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Health law - in determining whether a patient is medically indigent, County Boards can impute a patient's potential income and future tax returns - St. Luke's Magic Valley Reg'l Med. Ctr. v. Bd. of County Comm'rs of Gooding Count.

A leading reason behind the recent health care reform movement and the enactment of the Patient Protection and Affordable Care Act ("PPACA") is the inability of uninsured and underinsured individuals to pay their hospital bills. (1) Federal and state laws require that hospitals provide treatment to patients in a medical emergency regardless of their ability to pay; however, the laws are unclear as to who pays the hospital for such medical treatment. (2) In many jurisdictions, such as Idaho, hospitals can receive compensation from the state government for care provided to individuals who are deemed to be unable to reasonably pay for their medical expenses. (3) In St. Luke's Magic Valley Reg'l Med. Ctr. v. Bd. of County Comm'rs of Gooding Count, (4) the Supreme Court of Idaho contemplated possible factors boards of county commissioners may consider in determining whether a patient is medically indigent under the Medical Indigency Act ("Act").s The Act specifically requires that the patient have insufficient resources to pay for necessary medical services to be considered medically indigent. (6) As a matter of first impression, the court held that the Board of County Commissioners for Gooding County ("Board") properly imputed the patient's potential income and future income tax returns as one such factor in finding that the patient was not medically indigent under Idaho Code section 31-3502(15). (7)

In 2007, St. Luke's Magic Valley Regional Medical Center ("Hospital") provided emergency medical care to Mrs. Freeman ("Freeman") with costs totaling $19,419.91. (8) The Hospital claimed Freeman did not have medical insurance or sufficient resources to cover the amount she owed. (9) Freeman subsequently filed a Uniform County Medical Assistance Application with the Board, requesting that the county reimburse the Hospital's costs for Freeman's medical care pursuant to Idaho Code section 31-3501. (10) Idaho Code section 31-3501(2) provides that as a case of last resort, the relevant county will compensate a hospital for care provided to medically indigent patients, as defined under Idaho Code section 31-3502(15). (11) At the time Freeman filed the application, she was voluntarily unemployed and cared for her two young children. (12) She also admitted to be "able-bodied and able to work." (13) In the process of making its decision, the Board imputed Freeman's potential income, as well as her future tax returns, by assigning her a full-time minimum wage position and averaging her two most recent tax returns. (14) As a result, the Board ultimately denied Freeman's application after it considered her potential income and future income tax returns to be encompassed within the definition of "resources," as defined in Idaho Code section 31-3502(23). (15)

The Hospital subsequently requested that the Idaho Department of Health and Welfare conduct a pre-litigation screening to review the application denial. (16) After the review, the department panel determined that Freeman appeared to be medically indigent. (17) The Hospital then filed a petition for judicial review in the state district court. (18) On June 25, 2008, the district court remanded the case to the Board, ordering it to make findings of fact as there were no such findings in the Board's previous decision. (19) After the Board reached the same decision with its added findings of fact, the Hospital again petitioned the district court to review the decision. (20) The district court affirmed the Board's denial of reimbursement, and the Hospital appealed to the Supreme Court of Idaho, arguing that the Board improperly imputed Freeman's potential income and future tax returns in determining that she was not medically indigent. (21) However, the Idaho Supreme Court affirmed the decisions of the Board and the district court, holding that a patient's potential future income and future tax returns are within the meaning of available "resources" under subsections (15) and (28) of Idaho Code section 31-3502. (22)

The Supreme Court of Idaho has interpreted that the Medical Indigency Act's legislative purpose has two components: "to provide indigents with medical care and to allow hospitals to obtain compensation for services rendered to indigents." (23) However, a hospital can only receive compensation for medical care if a board of county commissioners determines that a patient is medically indigent within the meaning of Idaho Code section 31-3502(15). (24) In Carpenter v. Twin Falls County, (25) the Idaho Supreme Court noted that the definition of "medically indigent" under Idaho Code section 31-3502 does not mirror the definition of "indigent" under other Idaho statutes. (26) Thus, the court held that rather than requiring applicants to show that they are impoverished, applicants must only show that they are unable to pay for their medical expenses with their available "resources" to qualify as "medically indigent." (27) The court further held that the board was not limited to consider only the financial status of the applicant at the time of the hearings and could also consider factors such as whether the patient or patient's spouse voluntarily quit his or her job despite being a healthy individual. (28)

In Intermountain Health Care, Inc. v. County Bd. of Comm'rs, (29) the Idaho Supreme Court qualified the meaning of available "resources" within the definition of "medically indigent" under Idaho Code section 31-3502(15). (30) The court interpreted available "resources" to mean that the applicant has resources that are liquid and are of positive net value. (31) Seven years later, in Univ. of Utah Hosp. and Med. Ctr. v. Twin Falls County, (32) the Supreme Court of Idaho again considered what constitutes an available "resource" under the statute. (33) In Univ. of Utah Hosp., the county board looked at the patient's future social security income and Medicaid benefits in making its decision that the patient was not medically indigent. (34) The court, conversely, held that the board could not consider such potential resources in determining whether the patient was medically indigent, reasoning that such resources are not "immediately" or "currently available." (35) However, subsequently in Jefferson County v. E. Idaho Reg'l Med. Ctr. ("Application of Ackerman"), (36) the Idaho Supreme Court held that "available" does not necessarily mean present ability to pay but rather the ability to pay for medical expenses within a reasonable time. (37) The court reasoned that but for the petitioner's expensive lifestyle choices leading to his extensive credit card debt, he had the present ability to pay his medical expenses within a reasonable time. (38) Implicit in this reasoning was the court's consideration of the patient's other debts. (39) Nonetheless, the court did not clarify whether other types of debts, specifically other past medical debts, should be given more weight than other types of personal debt in determining whether the patient has the ability to pay the present medical bill. (40)

People lacking health insurance or with inadequate insurance are likely to accrue "medical debt," as those persons have significantly less ability to pay for necessary medical care. (41) In the past few years, sizeable medical debt has been the cause of about sixty percent of personal bankruptcies. (42) Although one of President Obama's initiatives upon taking office was to address medical debt, PPACA does not specifically distinguish medical debt from other types of personal debt, and it has yet to be addressed in Obama's first presidential term in other enacted legislation. (43)

