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.