Wanda Bryant said turning 65 was “the best thing that happened to me.”

She reached that age in January, making her eligible for Medicare.

Until her birthday, Bryant, a Birmingham retiree, had not had health insurance for 20 years. In December, a foot ailment left her reeling, and forced her to go to the UAB emergency room.

She incurred a $2,000 bill from that visit, which she said she can’t afford to pay.

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“But I was hurting, and I was in so much pain,” she said. “I had no other choice but to go.”

Bryant was sent home that day with a prescription for over-the-counter painkillers. But her arthritis was so severe that she couldn’t even walk to the bathroom some days. Bryant had to slide on the floor.

“That was a painful thing,” she said. “But then when I got the insurance and started seeing this primary care [doctor], they gave me a shot in both thighs, a pain shot and a steroid shot. When I didn’t have insurance, I didn’t get the shot. They didn’t even offer me the shot.”

In more than three dozen states, Bryant would have had access to care. But Alabama’s refusal to expand Medicaid has left Bryant and people in her age group particularly vulnerable to chronic disease and medical debt, limiting their quality of life and increasing health care costs across the board.

The near elderly population

People under 65 who are entering middle age, known as the near-elderly population, tend to have increased health needs. About 84% of people aged 55 to 64 had at least one preexisting condition, said Laura Harker, senior policy analyst at the Center for Budget Policy and Priorities, a progressive research and policy institute.

“Generally, people in their 50s and 60s – especially those with lower incomes who may have been uninsured for a while or may be in and out of coverage through their jobs or other sources – are much more likely to have serious conditions that consistent health coverage will help them manage,” Harker said.

Older adults are also more likely to have chronic health conditions, like diabetes, heart disease or arthritis, that require ongoing medical care. Without insurance, these individuals are often forced to delay or forgo necessary medical treatments, leading to more serious health problems and higher healthcare costs down the line.

And in Alabama, a lack of insurance among older populations is a problem. One in four uninsured Alabamians are middle-aged, and 15% percent of people between ages 55 to 64 are uninsured, according to estimates from the Kaiser Family Foundation.

Medicaid expansion would expand the program to cover able-bodied adults with income up to 138% ($34,307 for a household of three) of the federal poverty line. The federal government would pay 90% of the cost of expansion.

As of Tuesday, Alabama was one of 10 states that had not expanded Medicaid. Last week, North Carolina Democratic Gov. Roy Cooper signed a bill passed by the Republican-led legislature that expanded Medicaid in the state.

Medicaid expansion was initially a requirement in the 2010 Affordable Care Act, but in 2012 the U.S. Supreme Court made it a voluntary program. Researchers say that decision created a natural scientific experiment on health and economic outcomes in expansion and non-expansion states.

Delayed Care

Experts agree that expanding Medicaid would ensure that more near-elderly adults have access to healthcare, which would result in better health outcomes and reduced healthcare costs over time.

Many studies have shown that Medicaid expansion leads to increased access and use of healthcare services as well as reducing financial burden on patients.

A 2021 study published in the Quarterly Journal of Economics found that the Affordable Care Act’s (ACA) Medicaid expansion has contributed to reduced mortality rates among those who are close to the elderly age group.

Sarah Miller, an economist at the University of Michigan who researches public health and author of the 2021 study, said that Alabama experiences an estimated 192 annual deaths from this population due to not expanding coverage.

“It would probably be larger than that because we only look at this low-income population,” she said.

Before the ACA, mortality rates in both expansion and non-expansion states followed similar trends. But expansion states showed notable decreases in mortality rates after the first year of implementation that non-expansion states did not. While

The study found evidence that disease-related causes of death fell as a result of the expansions, but no evidence of a decline in deaths due to external causes, such as car accidents.

A 2018 study published in the Journal of the American Medical Association found an 8.5% decrease in one-year mortality for patients with end-stage renal disease with the ACA Medicaid expansions.

Other studies have demonstrated that this increase in coverage improved access to quality medical care that beneficiaries would not otherwise receive, including mortality-reducing prescription drugs, earlier detection and treatment of treatable cancers, and hospital and emergency department visits for conditions that require immediate care.

Before becoming eligible for Medicare, Harker said uninsured people are more likely to deal with chronic health conditions due to barriers to care. Older adults without insurance are more likely to skip medication that may prevent situations from getting worse, for example.

