Without Obamacare, rural economies may suffer most

Rural Americans played a big part in sending Donald Trump to the White House, with 64 percent of those voters pulling the lever for the billionaire real estate developer.

Yet the president’s and Republican leaders’ efforts to make good on a promise to repeal and replace the Affordable Care Act (Obamacare) would be “very harmful to rural America,” according to a rural healthcare expert.

Dr. Margaret Greenwood-Erickson, an emergency medicine physician who has a research focus, in part, on rural populations, said a bill the House recently passed, and now under consideration in the Senate, will roll back key measures from Obamacare that benefit rural America. Rural economies are lagging behind their urban counterparts in terms of economic growth. And while strengthening rural businesses is the long-term solution, a quick disappearance of Obamacare funding would be a step backwards, according to Greenwood-Erickson.

At the center of it are hospitals, which serve as the main providers of healthcare services in rural areas. If hospitals serve increasing amounts of uninsured individuals, it becomes difficult to make ends meet. This has been a rural trend, and a shuttered hospital is a severe blow to the local economy – taking away good paying medical jobs and making the area less attractive for individuals and businesses to locate.

“It sort of becomes this really vicious cycle where it’s really hard to attract new businesses to an area if you don’t have a hospital in the area,” Greenwood-Erickson said. “It’s hard to get young families to move into town, and it’s hard to get businesses to come back if there’s no medical care.”

A positive outcome of Obamacare in rural communities was increased access to health insurance – either through Medicaid or the health insurance exchanges that were created under the law. Sixteen percent of rural Americans have health insurance through the federally-funded Medicaid program. And over 1.7 million rural individuals use the Healthcare.gov marketplace to purchase insurance, with most of them eligible for tax credits to bring their monthly premiums down.

“If you look across the board across the U.S., at what populations had the largest increase in insurance under the ACA, it was rural areas,” Greenwood-Erickson said.Under Obamacare, states were given the option to accept new federal funding to expand Medicaid. Greenwood-Erickson pointed to Arkansas and Kentucky, where that expansion resulted in more residents consistently taking their medications, as well as being able to pay their medical bills and afford regular doctor visits.

States that didn’t expand Medicaid are seeing disproportionate amounts of healthcare industry problems.

“We’ve seen since 2010 there’s been 80 rural hospital closures, and the vast majority of them have been in states that did not expand Medicaid,” Greenwood-Erickson said.

“I don’t want to overstate that link, but it certainly seems that Medicaid expansion has really helped stabilize rural hospitals, and has really made it even more challenging for rural hospitals to survive in states that did not expand Medicaid.”

Obamacare utilizes tax dollars to plug a hole that has been created by struggling rural economies, where incomes are lower and workers are less likely to have insurance through an employer group plan. Medicaid expansion and the exchanges gave affordable insurance options to families whose incomes range between 100 and 400 percent of the poverty line, according to a report from the Kaiser Family Foundation.  That’s between $24,600 and $98,400 for a family of four and makes three out of four rural residents eligible for the new options.

Obamacare is not without its flaws. For one, medical costs and insurance premiums continue going up faster than inflation. The tax dollars required for Medicaid expansion and insurance premium subsidies are estimated at a cool $1.76 trillion over a 10-year period, according to the Congressional Budget Office. Also, insurance companies are dropping out of the health exchanges to a point now where a third of the counties in the U.S. have one option on the exchanges, and many of those counties are rural.

In the meantime, recent numbers show rural health has a long way to go. A new CDC study stated that more rural Americans are dying from potentially preventable causes, such as heart disease and cancer, than their urban counterparts. Several demographic, environmental, economic and social factors might put rural residents at higher risk of death from these conditions, the report stated. Those factors include higher rates of poverty, less access to healthcare and being less likely to have health insurance.

Quality of life indicators in rural areas are also key factors. For example, rural residents report less leisure physical activity.

