Rural voters oppose 'Obamacare', except when label is dropped and law is called by its real name

Party labels affect what rural voters think about the Patient Protection and Affordable Care Act, according to the latest National Rural Assembly and Center for Rural Strategies poll of rural voters in nine swing states, reports Bill Bishop of the Daily Yonder, which the center publishes.

When asked if they approved or disapproved of the "Affordable Care Act, sometimes called Obamacare," 60 percent of rural voters said they opposed the law, and 34 percent said they favored it. Without reference to "Obamacare," voters were asked if they approved or disapproved of the law, which "would give states the opportunity to extend Medicaid coverage to cover more low income families with health insurance, with the federal government picking up 90 percent of the costs," and 45 percent said they approved, while 42 percent disapproved.

Bishop concludes that partisanship is the culprit for such results. "Partisanship overwhelms issues in today's politics," he writes. "Voters are willing to change their beliefs -- even their religious affiliation ... in order to stay with their political tribe." (Read more)

North Dakota oil boom overloading rural hospital emergency rooms and leaving them with unpaid bills

The Bakken oil boom in western North Dakota -- with its massive equipment and its young, transient oil workers -- is puting tremendous strain on the region’s small hospitals that are finding it hard to shoulder the increasing emergency trauma load and the unpaid bills left behind it. John McChesney reports in the Daily Yonder that if that weren't enough, "Nurse and staff recruitments have become much more difficult due to high housing prices and high competitive wages in the oil patch. And attracting physicians, always a problem for rural areas, has gotten tougher, even as needs soar."

Randall Pederson of Tioga Medical holds
piles of unpaid bills returned from
addresses for people long gone.
(Photo by John McChesney)

Randall Pederson, president and CEO of the 25-bed Tioga Medical Center and a regular ambulance volunteer, says his town has seen a dramatic leap in ambulance runs and emergency room patients this year. “In 2007 we would see 600 patients in ER per year,” Pederson told McChesney. “In 2012, we anticipate seeing over 2,000.” That means in a five-year period, Tioga’s emergency room visits have more than tripled. “We are seeing a lot more industrial accidents, major trauma, many of those involving car accidents, because there’s a lot more vehicles on the roads these days,” Pederson explains. Many accidents involve 40-ton tank trucks colliding with 5,000-pound passenger cars, writes McChesney, "incidents that can bring several patients with horrible injuries into the small ER at the same time. The one doctor on call has to scramble for help."

According to Darrold Bertsch, president of North Dakota’s Rural Health Association, private insurers pay less in North Dakota than in most other states. And many of these ER patients -- many who come from out-of-state for piecemeal work -- don’t pay their bills. Tioga's Pederson in Tioga says his hospital had to write off $270,000 in bad debt. Other area hospitals report similar collection problems. McChesney reports that North Dakota's McKenzie County Hospital will lose more than half a million dollars this year because of patients' unpaid bills. Likewise, Montrail County Medical Center in Stanley, has 25 to 30 percent of revenue written off to bad debt. In Williston, Mercy Hospital’s bad debt has sky rocketed from a pre-oil-boom $2 million a year to $7 million this year, hardly something rural hospitals can endure for long. Mercy's CEO Matt Grimshaw says most of those charges have been billed to people who have jobs and could afford to pay, but he just can’t find them. Could Obamacare help here, with its mandate that everyone have insurance? In this red state, no one wanted to answer that question, McChesney reports. (Read more)

Health reform said to hurt rural doctor recruitment

Recruiting doctors to rural hospitals will get harder in the next few years as the Patient Protection and Affordable Care Act reaches full implementation and the demand for healthcare services increases, a new report suggests. An Association of Staff Physician Recruiters report, "In-House Physician Recruitment Benchmarking," says interview-to-hire ratios in rural areas are much higher than in urban, and rural recruiting officers are often responsible for several things, not just hiring new doctors, making them overworked. Both factors make it harder for rural hospitals to recruit, the authors concluded. (University of Chicago photo)

ASPR Benchmarking Committee Chair Shelly Tudor told John Commins of HealthLeaders Media that the cost of recruitment is rising, making it hard for rural hospitals to compete with their urban counterparts. "In lots of respects, the process favors urban providers. Physicians are coming to urban areas and they are looking for jobs, whereas rural providers have to go out and target physicians that are likely to come to their area," Tudor said. Rural recruiters have to "filter through a lot of people to find the right one who is willing to come in and even look at the opportunity," she said. (Read more)

Feds want 1,000 rural hospitals to switch to electronic health records by 2014

The federal government wants 1,000 "critical access" and rural hospitals to adopt electronic health records by 2014, and is funneling about $30 million through its Regional Extension Center to make it happen. The money could help as many as 1,500 rural hospitals, or 90 percent of those covered by the Small Rural Hospital Improvement Program.

