Chelle Gluch strokes the hair of Carson Davis, 10, as he eats lunch at Chelle's home day care in Nampa, Idaho. (Kyle Green/For the Washington Post)

Jamie Gluch lumbered into the kitchen and pulled from the freezer a bag of corn, the only affordable analgesic he had for his swollen face.

“You going to be okay?” asked his wife, 44-year-old Chelle Gluch. Jamie grunted “I’m all right” and joined the children at their in-home day-care business, who were watching cartoons on the sofa.

Gluch’s tooth had rotted weeks before, but seeing a dentist was an unthinkable expense after car trouble sucked up the family’s savings.

The Gluchs had hoped it wouldn’t come to this — a car or a tooth — when former president Barack Obama announced his health-care plan years ago. But then Idaho chose not to expand Medicaid, as the law allowed, and then Idahoans chose not to come up with their own plan, even though state leaders keep trying.

Now Idaho serves as an example of what could happen in states across the country if Congress, with the support of President Trump, repeals the Affordable Care Act. Many of the proposals to replace the federal law call for states to come up with their own health-care solutions, to be “laboratories for innovation.” But that doesn’t mean states will take up that challenge. Even if they do, it doesn’t mean they will succeed.

Chelle Gluch holds her Easter Egger chicken named "Baby" in her backyard. (Kyle Green for The Washington Post)

Here in Idaho, Gov. C.L. “Butch” Otter, a Republican, vowed to come up with a replacement after declining to fully embrace the Medicaid expansion that was offered as part of the Affordable Care Act. He’s tried to persuade his heavily Republican legislature to set aside their hands-off views about the government on this issue. Studies have been conducted. Proposals have been put forward. But after four years, lawmakers have come up with no alternative.

“While it is clear there is broad agreement on the fact there is a problem, agreement on what to do about it is another story,” Otter wrote in a statement to The Washington Post.

Now that Republicans in Washington are moving to undo Obamacare, as the federal law is commonly known, Otter has suggested that Idaho pause its efforts to see what happens.

That pause could last a while. After vowing to immediately repeal and replace the law, President Trump and congressional Republicans have indicated that the process could push into next year. Republicans have yet to agree on a plan to replace Obamacare but are hoping to gain a little traction after Rep. Tom Price (R-Ga.) is confirmed, presumably this week, to be secretary of the Department of Health and Human Services.

What’s happening in Washington, where there is a will to repeal but no plan to replace, feels familiar to those in Idaho.

“It feels like we’re watching the macro version in Washington of what’s been happening here,” said Liz Woodruff, a policy analyst who works with a network of hospitals and nonprofit organizations trying to persuade Idaho to expand Medicaid.

When Obama signed the Affordable Care Act, families such as the Gluchs hoped they’d benefit from the expansion, which was designed to help people who made too little to receive tax breaks when they bought insurance on government-organized marketplaces.

(Jayne Orenstein/The Washington Post)

But the state government, suspicious of Washington intervention, rejected the federally financed expansion. That decision created a gap among the working poor who made too much to be in the traditional Medicaid population and too little to purchase their own health insurance. A state-commissioned report found that as many as 78,000 — nearly 5 percent of Idaho’s population — fell into this uninsured in-between.

“I was thrilled with the Affordable Care Act and thought we’d get out of this mess,” Chelle Gluch said as snow piled up outside their home in the state’s Treasure Valley. “And then Idaho didn’t adopt it. I cried for days. It was our only hope.”

In the meantime, some of those the in-between have stopped working because it is a better deal to get Medicaid. Others forgo medical care and innovate on their own, just as Jamie Gluch did when he pulled that pack of corn.

Chelle Gluch, who lost a long shot bid for state Senate, has run her day-care for two decades and is finishing up work to attain a teacher’s certificate. Jamie is a roofer and welder who said he cannot keep steady work because of agonizing stomach pains no doctor has diagnosed. They began hunting more to cut grocery costs. A friend donated chickens. They get fresh eggs in the morning, and owe $65,000 in medical bills.

Searching for solutions

Before the Affordable Care Act, most lawmakers here thought they had a handle on health insurance. Costs were too high, for sure. But if you could not afford insurance and something catastrophic happened to you, you could just go to the emergency room and the state would pick up the bill.

So the Republican supermajority was thrilled when Otter joined 25 other governors in challenging the mandates that came with the 2010 law. When the Supreme Court ruled that Medicaid expansion was optional, Idaho and 18 other states rejected it, along with the three years of full federal reimbursements they would have gotten for it.

“We don’t like when the federal government interferes with our stuff,” said state Sen. Marv Hagedorn (R), who has served on the Senate Health and Welfare Committee.

But the governor’s view of Obamacare would soften over time. More than 100,000 Idahoans entered into the state-run exchange legislators approved as part of Obamacare rather than being forced into a federal one. The enrollment rate was the second-highest in the nation, behind Florida.

In 2012, Otter set up a 15-person working group to figure out whether the state should do more. The task force’s conclusion was unanimous: expand Medicaid.

Richard Armstrong, the state’s director of health and welfare, said Idaho was losing more than $50 million a year paying for indigent patients who would need less state help if they were insured. He also concluded that the price of unpaid emergency-room care meant higher costs for everyone.

An independent study found that at least two-thirds of those who couldn’t afford care were working families — foresters and restaurant workers, mechanics and house cleaners. For a family of four, they typically made between $6,000 and $24,000. Some struggle with chronic yet manageable diseases such as asthma and diabetes, the report found, and treatable diseases would kill more than 100 each year.

