Friday, January 27, 2017

Obamacare: can't live with it, can't live without it

One of the many, many political issues in recent headlines is the proposed repeal of the Affordable Care Act. Republicans on The Hill continually push to dismantle President Obama's pride and joy, but just six days ago I saw a woman marching through the streets of Oakland, CA sporting a sign with "The ACA saved my life" in large block letters. It's been a national debate for years: Is the ACA a blunder, destroying the federal budget, or is it a huge step toward universal healthcare? For rural communities, the ACA did not go far enough to save crumbling hospitals in small towns across the country.

Rural USA has a love-hate relationship with the ACA. Why? Well, just like for the rest of the U.S., the ACA allowed more people to get health insurance, allowed young people to stay on their parents' insurance for longer, and allowed people with pre-existing conditions to have the same access to insurance. That's the love part. The hate part is where millions were still left uninsured because states didn't expand Medicaid the way the federal government planned. Poorer states couldn't do it (as noted here). NPR's Weekend Edition reported that half of the 37 million people who were supposed to get coverage under the ACA would fall under the Medicaid expansion. But, if your state didn't expand, then you were left out. Millions of people in rural states: left out. That's the hate part. Not to mention that provisions in the ACA could have helped recruit and retain hospital employees, but Congress failed to fund those initiatives. That's the love-hate part - they tried, but execution didn't exactly pan out for everyone. (More gaps in ACA coverage in "the country" discussed here.)

ABC recently published an article entitled, "Rural hospitals bracing for effects of Obamacare repeal." Highlighting Marengo Memorial in Iowa County, National Rural Health Association's CEO, Alan Morgan, gives statistics showing both sides of this roller coaster of attitudes toward the ACA. Since the Act took effect, more patients are insured and hospital debt has decreased. On the other hand, as an employer, expenses have gone up due to coverage mandates. On the other other hand, Morgan cites the biggest concern as uncertainty among patients about where their coverage will come from moving forward. Repeal? No repeal? Replace? No replace? No one knows. Rural communities can't afford more uncertainty when it comes to healthcare.

In March of 2016, the PBS NewsHour did a special on hospital closings in rural communities. They cited that 19 states failed to expand their Medicaid programs under Obamacare. This in combination with Congress' decision to cut Medicare payments has "left many rural hospitals with unpaid bills." According to the National Rural Health Association, at the time of the PBS Program, more than 280 hospitals were on the verge of closing down.

The following week, The NewsHour followed up their story by highlighting a hospital in Fredericksburg, Texas (population: 10,000). Hill Country Memorial Hospital caused a horrible tragedy in 1999. A teenage boy, Quinn Kott, arrived at the hospital after suffering a stroke, but wasn't examined by a doctor until the following morning. He passed away that day. At the time, the hospital was "in the red," both employee and patient satisfaction was dwindling, and members of the community were known to find alternative sources of healthcare based on the hospital's reputation.

Like many small towns with hospitals, Hill Country Memorial was the largest employer in Fredericksburg; its success was vital to the community. After Quinn passed away, the hospital began turning itself around. They hired folks from Toyota, Southwest Airlines, and the Ritz Carlton to improve their efficiency, values, culture, and customer service. Now, it is one of the top 100 hospitals in the country. Unfortunately, Hill Country Memorial's ability to recover and excel as a healthcare provider is the exception, not the norm, in rural America. The original NewsHour episode did a better job of portraying the reality of rural healthcare: hours long travel times for people to get to appointments, inability to tend to emergency situations before the patient passes, debt, out of date equipment, lack of doctors and nurses, and myriad other problems.

But the ACA fixed America's healthcare problems right? Maybe? No? (See this previous post to learn that it depends.)

During NPR's report, Maggie Elehwany, also from the National Rural Health Association, said that she has concerns about a repeal of the ACA, but "We want to make sure that they understand that the well intentions of the ACA have really fallen short and may actually be exacerbating the hospital-closure crisis." A repeal could be extremely damaging, but that doesn't mean that our healthcare laws wouldn't bear improvement.