The Office of the National Coordinator for Health Information Technology has already secured $32 million in American Recovery and Reinvestment Act money for REC for IT improvement at critical access hospitals, which are classified as facilities with no more than 25 beds and an average of 10 patients a day, Neil Versel of Information Week reports.

The National Rural Health Association is enthusiastic about the funding, but still sees obstacles to implementation, Versel reports. "To realize this goal, we need all hands on deck. We need everyone rowing in sync, including leadership and staff in every critical access and rural hospital, electronic health records vendors, hospital associations and state offices of rural health in every state, Rural Health IT Network Development grantees, Office of the National Coordinator grantees, and many more public and private, federal and local partners," ONC Office of Provider Adoption Support director Mat Kendall, and ONC rural health IT coordinator at Leila Samy said. (Read more)

Rural people more likely to die from colon cancer

Rural people with colon cancer are more likely to be diagnosed late and receive inferior treatment than their urban counterparts, according to a new University of Minnesota study. Rural colon cancer sufferers are also more likely to die from the disease. This is the first study of its kind to show that outcomes in colon cancer are affected by where a person lives, Tiffany Chao reports for ABC News.

The study focussed on more than 100,000 patients diagnosed with colon cancer from 1996 to 2008, with rural people making up 15 percent of the total. Rural patients were 4 percent more likely to get a late diagnosis, had 17 percent lower odds of receiving chemotherapy and had an 18 percent lower chance of getting lymph nodes removed during cancer-removal surgery, indicating that their treatment was most likely inadequate. Overall, rural patients were 5 percent more likely to die from colon cancer. (Read more)

Rural areas have higher percentage of uninsured

The share of rural people under 65 without health insurance increased 8 percent during the recession, and is now higher than in cities or suburbs, according to U.S. Census Bureau data. Before 2005, rates of uninsured were about the same in rural and urban areas, but during the recession, the rate of uninsured rural people rose to 18.4 percent, compared to 17.7 percent in urban areas, Bill Bishop of the Daily Yonder reports.

The data show "a huge variation in the percentage of uninsured by state," Bishop writes. In 16 states, at least one in five rural residents under 65 didn't have health insurance. From highest to lowest, they were: Texas, Alaska, Florida, Nevada, New Mexico, Oklahoma, Georgia, Idaho, Colorado, Mississippi, Montana, South Carolina, Arkansas, Oregon, Louisiana and North Carolina. The rate of rural people without insurance was higher than in urban areas in all but six states: Illinois, California, Nevada, Connecticut, Florida and New York. (Read more)

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)

Study: Rural people more likely to get Alzheimer's

Rural residents are twice as likely to get Alzheimer's, according to a University of Edinburgh study that collected "all over the world and spanned several decades," Nikki Tucker of Medical Daily reports. Researchers say limited access to health care, exposure to unknown substances, and socioeconomic factors may lead to the increased risk.

Prior studies have analyzed the difference in what effects rural and urban areas might have on the disease, but because of debate about what constitutes "rural" and "urban," results have been deemed inconclusive. (Read more) The study was published in the International Journal of Epidemiology.

Federal grants will improve telehealth services for rural veterans in Virginia, Montana and Alaska

A disproportionate number of veterans are in rural areas, and telehealth could soon improve their health care, which is often lacking because of limited resources or long-distance travel to Department ofVeterans Affairs  hospitals. The Department of Health and Human Services has partnered with the VA to provide almost $1 million to rural veterans' health care providers to improve VA telehealth and HHS state health information exchanges. The three states with the highest rates of rural veterans -- Virginia, Montana and Alaska -- will each receive about $300,000.

The VA said its telehealth system, once it's fully integrated nationwide, will be capable of providing at least 1.2 million medial consultations annually for veterans who would otherwise have to travel long distances to be treated, Robert Longley of About.com reports. Under the Honoring America's Veterans Act signed by President Obama last month, the VA is authorized to waive co-payments for veterans who use telehealth services. (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.

Obama orders VA to focus on mental health, with special emphasis on rural areas

President Obama signed an executive order Friday directing the Department of Veterans Affairs to expand mental health services and suicide prevention efforts, with a special emphasis on rural areas, which provide a disproportionate share of military members, Megan McCloskey of Stars and Stripes reports. Much of the order contains initiatives that were announced earlier in the summer by the VA.

