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)

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)

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. 

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)

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)

Lacking money, insurance or dentists, oral health takes a back seat, and rural is barely on the bus

A dentist works at a Remote Area Medical Clinic in Wise, Va.
(Associated Press photo by Steve Helber)

Dental disease is the largest unmet health need in the U.S. among both children and adults, according to the Pew Children’s Dental Campaign. The worst-off are the poor, the young, the old, and those in rural America, reports Margot Sanger-Katz in the National Journal.

Dental disease is among the most common reasons that children miss school. It’s the most common medical reason that soldiers can’t deploy. It is a leading cause of emergency-room visits in several states. For proponents of a freer health care market, who want patients to be motivated by financial incentives to shop around and avoid “unnecessary” care, the dental system offers a glimpse of how such a system might work. And research shows that poor oral health can lead to disease elsewhere in the body.

In a world of medical priorities, dentistry takes a back seat to most, and In a world of health care, and rural America sometimes appears to not even be on the bus. The net result, writes Sanger-Katz, is that the United States faces a shortage of dentists that is particularly acute in poor, rural regions. "Huge pockets of the country have few (or no) providers. The federal government counts 4,503 mostly rural regions where more than 3,000 people share one dentist," she notes, "making it tough for many residents to find someone to fix their teeth."

Sanger-Katz continues, "For more than 100 years, dentistry has run on a separate -- and more laissez-fair -- track than the rest of medicine. Dentists have their own schools and treat patients in their own offices; fewer laws and regulations govern the field. Insurance plans typically demand high co-pays and limit their payouts for invasive procedures. About half of all dental expenses are paid out of pocket, compared with less than 10 percent of costs in the overall medical system. This is the free market. And, in some ways, it has worked: People do not drive up insurance rates by seeking frivolous procedures. Patients tend to shop around for care, and prices vary according to local economies. The rate of dental inflation, although higher than the rate for the economy overall, is lower than the rate in medicine, which is typically several points above the growth rate of the gross domestic product. (You don’t hear policymakers complain about the burden of “runaway” dental costs.)

“It’s very much a free market, with a greater spread between the haves and have-nots,” said Burton Edelstein, a professor of dentistry at Columbia University and the founder of the Children’s Dental Health Project. "Dental insurance is much less widespread than medical insurance; 130 million Americans lacked dental coverage in 2009, but only 50 million lacked medical coverage," Sanger Katz-writes. "And with most payouts capped at $1,000 to $2,000 per year, insurance can’t cover much beyond basic services. Medicare does not pay for dental care at all, so 70 percent of seniors lack any dental coverage, according to an Institute of Medicine report. Medicaid also fails to provide meaningful dental access for many of its beneficiaries: The program pays dentists so poorly for treatment that only about 20 percent of them see Medicaid patients." Meanwhile, seven of 61 dental schools closed in the last 30 years, meaning 2,000 fewer dentists every year, a 33 percent drop in supply, just as an older generation of dentists started retiring.

The result is a crisis. And, in a few lucky rural towns, the result looks like this: A mobile van outfitted with a volunteer dentist comes to a rural elementary school and offers free check-ups but no fillings. Or, better yet, a volunteer army of dentists, dental students and oral surgeons in a region volunteer for a two-day event at a vast arena where everyone is welcome to camp overnight for a place in line for care. Some of the dental expertise and hospitality is donated by Ronald McDonald House, or Remote Area Medical out of Knoxville, Tenn., or local community health centers. And while are limited in their ability to do much more than prevention, others can offer real dental care but no follow-up. The result is often a brutal kind of dentistry that involves, at best, mass extraction, some advice about what not to drink and explanations about how oral health is connected to overall health.

Dr. Nikki Stone is a dentist who works in Hazard, Ky., in one of the those federally qualified community-run clinics. A native of the Kentucky mountains, she knew that children in Eastern Kentucky weren’t getting enough dental care, but she was still "staggered by the prevalence of dental disease when she began examining them in 2004," Sanger-Katz notes. "Large numbers of the kids had never seen a dentist. Half had untreated tooth decay, and nearly 20 percent had urgent needs -- more than six cavities or an active abscess. She and her staff 'cried a lot,' she recalls. Crisscrossing four counties in her van, she painted fluoride on all the teeth and sent notes home with the children who needed immediate attention. In the early years, only 8 percent of those youngsters with urgent problems got the care they needed. The job was like fighting a forest fire on a mountain, she says. 'I felt like I was standing here on the line of the fire with a squirt gun.'

There seems little hope for any change soon in rural America, even if the federal health-reform law survives. "It deems dental coverage an essential part of any health plan for children, but regulators have yet to spell out what insurers must cover to meet that definition," Sanger-Katz writes. "The law expands existing loan-repayment funds for dentists who relocate to underserved areas, but it offers no expansion of dental coverage for adults and doesn’t try to integrate dental health into the larger health care system." (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):

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.