Ada County refused to pay for some indigent medical care. This is what happened next
Idaho’s two major hospital systems won court cases last month against counties that refused to pay the hospitals’ full bills for indigent patients.
In two Idaho Supreme Court cases, Saint Alphonsus Health System won a dispute with Ada County, and St. Luke’s Health System won a case against Gem County, home of Emmett.
Saint Alphonsus and St. Luke’s Health System, both based in Boise, were involved in cases in 2017, where two Idaho counties denied paying the full amount of an indigent patient’s care. If the county indigent fund program were to continue in its current form, the two cases would have provided clarity for counties and hospitals on how to handle indigent cases, the two hospital systems said. However, the new law limits those who qualify for the program.
In Idaho, when someone has a medical emergency, emergency services staffers and hospital staffers are required to take care of them. If the patient does not have health insurance, the hospital can apply to the county to be paid for the services provided to indigent patients. If the county finds the patient eligible, the county pays the first $11,000 of the medical bills. The state pays the rest.
The Ada County commissioners declined to pay the full cost of Saint Alphonsus’ care for an indigent patient in 2017. The commissioners said the services the patient received after Oct. 11, 2017, were “not medically necessary … because the patient was clearly ready for transfer to … rehabilitation, but had no funding.”
Saint Alphonsus challenged the rejection in court. District Judge Peter Barton in Boise reversed that determination, saying that the services were necessary because the patient needed rehabilitation, but nothing was available, therefore the hospital remained the “medically necessary” place for the patient. The state Supreme Court upheld the lower court’s ruling.
Saint Alphonsus, St. Luke’s on patient discharges
In an emailed statement, Saint Alphonsus said it is pleased with the decision and said it provides guidance to Idaho counties and hospitals when it comes to indigent care. Saint Alphonsus noted that the case specifically addresses guidance in cases where the patient’s condition or resources prevent the patient’s discharge from in-patient care to home or to another facility for care.
An identical determination was made in St. Luke’s Heath System vs. Board of Commissioners of Gem County.
The Gem County commissioners found that the second part of a patient’s stay in the hospital system was not “the most cost-effective service.” The district court sided with the commissioners, but the Supreme Court reversed the decision.
The county had found that the patient could be cared for in a rehabilitation facility, but none was able to take the patient at the time, said Christine Neuhoff, senior vice president and chief legal officer for St. Luke’s. It was not reasonable to compare cost effectiveness to something that was not available, Neuhoff said.
“If that arises in other indigent cases in the future, it is now clear that the county cannot compare acute care with care that is not actually available to the patient,” she said in a virtual interview.
She said it is not uncommon for a patient to be ready for discharge to a different level of care but not be ready to go home.
“It is hard to place patients who are on government plans or who are indigent into the lower levels of care, because some of those facilities are not available,” Neuhoff said. And even when they are, some facilities are unable to meet the needs of many patients, she said.
Poor patients must sign up for Medicaid or private insurance
The court decisions were long-awaited, but Neuhoff said they won’t really make much difference in the long run. That is because of House Bill 316, now law, that will limit who is eligible to have bills paid under the county and state indigent-care programs.
The law, which takes effect next March, says that someone who qualifies for Medicaid or private insurance on the state-run health exchange will no longer be eligible for county indigent care or its companion, the state Catastrophic Health Program. They must have Medicaid or private insurance instead.
As a result, far fewer patient bills will be paid under the indigent-care system.
The bill is in part a response to Idaho voters’ 2018 decision to expand Medicaid eligibility.
“The idea behind this is: Every Idahoan, whether you qualify for Medicaid or you qualify for a subsidy on the insurance exchange, has access to affordable health insurance and in essence, it becomes a lifestyle decision,” said Seth Grigg, executive director of the Idaho Association of Counties, in a committee hearing during the legislative session. “If you decide not to purchase subsidized insurance, you are making that decision. The question arises: Is it fair for the taxpayers to pay for that lifestyle decision?”
The indigent program does not give free money to patients unable to pay their medical bills, Grigg said. A patient is expected to pay back both the county and state for covering the cost when possible. A lien is placed on the patient’s house if the patient has one, Grigg said, and on a monthly basis the patient is expected to repay.
Nonetheless, some patients are unable to repay. Indigent care costs state and county governments millions of dollars each year.
State, county savings to be used for public health
The rollback of the indigent program will save counties money. So the bill also eliminated state funding to public health districts, replacing it with county funding with the expectation that indigent-care funds would be rerouted to funding public health districts.