The order instructs that any veteran with suicidal thoughts be seen by a mental-health professional within 24 hours, a standard already set by the VA but rarely met, McCloskey reports. In many areas of the U.S., psychologists, psychiatrists and social workers are sparse. To address this, the order directs the VA to partner with the Department of Health and Human Services to utilize community services to help meet demand. The agency will also create 15 pilot sites in underserved areas by contracting with local facilities, and it must create a plan for rural areas, which could include a mental health professional sharing program, McCloskey reports.

The VA put together a 21-person team in June to begin addressing these issues, and it has until June 2013 to hire just under 2,000 additional mental health staffers and the issues with pay, loan repayment, scholarships and partnerships with community-based providers to lure more mental health employees. (Read more)

Volunteer emergency medical services becoming less prevalent as they run short of volunteers

Volunteer EMTs in Maddock, N.D.

Volunteer emergency medical service squads appear to be dying out as rural populations change and EMS evolves. Volunteer squads have long been the sole emergency responders in many rural areas, reports Candi Helseth of the health-oriented Rural Assistance Center, but according to a 2010 study, "Rural Volunteer EMS: Reports from the Field," 69 percent of 49 local EMS directors in 23 states reported problems recruiting and retaining volunteers.

The North Carolina Rural Health Research and Policy Analysis Center study reported three main reasons for loss of EMS volunteers: high numbers of retirees or elderly in rural areas are unlikely to have physical strength required for EMS, many working-age individuals leave rural areas to find jobs elsewhere, and volunteers have too many obligations to cover weekends. Voluinteer fire departments have reported similar problems.

Almost three-quarters of the all-volunteer EMS agencies hosted fundraising events to get necessary funding, requiring further time commitments. At least one-half of these agencies have started some type of paid compensation, but it's still less than maintaining a full-time staff. Twenty percent of EMS leaders reported being "uncertain of their ability to maintain future service," and 8 percent were "frankly pessimistic" about the future. (Read more)

Tool allows detailed examination of inspection reports from nursing homes all over the U.S.

Journalists now have a tool at their fingertips that will allow them to find out about problems in their local long-term care facilities. (iStock photo)

The application is operated by ProPublica, a nonprofit, investigative news group, and allows "anyone to easily search and analyze the details of recent nursing home inspections, most completed since January 2011," report Charles Ornstein and Lena Groeger.

The tool has features that the federal government's Nursing Home Compare tool lacks, including the ability to search using any keyword. Results can also be sorted according to the severity of the violation, and by state. It has already resulted in several significant news stories, Ornstein reports, giving examples and tips on how to use the application.

About 1.5 million people still live in nursing homes nationwide, though more seniors are living at home or in assisted-living facilities. The reports show there were almost 118,000 deficiencies cited against 14,565 homes. According to the Centers for Medicare and Medicaid Services, the average number of deficiencies for a nursing home inspected in the U.S. is eight. ProPublica's analysis shows Texas had the most deficiencies in the country by far, with 183. 

While ProPublica ranks the states, nursing-home industry officials say "inspectors in different regions of the country have different thresholds for issuing a citation, and that could unfairly make one state's homes appear worse than another's," Ornstein and Groeger report. (Read more)

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)

Female lives in 622 rural and exurban counties, nearly 1/4 of total, shortened from 1999 to 2009

The life expectancy of the average U.S. female increased 1.7 years from 1999 to 2009 -- 79.6 to 81.3 years.  Good news on the whole, but Daily Yonder reporters Bill Bishop and Robert Gallardo went a little farther in their analysis of the data provided them by the Institute for Health Metrics and Evaluation at the University of Washington. They found that rural women hardly keep up and some have even lost ground in the last decade while their urban sisters are obviously gaining from widespread health advances.

Bishop and Gallardo report "that the solid gain in longevity was matched in only 168 rural or exurban counties, or 6.5 percent of all the counties outside the cities." That is, while women in most of the nation were living longer lives, in many rural counties -- some 622 of them, in fact -- their longevity shortened in the same decade. The 622 represent some 24 percent of rural counties and exurban counties (counties in a metro area where more than half the county population lives in rural census tracts), women lived shorter lives in 2009 than in 1999. (You can see a similar map and charts for rural men here.)

 As the Daily Yonder reporters point out, "in more than 95 percent of rural and exurban counties, changes in female longevity in the last 10 years failed to match the gains experienced in the rest of the country." The largest decreases in female life expectancy between 1999 and 2009 were clustered in Oklahoma, Eastern Kentucky, West Virginia, Alabama and Georgia. (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.)