Armstrong said his department spent hundreds of hours on research, consulting with governments in other red states and reading reports from think tanks, before drafting an expansion proposal.

But Armstrong said it was all for naught. No plan could rise above the toxic politics surrounding the health-care law.

“What Republican could want anything to do with Obamacare?” he said. “After the lawsuit, we kind of trapped ourselves.”

Advocates formed an organization called Closing the Gap. They tried to dispassionately argue the financial benefits of expansion. According to Hagedorn, he and his colleagues just didn’t believe the numbers. In today’s political climate, statistics often seem to be cooked up.

So advocates reached out to families in the in-between, hoping their personal stories would sway lawmakers.

Clella Steinke, 68, wrote the legislature about her daughter-in-law, Jenny. Jenny lived in Idaho Falls and worked in the service industry. They had no insurance. She tried to deal with her asthma by sharing her grandmother’s nebulizers and buying used inhalers from friends.

On Sept. 1, 2015, Jenny, 36, began gasping for air and had to be rushed to the emergency room. Three days later, her family surrounded her hospital bed, hoping that somehow she would breathe on her own when doctors removed a respirator. She didn’t.

“If Jenny could afford seeing a respiratory therapist, she would be alive today,” Steinke said. “How can you die of asthma in this country?”

Hagedorn’s perspective started to shift. Maybe the state should have taken the federal money. “I think everyone presumed everyone was getting the care they needed, and that was just not true,” he said.

With a more sympathetic stance among lawmakers, one of the 18 Democrats in the 106-person legislature began pushing two bills recommended by the task force — one calling for a full expansion of Medicaid, and one calling for a partial expansion. But a controversial bill from a Democrat couldn’t get a vote after a committee hearing.

Legislators looked to Wisconsin, Arkansas and Ohio to figure out how conservatives elsewhere addressed the uninsured. They studied drugs costs and health savings accounts from Oklahoma City to Singapore. The governor’s health department hired a consultant from Indiana to come up with ideas.

Proposals flowed. Some sought to use tax breaks to create health savings accounts. One senator lobbed the idea of offering the working poor tax incentives if they use a life coach to motivate them to get higher-paying jobs. None of the proposals caught on.

Last year, Otter pushed a $30 million idea to help provide primary-care doctors to those in the in-between. Another idea floated in the legislature was to persuade the federal government to allow Idaho to customize a health-care program with fewer federal rules, as states such as Michigan, Montana and New Hampshire had done.

Democrats pushed back on the primary-care plan because they felt it didn’t go far enough to address health-care needs, nor did it address a shortage of doctors in rural parts of the states. Conservative Republicans battled moderates, too. They were unsure about doing anything that could make Obamacare look like a success.

State Sen. Patti Anne Lodge (R) said she was swayed by middle-class constituents who were considering dropping insurance altogether because of the skyrocketing costs of private insurance since the law was enacted. How could you justify hard-working people not being able to afford to see a doctor, when government was giving lower-income people that benefit at no cost?

“When government continues to step in, we take the responsibility away from churches or friends helping each other,” Lodge said. “We’ve lost the human element. Government has no heart. It has no soul. It just cares about numbers. People care about people.”

As the legislative session continued, the governor’s $30 million plan was cut to $5 million. And it wouldn’t go to care, but rather to fund a study so health clinics could learn more about people who needed care.

On the final day of the legislative session, the Senate voted to enact the $5 million plan and allow the governor’s office to discuss a customized Medicaid plan with the federal government. House Republicans, thinking the bill gave the governor too much power, rejected it.

After all that, state lawmakers had come out with nothing.

‘Where do you draw the line?’

Twenty miles west of the Gluchs’ home, the highways and big-box stores give way to snow-covered fields and two-lane highways. Farm country. And then, the no-traffic-light downtown Main Street in the city of Homedale, where a group of eight men sat for coffee at Matteson’s Auto Shop on a recent day. All had private insurance or were on Medicare. The very mention of the Affordable Care Act drew groans.

“Obamacare?” said Ron Petsche, 62, a car salesman. “I don’t want anything to do with Obama.”

Across the table, a 53-year-old said he was considering delaying his retirement because the increase in his private insurance was cutting into his savings. An 81-year-old man discussed how the cost of his heart medication doubled and his eye medication went up $40 each month.

“What I hated most about Obamacare was how they want to mandate everyone get insurance,” the 81-year-old said. “Why should anyone tell me what I can and can’t have?”

“Amen, Brother Ben,” a man in a goatee and leather jacket murmured. The 81-year-old was neither his brother nor named Ben.

Jon Hayes, a 79-year-old architect, was worried about the country descending into socialism and not trusting the free market. Idahoans, he said, believed in themselves and not institutions.

“Amen, Brother Ben,” the man in the leather jacket said.

Yet Hayes wondered whether folks in this part of the country could see the big picture, whether they were being selfish. “When you have a city and you have urban poverty, it’s easy to see because it’s right there,” he said. “Here you have rural poverty, and it’s horrible!”

He continued: “Still, people are hurting, even if they work. Maybe we can slowly bring back these community colleges, by giving people more of a leg up so they have the ability to work and not depend on the government.”

“But where do you draw the line?” Petsche interrupted. “They don’t have health care, so you give them health care? They don’t have a house, so you give them a house? They don’t have a car, so you give them a car? When I was growing up, if I couldn’t afford it, I didn’t have it.”

“Then how do you fix it if there’s not help?” Hayes asked.

Petsche sat back in his chair and shrugged: “That’s outside my pay scale.”

“Amen,” the man in the leather jacket said.

Read more:

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