Betsy Russell reports every Tuesday morning at 9, they file in, some crying, some defiant – all with big medical bills they can’t pay, pleading with Kootenai County commissioners for help.

“It’s at times frustrating, and at times gut-wrenching,” said Commissioner Dan Green, “especially when I have people that really need the help and then they don’t qualify for the program. And then I see people that we are forced to help that think it’s some sort of entitlement.”

The emotional scene is played out in each of Idaho’s 44 counties, which state law makes the last resort for uninsured patients who can’t pay their medical bills.

Idaho’s unique system for paying the catastrophic medical bills of indigent patients – which relies solely on local property taxes and the state’s general fund – makes it the state that would possibly benefit the most from the expansion of Medicaid under the federal Affordable Care Act. The legislation would expand the federal-state medical insurance program for the poor to cover the same population that now is at the mercy of county commissioners, and do it almost entirely with federal money.

If Idaho were to replace its current system with a Medicaid expansion, the state and its property taxpayers could save hundreds of millions of dollars over the next six years, according to a Spokesman-Review analysis of current and projected costs.

But some prominent Idaho politicians already have come out against the move, saying they want no part of “Obamacare.” Idaho House Speaker Lawerence Denney and Majority Leader Mike Moyle wrote in an op-ed piece last month, “Resistance usually comes at a cost, but the state of Idaho must resist Obamacare. The cost of not resisting will be much higher.”

Gov. Butch Otter hasn’t yet decided; he’s instead waiting for the results of a working group that’s studying the issue.

House Minority Leader John Rusche, D-Lewiston, who is a retired physician, calls the decision a “no-brainer.”

He called Denney and Moyle’s stance a “political statement” that’s not “borne out in fact.” Rusche said, “A good business analysis will show that for the citizens of Idaho, there’s an advantage to the Medicaid expansion.”

Qualification based on incident, not income

Although 23 states make counties responsible for indigent patients’ medical bills, most handle that through county hospitals, which rely heavily on the Medicaid program as a main payer of the bills. Idaho doesn’t.

Washington handles health care for the poor at the state level.

Idaho also has a unique way of deciding who qualifies for its indigent care program: It’s not by income level. Instead, it’s by incident. If a patient has run up a hospital bill that the patient, tapping all his or her resources, can’t pay off in five years, the patient qualifies.

But as soon as a patient qualifies, the county slaps a lien on everything the patient owns in an attempt to recover the money. Although the money is supposed to be paid back, it seldom is.

“We only collect, I think, 10 to 12 percent of that money,” Green said. “It’s like trying to get blood out of a turnip, you know?”

Last year, Kootenai County spent $2 million in property tax funds on indigent medical care. Counties pay the first $11,000 of each bill, then the state’s Catastrophic Health Care Fund kicks in to pay the rest. Between the counties and the state, the program is expected to cost close to $60 million this year.

“People come in here with anything from something very minor to lung cancer or brain cancer,” Green said. “There are some very large bills. … They can be mental health issues, physical health … all of it.”

The commissioners only see those who are appealing a decision by county staff to deny benefits. The appeals, because they discuss people’s medical issues, are heard in closed session.

“It’s really tough,” said Tony Poinelli, deputy director of the Idaho Association of Counties. “It’s really hard to estimate what your costs are going to be.”

Because state law caps the growth in county property tax budgets at 3 percent a year, counties with unexpectedly large bills “have to borrow or steal from other funds in order to do it,” Poinelli said. “The other part is that medical costs have just continued to escalate.”

Some happy to see the program go

Counties had no state help with the costs until 1994, when the state catastrophic fund was created. “It’s one thing when your indigent care is setting a broken arm or something,” Rusche said. “But when you’re talking about cancer treatment, the costs get more and more and more.”

