Data show each county's number of uninsured, how many would benefit from Medicaid expansion

The U.S. Census Bureau released data this week showing 2010 estimates of health insurance coverage for all 50 states and each of the nation’s counties. The data are exactly what journalists need to do their own stories about the problem of the uninsured and the potential impact of Medicaid expansion under federal health reform.

The Census Bureau press release has a link to the map above and to a list of every U.S. county with estimates of the number of people who would be covered if Medicaid were expanded to 138 percent of the poverty level.

Laura Ungar of The Courier-Journal in Louisville used the data to show what parts of Kentucky and Indiana have the most uninsured and which would benefit most from Medicaid expansion. The greatest area of need in Kentucky was in the state's south-central region which is part of Appalachia but has no coal. Ronald Wright, judge-executive in Casey County told Ungar that his hilly county depends largely on industries such as timbering and farming, and many residents don’t have employer-sponsored health coverage. “I don’t know how we correct it,” Wright said. “Most people just can’t afford (insurance). It’s getting so expensive.” He said the uninsured often seek care in emergency rooms that can’t turn them away or at the local health department, which “is always busy.” (Read more)

Medicaid dental coverage is first to go when states can't tighten eligibility rules; has big rural impact

Many states have cut optional benefits for poor adults enrolled in Medicaid, rather than tighten eligibility requirements at a time when more people need the program, and dental services are often first to go. The problem likely won't improve under President Obama's health-care overhaul because it requires dental coverage just for children. The cuts probably affect rural residents disproportionately since many rural places are facing dentist shortages, according to the Pew Center on the States.

In about half the states, Medicaid dental care now covers only pain relief and emergencies, according to a recent Kaiser Commission on Medicaid and the Uninsured report. Other states cover preventative exams and cleaning, but not fillings and root canals, Abby Goodnough of The New York Times reports. Some states are also cutting vision, chiropractic and podiatry coverage, and requiring co-payments for prescription drugs. (Times photo by Gretchen Ertl)

Many adults on Medicaid are turning to community health centers for dental care. In Massachusetts, which has long been a state with very generous Medicaid, community clinics received 22,000 new dental patients in the first six months after dental coverage was dropped. And in states where Medicaid still covers dental care, "finding dentists who accept Medicaid can be next to impossible," Goodnough writes, because reimbursements have also been cut and dentists have dropped out of the program or refuse to join. (Read more)

Columnist points out rural America's heavy reliance on Social Security, Medicare and Medicaid

The latest offering from syndicated agricultural columnist Alan Guebert, right, delves directly into politics, starting with Mitt Romney's choice of U.S. Rep. Paul Ryan as a running mate. The Wisconsin Republican's "biggest reform ideas take dead aim at America’s three costliest social programs, Medicare, Medicaid and Social Security," Guebert writes. "Any change in either or all will have profound effects across farm country because rural America relies more heavily on all three than the nation’s urban areas. According to a November 2011 study by the National Academy of Social Insurance, 9.3 percent of 'total personal income' in rural counties comes from Social Security. By contrast, Social Security is just 5 percent of total personal income in urban America.

"Moreover," Guebert notes, "Social Security is the economic lifeblood of many rural counties. For example, Orangeburg County, S.C., gained $232 million of income -- or about $1 billion in overall economic activity -- in 2009 through Social Security. The story is the same for Medicare and Medicaid’s impact on farm and ranch country. While one in six, or 49 million, Americans, receive Medicare benefits, 12 million -- or one in four of those beneficiaries -- live in rural America. And that number is growing; 15 percent of rural America is 65 years old or more while just 12 percent of urban Americans are senior citizens."

Medicaid covers 16 percent of all rural residents and 35 percent of all rural children up to 18. The urban numbers, respectively, are 13 percent and 28 percent. Six out of 10 rural nursing home residents receive some form of Medicaid, and it is estimated that 56 percent of all rural physician income and 60 percent of all rural hospital cash flow is tied to Medicare and Medicaid. (To see all the documents used in this story, go here.)