“We’ve started to realize across the board that patients’ social needs are playing a very large role in their overall health,” Greenwood-Erickson said. “The term that’s getting thrown around a lot is called the social determinants of health.”

These determinants include where a person grows up, what the community is like and what the economic status is. Addressing unmet social needs is a critical component of effective healthcare delivery and doing so looks different in a rural area, where it’s harder to do interventions to improve job situations, find affordable housing and encourage healthy lifestyles.

Greenwood-Erickson acknowledged Obamacare is not perfect and doesn’t address every rural health problem, but added, “There is no way in an ideal world we lose the gains of insurance and improvements towards health in rural areas and towards more financially viable local hospitals.”

She believes a complete repeal of the Affordable Care Act would result in a sudden decrease in the insured, sudden loss in access to healthcare and higher rates of uncompensated care, which would lead to more hospital closures. “I’m not alone in this,” she said. “The National Rural Health Association and other large rural health groups have said that it would be really potentially quite devastating.”Rural health officials hope the country will be able to build on what has worked with Obamacare. This includes finding ways to further expand insurance coverage and transforming care in rural areas to better-treat preventative health problems. It also includes addressing the underlying social determinants that affect a person’s overall health.She said it’s important to think critically about how rural hospitals can streamline themselves in both emergency and preventative care and also temper continuing-to-rise costs.What’s next in federal law is up in the air. Uncertainty in whether health insurance exchange subsidies will be paid as promised under Obamacare may be baking in increased premium prices for next year. Lawmakers seem pessimistic that the Senate can come to an agreement on a healthcare bill.Regardless of how the law pans out, rural businesses and communities can make their areas healthier in various ways. Employers can provide financial incentives for healthy behaviors, like joining a gym, providing money for quitting smoking or getting employees involved in large scale diabetes prevention programs. Local leaders can work with the area hospital on community health initiatives and connect with various agencies to bring in programs and resources that promote community health. They can also work to stimulate the local economy to provide people one of the biggest health advantages of all. A good paying job.  Ben Rowley is a journalist and rural entrepreneur. Find more rural business content at RuralBusinessHQ.com.

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  1. Wheeler says:

    Gee, yeah – how did we EVER survive before the brilliantly unsustainable socialistic entitlement package known as Obamacare graced our misbegotten lives and strategically burrowed into our culture like a Godzilla sized Louisiana tick? How? Mayhem and pestilence at every turn, dogs and cats… living together… medieval mass hysteria?! But then, enter the doomed to fail Obamacare (not unlike the doomed to fail green subsidy mandate of our tax dollars 8 years ago), designed to fail while paving the way for single payer socialism – all hail Obamacare as we discover the 10 ton behemoth so dense we must pass it to discover what’s in it!!

    And what was in it?

    A humongous Orwellian hook up to big government as it tugs at the heartstrings of the simplistic voter while demanding that millennials give a damn (at the most least likely age) while endeavoring wholesale social engineering. The ‘rich’ need to be taken down a peg – or haven’t you heard (in 1968)?

    So, how did we EVER survive (yes, in rural Nevada) before the brilliantly unsustainable socialistic entitlement package known as precious ‘Obamacare’ graced our misbegotten lives, drove good doctors into retirement, and royally screwed with things in general just a few years ago (and long before Ben and Margaret ever heard of Obama or his mandated brand of ‘Care’ and most likely eventually hungrily voted for his ‘Change’)??

    It’s a rhetorical question, but are you really all that concerned, or just interested in lambasting Trump while protecting Obama’s legacy? Because really concerned voters tend to read things before blindly voting for them – and reject things when they don’t (or logically won’t) work, instead of clinging to ideological symbols and manipulative half-measures now characterized as ‘necessary’ and irrevocable.

    I guess the Kool-Aid they served (with that 10,000 page c%@p sandwich) was just that good, because now the song is ‘we CAN’T possibly live without the thing’ that can’t stand up for itself and must logically be replaced, soon.

    In the face of that fact, how is leaning into the failing thing and defending the sort of thinking that created it helpful?


