By The Washington Post · Amy Goldstein · NATIONAL, HEALTH, HEALTH-NEWS
Chapin had a thriving Reno, Nev., production company, We Ain't Saints, booking bands, managing weddings, hosting 600-strong karaoke nights at the Tahoe Biltmore Lodge & Casino. When the novel coronavirus came, forcing northern Nevada's entertainment industry to go dark, he said, "everything I knew all disappeared."
The family's health insurance gone along with their income, Chapin applied online for Medicaid on April 1, the day after his wife's job ended and three days before he needed a molar pulled. By the time his mouth was throbbing, Chapin and his family had become early additions to Nevada's Medicaid rolls - rolls swollen now to record levels while pandemic-inflicted fiscal wounds have damaged the state's ability to afford the safety-net health coverage.
By the most recent count, the roster of Nevadans on Medicaid has climbed from fewer than 644,000 in February, the month before the state reported its first case of covid-19, the disease caused by the virus, to about 731,000 through August.
That 13.5% increase places Nevada among at least three states, along with Kentucky and Minnesota, where the cadre of people on Medicaid has spiked that much, including families, like the Chapins, who have never before asked for government help. But increases are widespread: Caseloads had risen on average 8.4% through July in 30 states for which researchers have enrollment information. And in 14 states with enrollment data through August, the average is 10%.
If the past is a guide, this is merely the beginning.
During the Great Recession from late 2007 to mid-2009 and previous bad economic spells in the history of Medicaid, Americans have turned to the program more gradually than to unemployment benefits, food stamps and other aid for people sliding out of comfortable lives. Medicaid is insurance for the poor that is a shared responsibility of the federal government and states, begun as a pillar of President Lyndon B. Johnson's Great Society expansion of government help of the 1960s.
"We believe Nevada has not yet seen the full impact as a result of the covid pandemic," said the state's Medicaid director, Suzanne Bierman, echoing expectations elsewhere of experts on the social safety net.
With Nevada's tourism-fueled economy stalled, the unemployment rate soared to 30.1% in April, the highest ever recorded for any state in any month.
"You can pick just about any adjective you like to describe just how unprecedented the numbers are, and you wouldn't be exaggerating," said David Schmidt, chief economist for the Nevada Department of Employment, Training and Rehabilitation.
"When all the casinos had to close all at once by the end of March, 95% of our members were off work, so it was a complete wipeout," said Bobbette Bond, director of public policy for the Culinary Health Fund, which provides insurance to about half the cooks and dishwashers, porters and housekeepers and other unionized casino workers. The fund is covering unemployed members for another month.
Some casinos' lights are back on, but fewer than one-third of workers have returned to their jobs, Bond said, and some have too few hours to qualify for their old health benefits. Even Nevada's most recent reported unemployment rate - 14% for July - is higher than the nationwide rate at the Great Recession's worst.
With most Americans' private health insurance tethered to their jobs, this enormous disappearance of work is a central reason Medicaid programs are swelling and strained.
Another reason: Under the Cares Act, a broad set of pandemic relief measures Congress adopted in the spring, states may not remove anyone from their rolls if they accept extra federal Medicaid aid provided by the law. But in Nevada, most of the growth is fueled by people joining, with about two-thirds of the enrollment boom most months attributed to new applicants, according to state estimates.
The spiraling demand for Medicaid is colliding with a diminished ability by the state to pay for it. With Nevada confronting a $1.2 billion deficit and a requirement to balance its budget, the legislature has taken steps to slow the program's spending - notably, curbing payments to doctors, hospitals and others who care for Medicaid patients to save $53 million through next summer. That 6% rate cut is the largest so far in the nation.
"Nevada is the extreme of what's happening around the country," said Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities, who has been tracking Medicaid in the pandemic. "The fear is that it's the leading edge."
Chapin finally posted on his personal Facebook page July 1 what had been true for months: "It's with a heavy heart and a lot of fantastic memories, I regret to announce the closing of my business of 19 1/2 years. . . . With covid spiking again. Wedding season cancelled, no bars to do Karaoke, no venues to book bands, and no real return for the music and entertainment industry in sight."
It had been 2001, months into his sobriety, when he launched We Ain't Saints, with its logo of a devil holding a beer and its motto straight from Alcoholics Anonymous. Over the years, the weddings he hosted twice made Brides magazine. He counted Google, Instagram and Squaw Valley Ski Resort among his clients for events.
The business earned him $80,000 to $140,000, depending on the year. "My company allowed me to raise a family nicely," Chapin, 49, said. "This is what we do seriously for years and years and years. Bringing live music for people. . . . Making sure your bar is filled on Friday night. Not only is it something financially but emotionally you have all these ties with all these people."