The aforementioned decisions led to an unclear interpretation of available "resources" within the definition of "medically indigent" under Idaho Code section 31-3502(15). (44) As a result, the Idaho legislature amended the statute in 1996 to include a definition of "resources." (45) After the Idaho Legislature's 1996 amendment, the statute defined resources as including, "the ability of an applicant and obligated persons to pay for necessary medical services over a period of three (3) years." (46) The Idaho legislature amended the statute again in 2005 to extend the period from three years to five years. (47) Since these two amendments, the court has maintained its holdings established in Application of Ackerman and Intermountain Health Care, Inc. (48) Until 2010, however, the Supreme Court of Idaho had not considered whether assets patients have not yet obtained are within the meaning of available "resources" under Idaho Code section 31-3502, subsections (15) and (23). (49)

In St. Luke's Magic Valley Reg'l Med. Ctr., the Supreme Court of Idaho considered whether a patient's potential future income and future tax returns are available "resources" under section 31-3502 of the Idaho Code subsections (15) and (23). (50) The court first rejected the Hospital's argument that the statutory framework regarding medical indigence indicates that the Idaho Legislature did not intend for the Board to consider a patient's ability to work in determining their medical indigence. (51) The court noted the legislature's declaration in Idaho Code section 31-3501, which states that, "[i]t is the policy of this state that each person, to the maximum extent possible, is responsible for his or her own medical care...." (52) The court explained the legislature's declaration is consistent with section 31-3510A(1), which requires that any person who receives assistance for medical expenses reimburse the county for a "reasonable portion" that the person "is able to pay from resources over a reasonable period of time." (53) It further noted that section 31-3510A(6) explains that in seeking reimbursement from the medically indigent patient, boards can require the patient to find employment if the patient is "capable and able to work." (54) The court reasoned that because county boards can consider a patient's ability to work for the purposes of reimbursement, they should also consider a patient's potential income as a "resource" under section 31-3502(23). (55) Accordingly, the Idaho Supreme Court held that together, these statutes show that the Idaho Legislature intended for boards to consider a patient's ability to work as a "resource" under section 31-3502(28) in determining whether the patient is medically indigent. (56)

The Supreme Court of Idaho further rejected the Hospital's argument that it was against state precedent to consider Freeman's potential income in determining whether she was medically indigent. (57) The court reasoned that although it determined that the patient's spouse was medically indigent in Carpenter, it also held that it was proper for the board to consider whether the patient's spouse was a "healthy individual who had voluntarily quit his job." (58) The court further noted that in Application of Ackerman, it rejected the argument that the patient was medically indigent because he did not have a reserve fund to presently pay the bills and instead held that he had the "present ability to pay over a reasonable time." (59) The Idaho Supreme Court reasoned that these two decisions, along with the statutory framework, demonstrated that the Board properly considered Freeman's potential income in determining that she was not medically indigent. (60) Moreover, the court determined that future tax returns constituted a "resource" under the statute, specifically due to the language in the definition of "resources," which includes assets similar to future tax returns, such as "all forms of public assistance, crime victim's compensation, worker's compensation, veterans benefits, [Medicaid], [and] [Medicare] ... for which an applicant and/or an obligated person may be eligible." (61) Thus, the Supreme Court of Idaho ultimately held that the Board properly considered Freeman's potential income and future tax returns as a "resource" under Idaho Code section 31-3502 subsections (15) and (28) in determining that she was not medically indigent. (62)

The Idaho Supreme Court's decision in St. Luke's Magic Valley Reg'l Med. Ctr. is an accurate portrayal of the Idaho Legislature's intended analysis in determining whether a patient is medically indigent. (63) The legislature suggested its intent in its 1996 amendment to the statute, which explicitly rejected the holding in Univ. of Utah Hosp. and Med. Ctr. (64) Currently, the definition of "resources" under section 31-3502(23) in the Idaho Code includes "the ability of an applicant and obligated persons to pay for necessary medical services, excluding any interest charges, over a period of up to five (5) years." (65) The definition's inclusion of a patient's ability to pay over a five-year period thus suggests that boards of county commissioners need to consider a patient's future resources as they would their present resources, which necessarily includes a person's present income and tax returns. (66) Further, the Idaho Legislature stated that the 1996 amendment was "designed to encourage self reliance but show reasonable compassion for the truly needy without impoverishing local and state governments or providing services beyond that affordable by the average taxpayer." (67) This focus on self reliance and preventing the dilution of state and local government resources demonstrates that the legislature's intent was to require that county commissioners consider a wide variety of resources, including potential future income and future tax returns, to limit the application of who constitutes a medically indigent person under section 31-3502(15). (68)

Although the Supreme Court of Idaho's decision mirrored the Idaho Legislature's intended analysis, it did not answer the question Justice Jones posed in his concurring opinion. (69) Justice Jones inquired whether the Board should have considered the availability of reasonable employment for patients when it imputed potential future income as a resource. (70) He argued that with the recent recession and shortage of jobs, there is a diminished probability of finding a job, and "if no job is available to the applicant, it hardly seems appropriate to impute any income." (71) Another question unanswered in the court's opinion was how boards should determine the wage amount assigned as the patient's potential income. (72) In St. Luke's Magic Valley Reg'l Med. Ctr., the Supreme Court of Idaho approved of the Board imputing minimum wage to Freeman's potential income, but there will likely be future cases where the patient's previous income exceeds minimum wage. (73) In this decision, the court did not determine whether boards should always impute minimum wage, as it did in this case, or a wage comparable to one a patient previously received. (74) These unresolved questions could lead to future litigation, as the Supreme Court of Idaho did not establish a method for boards to assess employment opportunities or to calculate a patient's future income. (75)

