IDAHO FALLS, IDAHO — Jenny Steinke, 36, died of poverty.
Her mother-in-law, Clella Steinke, said that’s the most apt cause of death. Steinke’s asthma was treatable, according to the doctor who tried to save her. Without affordable care, Steinke resorted to short-acting inhalers. Relief waned as she used more; she died in September 2015.
“It was preventable,” said Jason Steinke, his 6-foot-something frame slouched as he sat across the table from his wife’s brushed metal urn. He’d arranged Jenny next to a picture and metal Coke bottle inscribed “Soulmate.”
Jenny’s death became a rallying call for activists in the push to expand Medicaid in Idaho, where a Republican-majority legislature refused expansion, in part, due to concerns that state taxpayers would be left to foot the bill if the federal government no longer wanted to pay for most of the policy. The lawmakers were also wary of policies that expand government.
Becoming an advocate
Clella became an advocate. Newspapers covering the expansion repeated her grim assessment of Steinke’s death — death by poverty. And Kenneth Krell, an Idaho Falls intensive care doctor who treated Steinke during her final days, pressed politicians along the way. Once, Krell even accused state lawmakers of causing the deaths of 1,000 Idahoans by their refusal to expand Medicaid.
Five years later, Krell is still in the public eye, pushing authorities in the reliably red state — last led by a Democratic governor in 1995 — toward scientifically-sound COVID-19 responses in a state where even rarely-enforced restrictions are a hard sell.
From the start of the pandemic, doctors across the state stepped in. They’ve become regulars at public meetings, nudging small-town public officials toward pandemic responses grounded in science.
At first, eastern Idaho’s public health board was reluctant to issue mask mandates. A handful of doctors, including Krell, soon told the board that mandates were needed immediately.
Later that month, that health board issued a county-level mandate. Over the coming months — as case counts grew, died down and grew again — it would issue, lift and re-issue mandates in the eight counties under its jurisdiction.
State vs. local control
Half of Idahoans live in an area where masks are mandatory. But compliance with health guidelines isn’t as high as experts would like. The pandemic once seemed like a far-away issue for some remote communities in the largely rural state. Several times, vocal mask and stay-at-home order critics in Idaho have made headlines for defying public health restrictions. A few instances have led to arrests.
As hospitals across the state began to fill up recently, Little has restricted large gatherings and deployed the National Guard to deal with health care staff shortages. But he continues to refuse calls for a statewide mask mandate.
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Idaho is routinely listed in the “red zone” by the White House Coronavirus Task Force. Hospitals from all corners of the state had a record number of COVID-19 intensive care unit patients last month. And Idaho, home to less than 2 million people, has had slightly more COVID-19 deaths than Oregon, with over 4 million people.
Krell pleaded bluntly in a letter he co-signed with 10 other Idaho hospital disaster planners in early November: “We strongly implore you, we beg you, to take the courageous step of immediately instituting a statewide, enforceable masking mandate,” they wrote.
Public health history rhymes
In many ways, his demeanor today mimics the tone he struck while he pushed lawmakers to expand Medicaid.
Five months after Steinke died, Krell stood before a state Senate committee. He told Idaho lawmakers that, by refusing to expand Medicaid, they killed about 1,000 Idahoans over three years.
“Jenny’s case for me really crystallized what’s wrong here,” Krell said in February 2016. “And I kept asking myself, How could this be? How could, in a state like Idaho where we care about each other, could I be seeing deaths and really damaging illness on a nearly daily basis?”
He rattled off possible reasons against Medicaid expansion — a policy that the Affordable Care Act encouraged states to adopt by offering almost all the funding for, that raises the income cap for Medicaid eligibility from 100% to 138% of the federal poverty limit. Krell said he could only come to one “inescapable” conclusion:
“That the Idaho legislature is unfortunately responsible for those deaths. Our intransigence, in failing to pass Medicaid in for the last three years, has probably resulted in over a thousand deaths in this state.”
The committee chairman told Krell that if he or others lobbed accusations, they’d be gaveled down.
Weeks after it went into effect, Krell and other doctors were faced with a new health crisis: the coronavirus pandemic. Responding seemed politically fraught, but evidence kept emerging on the success of mask mandates.
Krell popped in to eastern Idaho public health meetings many weeks, correcting common myths and providing updates on what he’s seeing in the region’s largest ICU.
“I don’t know how to keep my mouth shut,” he said in a recent interview.
Following that push to get Medicaid expansion on the ballot in 2018, Krell seemed bittersweet in his celebration. “It’s been three more years. That means another 1,000 Idahoans have died,” Krell said at a rally in February 2019. “But we’re about to put an end to that.”
In the years since Jenny Steinke’s death helped fuel the fight, the Steinkes hadn’t seen their lives change as a result.
Insurance had always been out of grasp for the Steinkes. They didn’t make enough to qualify for tax credits on the state health insurance exchange, but they made too much to qualify for Medicaid. Activists have coined that “the gap,” and estimates say 59,000 Idahoans are in it.
“Medicaid expansion didn’t help Jason and me,” Clella said.
Just before Jenny died, Jason began a job with benefits. His insurance policy became effective Sept. 1, the day Jenny was rushed to the hospital.
“Six years ago, I needed (Medicaid),” Jason said.
Kyle Pfannenstiel covers rural health care in eastern Idaho for the Post Register. This dispatch is part of a series called “On the Ground” with Report for America, an initiative of The GroundTruth Project. Follow him on Twitter: @pfannyyy