New level of dental professionals – therapists – could provide care to Medicaid-eligible kids, save a bundle

Research at the University of Connecticut suggests that adding a new kind of health professional – dental therapists – to clinics designated as Federally Qualified Health Centers could significantly expand the availability of care for millions of American children, many of them in rural areas. (Pew Center for the States photo)

The white paper from the Pew Center on the States notes that, "in particular, by including dental therapists as providers in school-based programs operated by FQHCs, the researchers estimated states could provide access to care for 6.7 million Medicaid-eligible children, nationwide." The analysis also suggests that this significant increase in access could be realized for a cost of approximately $1.8 billion, or just one half of 1 percent of combined state and federal 2009 Medicaid spending. To read the full Pew report, go here. 

Nationwide, 830,000 emergency room visits in 2009 were due to preventable dental problems, according to the center. Most of the children lacking care don't have insurance, live in areas without enough dentists or can't find doctors who accept Medicaid. Problems accessing dentists could grow in 2014, when 5 million more children are expected to get dental insurance under the federal health reform law.

Despite the undisputed need, not everyone is behind the concept. The American Dental Association argues that dental therapists lack the training and education needed to perform irreversible surgical procedures and to identify patients' other medical problems, writes Anna Gorman in the Los Angeles Times. Shelly Gehshan, director of the Children's Dental Campaign, said the therapists would be properly educated and would help close vast gaps in care that can lead to costly emergency room visits for dental problems.

In 2005, Alaska became the first state to try out the new dental-care model, when therapists began treating native populations. Minnesota authorized the new tier of practitioner in 2009, and the first graduates of dental therapy programs began practicing last year.

Health reform's expansion of insurance means doctor shortages are about to get worse

Doctor shortages are most chronic in rural America, but now even places with growing populations like Southern California's Inland Empire are feeling the considerable pinch of not having enough doctors to provide care for a growing number of patients. Thus, some medical crises that face California's Riverside County or suburban Phoenix mirror those found in places like the Mississippi Delta, where there are too few specialists, too few doctors willing to take Medicaid and all are overworked because 9 percent of the nation's doctors take care of 20 percent of the country's population, report Annie Lowrey and Robert Pear of The New York Times. (NYT chart)

The problem is expected to spread under federal health reform, they write. With the expansion of insurance coverage and aging baby boomers driving up demand, "The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. That number will more than double by 2025," Lowrey and Pear report. "Even without the health-care law, the shortfall of doctors in 2025 would still exceed 100,000." In addition, Medicare officials predict their enrollment will surge to 73.2 million in 2025, up 44 percent from 50.7 million this year because of the baby boomer demographic hitting their golden years. “Older Americans require significantly more health care,” said Dr. Darrell G. Kirch, the president of the medical-college association. “Older individuals are more likely to have multiple chronic conditions, requiring more intensive, coordinated care.”

Medical-school enrollment is increasing, but not as fast as the population. The number of training positions for medical-school graduates is lagging. Younger doctors are on average working fewer hours than their predecessors. And about a third of the country’s doctors are 55 or older, and nearing retirement. (Read more)

Time to check your local hospital's credit rating

What is your local hospital's credit rating? Did you even know it had a credit rating? It might be a good time to check it, since many hospitals are getting lower ratings these days.

Nick Tabor, senior staff writer for the Kentucky New Era in Hopkinsville, found that Jennie Stuart Medical Center's rating dropped, meaning that "The hospital may have to pay a higher interest rate if it needs to borrow money in the near future." Tabor wrote.

Fitch Ratings, one of the global agencies whose ratings guide investors, said uncertainty about the expansion of Kentucky's Medicaid system and how federal health reform will affect the hospital's finances were other reasons for the downgrade. The hospital has lost money in two of the last four years. Last year, it had a 1.9 percent loss.

Tabor explains there are eight ratings above the BBB level. If the facility's rating "were to slip two levels lower, to BB+, it would be on the level of 'junk bonds,' no longer considered investment grade," he reports.

