Beronice Archuleta drives along the narrow road that winds through the mountains to Lumberton, where a couple handful of homes are scattered. She turns down a gravel road on the outskirts of the Jicarilla Apache Indian reservation where the 2000 census recorded a per-capita income of $10,100. The promotora, also known as a health outreach worker, honks her horn and waits inside the car, in case the dogs that scare her are nearby.
Ralph Montoya appears. He’s 62 and has lived on the property for 40 years taking care of the owner, a disabled man who has become family to Montoya. He is willing to talk with a reporter but not inside their two-bedroom mobile home. A half-dozen cats wander nearby. Montoya looks down or to the side when he talks.
His cheeks are slightly sunken, evidence of a lifetime without dental care. He has never had health insurance and visited the doctor for the first time three years ago, after he got dizzy and fell while shoveling snow. Still, he waited another two weeks.
“Doctors cost a lot, and I can’t afford it,” he says matter-of-factly.
Ralph Montoya is at a dangerous age. At age 55 to 65, people like Montoya are too young for Medicare, usually unemployed and uninsured and developing age-related problems, says Dr. Suzanne Norman, who cares for patients in Abiquiú. Currently Medicaid, the government’s health-insurance program for low-income families and people with disabilities, isn’t available to these adults.
Medicaid expansion is designed for adults without dependent children who earn between 85 and 138 percent of federal poverty level, which is about $9,500 to around $15,000 a year for one person. As of December, nine states have rejected Medicaid expansion. That choice creates a gap in care for the poorest; people who earn more than them would be more likely to afford coverage on the new health-insurance exchange.
The Martinez administration has sought information from Washington to help with its decision making. Martinez’s deputy chief of staff, Scott Darnell, says the Governor will solicit input from hospital leaders, advocates, providers and business leaders while she waits to hear back from federal officials. Her decision is monumental in a state that routinely leads the nation in its poverty and uninsured rates.
Sen. Sue Wilson Beffort, a Republican who has served 16 years in the New Mexico Legislature, says she believes the governor is waiting for a definitive answer whether the federal government would allow New Mexico to shrink the expansion if Washington can’t deliver on the money it has promised. The federal government has said it would pay 100 percent of the expansion until 2017. At that point, the state’s share is 5 percent, which increases to 10 percent starting in 2020.
The Medicaid-expansion debate has become about economics in New Mexico. Some lawmakers worry about obligating New Mexico to future financial hardships by expanding a health-care program that constantly grows and cost the state $857.3 million last fiscal year. Others question the wisdom of rejecting a program that will infuse billions of federal dollars into New Mexico as well as generate millions in state tax revenues, thousands of new jobs and more insured residents.
Beffort says she’s hearing hints that federal officials would allow states to shrink back their Medicaid if Washington can’t financially sustain the program.
“I’m sensing the governor will probably go ahead and expand it,” Beffort says.
Who will care for the newly insured?
Rural health-care providers in New Mexico recognize their patients need health insurance, but wonder how they will be able to accommodate an influx of new patients when there aren’t enough providers to see the current amount.
About 170,000 New Mexicans could be newly eligible for Medicaid under an expansion, according to state estimates. Another 200,000 to 250,000 people would qualify for insurance through a health-insurance exchange that is a mandatory part of the federal health-care reform.
“There’s been a collective holding of breath until the election occurred, and the decision has been delayed,” says Jerry Harrison, director of New Mexico Health Resources.
In November, Harrison’s recruitment organization started hearing from more clinics looking for primary-care professionals. It takes one to two years to recruit a physician here, says Harrison, and some of the clinics need multiple providers, including doctors, nurses and dentists.
David Roddy, director of the New Mexico Primary Care Association, says his counterparts in Massachusetts struggled to recruit enough physicians after the state implemented health-care reform for its residents half a decade ago. Now there are multiple states expanding Medicaid and a national shortage of physicians and nurses.
“When everyone in the nation starts competing for providers, that worries me tremendously,” he says. “It worries me because of the supply.”
New Mexico hasn’t had enough providers for decades. Despite investments and successes with provider-enticement programs and telehealth initiatives, only one New Mexico county – Los Alamos – has enough providers to adequately care for its population, according to the federal government’s Health Resources and Services Administration.
In the context of a national shortage of health-care providers, New Mexico has incredible needs. Consider these statistics from the New Mexico Health Policy Commission, 2011 State Physician Workforce Data Book and U.S. Department of Health and Human Services:
• About a quarter of the state is uninsured, one of the highest rates in the nation.
• New Mexico ranks 49th out of 50 states for number of dentists per capita.
• New Mexico’s current nursing shortage will almost triple to 2,800 by 2015.
• New Mexico has one of the oldest physician populations in the country.
Postponing care complicates cases
“I’m already on the front lines,” Dr. Suzanne Norman says between seeing patients in the Abiquiú clinic, one of three operated by Las Clinicas del Norte. “I can’t imagine being busier.”
