There are three simple rules to avoid health care costs in America: Don’t get hurt. Don’t get sick. Don’t age. Simple? Yes. Possible? No. For many poor people and families in Crawford County who can’t meet those impossible standards, the costs of health care can be a barrier to necessary treatment. In 2010, 15.3 percent of county residents delayed seeking health treatment because they couldn’t afford it, according to data from the Centers for Disease Control and Prevention. But it also costs too much to be poor. There are any number of studies that show the poor are more likely to be sicker. According to one study, being poor is worse for a person’s health than either smoking or obesity. Health insurance can help address some of those costs. But that’s not always available or affordable. Of course, there have been attempts to help make health insurance accessible and affordable. Simply naming the legislation tends to give the topic a political spin. Further, state politics has its own, perhaps just as significant, effect on health care for the poor. Fortunately, despite the many challenges to getting health care, there are opportunities for the local poor to get assistance for care when they seek it.

Poorer and Sicker

The easiest way to explain how poverty affects health is a Columbia University study from 2010. Those who make up to twice the federal poverty level (which would be $23,340 for one person or $47,700 for a family of four) see 8.2 fewer years of good health than others. That’s eight years of good health wiped away by poverty. By comparison, obesity causes a 4.2-year loss in good health while smokers lose 6.6 years. The study said poverty is the biggest negative factor in health. Those who are poor are more likely to have asthma. They’re more likely to have diabetes, and more likely to have more serious issues with diabetes. They’re more likely to have parasites, more likely to be exposed to lead paint, more likely to have untreated cavities, more likely to smoke, more likely to have mental health issues, more likely to have heart disease and more. “Poverty and depression go hand in hand,” said Krista Postai, executive director of Community Health Center-Southeast Kansas. “We know that leads to shorter lives... Which comes first, the poverty or the severe illness?” One study, by the University of Georgia, shows that poverty directly causes high levels of stress hormones, high blood pressure, and a higher body mass index for kids and teens growing up in poverty. Those factors, they say, put them at greater risk for other health conditions sooner rather than later. Another study by Washington University in St. Louis indicates that poverty is a stronger and more persistent risk factor than exposure to war for veterans. Further, about half of those who experience poverty for at least one year have at least one disability. If the poverty remains for three out of four years, the number rises to two-thirds of adults, according to the Center for Economic and Policy Research. An additional problem is that the poor tend to put off treatment, which means diseases are often more severe than if health care had been sought earlier. “Poverty itself directly affects health. If you have no money for a doctor, you’ll put it off until there’s a crisis. By then, it’s a pay-me-now or pay-me-later situation. If you don’t get a small issue taken care of, it leads to a larger issue,” said Janis Goedeke, County Health Officer. “It’s a cycle effect. You don’t go to the doctor because you can’t afford it, and it worsens until it’s a major health issue.” There are any number of local anecdotes to support the delayed-care hypothesis. “We had a person with broken shoulders who didn’t seek help for two months because they couldn’t afford access to care. They didn’t have the means to follow up. We know it happens,” Postai said. “We had a farmer with no insurance, who was of humble means, who put off coming to see us until he couldn’t get out of his chair anymore. He was in the final stages of cancer. Lack of resources has a huge impact.”

Costs of Health

According to the CDC in 2010, almost one in six Crawford County residents (15.3 percent) did not seek health care because they couldn’t afford it. Who can blame them? If an average visit to a doctor’s office costs about $75 without insurance, that’s more than 10 hours of working at minimum wage, roughly a quarter of a typical, 40-hour work week. That’s for the most basic of services — a simple doctor’s visit. The costs skyrocket for anything more than that. The costs for a person with Type I diabetes is estimated at $2,100 each year. Without health insurance, the average cost of a broken leg is more than $10,000. An X-ray costs, on average, $210. The average cost per child for asthma is just shy of $800. An average hospital stay can cost $10,000, according to one study. Lung cancer can cost, on average, about $60,500 each year, according to the National Cancer Institute. [Information in the last two paragraphs found through, which gathered study details from a variety of sources.] Often, the emergency room can become a primary care center for those without insurance. “Some are apprehensive to get help when they feel ill. By the time you present yourself in the ER, you are sicker,” said Michael Hayslip, Via Christi Hospital public relations director. “It takes longer to take care of you because you are sicker. The longer you wait, the sicker you get, and the longer it takes to treat you.” With the costs of health care high and getting higher, health insurance is important, as it lowers many of the costs of health care. Recent Census data shows one in five county adults under age 65 don’t have health insurance. “It may be about $75 to walk into a doctor’s office,” Goedeke said. “If they have insurance, they may have a copay of $20. But that’s just the tip of the iceberg,” Goedeke said. “The doctor may send them to a pharmacy for medications that are expensive, and they can’t afford that.” In fact, even for those with health insurance, the premiums, co-pays, and other costs quickly add up. The federal government predicts out-of-pocket health care expenses will reach $3,301 for each household with health insurance. That number does not include premiums, either. The $3,301 is roughly 11.5 weeks of working 40 hours a week at the federal minimum wage with no taxes taken out.