There are three major rating companies in the U.S.: Fitch, Moody's and Standard and Poor's. Moody's expects downgrades of nonprofit hospitals to outnumber upgrades by the end of 2012, reports Jeffrey Young for The Huffington Post. Fitch expects the same will happen, said Senior Director Emily Wong. Smaller hospitals will especially feel the pinch since they "don't have as much ability to offset expense, inflation or reimbursement reductions," Wong said.

AA- and A-rated facilities are reviewed every two years. BBB and BBs are reviewed once a year, and B- and below-rated facilities are reviewed every six months. The easiest way to check ratings for hospitals is to get an account at each of the three major rating companies. "These accounts are free and easy to set up," Tabor tells us. (Read more)

Safety-net hospitals could get hit hardest when Medicare reimbursement changes in October

When hospitals start getting paid based on the quality of care they provide to their Medicare patients, so-called "safety net" hospitals, a last resort for the poor, could be the losers in the equation. That's because a main way of measuring quality will be patient experience ratings, and safety-net hospitals tend to get poorer marks from patients, according ta new study published in the Archives of Internal Medicine.

Since hospitals have had to publicly report their patient experience ratings, the gap between how patients rated these facilities and the scores that other hospitals got widened. "We found that [safety-net hospitals] performed more poorly than other hospitals on nearly every measure of patient experience and that gaps in performance were sizeable and persistent over time," the authors write.

When the Centers for Medicare and Medicaid Services agency starts using the scores to hand out bonuses and penalties, safety-net hospitals could be at a disadvantage, especially since penalties could mean a 2 percent cut on regular Medicare payments. Starting in October, patient experience scores will determine 30 percent of a facility's bonus. "The hospitals that perform best will gain money, while those that lag in scores and improvement over time will end up with less," reports Jordan Rau for Kaiser Health News. (Read more)

Governors of both parties undecided on Medicaid expansion, seeking answers on possible tweaks

There is hesitation among governors on both sides of the aisle regarding whether or not to expand Medicaid, which would cover millions more Americans under the program for the poor and disabled.

"At least seven Democratic governors have been noncommittal about their willingness to go along," N.C. Aizenman and Karen Tumulty report for The Washington Post. States would have to start paying part of the extra cost in 2017, rising to 10 percent by 2020. Several Republican governors have said they will not participate, while others say they have not decided.

The issue is surely a major discussion topic at the National Governors Association meeting this week in Williamsburg, Va. Questions remain unanswered: "Will states that opt in have the option of scaling back in future years? If a state that opts out decides it wants to participate at some later point, will the federal government still pay nearly the full cost of covering those who become newly eligible for Medicaid? And can a state participate only partially — for instance, by raising the income cutoff for its program to a level lower than the ceiling envisioned in the law, which is set at 133 percent of the federal poverty line?" Aisenman and Tumulty ask.

NGA Executive Director Dan Crippen said states are confused over what to do. The association has sent a list of questions to Secretary of Health and Human Services Kathleen Sebelius about the issue. "States need to be making these decisions now, and it's hard to make them if you don't have clarity," said Matt Salo, director of the National Association of Medicaid Directors.

Sebelius has said she will address concerns during meetings that will take place in various cities starting July 31. There is no deadline yet for when states must choose whether or not to expand. (Read more)

Here's a chart from The Washington Post, accompanying a story by Sarah Kliff, on who would be left in and left out in each state either way the expansion decision goes (click image for larger version):

Mostly Republican governors want to opt out of health care law's Medicaid expansion

When the U.S. Supreme Court declared yesterday that the Affordable Care Act is constitutional, it limited the federal government's power to make states expand their Medicaid programs, which will likely impact the implementation of the law in several states, especially those controlled by Republicans.

Medicaid expansion was challenged by 26 states as being "coercive" because it would have allowed the feds to take back all of a state's Medicaid funding if it refused to comply. But the court ruled that the U.S. Government can only take back funding designated specifically for expansion, and not any of a state's existing Medicaid funding. "What Congress can not do is to penalize states that choose not to participate in that new program by taking away their existing Medicaid funding," Chief Justice John Roberts wrote for the majority.