Where the ACA fell short, some states are trying to find their own solutions. In an effort to improve the scarcity problem of healthcare professionals, an Alabama law offers tax incentives for physicians who live and work in rural areas. Now, The Anniston Star reports, there is a bill in the works to expand the incentive. The bill would offer a $5,000 annual income tax credit to doctors and physicians in rural areas for 10 years, slightly expanding the current incentive (which only lasts 5 years and is only offered to physicians). Rising costs of medical school, increasing retirement of older doctors, and the promise of a higher pay in the city are all contributing to dwindling access to healthcare in rural Alabama. Only 2 of 54 rural counties in the state do not have a health professional shortage, that means that 52 counties are facing shortages. Wayne Rowe, CEO of Quality of Life Health Services, says that scarcity of professionals is the "main challenge" of his clinics and "'any kind of incentive would be beneficial.'"

So, what is rural America saying about healthcare? The ACA isn't bad, it's just not nearly enough. Elehwany got it just right, "We are not mad at Republicans or Democrats. We're mad at Republicans and Democrats." Maybe she was just speaking for rural hospitals, maybe she was speaking for the whole country.


Wynter K Miller said...

This is a wonderfully even-handed consideration of the state of healthcare access in rural America. I think the political conversation often leaps to the "repeal!" conclusion without considering the numerous extraneous factors that — independent of the ACA — affect healthcare coverage and access in rural places. I'm thinking specifically of the power state-level medical boards have in addressing the "scarcity of professionals" problem. Indeed, there are a plethora of factors that the ACA could not possibly be expected to ameliorate—e.g.,
• Declining matriculation in certain medical specialties (e.g., only 9% of medical students specialize in those areas most necessary for most Americans, including rural families: family medicine and general internal medicine)
• Inability by some states to retain medical school graduates
• Disinclination by institutional medicine to allow nurse practitioners, physician assistants, and other sub-specialists to fill the supply and demand gap
• Disinclination by state medical boards to allow distance-based care (i.e., telemedicine)

Regardless of where blame is placed, I think one thing is clear, and well-articulated in this post: current efforts to ameliorate access barriers are "just not nearly enough."

Courtney Hatchett said...

Personally, I was tickled by the NewsHour report’s reference to Fredericksburg as a “model of success” for rural hospitals. I couldn’t help but remember last week’s readings about rural gentrification and “recreation counties.” Fredericksburg is far from what I would consider rural. Over the past five years the entire county has rebranded itself as the “Texas Wine Country” and become a high-end retirement destination ( Even my own parents are currently considering moving to Fredericksburg. Hill County Memorial Hospital has locations throughout the hill country and has been a key magnet for many baby boomers looking to get out of Austin (and California: This seems less like an uplifting story about a rural hospital turn-around and more of a classic example of money flooding into a once “rural” area as it transitions into a recreation county.

Another article about rural hospitals that I found to be a bit more uplifting is here: The author draws similarities to major rural hospital closures in the 80s, but argues that now rural hospitals have tools and advocates to better combat the looming crisis. For example, the existence and diversity of the National Rural Health Association may help to keep rural hospitals a part of the conversation.

Kaly Rule said...

One of the biggest failures of the past administration, in my opinion, was their inability to simply and clearly explain the ways in which the Affordable Care Act was drafted to save people money. Without a healthy population to offset the costs of the sick insurance companies can't charge low costs and still be economically viable. This is why, as of last summer, the US was on track to spend 2.6 trillion dollars less from 2014 to 2019 than before the Affordable Care Act became law. ( This is despite the many states that didn't expand Medicaid coverage. Although small government has long been a tenant of the Republican party, so too has decreasing the budget deficit, which the ACA was on track to accomplish.

"Not to mention that there are provisions in the ACA that could have helped recruitment and retention of hospital employees, but Congress failed to fund those initiatives."

I was personally unaware of these provisions, but it makes it even more frustrating that the politics got in the way of increasing peoples life expectancys.

Mollie M said...

I wonder about the structure of healthcare plans in rural areas, how they worked themselves out logistically, and how much impact these issues might have on rural hospitals that are struggling. With the ACA's employer mandates and online insurance markets, I wonder if some of the rural hospitals closing down have to do with preventative care availability and coverage as well as the choice that some states made to not expand medicare. For example, I would like to know what kind of health care plans were available to people, and if it was an HMO or similar plan with a limited provider list (either because there aren't enough providers physical present or because not enough signed up with the HMO) are people able to access an appropriate amount of preventative care? In a rural area, I imagine that sometimes a hospital bears the burden of providing urgent care as well as actual emergency care to the community. Even if a patient has medical coverage technically, this doesn't mean that he or she can access the preventative care that is offered through the plan (think travel time, availability of providers, high deductibles, etc). All this is to say that though the ACA has provided relief to many rural hospitals, there may be an additional layer to the problem: people may be underinsured.