Costs for Idaho’s program ballooned over the past decade, jumping from $19 million in 2000 to $42 million in 2008. At that time, state lawmakers, led by Senate Finance Chairman Dean Cameron, R-Rupert, instituted major money-saving reforms in the program, including requiring every applicant first to be screened for Medicaid eligibility. Close to 10 percent qualified, diverting them out of the indigent program into one that’s 70 percent federally funded. Other changes diverted other patients into various new federally funded programs, but those are expiring in the next two years.

Growth slowed, but it’s now expected to start climbing again. “Unless we can come up with some kind of a rabbit out of a hat, we’re going to see some of the trends start going back up,” said Roger Christensen, a Bonneville County commissioner and chairman of the state’s Catastrophic Health Care Fund Board, which oversees the program.

“It’s a complicated system put together in law over years,” Christensen said. “It’s difficult to administer.” Christensen, who has served as a county commissioner for 18 years and headed the catastrophic fund board – an unpaid position – for five years, joked, “I get paid so well it won’t break my heart if I don’t have this job.”

Others also would be happy to see the program go. Steve Millard, president and CEO of the Idaho Hospital Association, said: “It’s a very complex program; there’s a lot of litigation involved and a lot of expense involved in its administration. We would be happy if something replaced it, sure. And so would the counties – I think we’re on the same page on that.”

Paul Beddoe, associate legislative director for the National Association of Counties, said states are “all over the map” in how they now handle health care costs for the uninsured poor, but said, “I have not heard of a system like Idaho’s.”

The impact of a Medicaid expansion – which the U.S. Supreme Court ruled in June is optional for states under the national health care reform law – will vary in every state, Beddoe said. But he said in states like Idaho, it’s important to have counties at the table, “speaking for the property taxpayers and really for the needs of the community.”

Sen. Joyce Broadsword, R-Sagle, is the vice chair of the Senate Health and Welfare Committee, but she’s leaving the Legislature after this year and running for a seat on the Bonner County Commission.

“I am in favor of expanding (Medicaid), mostly because we’ve got a huge population out there of uninsured that are putting off health care needs, especially catastrophic care, because they can’t afford to go to the doctor,” she said. “And if we can get people doing preventative care and going to the doctor early and catching melanomas before they’re bad enough to kill a person or go through major chemotherapy, if we can touch obesity before they develop diabetes or heart disease and get them on track to being healthy, it’s going to be, in the long run, a healthier population and a money-saver for the state’s accounts.”

Plus, she said, “As a potential county commissioner, I think it would be beneficial for my county. It could be a tax savings to the people of my county.”

Six-year cost of program: $436 million

The numbers are remarkable. Fund managers estimate Idaho will spend a projected $61 million next year on its catastrophic program for indigent medical care, roughly split between county property taxes and state general funds. With costs expected to escalate by at least 7 percent a year for the next six years, the total six-year cost for the program would be $436 million.

The Medicaid expansion would cover at least 90 percent of those currently using the catastrophic health care (CAT) program. Only those who make too much money to qualify for Medicaid, but who qualify for CAT because their medical bills are so high, wouldn’t be included. Over the six years, 90 percent of the cost comes to $393 million.

The Medicaid expansion would be 100 percent federally funded for the first three years: 2014 through 2016. The federal match would drop to 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and would be 90 percent in 2020 and beyond. The state would pick up the difference.

Taking into account all those percentages, Idaho would save $380 million over the next six years by replacing its indigent medical program with a Medicaid expansion.

A Kaiser Foundation study that estimated costs for all states of expanding Medicaid suggested Idaho would spend between $101 million and $133 million over the six years to expand its Medicaid program to more than 85,000 currently uninsured patients. That includes many beyond those eligible for the CAT program. But even by that estimate, the state would save at least $300 million compared to what it’s spending now from state and county funds on indigent care.

“Most of the cost of the new expansion will be borne by the federal government,” the Kaiser study concluded.

Christensen, the chairman of the catastrophic fund board, said he’s not wading into the political decision; he’s leaving that to state lawmakers. “All we can do is try to give the Legislature the idea of what the program will potentially cost, as realistically as we can,” he said. “Then those are the numbers they have to take and decide what’s best for the state of Idaho.”