There was a time—in some places, up to the 1950s—when the destitute were committed to county poor houses where they worked to repay their debt to society. Nowadays, Ada County's poor are brought before the county commissioners when they can't pay their huge hospital bills.
In fiscal year 2007, Ada County paid out $2.3 million in just medical assistance, most of it going to the hospitals. A state fund covers millions more each year, after the counties pay out the first $10,000.
In total, the county paid $3.8 million in charity care including mental health assistance and other needs.
"The counties feel that the indigent fund was created to cover emergency situations where a resident of the county can fall into dire straits," said Tony Poinelli, deputy director of the Association of Idaho Counties. "Most of the county commissioners are there to help their residents."
In many cases, county charity comes with strings attached. The counties frequently attach a lien on people's property until they can repay the debt. Traylor says the county does not repossess homes for failure to pay back this type of aid.
"We don't foreclose on people. We don't do that kind of stuff," he said.
But the liens stick and, according to advocates for the medically indigent, can send people even deeper into poverty if they need to sell their property or end up making a little bit of money later on.
Idaho's county welfare system was thrust into the spotlight on June 16 when the Idaho Supreme Court told Ada County it was wrong to deny undocumented immigrants access to the charity fund. For the past two years, Ada County has regularly denied any applications for assistance from those the county thinks are in the United States illegally. In the past nine months, Ada County has denied assistance to about 25 people who lack immigration papers, according to Traylor.
The court said that immigration status is none of the county's business—if you have lived in Ada County for 30 days and are not a student, tourist or seasonal worker, you are considered a resident.
The hospitals have tried for several years to get the courts to rule on whether undocumented immigrants count as residents, but counties often muddy the water by giving other reasons for denial, like incomplete applications.
"We wanted to challenge this legally," said St. Luke's Boise Medical Center spokesman Ken Dey. "We're certainly not standing at the door asking for a green card."
Javier Ortega Sandoval, a Mexican immigrant who suffered a stroke in 2006 while working at a garden center in Eagle, offered a test case for St. Alphonsus Regional Medical Center. The hospital was stuck with more than $187,000 in bills that Ortega Sandoval could not pay.
When the county denied the payment, the hospital appealed and Ortega Sandoval had to appear before the three county commissioners for questioning.
"I would like to get this solved well. My desire is to return to Mexico but to settle this the right way," he told them, according to court records.
Ada County denied the hospital the funds again and Fourth District Judge D. Duff McKee upheld the decision, suggesting that the Idaho Legislature should define "resident" better. Then the Supreme Court stepped in and said a resident is a resident.
Idaho's early state government interpreted its mandate to the poor in a similar fashion. In the heyday of mining when hardscrabble towns filled with poor folk from all over—including many Chinese miners—trying to strike it rich panning for gold, state law defined resident pretty liberally. Back then, a $2 head tax paid for welfare cases in Shoshone County and likely elsewhere.
But in the face of a national health-care crisis—legions of uninsured or underinsured Americans combined with skyrocketing medical bills—the indigence fund seems to be tilting at windmills.
And there is plenty of blame to go around, starting with the folks charging $187,000 for two months of care.
"What they should be doing, rather than sending people to the counties and building a big waiting room, they should put money back into the community," said Amber Mausling, who coordinates advocacy for the Living Independence Network Corporation.
Mausling thinks there should be more low-cost clinics and preventive care and eventually universal health care.
Hospitals say that they cannot turn people away and that every procedure has a cost associated with it.
"Someone always pays for the care," Susan Gibson, vice president of mission services at St. Al's told the Associated Press. "It can be paid for by government entities such as the county, or we can absorb it as charity care and shift the cost of that care to other service ... Then everybody pays, especially the business community."
St. Al's and St. Luke's both offer charity care, including 100 percent assistance for the poorest patients. Larger charity cases that are likely to qualify for county assistance are forwarded to county indigent services. The rest of the patients who can't afford their bills are reported to collection agencies and written off by the hospital as bad debt.
For St. Luke's in 2007, that number was $18.5 million compared to $8.4 million in pure charity care. At St. Al's, $8.6 million was written off as charity in 2007 and $7.7 million was reported as bad debt. Both hospitals also write off millions of dollars in losses between what they charge and what the federal programs reimburse them.
It's a system that few county commissioners are prepared for.
"When I hired onto this job, there's a lot of things they didn't tell me," said Canyon County Commissioner Matt Beebe, recalling an old cowboy cartoon. Beebe, who also chairs the state catastrophic fund, which helps counties pay medical bills in excess of $10,000, said he never expected to be ruling on charity cases when he ran for county office.
"Some are so clear-cut," Beebe said. "There's no issue that they qualify."
But the health system is not so clear-cut, and Ada County Commissioner Paul Woods says lots of time and energy are wasted in haggling between the county and the hospitals.
"It's a random outcome, not a system," Woods said, explaining that some poor people get the hospital to pay for their care, some get sent to collection agencies and some have to repay the county.
Tony Pozeck was glad the county was there when he needed five emergency brain surgeries at St. Al's. Pozeck, now living in Chicago, was between jobs in Boise and without health insurance when doctors found the tumors. His hospital bill: $500,000. The county took care of it at Medicaid reimbursement rates and Pozeck gladly sends a monthly check to the county for the next five years.
"The indigent services process was scary and complicated but did very well by me," he said.