Its the unfortunate part of fee-for-service. We dont get paid for quality or value. We get paid for volume. We get paid for encounters. Thats the way we keep the doors open, Brooks said.

For patients, the care is warm, welcoming and culturally sensitive. About half of the patients speak a language other than English, mostly Spanish. More than half of providers also are bilingual and the clinic works on issues like transportation that can be a challenge for low-income people.

Providers dont know and dont care whether patients have proper documents to be in the U.S. Thats a question that comes up only when financial counselors try to help people enroll in Medicaid, a program, that, like the health exchange, requires proof of citizenship or legal residency.

For people left out of health reform either because they are ineligible or because insurance costs too much Mountain Family intends to keep providing patients with a health home.

Theres a fairly high trust level among the low-income, undocumented population. In part, thats because they dont have a lot of other choices, said Brooks.

The bottom line is that its a lot cheaper to receive prevention and good primary care than to show up in the hospital really sick. Its cheaper for the individual. Its cheaper for society as a whole. And its better for these individuals to have an ounce of prevention.