Assuming that Freeman can find employment that pays the wage the Board imputed, it is still questionable whether the effect of the decision fulfills the purpose of the Idaho Medical Indigency Act. (76) The court noted that when Freeman worked, she and her spouse had a combined income that totaled $28,023 in 2005 and $23,067 in 2006. (77) However, the Freemans have two children, so as a family of four, the Freemans came very close to the national poverty line assessed to Idaho in 2006. (78) Thus, the Board's decision may have been unreasonable because it seems to assume that the little surplus the Freemans are able to gain above the poverty line can be used to pay off the entire medical bill in five years. (79) Moreover, it appears that the court failed to carefully consider, under an abuse of discretion standard, whether the Board reasonably found that Freeman could pay the bill over the next five years as Idaho Code section 31-3502(23) establishes. (80)

The recently adopted PPACA could change the impact of the Medical Indigency Act for Idaho citizens and has the potential to alter the scope of this decision in future cases. (81) PPACA addresses the problems of the uninsured, including unpaid hospital bills, by creating programs and mandates that will ideally insure many of the currently uninsured citizens of the United States. (82) In the upcoming years, the implementation and enforcement of PPACA will likely decrease the amount of people the Idaho Medical Indigency Act affects because fewer people will need assistance from the counties to pay their medical bills as the number of uninsured people will likely decrease. (83) However, the Idaho Medical Indigency Act will still be necessary for people that PPACA exempts from the individual mandate, those not covered under the expanded Medicaid program, and those who choose to pay the tax fee instead of purchasing insurance. (84) Conversely, if Idaho successfully shields itself from the individual mandate through state legislation exempting Idaho citizens from the enforcement of PPACA, the effect of the Idaho Medical Indigency Act will be unchanged. (85) In the above instances, the holding of this case will nonetheless be applicable. (86) Where PPACA affects Idaho citizens as intended, the Supreme Court of Idaho may be willing to support boards of county commissioners considering a patient's past ability to purchase insurance. (87) The Supreme Court of Idaho previously refused to recognize such a factor in determining whether a patient was medically indigent. (88) However, in light of the requirement to purchase insurance pursuant to the individual mandate under the PPACA, the court may hold differently in future cases. (89)

In St. Luke's Magic Valley Reg'l Med. Ctr., the Supreme Court of Idaho held that boards can consider a patient's potential future income and future tax returns as a "resource" under Idaho Code section 31-3502(23) in determining whether a patient is medically indigent. (90) The court likely followed the Idaho legislature's intended analysis in making its determination. (91) However, the court left questions unanswered, such as whether boards should consider if there are employment opportunities available in imputing potential income and how it should determine a patient's potential wages. (92) Further, even though the Supreme Court of Idaho likely produced the legislature's intended analysis, it is questionable whether it effectuated the intended statutory purpose. (93) As a result of the court's decision, Freeman will likely struggle close to the poverty line in attempting to pay her medical bill over the next five years. (94) Additionally, the scope of this decision may change in light of the recently adopted PPACA, as the new federal health care reform law will ideally decrease the number of people the Medical Indigency Act affects. (95) Nonetheless, regardless of the altered reach of the Medical Indigency Act in the future, the holding in this case will still be applicable in some instances. (96) Ultimately, the effect of this decision should prompt the Idaho legislature to amend the state statute to provide clear guidelines directing how boards of county commissioners should make decisions regarding a patient's medical indigence. (97)

(1) See Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stac 119, amended by Health Care and Education Reconciliation Act of 2010, Pub. L. 111-152, 124 Stat. 1029 (codified as amended in scattered sections of 42 U.S.C.). One major change resulting from PPACA is the requirement that individuals, who are not otherwise covered by insurance, purchase minimum coverage or face tax consequences. Id. [section] 1501 (to be codified as amended at 42 U.S.C. [section] 18091; see Richard G. Cowart, Summary of Key Insurance Provisions in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act, in HEATH LAW PRACTICE GUIDE, 2010-2011 HEALTHCARE REFORM LAW SUPP. [section] 2:1 (2d ed. 2010) (providing a summary of the key insurance provisions of the PPACA); see also Allison K. Hoffman, Oil And Water: Mixing Individual Mandates, Fragmented Markets, and Health Reform, 36 AM. J.L. & MED. 7, 8 (2010). The main drive behind the health care reform is to address the problem Of "an estimated 46 million uninsured Americans." See Hoffman, supra. A major reason for the individual mandate to purchase health insurance within PPACA is to solve the problem of unpaid hospital bills that ultimately increase the cost of insurance for other individuals. See Hoffman, supra, at 9-10. See generally Reed Abelson, Bills Stalled, Hospitals Fear Rising Unpaid Care, N.Y. TIMES, Feb. 9, 2010, at B1, available at http://www.nytimes.com/2010/02/09/health/policy/09hospital.html (asserting that without health care reform, hospitals will continue to have unpaid bills from uninsured patients); World Healthcare: Key Player--HCA's Offering Healthcare & Pharm. Forecast, ECONOMIST INTELLIGENCE UNIT, July 5, 2010 (commenting health care expansion to uninsured or underinsured may solve the problem of unpaid hospital bills).

(2) See Emergency Medical Treatment and Active Labor Act, 42 U.S.C. [section] 1395dd(b) (2006). Where a hospital receiving Medicare funds determines that a patient has an emergency medical condition, the statute requires the hospital to either stabilize the emergency medical condition or transfer the patient to a facility better equipped to handle the patient's condition. Id.; see also ARK. CODE. ANN. [section] 20-9-309 (West 2010) (Emergency Medical Care Act); FLA. SWAT. ANN. 395.1041 (West 2010) (discussing access to emergency services and care); 210 ILL. COMP. SWAT. ANN. 70/1 (west 2010) (discussing refusal to provide emergency treatment due to inability to pay); KAN. SWAT. ANN. [section] 75-5669 (2010) (requiring Kansas state laws remain consistent with laws set forth in 42 U.S.C. [section] 1395dd); LA. REV. SWAT. ANN. [section] 40:2113.6 (2008) (discussing emergency diagnoses and services); NEV. REV. SWAT. [section] 439B.410 (2010) (requiting hospitals to provide emergency services and care); N.Y. PUB. HEALTH LAW [section] 2805-b (McKinney 2007) (discussing admission of patients and emergency treatment of non-admitted patients); OR. REV. SWAT. 441.094 (west 2011) (outlining the prohibition of denial of emergency medical services); TENN. CODE ANN. [section] 68-140-302 (2011).

