Study: Rural residents have equal access to health care -- if they have insurance and like the drive

A health-care study in Tennessee, which started with the premise that people in rural areas have less access to care than urban dwellers, ended with a rather surprising conclusion: They don't. Not if they have health insurance. "When it comes to commercially insured patients, there’s little disparity in access to health care between residents of rural communities and urban areas in Tennessee," said Dr. Steven L. Counter, president of the BlueCross BlueShield of Tennessee Health Institute.

How can this be? The study found that almost half of rural residents pass up the hospitals closest to their homes to go to larger urban hospitals, even if the same services are available locally, writes Getahn Ward of The Tenneseean. "The conclusion we came to is that we’re living in a very mobile society, and the distance is not necessarily a determinant factor in whether people get care or not," said Coulter.

Because the survey did not include consumers, it's only a guess about why they chose to take the time and trouble to go to the big town, but experts says it's a combination of services not being available or a perception that they aren't, even if they are. This raises, again, age-old questions about the viability of rural hospitals, some of which often don’t have the money for capital-intensive technology and services. However, Coulter told the Tennessean that "a recent increase in alliances between rural hospitals and larger hospitals and urban health systems raises hopes that non-urban hospitals may be able to expand their menus of services."

Such partnerships between non-profits and for-profit chains are becoming more common, reports Ward, and some say those efforts will change the perception of those in far-flung regions that great medicine is being practiced close-by. This could be especially important, said Wes Littrell, chief strategy officer and president of Nashville-based Saint Thomas Health, in the new world of health reform. “We expect that when you get more into population management that you need to take care of the patient closer to home in the lower-cost setting,” he said. (Read more)

Kaiser Foundation video explains health reform

For those of us who find health reform confusing, the Henry J. Kaiser Family Foundation has done a favor. Its video "Health Reform Hits Main Street" wrestles the topic down to a 9-minute, animated movie that will "explain the problems with the current health care system, the changes that are happening now, and the big changes coming in 2014," the foundation says.

The foundation promises that viewers will learn "more about how the health reform law will affect the health insurance coverage options for individuals, families and businesses with the interactive feature 'Illustrating Health Reform: How Health Insurance Coverage Will Work'." Whether you actually learn that, we figure, is up to you, but they have given it a good try. Watch the video by clicking on this website where a link will take you to the video. It's also available in Spanish.

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)

One story of health insurance and health reform, doable in any American community

Here's a story for every news outlet in the United States, no matter how small or large: Randall Patrick of The Kentucky Standard in Bardstown shows how the federal health-care reform law is having an effect at the individual level by telling the story of Bonnie Varnell, right, a local resident who was uninsured and is more than $65,000 in debt due to her fight against cancer.

For 18 years, Varnell worked at a daycare that didn't offer health insurance. She wasn't able to buy individual coverage because she had pre-exisiting conditions as a result of surgeries. She is only 59, so does not qualify for Medicare, and she didn't qualify for the federal law known as COBRA, which "allows workers to keep their company group health insurance benefits for up to 18 months after leaving their jobs, as long as they pay the entire premium," Patrick explains.

As a result, the bills kept mounting, despite hospitals giving the Varnells reduced rates through charity care. "I've been trying to pay something on every one," Varnell's husband Ed said of the bills he receives and has to delay paying in full. "It's really frustrating. We had never been late a day in our lives."

Now, Varnell has health insurance through a program created under the Patient Protection and Affordable Care Act. "It costs her $315 a month and covers most of her costs after the deductible is met, but the law stipulates that a person with a pre-existing condition must be uninsured for at least six months before she or he can be eligible," Patrick explains.

Varnell's fear now is the program will be taken away if the Affordable Care Act is repealed after the November election. Patrick gives opponents of the law their say. (Read more)

Varnell is among the estimated 15 percent of people in her county who didn't have health insurance in 2009, the last year for which estimates are available. For the Census Bureau website with estimates for every county, go here. 

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):

Texas hospital boss says health law won't help much in remote rural areas without health services

Many rural advocates have applauded the Supreme Court decision that the Affordable Care Act is constitutional, saying millions more will gain access to affordable health coverage. But, at least one health industry executive thinks the law will not help rural people very much, reports Ray Westbrook of the Lubbock Avalanche-Journal.

Texas Tech University Health Sciences Center President Tedd Mitchell said the individual mandate won't help those in rural America who can't find health care in their regions. "What everybody talks about with the Affordable Care Act is making sure that everybody has insurance coverage. And having insurance coverage in West Texas does not mean having access to care." In West Texas, in particular, there are 54 counties that are considered "frontier counties" because very few people live there, and 32 have no hospital.

A similar situation exists northward in the Great Plains, and "for a lot of rural America," Mitchell said. "While making sure everybody has an insurance card is a noble thing, it really doesn’t address our needs.” (Read more)

Health-care law is a lot about rural America

The historic Supreme Court decision last week upholding almost all of the Patient Protection and Affordable Care Act prompted Jon Bailey, director of research and analysis at the Center for Rural Affairs, to point out the law's very rural focus. He said it "talks about the rural health-care infrastructure system, how we pay for that, how we incentivize that, and how we get people to become health-care professionals in rural areas." Bailey told Janell Baum of Farm Futures that several provisions of the act specifically address rural health facilities, financial assistance to bring in extra doctors and hospital staff, and funding for preventive services. He said provisions in the insurance portion of the law may also help more rural businesses and farms find ways to insure their employees.

Bailey acknowledged that along with these benefits come significant funding challenges. "I think that is may be the next big part of health care," he said. "We are probably never going to reverse the costs, but how can we control it? The ACA doesn't really address that but that’s the next big issue on the horizon."

American Farm Bureau President Bob Stallman told Baum his federation is "concerned" about potential increases in costs for businesses and individuals, and fears the law would "impose a new financial burden on our members." Stallman called for a market-based reform, encouraging Congress and President Obama to address remaining concerns. The more liberal National Farmers Union supported the findings of the Supreme Court, and praised the "significant, necessary reforms that help all Americans … afford insurance and the preventive care they need," Baum reports.

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."