Physicians, nurse practitioners, dentists and psychologists were some of the first in Flagstaff to witness the human impact of the 2008 recession.
Flagstaff Medical Center emergency room workers reported diabetics off their insulin and heart patients off their meds in 2009, and patients with mouths inflamed due to cavities they hadn't had drilled or filled.
Next came $2.5 billion in cuts to the state's health insurance for the poor, AHCCCS, in 2011, when nearly 5,000 adults without young children in Coconino County lost insurance coverage, as did some children, and some with chronic disease that had previously received financial help.
These included adults with injuries, heart disease, lung disease, diabetes and cancer.
The Arizona Legislature faces a choice this year on whether it should accept federal aid and expand the state's Medicaid program (AHCCCS) to the federal poverty level and above.
Arizona voters have twice passed measures saying people living at or below the federal poverty level ($11,490 for an individual and $19,530 for a family of three) should be insured by Arizona's version of Medicaid.
Republican Gov. Jan Brewer proposes to the federal offer of matching funds to expand eligibility to 133 percent of the federal poverty level ($15,282 for an individual, $25,975 for a family of three), by adding new taxes on hospitals, in part.
She's meeting objections from Republican lawmakers who say the federal funding promised to Arizona could evaporate after three years, amid other objections.
States have a choice about whether to expand their Medicaid systems under the 2010 Affordable Care Act (also called "Obamacare"), the Supreme Court ruled last year.
Arizona would need to spend $154 million more in fiscal year 2015 in order to gain $1.6 billion in federal funding that year.
If approved, more than 5,000 additional people would have health insurance in Coconino County.
If defeated, there could be a gap in health insurance that applies mainly to people living below the poverty line -- people with greater incomes would have more choice in purchasing their own health insurance.
Flagstaff's local sheriff, physicians, hospital and Chamber of Commerce support expanding Medicaid.
Here's their reasoning.
C.J. Hansen is the chief operation officer at Canyonlands Healthcare in Page, a walk-in center offering urgent care, vaccinations, obstetrics and more.
Expanding AHCCCS makes financial sense to him.
"If they lose their coverage, they are seeking care in emergency rooms, which costs a lot more," Hansen said to a group of more than 50 gathered at Flagstaff Medical Center last week to discuss AHCCCS plans.
Ron McArthur is the chief executive officer at Summit Healthcare in Show Low, and he's seen a big increase in the number of people who land in the emergency room but don't or can't pay the bill since the Medicaid cuts -- as have hospitals statewide.
"Bad debts have gone up in the ER $3 million," he said.
The same has been true at Flagstaff Medical Center, which wrote off $13.2 million in bad debt collected between July 2010 and June 2011.
About 2.4 percent of patients didn't pay their bills from FMC in June 2010.
By December 2012, that figure had grown to 6.4 percent.
While FMC gets less for Medicaid patients than the hospital spends caring for them, it supports the idea of expanding Medicaid to gain federal dollars, even if it means a yet-to-be-quantified tax of up to 6 percent of FMC patients, the hospital's chief financial officer said.
Whether later found guilty or innocent, a person loses AHCCCS coverage when booked into jail, and those costs become the jail's responsibility, said Coconino County Sheriff Bill Pribil.
The jail district has worked out a deal to share costs with the state for treatment, but it's one of Pribil's bigger concerns.
"We're in constant fear that we get someone in custody that has a serious charge, where we know they're not going to release him or her, and the person has a serious condition like heart disease or cancer and it will cost us a small fortune," he said.
He's had 28 inmates hospitalized since January 2009, with costs shared with the state for each of them, so county taxpayers paid $62,975, and avoided $388,104.
He supports the Medicaid expansion.
"What we're obviously looking for is trying to offset the costs to the jail," he said.
Eric Henley is a physician and chief medical officer at North Country HealthCare.
That's a group of federally subsidized clinics in Flagstaff and 14 other communities in northern Arizona.
He estimates Flagstaff's uninsured rate was somewhere in the teens but is now closer to 24 or 25 percent, based on the patients he's seeing.
"They either don't come, or they come and they hope they don't have to go anywhere else -- like needing imaging or surgery," Henley said.
He's had a patient carried in by her husband for a nagging leg injury, for example, only to find she needed surgery, and her injury had worsened with waiting.
This puts health care workers in another dilemma, Henley said: A physician might be able to successfully beg for charity on a CT scan, but if it reveals problems, it's less likely he or she would ever get a patient an affordable surgery.
"They're essentially on their own," he said.
THE CHAMBER OF COMMERCE
The Flagstaff Chamber of Commerce supports expanding the number of patients on Medicaid for the federal funding it would bring, and also because local businesses providing private insurance figure they're already paying some of the costs for the uninsured.
When people cannot pay hospital bills, hospitals try to negotiate higher rates for people who have insurance through an employer, to cover the unpaid bills from others.
"This cost-shifting is termed a 'hidden health care tax,' which has been a burden on local businesses for too many years to count," the Chamber recently wrote, supporting expansion.
Cyndy Cole can be reached at firstname.lastname@example.org or at 913-8607.