Pharmacies, too

Dentists, pharmacists, optometrists and other health professionals see their own effects from poverty. Taking just one aspect — pharmacists — gives a better perspective of the costs and challenges of the poor. “Mostly what I see is the working poor. They are working, but they can’t get insurance through their employer or they don’t qualify yet. They fall into the gap,” said Laurie Graham, Arma Drug owner/pharmacist. After making a visit to the doctor’s office or ER, often the next step is to pick up a prescription, whether for blood pressure, antibiotics, or mental health. But medications don’t come without a cost of their own. “A lot of times, people literally can’t afford them. A lot of times, we’ll see people turn around and walk out without paying for it. We try working with their doctor to find cheaper alternatives,” Graham said. “We see it most with antibiotics to fight infection. A lot of them are really expensive and people can’t afford it. We may have to go with something cheaper hoping it will work as well.” Most of the time, she said, the cheaper alternative does the trick. On occasion, a person may return for a different drug. Many pharmacies on the national and local levels have introduced lists of drugs that can be bought for less than $10. Target and Walmart list blood thinners, prostate drugs, blood pressure drugs, anti-inflammatory drugs, arthritis drugs, diabetes drugs, pain killers, muscle relaxants and more among their medicines available for $4 for a 30-day supply. Graham has a similar program, with an “extensive” list of $5 drugs. That’s just one way pharmacies can work to try to mitigate the cost of needed medicines. “We steer people toward those. We also go online with the manufacturer. A lot of times they have patient-assistance programs. If the patient fills out paperwork, and the doctor does, too, they can get a free or reduced cost if they qualify,” Graham said. But it’s not always the case that medication can be found at a lower cost. The cost of medication and treatment can often force a “Sophie’s Choice” for those who are just getting by. “We have people with hypertension who don’t have enough money to afford medicine. They have to choose between food and medicine,” Postai said. “It can be $600-800 a month for medications for some. If it’s food or medication, people choose food first. It’s a hard decision when your income is limited.” Some react to that forced decision by attempting to make their medicine last longer. That may mean fewer benefits of the drug at all. “A lot of times, we see people take a one-month supply, and stretch it into two months. We see that happen quite a bit,” Graham said. “It’s not ideal. The choices are between gas and food and medication. You have to do it to make it stretch.”