    Get out of the way and let private competitive industries solve the problem for half the price and twice the quality – yes, even in rural anywhere – and stop automatically expecting curbside government parenting under any/all circumstances.

  2. Jon Lewis says:

    “A positive outcome of Obamacare in rural communities was increased access to health insurance”

    In a word; excrement.

  3. Under Obamacare and living in this rural community, I signed up and the first month I paid a $49 something premium. The second month they wanted a $100 something premium. The third month a $150 something premium. No thank you. I’ve had to pay a dentist and travel hundreds of round trip miles to be seen by a dentist when no local dentist would see me because they all want cash upfront. No compassion at all. I made that trip numerous times and still need dental work. Thousands of dollars later out of my own pocket and having to make payments to the good dentist in another state… Then I fell at Ridleys and they destroyed the videotape where I had fallen in the store due to their unsafe display. I suffered greatly and they lied and denied, corrected the faulty display and claimed I was never hurt and that I made it all up. Even though I was taken to the ER in an ambulance and Ridley’s even promised me that night that they would take care of me and pay for the ambulance. A Ridley’s worker told me there was a video and that it was taped over. He didn’t want to lose his job, but he told me that and Ridley’s wanted his name, but I did not tell who it was and he was telling the truth that the tape of me falling was destroyed. The Ridley’s manager at the time was transferred to Colorado and I’ve seen him back here and then gone again and he is the biggests denier and liar this far side of the Mississippi River! This all under Medicare/Obamacare and local hospital collected thousands and thousands of dollars and still came after me for thousands more when it was Ridley’s responsibility. They even changed insurance companies in the middle of all this and claimed I never reported the accident. A damn lie. Damn ripoffs all in coots as far as I can tell. Let’s not mention the local hospital padding my state insurance when I had it with another patient’s unpaid medical bills and then firing the billing person who told me. What about the director of this local hospital who embezzled over $65,000 from them. Go after that thieving crook and stop gauging the patients and padding their hospital bills with non-paying patients! One time I was taken to ER with very extreme pains and it turned out to be a stone lodged in a duc and was told I would need surgery. My back was painful, my stomach painful, my right upper rib cage and I was vomiting over and over, dehydrated and suffering with constant pain. They gave me strong pain narcotics that knock me out, I hardly even take aspirins! I woke up at some point, but very disoriented. I could not see well everything was blurry, I could hardly walk or think straight. They released me about 3:00 am and I could not get anyone on my cell phone so I went and sat in the ER waiting room waiting until daylight when someone would be up a couple of hours later. I was so weak and needing assistance. Then a male RN who had been on the floor in ER came to the waiting room and told me to leave or he was going to call security and have me removed. I was the only one in there and I tried to explain I could not reach anyone that no one was answering, he said that wasn’t his problem and for me to leave or security would be called. I was so sick and wounded emotionally by his treatment of me and drugged…I cannot even say how I made it home that time, but that person would have been terminated had I reported him, at least he should have been for jeopardizing my safety that night. Obamacare and some of the local hospital staff…are negligible and incompetent of the needs of patients with serious medical issues. And this is only the tip of the problem I’ve had in seeking medical care in this rural area. Then we have to travel hundreds of miles for specialized care. This is one hospital that needs an outside agency advocating for the patients who hold them accountable! I have no problem with the doctors here, but more so with the lack of compassion and competence from several nurses in ER and in the hospital. I don’t know if I would have been alive today had I not stopped one from giving me an injection that should have been a slow push over a 10 minute period, but she was going to give the heart med to me all at once. I stopped her and she said she had never heard such a thing before. Well she went and got a medical book and sat by my bed reading it. After a while she said I was right and she gave me the injection in a 10 minute slow push. What would have happened had she not…well my blood pressure could have dropped dangerously low and it would have been most likely another unreported cause of death due to staff or hospital error. If you are a patient you have a right to question everything about your care. All under Obamacare…Beware!

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