(3) See ARIZ. REV. SWAT. ANN. [section] 11-293 (2011) (indicating each county shall provide care for qualified indigent persons); CAL. GOV'T. CODE [section] 29606 (west 2008) (noting necessary expenses incurred by county hospitals for care provided to the indigent sick are county charges); IDAHO CODE ANN. [section] 31-3501 (2010) (stating medically indigent patients can apply for assistance from the county to pay unpaid hospital bills); N.Y. PUB. HEALTH LAW [section] 2807-k (McKinney 2007) (stating general hospital indigent care pool established to distribute funds to public general hospitals); S.C. CODE ANN. [section] 44-6-150 (2010) (establishing medical indigent assistance program where hospitals are compensated when patient qualifies for the program); TEX. HEALTH & SAFETY CODE ANN. [section] 61.022 (Vernon 2010) (expressing a county shall provide assistance to eligible residents for health care).

(4) 237 P.3d 1210 (Idaho 2010).

(5) Id. at 1212; see also IDAHO CODE ANN. [section][section] 31-3501-31-3557 (codifying the Idaho Medical Indigency Act).

(6) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1214; see also IDAHO CODE ANN. [section] 31-3502(15). The statute defines "medically indigent" as:
   [A]ny person who is in need of necessary medical services and who,
   if an adult, together with his or her spouse, or whose parents or
   guardian if a minor, does not have income and other resources
   available to him from whatever source sufficient to pay for
   necessary medical services. Nothing in this definition shall
   prevent the board and the county commissioners from requiring the
   applicant and obligated persons to reimburse the county and the
   catastrophic health care costs program, where appropriate, for all
   or a portion of their medical expenses, when investigation of their
   application pursuant to this chapter, determines their ability to
   do so. IDAHO CODE ANN. [section] 31-3502(15).


(7) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1217; see also IDAHO CODE ANN. [section] 31- 3502(15).

(8) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1212. The court does not provide the full name of Freeman or more details about her treatment. Id.

(9) Id.

(10) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1212; see IDAHO CODE ANN. [section] 31-3501(1). The statute states that its purpose is:
   [T]o safeguard the public health, safety and welfare, and to
   provide suitable facilities and provisions for the care and
   hospitalization of persons in this state, and, in the case of
   medically indigent persons, to provide for the payment thereof, the
   respective counties of this state, and the board and the department
   shall have the duties and powers as hereinafter provided.


IDAHO CODE ANN. [section] 31-3501(1).

(11) See id. [section][section] 31-3501(2), 31-3502(15).

(12) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1213, 1221.

(13) Id. at 1216.

(14) Id. at 1217. The Board noted that in 2005, Freeman and her spouse had a combined income of $28,023 and received a tax return totaling $4,062. Id. It further found that in 2006, Freeman and her spouse had a combined income of $23,067 and received a tax return of $5,447. Id. Based on these numbers, the Board imputed a combined annual income of $26,188.32 and a future tax return of $4,000 for the Freeman family. Id.

(15) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1212, 1215 (analyzing what constitutes a resource); see IDAHO CODE ANN. [section] 31-3502(23). The statute defines "resources" as meaning:
   [A]ll property, whether tangible or intangible, real or personal,
   liquid or nonliquid, or pending, including, but not limited to, all
   forms of public assistance, crime victims compensation, worker's
   compensation, veterans benefits, Medicaid, Medicare, supplemental
   security income (SSI), third party insurance, other available
   insurance and any other property from any source for which an
   applicant and/or an obligated person may be eligible or in which he
   or she may have an interest. Resources shall include the ability of
   an applicant and obligated persons to pay for necessary medical
   services, excluding any interest charges, over a period of up to
   five (5) years. For purposes of determining approval for medical
   indigency only, resources shall not include the value of the
   homestead on the applicant or obligated person's residence, a
   burial plot, exemptions for personal property allowed in section
   11-605(11) through (3), Idaho Code, and additional exemptions
   allowed by county resolution.


IDAHO CODE ANN. [section] 31-3502(23); see also supra note 6 and accompanying text (providing definition of "medically indigent," which includes the phrase "resources available to him").

(16) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1212.

(17) Id.

(18) Id.

(19) Id. at 1212; see also Crown Point Dev., Inc. v. City of Sun Valley, 156 P.3d 573, 578 (Idaho 2007). The Supreme Court of Idaho held that a city council must make actual findings of fact, rather than merely reciting the facts in the record, and the findings of fact must include "a reasoned statement in support of its decision." Crown Point Dev., Inc., 156 P.3d at 578.

(20) St. Luke's Magic Valley Reg'l Med. Cir., 237 P.3d at 1212.

(21) Id. at 1212; see also IDAHO CODE ANN. [section] 31-3505G (2010) (providing the right of an applicant or third party making an application on the appellant's behalf to seek judicial review of the board's final decision in denying financial assistance for necessary medical care); id. [section] 31-3505D (outlining the manner by which an interested party may seek judicial review of the board's final determination to deny financial assistance); Losser v. Bradstreet, 183 P.3d 758, 760 (Idaho 2008). The Supreme Court of Idaho held that when it acts in an appellate role to review a district court's decision, it will affirm the decision after determining that there was sufficient evidence to support the board's findings of fact and that the board's conclusions of law follow those findings. See Losser, 183 P.3d at 760.

(22) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1215. The court reasoned that the legislative framework of the statute suggested that it was the legislature's intention for boards to consider potential income in determining whether a patient was medically indigent. Id.

(23) See St. Luke's Reg'l Med. Ctr., Ltd. v. Bd. of Comm'rs of Ada County, 203 P.3d 683, 685-86 (Idaho 2009) (quoting Univ. of Utah Hosp. v. Ada County. Bd. of Comm'rs, 153 P.3d 1154, 1156 (Idaho 2007)).

(24) IDAHO CODE ANN. [section] 31-3502(15) (2010) (defining "medically indigent"); see also id. [section] 31-3502(23) (defining "resources" considered for the purposes of determining indigency); id. [section] 31-3501 (providing the code chapter's policy declaration).

(25) 691 P.2d 1190 (Idaho 1984).