The new law would save the state money, too. Money now spent on the catastrophic care program will be put toward Medicaid.
When Idaho voters authorized Medicaid expansion, they made Medicaid available to households whose income is up to 138% of the federal poverty level. Tens of thousands of Idahoans have signed up since the expansion took effect in November 2019.
Medicaid provides health coverage to low-income adults, children, pregnant women, elderly adults and people with disabilities.
Medicaid is funded mostly by the federal government and administered by states. According to Brian Whitlock, president of the Idaho Hospital Association, Idaho pays 10% of the cost of Medicaid and the federal government covers the rest. The state is responsible for an estimated $68 million.
According to the Kaiser Family Foundation, in 2019 about 10% of Idahoans were uninsured.
Undocumented immigrants remain eligible for indigent care
The new law does not repeal the county indigent or state catastrophic programs, Grigg said in an email. There still may be people who meet eligibility requirements for them and aren’t on Medicaid or insurance. Grigg said one such population is undocumented Idaho residents.
“Under law, the county and state programs will reimburse costs associated with stabilizing those individuals,” Grigg said.
If an undocumented individual is involved in an accident, they will receive necessary care from a hospital in Idaho. If they are unable to pay immediately, they would qualify for the indigent medical program and the state program. They would be required to pay the funds back.
Other people may fall through the Medicaid and private-insurance cracks, too, Whitlock said. For example, if someone has an employer-sponsored health plan that offers family coverage, that person’s spouse and children are not eligible for a subsidized plan on the health exchange.
“The challenge is in some cases for an employee that has health coverage, bringing their spouse and kids into that plan may be cost-prohibitive,” Whitlock said. “They could be looking at $1,000 or $1,500 a month to bring a spouse on, that is not affordable. You are going to have people who can’t afford it and who are ineligible to buy insurance through the exchange.”
When someone in that situation ends up in the emergency room, hospitals are legally required to care for them.
Medicaid expansion, new law affect charity care
Whitlock said the hospitals can absorb those costs through their charity care programs, or if a patient is unable to pay at all, the costs would be counted as bad debt.
In 2019, Idaho hospitals provided $361 million in uncompensated care, according to Whitlock. He expects the number to be lower in 2020 because of Medicaid expansion. But the decline will be offset by an estimate $40 million in annual costs to the hospitals under the new law, he said.
In 2019, Idaho had 2,189 indigent claims for physical health and 2,359 for mental health. Whitlock said claims for physical health have been decreasing, but mental health claims have been increasing.
In fiscal year 2020, the average indigent payment from the program was $9,046, Whitlock said.
In 2022, counties will save an estimated $6 million in indigent fund expenses, according to the new law’s fiscal impact statement. The funding to public health districts would be an estimated $4.9 million. In 2023 and beyond, counties will save an estimated $12 million per year in indigent fund expenses.
Whitlock said doctors and hospital staff have been working with uninsured patients they’ve seen to talk to them about their options and sign them up for Medicaid if they ask.
When Whitlock testified during the committee hearing, he was neither for nor against the bill. He did ask the committee to extend the timing before the bill comes into effect until after open enrollment.
“If the state is going to ask every Idahoan to be responsible for their own coverage, give them a chance to sign up,” he said.
Eventually lawmakers agreed and amended the bill to go into effect March 1, 2022.
How to get help paying medical bills
Medicaid: You can review Medicaid information and sign up through the Idaho Department of Health and Welfare at healthandwelfare.idaho.gov/services-programs/medicaid-health.
Health insurance: To shop for insurance through the state-run health exchange, Your Health Idaho, people can visit yourhealthidaho.org. Your Health Idaho is the only place where you can get a subsidy, in the form of a tax credit, to help pay your monthly health insurance bill.
St. Luke’s Health System provides financial aid for patients who meet certain qualifications and need help paying for some or all of their emergency care. Visit stlukesonline.org/resources/before-your-visit/financial-care, or call 208-706-2333.
Saint Alphonsus Health System offers the same service. Find it at saintalphonsus.org/for-patients/after-your-visit/financial-services/financial-assistance, or call 208-367-2130.
West Valley Medical Center in Caldwell offers assistance to patients who have received non-elective care, who do not meet qualifications for Medicaid, and whose income is less than 200% of the federal poverty level. Visit westvalleymedctr.com/patient-financial/charity-policy.
Rachel Spacek covers western Ada and eastern Canyon counties. Have a story suggestion or a question? Email Spacek at rspacek@idahostatesman.com.