His wife's final day as an administrative assistant for an organization working with children who have autism was March 31. Her health benefits ended at once. He already had stopped paying into Access to Healthcare Network, a nonprofit medical discount program that covered him and their daughter for a monthly fee. Chapin was approved for Medicaid hours after he typed up an application - a contrast to delays often vexing people as they try to get unemployment checks flowing.
For the emergency molar extraction, he had to find a dentist open in the pandemic and willing to accept SilverSummit, a Medicaid managed-care plan. Discovering none in Reno, he drove to Carson City, about 30 miles south. But he could still go to Northern Nevada HOPES, a community health center where he gets some of his care, when he awoke in April with a blood clot in his left calf. Medicaid paid for him to have it removed and is paying for a blood-thinning drug. His daughter, who has entered sixth grade online, has just been approved for braces.
If not for Medicaid, "we would have sold things, or we would have gone into debt," Chapin said. "I think about it all the time."
As it is, they are scraping by, using savings for house payments. Even without a job, he is finding a way to give back. Before starting his production company, he was a chef. Now, he is raising money, making beef stroganoff and peach and avocado salad, pork loin with mushroom sauce and grilled asparagus, and giving the meals to families in need. A lot of the people picking up his meals are recent exiles from the middle class.
Looking over his own rise and pandemic fall, Chapin said, "It's part of being American. I started this business, and I was living the dream." And now, to get health insurance, "I have to ask" the state.
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Nevada Democratic Gov. Steve Sisolak issued a report just after July 4, laying out the depth of the economic wreckage wrought by the coronavirus. In nearly three years during and after the Great Recession, the governor noted, Nevada lost 180,000 jobs; in the previous three months, the state had hemorrhaged more than 250,000.
The governor said he wanted to go easy on cuts to health services. But with the Nevada Department of Health and Human Services accounting for one-third of the state's budget through next summer, and Medicaid the department's biggest expense, the program was a target.
To help carve $233 million from the department, Sisolak urged lawmakers to eliminate a raft of services that Nevada has offered Medicaid patients, beyond what the federal government requires.
A $3.2 million savings by getting rid of optometry for adults. Another $2.1 million by no longer covering adults' prostheses. Other services would be restricted. No more than a dozen physical therapy sessions. Limited dental care, except for pregnant women and children.
By the time state legislators finished their special session in late July, they had set aside the idea of reducing benefits - for as long as the nationwide public health emergency continues, at least through the end of the year. Other cuts were approved and, if federal health officials accept them, will be retroactive to mid-August.
Beyond lowering doctors' pay, the state reversed a 2.5% increase that had begun in January in the daily rate for hospitals' inpatients. It delayed certain payments to HMOs. It reduced payments for treating the sickest newborns. More than $130 million worth of Medicaid cuts in all.
The health-care industry and some consumers are fuming.
"We have real concerns about our ability to continue to provide for Nevada Medicaid patients," William Ziesmer, chief financial officer for Sunrise Hospital & Medical Center, the state's largest, said at a public hearing last month on the changes.
Sunrise officials are examining services "to determine which can be saved and which we'll be forced to reduce," Ziesmer said. "This is an incredibly difficult position to put hospitals in, when there is so much need in the community."
Pam Berek, whose 18-year-old son, Carson, has cerebral palsy, epilepsy and autism, implored officials at the hearing to rethink the cuts. "We don't want to put our children away in an institution," Berek said, predicting that an undersupply of home therapists and nurses will worsen, costing the state more in the long run. "We are not just numbers on a paper. We are actually families struggling to keep our children at home."
On the third floor of a medical office building three miles east of the Las Vegas Strip, Howard Baron has been in practice for 27 years. Nevada's first pediatric gastroenterologist recruited him in 1993. Baron was the second.
He and three partners treat children with growth failure, nutritional deficits, malfunctioning gastrointestinal tracts, liver disease, a need for feeding tubes. Their patients' families vary from well-off to undocumented, but many live in the poor neighborhoods nearby. Nearly 6 in 10 of the children the practice cares for are on Medicaid.
To avoid the virus, Baron and his partners stopped performing elective procedures for two months. Other patients simply stayed away. He applied for a federal Paycheck Protection Program loan for small businesses, was turned down on the first round, then received nearly $150,000 on the second. It allowed his practice to pay two months' salaries and health benefits for the nurse practitioner and dietitian who work with the doctors.
The immediate past president of the Nevada State Medical Association, Baron was in his office around the time the loan ran out in early July, before a special session of the legislature began, when he got an email from Jaron Hildebrand, the association's executive director. The governor, Hildebrand was hearing, wanted to cut doctors' Medicaid payments by 6%.
