When last we heard from Rep. Mark Amodei (R-NV2) it was in early May at which time he smoothly flipped his vote on the disastrous ACA replacement bill, with a convoluted explanation that “it” wouldn’t hurt Nevada…and then came the CBO scoring. The District 2 Congressional representative has kept his head down like a ground squirrel in his burrow by the side of the highway. This prevents him from dashing into the roadway, or as constituents might call it — holding an in person town hall meeting.
Tossing statistics about like so much confetti doesn’t remove the cold fact that the bill for which Amodei voted cuts $839 Billion with a B from the Medicaid expansion. Cue the GOP lament that there are “able bodied” people who benefit from the Medicaid program, a program initially meant to serve the desperately poor. The expansion aided people who may not be homeless without a tent but who were certainly desperate in terms of their ability to afford health insurance for themselves and their families. These are the people who waited until the medical situation was so dire expensive emergency room treatment was required; who used the emergency rooms as a form of walk in clinic for the lack of any more available alternative; who went without any medical attention whatsoever — 48,000 who died according to the Harvard study because health insurance was unaffordable.
Representative Amodei may not have believed the ACA replacement bill would have profound impacts on Rural health services, but other politicians from other states have pointed this out with remarkable clarity.
Missouri, for example, refused the Medicaid expansion, and the results aren’t positive, as described by Missouri Senator Claire McCaskill:
“Well, we have, first, more than 2 million Missourians live in rural areas of our state. And 41 percent of our state’s hospitals are in rural areas. We know that they are under particular stress right now, particularly in states like Missouri that have refused the money that has been offered them for their Medicaid program under the Affordable Care Act. We know that there’ve been 78 rural hospitals closed, including three in Missouri. We know that 74 percent of those hospitals were actually in states that refused to accept the Medicaid money that was offered by the federal government back to the federal taxpayers in those states.”
Arkansas which accepted the Medicaid expansion also has some issues related to its rural hospitals:
“The ACA’s crafters essentially made a deal with hospitals: The ACA cut Medicare reimbursements, but the reduction in uncompensated care through the Medicaid expansion helped offset some of those cuts. Without that offsetting boost, some of the state’s smaller rural hospitals might not be able to survive. A hospital like Baxter — the fifth most Medicare-reliant hospital in the nation, according to Moody’s, thanks to the community’s significant proportion of retirees — would be forced to make dramatic cuts in services without the Medicaid offset. “The expansion of Medicaid through Arkansas Works is one of the key components that’s been able to help us through the change in the ACA,” Peterson said. “Not just Baxter, but it helps all of rural Arkansas.”
What is true of Missouri and Arkansas is true for rural health care in general:
Of the more than 11 million people who have gained Medicaid coverage through the ACA expansion, nearly 1.7 million live in rural America, according to new CBPP estimates (see Appendix Table 1). The expansion population is more rural than the population as a whole: rural residents make up 12.1 percent of the population of expansion states but 14.1 percent of expansion enrollees in these states. In at least eight expansion states, more than one-third of expansion enrollees live in rural areas: Alaska, Arkansas, Iowa, Kentucky, Montana, New Hampshire, New Mexico, and West Virginia.
The Medicaid expansion has been a lifeline for rural areas in other ways. The ACA coverage expansions, especially the Medicaid expansion, have substantially reduced hospital uncompensated care costs: uncompensated care costs as a share of hospital operating budgets fell by about half between 2013 and 2015 in expansion states. Reductions in uncompensated care and increases in the share of patients covered by Medicaid have been especially important for rural hospitals.
Nevada hasn’t been immune from the problems associated with a lack of access to affordable health insurance and uncompensated care:
“Rural residents are themselves a public health challenge, as they are generally older, more isolated and less likely to be covered by insurance than their urban counterparts. They’re also more likely to smoke, suffer from obesity and hypertension and die from complications of diabetes.
But preventive care that could head off medical emergencies is hard to come by in many areas. Nevada’s rural and “frontier” counties – a term used for the state’s most-remote and sparsely populated regions – and reservations face severe shortages not just of doctors and primary care services, but also nurses, EMTs, dentists and substance abuse and mental health professionals. And in some areas, the numbers are dwindling, despite efforts to reverse the trend.”
And so, there are rural hospitals in Representative Amodei’s district — Elko, Lovelock, Battle Mountain, Yerington, Winnemucca, Ely, Fallon and others — wondering what effects will be felt if the GOP adopts the framework in the House bill for which Amodei voted. Residents in Tonopah watched as their hospital closed in August 2015, an unfortunate testament to the perils of privatization. The question which might, and should be raised, to Representative Amodei in some town hall (should he ever emerge) is how does the Republican version of health care insurance “reform” protect rural hospitals from financial pressures endangering rural hospital administration.
Ah, but all this is “old news” now that the Representatives voted on an unscored bill in their haste to get something, anything, done and have tossed the blazing ball into the lap of the Senate — in which we might expect Senator Dean Heller to lament the inadequacies of the measure to the Heavens, and then vote along with Senate leadership for the final (probably dismal) result.
Let’s guess that Senator Heller will announce his ‘profound misgivings and questions’ and then after consultations with some officials, reverse his position and do what he has always done — vote against any augmentation of health insurance affordability for his constituents (see his votes on SCHIP on multiple occasions.)
And so it remains — all quiet on the Humboldt — as Representative Amodei and Senator remain quiet (unless we count Heller’s scripted telephone town hall) on an issue of profound significance to District 2’s health care service providers.