States stand to gain a lot by expanding the program, Christine Vestal of Stateline reports, because the federal government pays 100 percent of costs for the first two years, then reduces its funding to 90 percent in 2020. The Congressional Budget Office estimates this would add up to a $20 billion transfer to states over the first 10 years of expansion. But, some states say covering 10 percent of the cost of new beneficiaries would put more strain on their budgets. (Read more)

Most Republican-led states have done little to set up online exchanges which allow residents to compare private health insurance for the best price and serve as a portal for joining Medicaid expansions, The Associated Press reports. State have to tell the federal government in November whether or not they will build exchanges. The federal government will build a common exchange for states that don't build their own.

Wisconsin's Republican Governor Scott Walker denounced the law on Thursday, saying he would not implement any parts of it in Wisconsin before the presidential election. "While the court said it was legal, that doesn't make it right," Walker said. "For us to put time and effort and resources into that doesn't make a lot of sense."

GOP leaders in Mississippi say they don't have the money to expand Medicaid. Emily Wagster of AP reports Mississippi receive a large chunk of federal money for Medicaid because it has a high percentage of low-income residents. Republican Governor Phil Bryant said deep cuts in education and transportation would have to be made to cover the cost of Medicaid for more than 400,000 additional people. He said the state is looking at "some leeway in the decision to not penalize states for not complying with Medicaid requirements."

The question of Medicaid expansion is still up in the air in several other Republican-controlled states, including Nebraska, Ohio, South Carolina and Indiana, where governors say they would be hard-pressed to implement it. But Washington Republican Attorney General Rob McKenna, who joined the lawsuit against the Affordable Care Act last year, split with most of the GOP and said Congress shouldn't repeal the law, or any of its provisions, including the individual mandate. McKenna, who's currently running for governor, said he's ready to implement health-insurance exchanges and Medicaid expansion if elected, Jim Brunner of The Seattle Times reports.

If Obama is re-elected, in a sort of referendum on the health-care law, battles likely move to states

The political battle over the Patient Protection and Affordable Care Act will continue in Congress and on the presidential campaign trail, but if President Obama keeps his current lead and is re-elected the battle seems likely to move to the states. Congressional Republicans said they would keep moving to repeal the law, but they do not have the votes to override a presidential veto. That makes the November election a sort of referendum on the law.

While the Supreme Court upheld the law's individual mandate to buy health insurance or pay a penalty, starting in 2014, it struck down a key provision for expanding coverage through the Medicaid program. It said the federal government can't take away states' current Medicaid funding if they refuse to participate in the expansion. That is "a gun to the head," Chief Justice John Roberts wrote in the 5-4 majority opinion.

The decision means that "A state can refuse to participate in the expansion without losing all of its Medicaid funds," Kevin Russell writes on SCOTUSblog. "Instead the state will have the option of continue the its current, unexpanded plan as is." (Read more)

"The Medicaid provision is projected to add nearly 30 million more people to the insurance program for low-income Americans -- but the court’s decision left states free to opt out of the expansion if they choose," MSNBC's Tom Curry writes. The law requires states in 2014 to cover adults with incomes at or below 133 percent of the federal income threshold definition of poverty, now $14,856 a year for single adults. "Many states now cover adults with children only if their income is considerably lower, and do not cover childless adults at all," Roberts noted.

The chief justice said it is not constitutional to "penalize states that choose not to participate in that new program by taking away their existing Medicaid funding," because the law transforms Medicaid into a more general health program. "The threatened loss of over 10 percent of a state’s overall budget is economic dragooning that leaves the states with no real option but to acquiesce in the Medicaid expansion."

Liberal justices Stephen Breyer and Elena Kagan joined conservative Roberts in that part of his opinion. The other liberals, Ruth Bader Ginsburg and Sonia Sotomayor, said the administration does have the right to withhold Medicaid money if a state doesn't follow the new rules, and said this was the first time that the court had ever found "an exercise of Congress’ spending power unconstitutionally coercive." However, Ginsburg wrote in their concurring opinion that a majority of the court (all but Breyer and Kagan) "buys the argument that prospective withholding of funds formerly available exceeds Congress’ spending power. Given that holding, I entirely agree with the chief justice as to the appropriate remedy" — banning the withholding of Medicaid funds, "not, as the joint dissenters would have it, to scrap the expansion altogether."