(26) Id. at 1199. The court noted that the legislature has defined "indigent" as "any person who is destitute of property and unable to provide for the necessities of life." Id.; see also McMullen v. Harris, 624 P.2d 339, 342 (Ariz. App. 1980) (holding applicant need not show that he or she is impoverished to qualify as medically indigent).

(27) Carpenter, 691 P.2d at 1200 (citing Albany Med. Ctr. Hosp. v. Harris, 28 A.D.2d 784 (N.Y. App. Div. 1967)). In HarKs, the New York Appellate Division held that in determining whether a patient's spouse is medically indigent, a commissioner should also consider the facts after the patient's death, such as the spouse's state of unemployment. See Harris, 28 A.D.2d at 784.

(28) Carpenter, 691 P.2d at 1197. Carpenter filed for financial assistance for his wife; however, at the time of the filing, Idaho Code [section] 31-3502 defined "medically indigent" differently than the present statute and it read, "any person who is in need of hospitalization and who, if an adult together with his or her spouse ... does not have income and other resources available to him from whatever source which shall be sufficient to enable the person to pay for necessary medical services." Id. at 1198 (quoting IDAHO CODE ANN. [section] 31-3502). Although the Supreme Court of Idaho found that the board could properly consider that the applicant voluntarily quit his job, the court held that the district court did not err in ruling that the county board erroneously found that the applicant was not medically indigent. Id. at 1200. The court reasoned that even if it assumed that the applicant was still employed at the time of the heating, his expenses would supersede his income without even factoring in the existing hospital bills. Id. at 1199-1200.

(29) 707 P.2d 410 (Idaho 1985).

(30) Id. at 414.

(31) Id.; see also IDAHO CODE ANN. [section] 31-3502(15) (defining "medically indigent," which also refers to "available resources").

(32) 842 P.2d 689 (Idaho 1992).

(33) Id. at 690.

(34) Id. at 691. The patient received emergency medical care that amounted to over $20,000 in medical bills, so the patient applied for Medicaid and federal supplemental social security income to cover the costs, but both applications were denied. Id. at 690-91. The patient appealed these decisions, but the administrative boards had not yet reached a decision at the time of this decision. Id. The board found that the patient was not medically indigent due to the possibility of receiving assistance from Medicaid and Social Security Income. Id.

(35) Univ. of Utah Hosp. & Med. Ctr., 842 P.2d at 694.

(36) 903 P.2d 84 (Idaho 1995).

(37) Id. at 86-87. But see Univ. of Utah Hosp. & Med. Ctr., 842 P.2d at 694. In that case, the court stated the reasonable interpretation of "available resources" under IDAHO CODE [section] 31-3502(1) means income currently obtainable, as well as the present ability to pay instead of a future possibility to pay. Id. It also stated that to find that such resources are within the meaning of statute, "would be a denial of justice to make distant hospitals wait indefinitely for payment of just claims, perhaps until some point in the future when it can be authoritatively declared, beyond challenge, that all other potentially available resources have been exhausted." Id.

(38) Application of Ackerman, 903 P.2d at 86-87. The court further reasoned that the credit card bills were non-judicial obligations that did not have priority over the hospital bills. Id.

(39) Id.

(40) Id. See generally In re Johnson, 386 B.R. 272 (Bankr. D. Idaho 2008) (maintaining lien imposed on the patient's house due to the patient's prior medical debt).

(41) See Amanda W. Thai, Is Senator Grassley Our Savior?: The Crusade Against "Charitable" Hospitals Attacking Patients for Unpaid Bills, 96 IOWA L. REV. 761, 781 (2011) (noting that sixty percent of uninsured patients claim problems involving medical debt); see also Sara R. Collins, The Affordability Crisis in the U.S. Health Care: Findings from the Commonwealth Fund Biennial Health Insurance Survey, COMMONWEALTH FUND, (Mar. 2004), available at http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2004/ Mar/The%20Affordability%20Crisis%20in% 20U%20S%20%20Health%20Care%20%20Findings%20from%20the%20Commonwealth%20F und%20Biennial%20Health%20In/collins__biennia12003_723%20pdf.pdf. Surveys found forty-one percent of adults under the age of sixty-five either had medical bill problems in the last year or were paying off medical debt. See Collins, supra. The survey further revealed that the problem was most severe with those individuals who were uninsured. See Collins, supra.

(42) KEVIN BORDEN, DON'T LIEN ON ME: WHY THE STATE'S MEDICAL INDIGENCY CARE PROGRAM IS UNHEALTHY FOR IDAHOANS 5 (2001), available at http://www.accessproject.org/ downloads/IdahoLienR.pdf. Researchers found that "over half of people filing for personal bankruptcy in the United States do so because of a medical problem or medical debt." Id.; Melissa B. Jacoby, et al., Managing Medical Bills on the Brink of Bankruptcy, 10 YALE J. HEALTH POL'Y L. & ETHICS 239, 241 (2010). Researchers also found that sixty-two percent of all personal bankruptcies were due to medical debt. See Jacoby et al., supra. Medical debt affects patients by imposing concerns regarding how to rationalize medical care, including self-rationing "medically necessary care and drugs ... patients may self-ration important non medical expenses." Id. at 247.

(43) See Sarah Rubenstein, Obama Aims to Help Patients Wipe Away Medical Debts, WALL ST. J. HEALTH BLOG (Jan. 7, 2009 2:06PM EST), http://blogs.wsj.com/health/2009/01/07/ obama-aims-to-help-patients-wipe-away-medical-debts; see also Hoffman, supra note 1. Although PPACA does not specifically distinguish medical debt from other types of debt, the individual mandate attempts to resolve the major issue of medical debt in general. See Hoffman, supra note 1. One of the major purposes behind the individual mandate to purchase health insurance in PPACA is to ensure that all individuals have access to medical care, thus making it less likely that those people will accrue medical debt for necessary care. See Hoffman, supra note 1, at 10-11. Butsee Gayland Oliver Hethcoat II, Free Hospital Care and the Takings Clause: Franklin Memorial Hospital v. Harvey In a Changing Health-Care Landscape, 65 U. MIAMI L. REV. 169, 200 (2010). PPACA purports to insure thirty-two million once uninsured Americans by 2019; thus, fewer hospitals will go uncompensated for provided care. Id. See generally Medical Bankruptcy Fairness Act: Hearing on H.R. 901 Before the H. Subcom. on Commercial and Admin. Law on the Judiciary, 111th Cong. 111-114 (2010).

