There's no such thing as a typical family. But Sarah Cox wants more people to envision the near-typical American family: a mother, a father and two kids.
"They are just able to keep themselves in a reasonable house with reasonable food on the table and keeping the kids well clothed to go to school," said Cox, a nurse-midwife and women's health practitioner with the Family Medicine Residency in Boise.
Cox's scenario was a bit more specific, presuming that the husband and wife were "just getting by" with both working low-wage jobs.
But just as typical, Cox said, was the chance that the wife's birth-control failed.
"So maybe she finds herself pregnant," said the nurse who regularly sees instances of women who need care but have no insurance. "And now they go and apply for Medicaid but they find they don't qualify."
It's a scenario that Cox sees time and again: an Idaho family of four, in which the parents both work minimum-wage jobs and their gross income is barely over $30,000. To be eligible for Medicaid, that same family cannot exceed 133 percent of the federal poverty line ($23,050 for a family of four), which is $29,326.
Cox's employer, Family Medicine Residency, not unlike Planned Parenthood or Terry Reilly Health Services, provides care to tens of thousands of individuals and families throughout the Treasure Valley. The program is a teaching health center, where doctors go to complete their residencies and can offer discounted services for low-income individuals and families.
But even "low cost" clinics discharge many of their clients with a bill. Facing unexpected out-of-pocket costs many women, Cox warned, put too many babies in danger because of their decision not to access pre-natal care.
"The simple fact is that [the public ends up paying] for that really sick person going to the emergency room or that baby who goes to the Neonatal Intensive Care Unit because its mother didn't get any prenatal care," said Cox. "The person who ends up paying for that is not that poor woman or all the other poor people. It's someone working really hard and just barely getting any insurance, and then those costs are passed on to them."
Twenty-three percent of all women in Idaho aged 15 to 44 are uninsured, almost identical to the national average. Thirty-two percent of patients with Planned Parenthood of the Great Northwest are uninsured, with 43 percent under the federal poverty level.
"If they don't have health insurance, then they would come to some place like Planned Parenthood," said Kristen Glundberg-Prossor, with Planned Parenthood of the Great Northwest. "Our services are fee-based in Idaho because we don't have state funding."
This means that, unlike other states, no one in Idaho receives services at Planned Parenthood for free.
"Everybody who comes in has to pay for their health services. We have some funding available because we are a nonprofit charity," said Glundberg-Prossor. "There are some funds if someone is really, really indigent and just can't pay for the services. We can look for some source within our funding structure."
In fact, Idaho is one of the only states in the nation that does not subsidize Planned Parenthood. Glundberg-Prossor said the funding schedule for Planned Parenthood is "one-third from state and federal, one-third from patient fees, one-third from donations."
This funding model allows Planned Parenthood in many states to offer basic women's health care to women for free or at a discounted rate. But in Idaho, it is very different.
"In Idaho, because we didn't have state funding, we really had to do that fee. So we have a slightly different funding mechanism than we do in Washington or Alaska," said Glundberg-Prossor. "[The Idaho] pie does look a little different than the whole PPGNW."
Cox said as a result, too many Idaho women are left with few, if any options. The income levels for qualifying for help are very low. For a single individual to qualify for Medicaid, he or she must make no more than $14,856. The federal poverty level is $11,170.
"You could save the state a lot of money by just funneling more money into preventing unwanted pregnancy," said Cox. "Instead of worrying about all the other stuff that they're worried about right now."
Pregnancy and birth control are not the only health care issues for women Idaho is lacking in right now. When the Susan G. Komen Foundation announced it would pull funding from Planned Parenthood earlier this year, many were outraged. (Komen quickly back-pedaled, saying Planned Parenthood would be eligible to apply for grant funding in the future.)
"We've been working with Komen in Idaho for about 10 years," said Glundberg-Prossor. "We helped them get to very underserved populations. The breast screening was very low and Komen was getting out there to get women screened. We had this partnership for many years to reach rural and underserved populations."
The outreach may surprise many who only associate Planned Parenthood with abortions. In fact, abortions are only 7 percent of the services Planned Parenthood of the Great Northwest provides; nationally it's only 3 percent. A total of 26 percent of its services are for things such as breast exams, cervical exams and basic physicals.
According to Cox, women have generally improved their health care knowledge about the importance of tests such as pap smears. But for poor families, knowing the importance and being able to afford it may be two different things.
"For the woman who just says, 'We're choosing between feeding the family and me getting this test, and this year, I think we'll just skip it,'" said Cox.
Seventy to 80 percent of the patients at the Family Medicine Residency are on Medicaid, but, according to Cox, a fairly significant number of patients don't have any form of insurance and most of her patients don't qualify for Medicaid.
Women's health is usually associated only with pregnancy and family planning, but Cox is quick to point out that women suffer from all kinds of health concerns that need to be addressed on a regular basis.
"We have our women's health-check program, which provides for breast exams and pap smears at a very discounted rate--sometimes free--depending on their income," said Cox. "Plus, we've got our health access program that allows women to just get regular health care at a very inexpensive rate. That is partially funded by the two hospitals here in town. ...
"These programs that we provide allow women to be seen at a very discounted rate. In the absence of those programs, these women don't get care. And they die of cervical cancer, of breast cancer and of other things," said Cox.
Cox returned to her original scenario, but the family of four has now grown to a family of five
"So now they have this bill for the birth, and a new mouth to feed," said Cox. "They still can't afford insurance for their children and their annual salary of $30,000 now must be split up five ways."
Cox said her scenario is just one of thousands real-life cases.
"This does not end with pregnancy and birth control and pap smears," she said. "There are women who have, like everybody, all kinds of health issues that they don't get care for early because they can't afford whatever it is. And then they end up in our emergency rooms or in our clinics and then in our hospitals with a very difficult-to-deal-with problem that could have been avoided entirely in the first place because of funding issues. When we think about our priorities and what we want our country to be like--that's what we should be thinking about."