While polls have never shown that a majority of American adults favored the law, majorities favor its major components, the exception being the individual mandate. Here's a graph from the Kaiser Family Foundation, via a Washington Post blog post that includes other polling data:

Will states that challenged the law as unconstitutional also refuse to expand their Medicaid programs? Not necessarily. Matthew Yglesias of Slate explains the workings of Medicaid: "The more a state spends, the more the federal government kicks in—but you get diminishing returns in terms of how much extra money you can get. So the upshot is that a stingy, conservative state can expand for cheaper at the margin than can a generous liberal state." (Read more)

John Barro of Bloomberg News notes that some reform advocates "worry that states will opt out and low-income people in conservative states will be left without coverage. But I think we will have expanded Medicaid in all 50 states in pretty short order," because the federal government will pay "100 percent of it in the early years, gradually declining to 90 percent. That’s a pretty big carrot. States that refuse to expand Medicaid will be rejecting nearly free federal money. Such a rejection would be tantamount to saying that government health insurance for low-income people is so undesirable that a state is not even willing to pay ten cents on the dollar for it." (Read more)

Stateline notes that Wisconsin Gov. Scott Walker said his state "will not take any action to implement Obamacare," so that could play in his 2014 re-election bid, and the Birmingham Business Journal said "opting out of the Medicaid expansion seems increasingly likely for Alabama." Mary Orndorff, who covers Washington for Alabama's largest newspapers, writes that nearly 1 million people in that state "get their health care through Medicaid and the expansion could increase that by more than 500,000 people. In other words, the state would go from 21 percent of its state population eligible for Medicaid to about 40 percent. . . . Alabama officials had expressed concern that the expansion is something the state cannot afford, estimating that administrative costs alone would rise by $389 million." (Read more)

It's also likely that this year's presidential candidates will continue to spin the truth about the Affordable Care Act to suit their needs, reports The Annenburg Public Policy Center's FactCheck.org. Both Obama and Romney "wasted little time in taking to the airwaves to rehash plenty we've fast-checked before," the website writes. Obama was quoted as saying workers will be able to keep their current plans, but "at least a few million" won't be able to keep employee-sponsored plans under the new law. He was also caught exaggerating the benefits of the law. Meanwhile, Romney "repeated a number of distortions," including the law would cut Medicare by $500 billion and add trillions to the deficit.

ProPublica has a report on reactions from some states that sued to overturn the law. For a report by Tara Kaprowy of Kentucky Health News, including details on how the law will affect individuals, click here.

Supreme Court to issue decision on health law Thu.; Poynter's Al Tompkins offers guide to covering it

The Rural Blog is designed mainly for rural journalists, most of whom are interested mainly in local issues. But every now and then a national issue is so broad and deep that it affects everyone, and calls for localized coverage everywhere. That is the case with the U.S. Supreme Court's decision on the federal health-reform law, which is to be released at 10 a.m. EDT Thursday.

As he so often has, Al Tompkins of the Poynter Institute anticipates an opportunity for coverage and provides advance help for doing it. Tompkins is a broadcaster by trade, but he's also a policy wonk and offers a rundown of the issues that almost any journalist would find helpful. "The public has said that journalists spend too much time covering the politics of the story and not enough time and space covering what the health care plan does and how it affects them, Tompkins writes. "Let’s fix that."

First, he points us to "an easy-to use tool" from The Washington Post that shows how the law affects you. Then he runs down the three big issues in the case (the individual mandate to buy health insurance, the various reforms in health insurance, and the expansion of Medicaid); Republicans' main objections to the law; what might happen under various scenarios; and fact-checking by PolitiFact, a service of the Tampa Bay Times, which is owned by the Poynter Institute. We also like FactCheck.org and the Post's Fact Checker column.

"The decision will immediately be a national story, a legal story, a political story, a business story, a health care story and a local story," Tompkins writes. "Let’s make sure you are ready to cover it."