Friday, July 7, 2017

BCRA has rural hospitals, rural health in the headlines (Part I)

The now-months long effort to repeal and replace Obamacare (aka the Affordable Care Act) has brought rural people, their health and the hospitals who serve them onto politicians lips and into national headlines in recent weeks.  I've seen a number of U.S. Senators--mostly Democratic, but  also Susan Collins, Republican of Maine--mention their rural constituents as a reason they are opposed to the Senate version of Obamacare's repeal, the so called Better Care Reconciliation Act (BCRA).  Indeed, on June 27, Collins posted three consecutive Tweets (emphasis added), two of which used the word "rural":
○ “I want to work w/my GOP & Dem colleagues to fix the flaws in ACA. CBO analysis show Senate bill won’t do it. I will vote no on mtp.” 1/3 
○ “CBO says 22 million people lose insurance; Medicaid cuts hurt most vulnerable Americans; access to healthcare in rural areas threatened.”2/3 
Senate bill doesn’t fix ACA problems for rural Maine. Our hospitals are already struggling. 1 in 5 Mainers are on Medicaid.”
In this post, I want to highlight a few recent mentions of rural health care in the national media, starting with this piece on NPR on June 22:
Since 2010, at least 79 rural hospitals have closed across the country, and nearly 700 more are at risk of closing. These hospitals serve a largely older, poorer and sicker population than most hospitals, making them particularly vulnerable to changes made to Medicaid funding. 
"A lot of hospitals like [ours] could get hurt," says Kerry Noble, CEO of Pemiscot Memorial Health Systems, which runs the public hospital in Pemiscot County, one of the poorest in Missouri.

The GOP's American Health Care Act would cut Medicaid — the public insurance program for many low-income families, children and elderly Americans, as well as people with disabilities — by as much as $834 billion. The Congressional Budget Office has said that would result in 23 million more people being uninsured in the next 10 years. Even more could lose coverage under the budget proposed by President Trump, which suggests an additional $610 billion in cuts to the program.
That is a problem for small rural hospitals like Pemiscot Memorial, which depend on Medicaid. The hospital serves an agricultural county that ranks worst in Missouri for most health indicators, including premature deaths, quality of life and even adult smoking rates. Closing the county's hospital could make those much worse.
And a rural hospital closure goes beyond people losing health care. Jobs, property values and even schools can suffer. Pemiscot County already has the state's highest unemployment rate. Losing the hospital would mean losing the county's largest employer.
And on top of all that, annual payroll is about $20 million for the hospital as employer.

That provides some helpful background from a persistent poverty county in the Ozarks, where the need for healthcare for the poor is especially acute, not least because so many are so poor and in need of government assistance--for healthcare and otherwise.  The story, reported by Bram Stable-Smith, also covers the Missouri decision NOT to expand Medicaid, which was on offer as a bargain to states under the Affordable Care Act.

Since this story out of Missouri several weeks ago, the situation with the BCRA has gotten more acute in the sense that we now know what is in the BCRA.  The other two stories I'm featuring here are also by NPR and were published on July 1 and July 5, the first out of Hugo, Colorado (population 730), and the second out of Modoc County, California (population 9,686).  Both of these stories illustrate well the critical role that rural hospitals and healthcare facilities play in rural communities.

From the NPR story reported by John Daley out of Hugo, home to a regional hospital that lies between Denver and the Kansas state line, comes this quote:
From the outside, Lincoln Community Hospital looks more like a small 1960s-era apartment building. But it has all the essential high-tech health care equipment: modern imaging machines, tele-medicine links — even an AirLife helicopter. Rachel Smith, the assistant director of nursing, says the thing that really sets the hospital apart is the quality of its care. 
"It's definitely not treat 'em and street 'em," Smith says. "It's definitely somebody you're going to see — maybe even later that day, later that week."
From the NPR story out of Modoc County:
Modoc County, in the northeast corner of California, is roughly the size of Connecticut. It's so sparsely populated that the entire county has just one stoplight. The nearest Walmart is more than an hour's drive, across the Oregon border. Same with hospitals that deliver babies.
Greta Elliott runs a tiny health clinic in Canby, on the edge of the national forest. "Rural" doesn't begin to describe the area, she says. This is "the frontier."
"There are more cows in Modoc than there are people," Elliott says. 
There's a frontier mentality, too. People take care of each other, and they take care of themselves.
April Dembosky of NPR goes on to report that Ms. Elliott has herself chosen not purchase health insurance, thus reflecting the frontier mentality.  But the "frontier" reference is not just cultural.  It's a term used to designate the least populous MSSAs (Medical Service Study Area) in and by the State of California, which also uses "rural" and "urban" designations, though not in a way synonymous with the U.S. Census Bureau definitions.

Dembosky then explains the regional politics of far northern California (discussed in this recent post) and explains how the region's reliance on California's expansion of the ACA/Obamacare--called Covered California in the Golden State--has made strange political bedfellows.  She quotes Dean Germano, CEO of  Shasta Community Health Center.
The data shows it's the rural communities that have greatly benefited from the Medicaid expansion. That's the irony.  These are places that voted much more heavily for Donald Trump.
In fact, 70% of the voters in Modoc and neighboring Lassen County voted for Trump in 2016, and 64% of voters in neighboring Shasta County (home of the regional population center, Redding) voted for him.
But now a coalition of clinics from across the northeast corner of the state is lobbying local officials to take an unpopular position in this conservative land: defend the Affordable Care Act. 
And the right-leaning Shasta County Board of Supervisors took them up on it.
Germano commented on that decision:  
We thought "Whoa! That is really bold." I was surprised.
Though the Shasta County Board of Supervisors has lobbied their U.S. Congressman, Doug LaMalfa, to vote against the AHCA--the house version of Obamacare's repeal--LaMalfa has supported the repeal, defying at least this faction of his constituents.  

I'll return soon with another post on the issue of rural health care and the attention it's drawing from the national media and politicians.  

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