(44) See supra notes 22-37 and accompanying text (discussing divergence of interpretation surrounding the definition of available "resources").

(45) IDAHO CODE ANN. [section] 31-3502(23) (2010).

(46) 1996 Idaho Sess. Laws 1360. The Statement of Purpose for the amendment "is designed to encourage self reliance but show reasonable compassion for the truly needy without impoverishing local and state governments or providing services beyond that affordable by the average taxpayer." Id.

(47) 2005 Idaho Sess. Laws 917.

(48) See Jefferson County v. E. Idaho Reg'l Med. Ctr. ("Application of Ackerman"), 903 P.2d 84, 86 (Idaho 1995) (holding "available" does not necessarily mean present ability to pay); Intermountain Health Care v. Bd. of County Comm'rs of Blaine County, 707 P.2d 410 (Idaho 1985) (holding "available resources" means assets with present value not encumbered by other liabilities); see also Sacred Heart Med. Ctr. v. Kootenai County Comm'rs, 41 P.3d 215 (Idaho 2001). In Sacred Heart Med. Ctr., the court determined that the board is not required to consider the total debt, other than just the present medical bills, a patient owes in determining whether the patient is medically indigent. Sacred Heart Med. Ctr., 41 P.3d at 217; see also Bonner Gen. Hosp. v. Bonner County, 981 P.2d 242 (Idaho 1999). The court considered whether the choice to not purchase medical insurance is a factor that the board can properly consider in making their determination that a patient is medically indigent. Id. at 244; see also St. Joseph Reg'l Med. Ctr. v. Nez Perce County Comm'rs, 5 P.3d 466 (Idaho 2000). In St. Joseph Reg'l Med. Ctr., the court held that "other resources" does not mean other possible programs that provide similar medical treatment as the hospital that provided emergency medical care provided. Id. at 470.

(49) See St. Luke's Magic Valley Reg'l Med. Ctr. v. Bd. of County Comm'rs for Gooding County, 237 P.3d 1210, 1213 (Idaho 2010); IDAHO CODE ANN. [section][section] 31-3502(15), (23) (2010).

(50) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1213. St. Luke's Magic Valley Regional Medical Center argued that the statutory framework of Idaho Code section 31-3501 shows that the Idaho Legislature did not intend for boards to consider a patient's ability to work, state precedent also indicates that it should not be a factor, and it was error for the county to impute Freeman's potential income and future tax returns in deciding that she was not "medically indigent." Id.

(51) Id. at 1213-14; see also id. at 1217-18 (Jones, J., concurring). Justice Jones agreed that the statutory framework reflected the Idaho Legislature's intention to put the burden on patients to cover their own medical costs rather than the tax payers; thus, he reasoned that the legislature likely intended the county boards to consider many types of resources, including a patient's potential income. Id. at 1218.

(52) Id. at 1214 (quoting IDAHO CODE ANN. [section] 31-3501(1) (2010)).

(53) St. Luke 's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1214. The court noted that the statute makes no mention of "potential income" or "future tax returns;" thus, the statute fails to expressly answer the question raised in the appeal. Id. at 1213; see also IDAHO CODE ANN. [section] 31-3510A.

(54) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1214-15. The court reasoned that since the appearance of such language is in this section, the legislature likely intended consideration of such factors when determining whether a patient is medically indigent. Id. at 1215; see also IDAHO CODE ANN. [section] 31-3150A(6). The statute states, "[t]he county commissioner may require the employment of such of the medically indigent as are capable and able to work and whose attending physician certifies they are capable of working." IDAHO CODE ANN. [section] 31-3150A(6).

(55) St. Luke 's Magic Valley Reg'l Med. Cir., 237 P.3d at 1215. The court noted the declaration found in Idaho Code section 31-3502, which states "as used in this chapter, terms defined in this section shall have the following meaning, unless the context clearly indicates another meaning." Id. (quoting IDAHO CODE ANN. [section] 31-3502 (2010)). The court reasoned that the mandate demanded that "resources," as mentioned in section 31-3501A, should have the same meaning as the definition of "resources" in section 31-3502(23). Id.

(56) Id. But see id. at 1218 (Burdick, J., dissenting). Justice Burdick found that the statutory framework did not show the legislature's intention for the boards to consider potential income. Id. at 1219. Rather, he found that that the subsection regarding reimbursement could not be read together with the definition of resources in Idaho Code section 31-3502(15). St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1219. He stated that there can be no reimbursement and that section 31-3510A cannot apply unless a board determines a person to be medically indigent and has received assistance from the county in satisfying their debt. Id.

(57) Id. at 1215.

(58) Id. at 1215-16; see also Carpenter v. Twin Falls County, 691 P.2d 1190, 1200 (Idaho 1984).

(59) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1216 (quoting Application of Ackerman, 903 P.2d 84 (Idaho 1995)).

(60) Id. at 1216. But see Univ. of Utah Hosp. & Med. Ctr. v. Twin Falls County, 842 P.2d 689 (Idaho 1992). In this decision, the Supreme Court of Idaho determined that the term "available" in section 31-3502 means "currently" or "immediately." Id. at 694. However, in St. Luke's Magic Valley Reg'l Med. Ctr., the court reasoned that the addition of the definition of "resources," in the 1996 amendment, which in part states that it "includes the ability of an applicant and obligated persons to pay for necessary medical services over a period of three years," suggests that the legislature intended for a patient's potential income to be considered as a "resource." St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1216-17.

(61) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1216-17. The hospital argued that in Univ. of Utah Hosp. & Med. Cir., the court held that the possibility of future benefits from government agencies could not be considered as a "resource" within the meaning of section 31-3502(23). Id. at 1216 (citing Univ. of Utah Hosp. & Med. Ctr., 842 P.2d at 696). However, the Supreme Court of Idaho reasoned that at the time of the decision in Univ. of Utah Hosp. & Med. Ctr., the legislature had not yet amended the statute to contain the definition of "resources," which now includes assistance from other agencies. Id. Thus, it reasoned that the legislature did not agree with the decision in Univ. of Utah Hosp. & Med. Ctr. Id.

