Rural Nevada Health Care and the Great Bamboozle AHCA

The state of Nevada consists of 110,567 square miles of miles and miles and miles.  271,985 people live in those miles and miles and miles out of a total population of  2,940,058.  A quick poke at the calculator shows a state in which 93% of the population is urban, while most of the real estate is rural.   This situation poses some easily apparent problems for health care services and the delivery thereof.

Rural health services must literally cover wide spans of territory in which there is a small population.   There is one hospital in Battle Mountain (Lander County, NV) to serve a total population of 5,702.  There is one hospital in Winnemucca (Humboldt County, NV) serving a total population of 16,528.  There is one hospital in Lovelock (Pershing County, NV) with a total population of 6,753.  There is one hospital in Elko (Elko County, NV) serving a population of 48,818.  Two conclusions can be reasonably drawn from this quick view of the northern tier of rural counties: (1) In none of these areas can a hospital draw upon “economies of scale” in terms of hospital services.  The obvious example may be that an expectant mother will usually require the same obstetric services in Battle Mountain, as in Winnemucca, as in Las Vegas or Reno.  (2) These rural hospitals serve populations which are generally not as affluent as in urban areas;  the rural per capita income lagging slightly behind urban areas. [RH] This places the northern tier of counties in a predicament similar to other western states:

“In the rural West, many farmers, ranchers and other agricultural workers are self-employed, so they can’t get coverage through an employer. Hence, a higher percentage of agricultural employees are covered by Medicaid (11 percent) than in non-agricultural industries (8 percent). Before the ACA was enacted in 2010, workers in the agricultural sector had fewer options, so many remained uninsured. But under the Obama-era plan, many states expanded Medicaid, increasing the percentage of those covered. Under the AHCA, that expansion would be significantly scaled back, according to the Joint Economic Committee report.”

Thus, the National Rural Health Association issued this warning:

“Though most rural residents are in non-expansion states, a higher proportion of rural residents are covered by Medicaid (21% vs. 16%). Congress and the states have long recognized that rural is different and thus requires different programs to succeed. Rural payment programs for hospitals and providers are not ‘bonus’ payments, but rather alternative, cost effective and targeted payment formulas that maintain access to care for millions of rural patients and financial stability for thousands of rural providers across the country. Any federal health care reform must protect a state’s ability to protect its rural safety net providers. The federal government must not abdicate its moral, legal, and financial responsibilities to rural, Medicaid eligible populations by ensuring access to care.”

In short,  cuts to the Medicaid program will disproportionately affect rural health care providers serving rural populations.

But, but, but, sputter the advocates of the Republican offering — We’re Giving People A Choice — you can buy what you want!  Not. So. Fast.

“Though some provisions in the modified AHCA bill improve the base bill, NRHA is concerned that the bill still falls woefully short in making health care affordable and accessible to rural Americans. For example, the modified bill contains a decrease in the Medical Expense Deduction threshold from 10% to 5.8% in an attempt to assist Americans between the ages of 50 and 64 who would see their premiums skyrocket under the current plan. However, this deduction is not a credit and therefore would be of little use to low income seniors that are in very low tax brackets or do not pay income tax at all. Additionally, the new amendments to freeze Medicaid expansion enrollment as of Jan. 1, 2018, and reduce the Medicaid per-capita growth rate will disproportionately harm rural Americans.”

Well, that didn’t go well.  What about that “get what you want argument?”  The first question might well be — What can you afford?  The annual earnings of a farm or ranch owner (manager) in Nevada is reported at an annual mean of $91,970.  However, the range runs from 10th percentile $39,850 to 90th percentile $150,410.  The annual mean wage for a farm or ranch worker is $34,520. [BLS]  Nevada’s reported average annual mean for farm and ranch workers is slightly higher at $36,480. [DETR download] Now we have a problem — 138% of the federal poverty level is $16,374 for a single person or $33,534 for a family of four.   Our hypothetical average annual mean earnings for a farm or ranch worker isn’t eligible for Medicaid expansion enrollment, but has an income well below the Nevada average household income average of $52,431, or 63.96% of the annual average household income level.

How to market an insurance policy this hypothetical average family could afford?  Either offer a comprehensive insurance plan and provide premium assistance to make up the difference between what the premium costs and what the family can reasonably afford — or there’s always the Junk Insurance option.   Consumer Reports offered some excellent advice concerning what constitutes Junk Insurance — aka “affordable plans” —  watch out for fixed benefit indemnity plans, and medical discount cards.  Another Consumer Reports bulletin specified the elements of Junk Insurance, your insurance plan could be very hazardous to your physical and financial health if it contains: Limited benefits; Low overall coverage limits; unrealistic “affordable” premiums; No coverage for important health care services; Ceilings on categories of care; No limits on out of pocket costs; Random catches — like covering hospital care after the second day, when it’s known that the first day is usually the most expensive.

The problem at this juncture for rural Nevadans is that those in the agriculture sector may or may not have earnings allowing them to enroll in Medicaid.  If “yes” then a reduction in Medicaid — whether it happens now or just after the 2020 elections — will have a negative impact on many citizens in the northern tier of “cow counties;” similarly, a return to the Bad Old Days pre-ACA makes those who are certainly less than affluent vulnerable to the offerings of Junk Insurance, which is fine as long as they don’t mind paying for a product which will not cover their medical expenses at the time they actually need it.  Exacerbating this issue is the fact that jobs in agriculture (farming and ranching) are listed by Forbes as the 4th most dangerous occupations in the country.

There’s no way to bestow a bright face to the Republican tax cut disguised as a health insurance ‘reform’ bill in terms of what happens to rural Nevadans and their health care providers.  Those it doesn’t cut out completely it leaves vulnerable to incomplete and almost useless “catastrophic coverage” plans — which for too many policy holders leaves them facing health care costs well beyond their ability to pay for out of pocket.  If there were a recipe for increasing the “uncompensated care” costs for local hospitals and clinics this is definitely IT.  Rural hospitals and clinics, already stretched to meet costs, would be especially at greater risk — and we haven’t even touched on the topics of long term care for the aging or home health care services which prevent individuals from having to reside in more expensive residential care facilities in rural areas.

NOW is the time to contact, and continue to contact, our Senators (Heller and Cortez-Masto) and urge their opposition to this assault on medical care for northern Nevada citizens and their health care providers.

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