Bryant takes medication for arthritis and blood pressure. She was never able to afford all of her prescriptions at the same time, but she thinks the total cost went over $100 a month. That forced her to make difficult decisions.

“Especially my blood pressure meds. You kind of have to have those, and it’s bad when you might have to substitute – when you’re on meds and they prescribe you meds, you need all your meds,” Bryant said. “But sometimes I would get the ones I feel were more important.”

She sometimes ran out of medications and said that she would be in so much pain that if a friend had the same medication, she would borrow a couple pills to help until her next check came. Bryant said she didn’t want to have to borrow money to buy her medications.

“I borrowed medicine, and that’s not safe,” she said.

Uncompensated Care

Without insurance, people like Bryant will turn to emergency rooms, whether or not they can afford it. In Alabama, there is an average of $600 million in uncompensated care, or unpaid medical bills, according to the Alabama Hospital Association. When these bills go unpaid, hospitals and providers must absorb these costs. And 20% of Alabamians have some sort of medical debt.

Miller said that unpaid bills, or uncompensated care, negatively impact both patient and provider.

“There’s sort of an economic rationale both on the patient side, it’s better not to have collection agencies chasing after you, but also for the hospital or for the physician if they’re able to get their bills paid,” she said.

Kenneth King, a 58 year-old from Birmingham who lacks insurance, said that the last bill he opened was for about $1,300. In total, he said, King owes a little over $90,000 to the different specialists he saw.

So far, he’s paid $50. A receptionist in one office told him he would need to make some sort of payment before a follow-up visit, and that’s what he had in his wallet.

But the uninsured can’t opt out of debt, especially when faced with life-threatening situations. After King was stabbed multiple times by a friend who was having a mental breakdown, his wife rushed him to the emergency room.

When doctors performed tests on his wounds, they noticed something that required a second round of tests. He learned his aorta was tearing, and not because of the stabbing.

The condition, medically known as an aortic dissection, is a rare but dangerous heart illness where the aorta, the main blood vessel that moves blood away from the heart, tears. If the tear in the lining is not treated before the aorta bursts, the chances of survival are below 50%.

Without the diagnosis – triggered by the stabbing – King could have collapsed at any time, whether at church with his family or playing at the park with his daughter.

“And when I was gonna fall, you all would go ‘Hey, get him some ice. Let’s pray. Call the medicals,’ and there was nothing that could have been done because it was internal,” he said.

Bryant said she doesn’t know how much she currently has in medical debt, but said she owes “a lot.” Some of the older debt has been forgiven, but most are in collections. She said the hospital hasn’t started calling her yet about the visit from December, but she knows that after 90 days, the calls will begin.

“I sit back and just listen to the answering service, because once they call, I know who it is next time,” she said. “And it’s been so long – it’s been so long since I had insurance.”

Shifting costs

Bryant cares for her three grandchildren, who she said are still too young to stay home by themselves. But if she did work, she would lose additional coverage she receives from Medicaid that helps her pay for co-pays on prescription and check-ups. She simply wouldn’t be able to work enough to make up that difference.

She is one of a small population who qualifies for both Medicare and Medicaid.

States that don’t cover low-income older adults before they qualify for Medicare don’t incur the costs of treating those illnesses once they turn 65. The federal government picks up that tab as they pay for 100% of Medicare costs.

But for seniors like Bryant who are both on Medicare and Medicaid, states end up paying for some of that care.

According to most recent data from the Alabama Medicaid Agency, there were about 55,000 eligible Alabamians in 2020 that were dually enrolled in Medicare and Medicaid for outpatient care. Another 19,000 Alabamians received benefits in in-patient care, like long-term care facilities, nursing homes and other overnight medical care.

“With Medicaid, it’s really important in paying for long term care, like nursing home care, for example. As people get older, they need assistance. Medicaid is one of the largest payers for nursing home care,” Harker from CBPP said. “So, it really fills that gap that Medicare doesn’t pay for – much of the long-term care, nursing home care.”

Bryant said that since she became insured, she is even treated differently in healthcare settings.

“The first thing they ask you is, ‘do you have insurance – what kind of insurance?’ It’s like the whole thing changed by me not having insurance. It’s like I’m treated a different way,” she said.

She went to the hospital a month before she had insurance, and she recalled the difference in treatment.

“The lady at the UAB hospital – she wouldn’t even touch my foot,” she said.