(62) Id. at 1217. The court reasoned that the Board properly imputed her potential income by noting that she was "able to work" and could potentially receive minimum wage. Id. It further held the Board properly imputed her future tax returns by averaging her two most recent tax returns. St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1217. But see id. at 1218 (Burdick, J., dissenting). Justice Burdick found that in arriving at its decision, the court improperly interpreted the statutory framework, misinterpreted the legislative intent of the Medical Indigency Act, and misapplied case precedent. Id.

(63) Id. at 1218; see also infra text accompanying note 64.

(64) See 1996 Idaho Sess. Laws 1360 (amending the statute to include a definition of "resources" that was more expansive than a "present ability to pay"); see also Univ. of Utah Hosp. & Med. Cir., 842 P.2d at 694. The court held that "available" more accurately means "present ability to pay rather than a future ability to pay, or a potential future ability to pay." Univ. of Utah Hosp. & Med. Ctr., 842 P.2d at 694. But see St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1220 (Burdick, J., dissenting). Justice Burdick found that the majority failed to apply the precedent set in Univ. of Utah Hosp. & Med. Ctr. v. Twin Falls County, where the court held that it was not appropriate to make hospitals wait for an indefinite period for possible resources to become available to the patient. Id. (citing 153 P.3d 1154 (Idaho 2007)); Steven B. Pitts, Medical Agency and Bankruptcty, 48 ADVOCATE IDAHO 18, 19 (2005) (noting that number of uninsured persons in Idaho continues to increase and finding that "the medical indigency program is a necessary resource for both patients and providers alike").

(65) IDAHO CODE ANN. [section] 31-3502(23) (2010).

(66) See id.

(67) See 1996 Idaho Sess. Laws 1360. But see BORDEN, supra note 42, at 6. Researchers found the money allocated to counties for the program is "vastly under spent." Id.

(68) See 1996 Idaho Sess. Laws 1360; see also St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1218 (Jones, J., concurring). Justice Jones recognized that the legislature has attempted to reduce the burden on taxpayers by making it harder to qualify as being medically indigent and by placing more of the financial burden on applicants. St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1218 (Jones, J., concurring).. In 2008, Canyon County paid $1,636,091.95 for medical indigent claims, and in 2009, Canyon County paid $818,441.721. See Dollars and Cents: What Does the Medical Indigency Program Cost?, CANYON COUNTY IDAHO: COUNTY NEWS, http://www.canyonco.org/news.aspx?id=8779 (last visited Mar. 23, 2011). This was a decrease of almost fifty percent in just one year. Id. But see BORDEN, supra note 42, at 5. Researchers found that more than half of personal bankruptcies are due to a medical problem or medical debt. Id. Medical debt affects patients by imposing concerns regarding how to rationalize medical care, including self-rationing "medically necessary care and drugs." See Jacoby et al., supra note 42, at 247.

(69) St. Luke's Magic Valley Reg. Med. Ctr., 237 P.3d at 1218 (Jones, J., concurring). Justice Jones reasoned that courts similarly consider the efforts of a plaintiff to mitigate damages in employment and personal injury suits, where the fact finder determines whether the plaintiff had a reasonable opportunity for alternate employment in determining lost income. Id. at 1218-19; see also Fellowship Tabernacle Inc. v. Baker, 869 P.2d 578, 582 (Idaho Ct. App. 1994) (holding the plaintiff's efforts seeking alternate employment to mitigate damages to be insufficient to sustain a verdict in a wrongful discharge suit).

(70) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1218 (Jones, J., concurring). A survey in Idaho revealed that unemployment rose to 9% in September of 2010, with a total of 688,900 residents unemployed, which was 4,100 more residents than the same period in 2009. STATE OF IDAHO DEPT. OF LABOR, SEPT. JOBLESS RATE EDGES HIGHER FOR SECOND STRAIGHT MONTH (2010), http://labor.idaho.gov/news/PressReleases/tabid/1953/ctl/PressRelease/mid/ 2527/itemid/2264/Default.aspx (last visited Mar. 23, 2011). In his dissent, Justice Burdick argued that Freeman's "ability to pay was premised on the arbitrary assumption that she could promptly obtain employment, no more than 2.5 miles from home, during the hours that her husband did not work, which were the primary hours of employment, 8:00 AM to 5:00 PM." St. Lake's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1221 (Burdick, J., dissenting). Justice Burdick further argued that the majority's decision frustrates the purpose of the statute as it
   restricts the medically indigent from access to aid for mandatory
   emergency care in contravention of the Act's purpose of
   safeguarding the public health, safety and welfare ... the
   medically indigent should be granted benefits and the county should
   then use its legislatively provided authority to force
   reimbursement through employment.


Id. at 1220-21.

(71) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.2d at 1212.

(72) See id. at 1212-17.

(73) See id. at 1216.

(74) See id. at 1210-12; Hutton v. Sally Beauty Co., No. 4:02-CV-00190-SEB-WG, 2004 WL 2397606, at *3 (S.D. Ind. Oct. 22, 2004). In Hutton, the plaintiff previously worked as a store manager for the defendant company and claimed that the defendant wrongfully terminated her. Id. at *1. After the defendant terminated the plaintiff, she bartended full time, but she did not look for another managerial position. Id. at *1-*2. The court determined that the "general test of whether a plaintiff has failed to mitigate damages is two-pronged: the defendant must show that (1) the plaintiff failed to exercise reasonable diligence to mitigate her damages; and (2) there was a reasonable likelihood that the plaintiff might have found comparable work by exercising reasonable diligence." Id. at *3. The court held that the plaintiff failed to mitigate her damages by failing to look for comparable employment that paid a comparable salary in good faith. Id. at *4. See also Hutchinson v. Amateur Elec. Supply, Inc., 42 F.3d 1037, 1044 (7th Cir. 1994) (holding that in retaliatory discharge suit, plaintiff is required to mitigate damages by seeking comparable employment).