Norman has worked for 22 years caring for poor, rural residents in Northern New Mexico. Medical providers are concerned they will be overwhelmed if more people are insured, she says.
Montoya considers what he could do for himself if Medicaid could pay his doctor bills. He would need to have his mouth fixed, which probably means all his teeth would be pulled, he says.
“Well, and I have a lump,” he says, raising his grey sweatshirt and placing his hand in the center of his soft, hairy stomach. There a tight knot is growing under the skin.
Montoya earns $9 an hour taking care of the 86-year-old man through Addus Home Health Care in Española. Montoya could go to Las Clinica del Pueblo de Rio Arriba on a sliding-fee scale. At the most, he would pay $40 for a dental exam and $20 for medical. Medications and X-rays would cost more.
Even though these clinics are busy caring for the uninsured, there are many, like Montoya, who still avoid care. People can’t afford the gas to get there. Or they don’t have a car. Or the co-pay is too much. So Montoya lives with a growing lump in his stomach, yanks his teeth when they get loose and stops noticing his football-worn knees should be replaced.
“It’s the way things are,” he says. “It doesn’t hurt.”
This is why nurse practitioners and physicians are concerned. Not only will the expansion bring more people to their clinics; those people will have complicated health problems from years of being unable to afford medical care.
Montoya’s story isn’t unique to Beronice Archuleta, who has been checking on him and the older man for the past 16 years as part of her role at Tierra Amarilla’s sole health clinic, La Clinica del Pueblo de Rio Arriba.
“People haven’t had insurance ever since I can remember,” she says. “When we first started La Clinica as volunteers, the clinic paid our electricity and telephone, and we depended on food stamps. That’s the only way we could make it.”
Confronting provider shortages
Considering the potential Medicaid expansion and provider shortage, Dr. John Andazola is mulling ways to expand the Southern New Mexico Family Medicine Residency Program, which exists to train and keep physicians in New Mexico.
“We’re going to increase access because we’re going to have (Medicaid) funding so more patients will be able to get care,” says Andazola, program director in Las Cruces. “The problem is where are they going to get that care? We do concern ourselves with that.”
Unable to compete against other states’ higher wages, New Mexico has tried to increase its supply of nurses, physicians, dentists and pharmacists with common recruitment practices like tax credits and loan forgiveness programs as well as residency programs that require rotations in rural communities.
Just as important, educational institutions are adjusting their programs to encourage physicians to partner with other professionals, and organizations are using more remote professionals and promotoras, like Archuleta, who follow up on patients with complex medical needs.
Facing uninsured realities
Norman, who works in the Abiquiú clinic next to Bode’s General Store off Highway 84, doesn’t spend much time wondering whether Medicaid expansion will happen or how providers will accommodate more patients. Between caring for patients, the self-described bulldog pushes for them to get what they need from others — insurance companies, specialists, Social Security disability and pharmacies.
Because her uninsured patients can’t pay for a specialist, Norman has honed her own specialty skills. She sets bones, removes moles and conducts biopsies.
“Specialists is the biggest gap in care for our uninsured patients,” says Andy Lopez, executive director of Norman’s clinic and two others in Ojo Caliente and El Rito.
If Medicaid is expanded, Las Clinicas del Norte would receive $1.7 million in new annual revenue because the clinics would get reimbursed for the care they provide to their uninsured patients, Lopez says. For the first time, those patients would have access to specialty care as well.
“It would be a godsend for them,” Lopez says.
Even if a patient is insured, the time it takes to get an appointment – one measure of whether people can get the care they need – can be several months in rural and urban areas of New Mexico.
Norman steps away to see her last patient of the day. It’s dark outside; the patient was late traveling from Santa Fe, where he bid on a paint job. His arms are covered in ink. “The good, the bad and the ugly,” he says with a staccato laugh, pointing to three intricately drawn ladies on his left arm.
Andrew Martinez, 29, grew up in Chimayo. He drew some of the detailed images — like the man holding a smoking gun — upside down. He honors his dead relatives with their tattooed names, his brother on his right arm and his cousin on his left.
Martinez drives a little more than an hour to Abiquiú, the closest clinic that provides prescriptions for suboxone. The medication helps him avoid heroin. His girlfriend is pregnant with his first child, and he hopes it’s a boy he can take fishing.
He checked into buying private insurance, but says his pay barely covers gas and food. He lives with his girlfriend in his Grandma’s house. His cheeks bear the hollowed-out look of dental-care needs.
“Insurance would help me out a lot,” he says.
He is trying to pay off a $3,000 bill from Los Alamos Hospital, a visit he postponed until chest pains, that turned out to be panic attacks, woke him at night. He works with chemicals and machinery, and installs glass with his step-dad.
“I’m always getting cut. I needed stitches quite a few times, and some cuts haven’t healed right,” he says. “I’m afraid one of these days something is really going to happen to me.”
Editor’s note: Deborah Busemeyer, a freelance journalist, worked as communications director for the New Mexico Department of Health from 2005 through 2010.