KanCare and Obamacare

Clearly, the costs are a large barrier to health for many who are at or near the poverty line. In theory, there are federal and state programs to help with these costs. In practice, there are many people who don’t qualify for these programs because they — quite simply — don’t make enough money. Perhaps the biggest, most well-known such program is the Affordable Care Act, aka Obamacare. Part of Obamacare is the creation of health insurance “marketplaces” that allow most people who don’t get health insurance through their work to purchase health insurance. In Crawford County, the cost of health insurance for an average 30-year-old adult through the Kansas marketplace falls between a low of $195.71 and a high of $236.74 per month. To help offset these costs, those that make between 100-400 percent of the federal poverty rate receive a tax credit through the ACA. For those between 100-133 percent of the federal poverty rate, premiums are limited to 2 percent of their income. On a state level, the debate about the ACA comes from another provision. The ACA provides incentive for states to expand Medicaid coverage for those making up to 133 percent of the federal poverty line. The federal government will pay 100 percent of the costs of Medicaid expansion for the first three years, dropping to 90 percent of the costs of expansion for every year after 2020. The Supreme Court, in its major Obamacare ruling, included a provision that states did not have to be compelled to expand Medicaid and accept the federal funds. They had the option of whether to expand Medicaid or not. Kansas was among the 24 states that chose not to do so. That has created a gap, because KanCare (state Medicaid) doesn’t cover everyone. It covers those over 65 and disabled. It covers those with tuberculosis or the blind. It covers pregnant women and children. It does not individuals under the federal poverty level ($11,490 a year) who don’t have kids. It does not cover most parents under the poverty level except for those who make less than $7,770 a year for a family of four (the poverty level for a family of four is $23,550). “We found, in Southeast Kansas, that more were not eligible for the marketplaces because we’re too poor,” Postai said. “Medicaid expansion, because of the state option to not expand, has left a huge population of individuals who don’t qualify. Expanding Medicaid is considered, for able-bodied individuals, as a handout. The assumption is that if you’re working, you have access to health care. That’s not true. A lot work for cash or are day laborers. There’s a huge gap. SEK is a poster child for the gap. If you make less than $12,000, you can’t shop on the marketplace. That means waitresses, convenience store clerks and students are left in the dark.” Postai said that although the kids may qualify for coverage through KanCare, the parents might not. She said a family unit should be considered. “Healthy parents raise health children,” she said. “Sick parents are trying to raise healthy children.” Through the ACA, Postai said she has seen a slight decrease in the number of uninsured, largely those above the federal poverty line and those who had pre-existing conditions and did not qualify for health insurance before the ACA. Also, she said she’s seen more college students, as those up to age 26 are allowed to stay on their parents’ coverage. Goedeke said a large percentage of the patients they see are on Medicaid at the CCHD. However, this is where the other problems of poverty — food, transportation, housing — can factor in. We see Medicaid people. We have had a few we’ve got on the ACA. That’s not the majority of our population. The majority are on Medicaid,” Goedeke said. “Medicaid allows those who qualify with access to health care. It helps, but then you’re into the transportation barrier. That’s a lot of it, even though they have the Medicaid card. A lot of it is just the knowledge to make health choices.” She described two groups of people in Medicaid — those who have trouble navigating the health care system and those who “use it very readily.” “We have some who don’t know how to advocate for themselves. Even though they have a card, some can do it very well, and others are not sure what to do with it,” Goedeke said. Via Christi Hospital has taken a position when it comes to Medicaid expansion in Kansas. They’re all for it. “As with any program, we’ve seen the positives and some of the drawbacks. The most important thing we’ve experienced is advocating for the expanded Medicaid state coverage in Kansas,” said Michael Hayslip, Via Christi public relations director. “When we look at the uninsured and underinsured people in Southeast Kansas and the Four States, we vehementlly advocate expanded services for insurance for those in the state of Kansas.”

Helping Hands

There are some signs that things are improving just a little bit. The county’s health outcomes were ranked 77th out of 98 counties with data available in the state this year. That may sound bad, but that’s actually an improvement over the last several years. The county was 81st in 2013, 88th in 2012 and 89th in 2011. “The community is eager to make changes,” Goedeke said. “We’re seeing more of a community-wide effort to change the poverty level in Southeast Kansas, which will help us here in Crawford County. That includes Project 17 and health assessments.” Goedeke talked about the countywide effort to address social issues with families. Further, those in poverty are not turned away for most locations when they seek health care. At Via Christi, Hayslip said that the hospital spends an estimated $17 million a year on “community benefit.” That includes $3.5 million in unreimbursed Medicaid costs, $4 million in direct financial assistance and $10 million in costs not covered for services rendered. “We would never deny coverage to anybody without the ability to pay. We want to do our best with financial assistance. We encourage everybody to apply for assistance. We don’t want people thinking they can’t come to the hospital because they can’t afford it,” Hayslip said. The CHC-SEK is also a resource for those who need help. According to financial assistance forms on the CHC-SEK website, a family of four making less than $28,620 a year or an individual making less than $14,000 could get medical services for $15, mental health care for $25, and dental care for $35. The cost scale slides more based on income. Pharmacy services are available for little or no cost depending on the drug and the patient’s income level/family size. Other services and resources are available throughout the county. But sometimes, people don’t seek such resources because of varying reasons, like pride or the lack of desire to leave work for health care for themselves or their children. Pride can be a factor when it comes to available programs and resources. “A lot of times, people are not going to a doctor when they need to. The assumption is they can’t afford office visits and medications,” said Laurie Graham, Arma Drug. “There are programs out there, but a lot are too proud to go through those. A lot of people are underserved. Sometimes, you don’t want a handout. There are some people like that.”