(75) See St. Luke's Magic Valley Reg. Med. Ctr., 237 P.3d at 1216-17. The Supreme Court of Idaho appeared only to require that the Board of County Commissioners first determine that the patient is "able-bodied and able to work" before imputing future income to the patient. Id. at 1216; see also 2010 Idaho Sess. Laws H.B. no. 681. The most recent bill amending the Medical Indigency Act does not require consideration of whether there is available employment for the applicant in imputing future income and how to determine the wage to be imputed. Id.

(76) See St. Luke's Magic Valley Reg. Med. Ctr., 237 P.3d at 1214-15; see also IDAHO CODE ANN. [section] 31-3501(1) (2010) (declaring the purpose of the Medical Indigency Act).

(77) St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1217 (relating Freeman's income to the statute); see also IDAHO CODE ANN. [section] 31-3501.

(78) See St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1217, 1221. The court noted that between their combined income in 2005 and 2006, the Freemans had an average income of $26,188.32 to support a family of four. Id.; see also Annual Update of the HHS Poverty Guidelines, 71 Fed. Reg. 3848, 3848-49 (Jan. 24, 2006). In 2006, a family of four was under the poverty line if it earned an annual income of less than $20,000. Annual Update of the HHS Poverty Guidelines, 71 Fed. Reg. at 3848. In 2006, the Freemans were $1,017 away from being under the poverty line. St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1217. In 2009, a family of four was under the national poverty line if it earned an annual income of less than $22,050. Annual Update of the HHS Poverty Guidelines, 74 Fed. Reg. 4199, 4200 (Jan. 23, 2009).

(79) See St. Luke's Magic Valley Reg. Med. Ctr., 237 P.3d at 1216-17. Assuming the Freemans' combined income was $26,188.32, as imputed by the Board of Gooding County Commissioners, the Freemans would have a yearly surplus of $4,138.32 over the poverty line to apply to the medical bill. Id. at 1217. Aggregated over five years, this surplus would narrowly satisfy the $19,540 medical bill. Id. at 1210. Assuming that the Freemans' combined income was the same as the most recent year available in the record, which was $23,067 in 2006, it would be impossible for the Freemans to satisfy the $19,540 within five years without dipping under the poverty line. See id.; see also Annual Update of the HHS Poverty Guidelines, 74 Fed. Reg. at 4199-4200.

(80) See St. Luke's Magic Valley Reg'l Med. Ctr., 237 P.3d at 1216; Application of Ackerman, 903 P.2d 84, 85-86 (Idaho 1995). The Supreme Court of Idaho has the authority to reverse when an agency's decision was "arbitrary, capricious, or an abuse of discretion." IDAHO CODE ANN. [section] 67-5279(2)(d) (2010). Thus, the Supreme Court of Idaho had the authority to reverse the decision under the abuse of discretion standard. Id.

(81) Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stat. 119, amended by Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (codified as amended in scattered sections of 42 U.S.C.); see also supra note 6 and accompanying text (referencing parts of the Idaho Medical Indigency Act).

(82) Patient Protection and Affordable Care Act of 2010 [section] 1501 (to be codified as amended at 42 U.S.C. [section] 18091); see Hethcoat II, supra note 43 and accompanying text.

(83) Patient Protection and Affordable Care Act of 2010 [section] 1501 (to be codified as amended at 42 U.S.C. [section] 18091) (requiring individuals to maintain minimum essential coverage); see also supra notes 5-6 and accompanying text (explaining Idaho Medical Indigency Act).

(84) Patient Protection and Affordable Care Act of 2010 [section][section] 1311, 1401, 1501 (to be codified as amended at 42 U.S.C. [section] 18031, I.R.C. [section] 36, 42 U.S.C. [section] 18091) (stating individual mandate and exemptions); id. [section] 2001 (to be codified as amended at 42 U.S.C. [section] 1396a) (stating Medicaid expanded to citizens and legal immigrants with incomes below 133% of the federal poverty level by 2014); see Cowart, supra note 1, at 1 (providing a summary of the key insurance provisions in PPACA).

(85) See IDAHO CODE ANN. [section] 39-9003 (2010) (purporting to shield Idaho citizens from the federal individual mandate to purchase insurance and requiring the State Attorney General to sue the federal government regarding the Constitutionality of the individual mandate under the Patient Protection and Affordable Care Act). See generally Commonwealth ex rel. Cuccineilli v. Sebelius, 728 F.Supp.2d 768 (E.D. Va. 2010) (challenging the constitutionality of the individual mandate).

(86) See supra notes 82-85 and accompanying text (describing how PPACA will impact the necessity of the Idaho Medical Indigency Act).

(87) See Hethcoat II, supra note 43, at 200 (explaining that PPACA is intended to reduce the number of uninsured individuals in America). The federal mandate to purchase insurance may provide the boards of county commissioners grounds to consider a patient's previous opportunity to purchase insurance. Id.

(88) See General Hosp. v. Donner County, 981 P.2d 242, 245-46 (Idaho 1999) (holding board of County Commissioners cannot consider a patient's past ability to purchase insurance as an available resource under Idaho Code section 31-3502 (17)).

(89) Id. at 246; see supra note 1 and accompanying text (explaining the individual mandate under PPACA).

(90) St. Luke's Magic Valley Reg'l Med. Ctr. v. Bd. of County Comm'rs for Gooding County, 237 P.3d 1210, 1217 (Idaho 2010).

(91) See supra notes 64-68 and accompanying text.

(92) See supra notes 69-75 and accompanying text.

(93) See supra note 10 and accompanying text (explaining the purpose of the Act).

(94) See supra notes 78-79 and accompanying text.

(95) See supra notes 82-83 and accompanying text (describing the relationship between PPACA and the Medical Indigency Act).

(96) See supra notes 84-85, 87 and accompanying text (describing how PPACA will potentially impact different categories of indigent patients in Idaho).

(97) See supra note 75 (explaining the most recent amendments to the Act).

Laura Thayer, J.D. Candidate, Suffolk University Law School, 2012; B.A., magna cum laude, University of New Hampshire, 2009. Ms. Thayer can be contacted at ltthayer24@gmail.com.
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