Small Towns, Big Stakes: How Medicaid Cuts Threaten Health Care in the Adirondacks

“What we could see is a medical desert from Glens Falls to Plattsburgh,” a vast area stretching from below the Adirondack Park to the Canadian border some 114 miles away, he said.

The Adirondack region includes six million acres of protected wilderness, featuring mountains, rivers, and lakes beloved by hikers and canoeists. The Adirondack Park is a checkerboard of public and private land, with 105 villages and towns — some home to just a few hundred people — scattered across rugged terrain. Vacationers crowd the region in the summer. Skiers come in winter.

But the year-round population is small, declining, and aging. Many residents patch together part-time and seasonal jobs — work that doesn’t come with health insurance. Twenty-eight percent of the residents in the congressional district that includes the Adirondacks rely on Medicaid, the federal-state health insurance program for low-income people. Half of births and two-thirds of nursing home residents are covered by Medicaid.

Rural hospitals and nursing homes operate on razor thin margins, and many have been losing money for years. Nearly a third of rural hospitals in New York are at immediate risk of closing, according to the Center for Health Care Quality and Payment Reform, a national policy center. Maternity care is particularly vulnerable.

The bulk of House Republicans’ planned health care cuts — $625 billion — would come from Medicaid. The remainder would come from changes to the Affordable Care Act, also known as Obamacare, which helps individuals pay for private insurance and also pays for the Essential Plan, New York’s free program for people with somewhat higher incomes than Medicaid allows.

Governor Kathy Hochul has said the proposed cuts could lead to 1.5 million New Yorkers losing health insurance in the next 10 years, and would cost the state $13.5 billion annually in lost federal revenue. “No one state can backfill these massive cuts,” she said in a news release last week.

Rugge said people of all political stripes have an interest in preserving the Adirondacks’ fragile health care system. He leads a nonpartisan group, the Health Care Coalition for the North Country, that has been meeting with local town and county officials and encouraging them to write to their federal representatives, particularly Rep. Elise Stefanik, about the importance of Medicaid to their communities.

Stefanik, who won reelection in November with more than 62 percent of the vote, maintains that the Republican bill would “strengthen and secure” Medicaid by ensuring that only eligible recipients are enrolled.

Stefanik spokesman Wendell Husebo pointed to research by the Empire Center for Public Policy, a conservative think tank, suggesting that many people lie about their income to meet the eligibility requirements for Medicaid and that there has been a surge in the number of undocumented immigrants approved for emergency care.

Kevin McAvey, managing director of Manatt, a healthcare consulting firm, pushed back at the notion that ineligible people are flooding the Medicaid rolls.

“This is not an honor system,” McAvey said. “Individuals seeking Medicaid coverage in New York predominantly apply through the state-based marketplace, where their income attestations are checked against federal and state data sources. If such checks cannot be completed, individuals must present documentation that proves their income.”

As for the undocumented immigrants receiving emergency room care — as required by federal law — he said the payments help keep hospitals afloat. “Emergency Medicaid reimbursements in New York state and across the country protect our health care providers,” he said.

The bill, narrowly passed by Republicans in the House last Thursday, would make a series of technical changes to how the federal government reimburses states for health care costs. It would impose a penalty on states like New York that use state money to offer care to some undocumented immigrants. (Federal law requires hospitals to offer emergency care to everyone, including undocumented immigrants. New York uses its own funds to provide non-emergency care to undocumented pregnant women and people over 65.)

Most significantly, the Republican bill would require working-age Medicaid recipients without children or disabilities to provide documentation each month that shows they have worked at least 80 hours — a requirement that proponents say will prevent abuse and that Medicaid advocates say would add red tape and burdensome administrative costs.

One of the bill’s technical changes could have an immediate impact on the state’s hospitals and nursing homes: The Centers for Medicare & Medicaid Services this month rolled back its approval of an obscure mechanism, called an MCO tax, that New York had planned to use to draw down an additional $2 billion this year in federal funds. The state was counting on that money to increase Medicaid payments to hospitals and nursing homes.

Elderwood has about 70 residents, mostly elderly, and a staff of about 100. Most of the residents worked and paid taxes for decades and qualified for Medicaid only because they’ve spent their life savings, she said. Medicare, the federal health care plan for people over 65, does not cover the cost of long-term care, so residents typically pay out-of-pocket until their savings are depleted. Elderwood charges about $11,000 a month.

The nearest nursing homes are in Glens Falls, a 45-minute drive south, and Tupper Lake, more than an hour north.

“Can you imagine not being able to see your spouse because they had to move into a nursing home far away?” Schempp said. “It’s just devastating.”

In a bid to ensure Elderwood’s survival, Daniel Way, a retired family doctor and photographer, photographed nursing home residents and interviewed them about their lives, posting their stories online.

“If I didn’t have Medicaid I’d be out on the streets,” said one resident, 77-year-old JoAnn King. “I worked a long time, never been in trouble, loved my country all my life. To the politicians threatening to cut Medicaid, shame on yourselves!”

The Hyde Amendment has long banned the use of federal funds for abortion, except in cases that endanger the life of the mother or that result from rape or incest. The House bill would go much further; it would cancel all federal funding for Planned Parenthood — including for the routine health care that the organization offers. Although abortions make up only about 3 percent of the services Planned Parenthood provides, the organization has become a lightning rod for anti-abortion groups.

The House bill now goes to the Senate for debate, and revisions are expected. The proposal to ban funding for Planned Parenthood may not pass the Senate, where several Republican senators have voiced their support for the organization.

Nonetheless, pushing able-bodied people who cannot regularly document their work hours off the Medicaid rolls — as the House bill proposes — would also hurt Planned Parenthood financially. With many North Country residents working part-time jobs with irregular hours, self-employed as carpenters or handymen, or working off-the-books at jobs such as housecleaning, that documentation may be hard to provide, Medicaid advocates say. Without payments from Medicaid, Planned Parenthood would be faced with many more patients who have no ability to pay.

Work requirements overload Medicaid recipients with paperwork that they may not be able to complete even if they are eligible, McAvey said. “What winds up happening is that eligible recipients end up losing coverage,” he said, citing the experience of Arkansas and Georgia. When Arkansas imposed work requirements, 18,000 people lost health insurance and there was no increase in employment; a judge ordered the state to abandon the plan. In Georgia, the administrative costs of verifying employment far outstrip the cost of health care.

“This debate over a work requirement goes back to ideological differences in views about Medicaid,” said Larry Levitt, executive vice president for health policy at KFF, the national health policy group. “Some people view Medicaid as a welfare program that should only be for the ‘deserving poor’ and others view Medicaid as a stepping stone towards universal coverage and that access to healthcare should be a right irrespective of work.”