Texarkana reveals health-law disparity

Low-income Arkansas residents insured; Texans fend for themselves

TEXARKANA, Texas -- On a hazy, hot evening in Texarkana, Janice Marks ate a dinner of turkey and stuffing at a homeless shelter filled with plastic cots before crossing a few blocks to the Arkansas side of town to start her night shift restocking the dairy cases at Wal-Mart.

The next day, David Tramel and Janice McFall had a free meal of hot dogs and doughnut holes at a Salvation Army center in Arkansas before heading back to their tent, hidden in a field by the highway in Texas.

None of the three have health insurance. But had Marks, 26, chosen to sleep on the side of town where she works, or had Tramel and McFall, who are both in their early 20s, made their camp where they had eaten their dinner, their fortunes might be different.

Arkansas accepted the Medicaid expansion in the Patient Protection and Affordable Care Act. Texas did not.

That makes Texarkana perhaps the starkest example of how President Barack Obama's health-care law is altering the economic geography of the country. The poor living in the Arkansas half of town won access to a government benefit worth thousands of dollars annually, yet nothing changed for those on the Texas side of the state line.

After the Supreme Court decided in 2012 that states could not be compelled to expand Medicaid to cover more low-income residents, many politicians voiced fears that the poor in states that opted out of the expansion might flood into states that opted in.

So far, 26 states and Washington, D.C., have chosen to extend Medicaid. The others -- including Texas -- have so far declined.

But none of the low-income Texarkana residents interviewed realized that moving to the other side of town might mean a Medicaid card. In fact, health researchers and those who work with the poor expect very few Americans to move between states to take advantage of the law.

"It's impossible to understand what it is to move when you have nothing," said Jennifer Laurent, the executive director of Randy Sams' Outreach Shelter, where Marks is staying until she puts together enough savings from her two low-wage jobs to find her own place. "To risk everything -- losing your bed, your sense of community -- for an uncertain benefit? There's no way you want to risk that."

Research on other expansions of government benefits has borne that out: A study in the journal Health Affairs looked at the "welfare magnet hypothesis" and found no evidence that it exists.

Both sides of Texarkana are largely middle and lower-middle class; its major employers are big-box stores, hospitals, chicken-processing plants, an Army depot and a tire factory. But unlike much of energy-rich Texas, it has seen its economy stagnate in recent years. Laurent said she struggled to meet more need with less money; grants and donations to the shelter dropped sharply last year.

For the town's lowest-income residents, finding health care is one more hardship. Another resident at Randy Sams' Outreach Shelter, Ed Miller, 42, has congestive heart failure and sleep apnea. Recently, he went to the hospital and received a diagnosis of bronchitis. Asked whether he would consider moving to Arkansas to gain access to Medicaid, he said, "I might look into that."

The shelter helps its residents gain access to the government programs they are eligible for: food stamps, Social Security, disability, housing vouchers when available. Once, Laurent said, an Arkansas social worker went across the state line to see whether anyone might be eligible for the Medicaid expansion.

Until the Supreme Court ruling, the Obama administration had intended for the Medicaid expansion in the Affordable Care Act to be universal, covering almost all adults earning up to 138 percent of the federal poverty line, about $16,105 annually for a single adult or $32,913 for a family of four.

That is the way it is working out on the Arkansas side of the border, where health clinics and social service agencies are signing up eligible residents.

Under the so-called private option, most of those who qualify are covered under plans on the state's federally run health-insurance exchange, with Medicaid paying the premium along with payments to the insurance companies to reduce or eliminate any of the recipient's out-of-pocket costs for medical care.

The expansion is already having an effect on the city's biggest provider of charity care, the nonprofit Christus St. Michael Health System.

"We're seeing more patients with a payer," said Chris Karam, its president, referring to those with health-insurance coverage.

On the Texas side, though, it's business as usual.

"It makes me mad," said Miller, who is not receiving any federal benefits. "They need to quit playing games with people's lives. Rich people. Government people."

Information for this article was contributed by Andy Davis of the Arkansas Democrat-Gazette.

A section on 06/10/2014

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