Baron's first thought: "Wow, how are we going to continue to do what we do?"
He does not yet know how he and his partners will cope. But he knows that, even before these cuts, Medicaid reimbursement for their patient visits are slightly less than they usually cost. "We are going to have to make some difficult decisions," he said. Perhaps letting staff go. Perhaps limiting patients on Medicaid.
And he knows the costs to Nevada's low-income children and their parents if his practice was to shut its door to Medicaid - and if other doctors reeling from the fresh cuts did the same.
In a state with a scarcity of medical professionals, Hildebrand said, "It's only going to exacerbate the shortage and lack of access to care," coinciding with more and more Nevadans depending on Medicaid.
At Nevada HOPES, the Reno community health center where Chapin gets care, executive director Sharon Chamberlain steels for the strain on clinics such as hers as more doctors with private practices may become less welcoming of Medicaid patients.
"We're bracing for it," said Chamberlain, who founded Nevada HOPES as a pioneering HIV clinic 23 years ago, eventually turning it into a full-service health center.
The clinic has always helped patients apply for Medicaid. Before the pandemic, it was helping an average of eight households a month get on the program. Since mid-March, the monthly average has been 24. Of the 136 households HOPES has led onto Medicaid during the pandemic, almost half are new to it.
"I just think we are headed into a dark time," Chamberlain said, with private doctors likely to back away.
Baron broached the subject a couple of weeks ago, at the monthly lunch when he and his partners gather in their small conference room, usually ordering in Thai. The cuts are significant, he said. If Medicaid patients could return more often to their main pediatricians for follow-up care, that might be something to consider.
He hates the idea of treating sick children differently, depending on who is paying the bill. Still, Baron said, "the fact is, we won't be here for any patient if we continue to absorb the cost of providing the care."
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In this time of covid, Medicaid offers a broader tent than it did during the Great Recession. The Affordable Care Act, the sprawling health-care law, did not exist then. Now, 38 states and the District have expanded Medicaid as the law allows, enabling people with somewhat more money to sign up.
In Nevada, 4 in 10 of the state's new enrollees are in that group, according to state estimates.
That does not mean Medicaid is rescuing everyone who needs it. Rechica Ledesma, 48, was an administrative assistant in the conventions and catering department at Caesars's Rio Hotel and Casino. Her last day in the office was March 18. After working from home, she was furloughed a month later, then laid off in August. Conventions were not viable once the governor banned public gatherings of more than 50 people.
Her husband, Arnulfo Ledesma, lost his commercial roofing job in May, the month he was diagnosed at age 44 with colon cancer. With unemployment checks of about $700 between them and her health insurance ending, she realized last month the price of Cobra coverage - insurance laid-off workers can buy - that the hotel offered was out of reach. She began exploring Nevada's ACA insurance marketplace, soon turning off her phone, pummeled with marketing calls for health plans she could not afford.
Finally, with a medical appointment looming to decide on treatment for her husband's Stage 2 cancer, she applied to Medicaid. When she checked the online app Aug. 31 - the last day of her coverage from Caesars - she found a ruling that they are ineligible because they have too much money.
She does not understand the denial. After months of looking for work, she finally had a job interview this month. She does not know how many other out-of-work Nevadans are being interviewed, or how she and her husband will pay for his cancer treatment if she is not hired.
If Nevada's Medicaid is not rescuing everyone, it is helping many. It is helping Rich Cox, who takes 14 medications, nine of them psychiatric drugs for the chronic PTSD he came home with after Army stints in Somalia, Bosnia, North Africa and Iraq.
Cox, 47, lost his Aetna health plan when he got an email in mid-April, abruptly ending the job he'd held for 15 years with an auto-repair retailer, working his way up to running a store and being sent into stores around the country to train other managers.
He'd been earning $150,000 to $180,000 a year, mostly in commissions and bonuses, said Cox, whose two daughters live with him half the time.
"I was not exactly careful with my money," he said. "So losing my job meant losing everything - home, car, of course the insurance."
He gave up a five-bedroom house on a lake in Summerlin, on Las Vegas's west side, his bedroom the size of the entire first floor of the two-bedroom he found for a cheap rent. He traded his high-horsepower truck for a small car.
Medicaid approved him before his one month of Cobra insurance ran out in May. He discovered that his psychiatrist, primary care doctor and the orthopedic surgeon - for his bad knees and tendon trouble in his arms - he'd been seeing through Aetna do not accept Medicaid. He has found doctors who do.
Still, he said, Medicaid is "the only good thing to come about with this whole lifestyle change that covid forced me into. . . . Instead of feeling like I was thrown off a cliff, I feel like I was thrown off a boat."