Anti-pill-mill law makes some Ky. doctors stop, or threaten to stop, writing prescriptions

Fighting prescription drug abuse, which has become epidemic in Appalachia and many other rural areas, isn't a simple matter of passing a law. Kentucky, one of the most over-medicated states, is learning that as some doctors are putting up their prescription pads, or threatening to stop prescribing, because they find a new law aimed at "pill mills" to be confusing and overreaching, reports Mike Wynn of The Courier-Journal in Louisville.

"Patients who have never been a problem are bound up in all of this," Greg Hood, Kentucky chapter governor of the American College of Physicians, told Wynn. "There are so many unintended consequences." Hood's group and the Kentucky Medical Association are trying to determine how many clinics are declining to write prescriptions, but neither is advocating that approach. According to state offices of the Drug Enforcement Administration, only three in-state doctors have voluntarily surrendered their DEA registration — required for prescribing controlled substances — in recent weeks for reasons related to the new law. (Read more)

South Dakota starts program to get health workers, not just doctors, to work in rural areas

Mindy Jagerson, left and Julie Crick at
work at the Freeman Regional Health
Services Hospital (Argus-Leader photo)

Incentives to get doctors in rural areas, like this one in Missouri, are common. Now a program will put $10,000 bonuses into the hands of newly hired health-care employees if they promise to keep working in rural South Dakota for three years. The money comes from the state with a matching share from the worker's employer, reports Jon Walker of the Argus Leader in Sioux Falls. The South Dakota legislature approved the arrangement this year to protect towns where hospitals and nursing homes struggle to find employees.

The jobs include nurses, dietitians, nutritionists, lab technicians, pharmacists, paramedics, X-ray technologists and occupational, physical and respiratory therapists. "It's a no-brainer for the staff person," said Dan Gran, CEO at Freeman Regional Health Services. "They get their $10,000. All they've got to do is show up and maintain their employment. We benefit because we've retained them."  The program is limited to communities with less than 10,000 people.  If the town is smaller than 2,500, the state will pay 75 percent.

The new program bypasses federal involvement, notes Walker. It would use about $300,000 a year from the state general fund. A companion program sets up bonuses for rural health professionals with more training. They range from $35,000 for midlevel professionals to $100,000 for doctors starting new jobs and promising to stay three years in towns smaller than 10,000. The state again covers up to 75 percent of costs. Annual cost is $515,000 for the state. Deputy State Health Secretary Tom Martinec said it's reasonable to use public money to assist private business. "The fact of the matter is we need health care workers in rural areas. They're competing against larger towns. That's why we needed to step in."
 

Once destitute Calif. tribes fight to keep others from benefiting from off-reservation casinos

Thomas  Lozano at the planned
Enterprise Rancheria Casino site
(NYT photo by Max Whittaker)

To pull itself out of poverty, the Maidu Indian Tribe of California in 2002 applied to build an off-reservation casino about 35 miles south of the few acres of reservation land where a handful of the tribe's people live in broken-down trailers. The federal government has approved the plan, but the final decision rests with California Gov. Jerry Brown, who is expected to decide on the fate of the planned Enterprise Rancheria casino and another tribe’s off-reservation proposal by an Aug. 31 deadline. But, reports Norimitsu Onishia of The New York Times, "Plans for the two casinos are drawing fierce opposition and last-minute lobbying in the state capital from an unexpected source: nearby tribes with casinos that they say will be hurt by the newcomers. Leading the fight against Enterprise is the United Auburn Indian Community, whose casino, Thunder Valley, has become one of America’s most profitable and has brought the formerly destitute tribe unimaginable riches."

How unimaginable? Onishia reports that "with 80 percent of its revenues coming directly from gambling, Thunder Valley is so profitable that it has transformed the lives of its owners, the 400-member United Auburn tribe, most of whom received welfare benefits until the casino opened in 2003. The tribal council has provided housing for members, built group homes for troubled children and connected residential areas to water and sewer systems. All members receive free health care and dental benefits. Children making the honor roll receive hundreds of dollars in incentives. The tribe’s 200 adult members each get a share of the casino’s revenues, which local news media have reported as $30,000 per month, and which industry experts have estimate is more. Douglas G. Elmets, a spokesman for the tribe and a former White House spokesman during the Reagan administration, said only that members did not need to work for financial reasons, but that many did in tribal affairs."

Since Indian gambling was legalized in the United States in 1988, only five tribes have gotten final clearance to build casinos off their reservations.  The issue in California now has raised larger issues in Indian communities across the nation about the goals of gambling. A decade ago, tribes were united in their efforts to further Indian gambling, which was supposed to give them the means to become self-sufficient, said Steven Light, co-director of the University of North Dakota’s Institute for the Study of Tribal Gaming Law and Policy. But he said that talk of “fairness and justice” has given way in an increasingly competitive market. (Read more)