Rural Areas Brace for Health Care Bill Impact – Roll Call
While the exact text of the Senate bill is not yet posted publicly, all signs point to somewhat similar language to the House bill (HR 1628), which would reduce funding for Medicaid compared to current law and impose caps on Medicaid funding. Under the House bill, older people also would face higher premiums — and rural areas tend to be home to a large number of older Americans.
These proposals worry advocacy groups, as rural areas are disproportionately affected by cuts to Medicaid and premium increases. Rural areas already have more uninsured and underinsured people per capita than the rest of the country. In addition, these organizations are expressing frustrations over the increased levels of bad debt to rural hospitals and the need for marketplace changes.
“It’s very polarizing when it used to be one of the health care issues that really brought Republicans and Democrats together,” said Maggie Elehwany, vice president of government affairs and policy at the National Rural Health Association.
Many of the holdout Republican senators are from states with large swaths of rural areas.
“For us in Alaska we’re pretty much the definition of rural, so we’re trying to highlight the issues that impact us and why so much of what we see in the House-passed bill is not helpful for us,” said Sen. Lisa Murkowski, R-Alaska.
The difference in the dynamic is striking. Senate leaders and committee chairmen over the past two decades traditionally paid special attention to the impact of health care changes on people in small towns and the countryside.
That was particularly true for the Senate Finance Committee leaders when the 2003 Medicare drug benefit and 2010 health care overhaul laws were enacted, Charles E. Grassley, R-Iowa, and former Sen. Max Baucus, D-Mont. Another leader in these efforts was Tom Daschle, D-S.D., who led the Democrats as majority or minority leader until his 2004 electoral defeat.
In 2003, Grassley and Baucus added $25 billion in Medicare funds for rural health providers over a 10-year period to the prescription drug law (PL 108-173). And Grassley helped in pushing for a change added to the Democrats’ 2010 health care overhaul (PL 111-148, PL 111-152) that took steps to shore up rural health care, such as improving pay for doctors in rural areas.
Senators also have championed a range of programs over the years to bolster rural health care, including the critical access hospital program, Medicare dependent hospital program, rural referral center program and sole community hospitals.
To be sure, Grassley and other senators such as Steve Daines, R-Mont., have talked during the current debate about trying to help rural areas. But the overall impact of the legislation would undercut coverage, according to the Congressional Budget Office. And rural areas would be hit particularly hard.
Grassley said, however, that he is concerned about significant problems and a lack of insurers in the Iowa marketplace under Obamacare.
“Obamacare’s unaffordability and collapse in Iowa are causing serious problems. For Iowans in the individual market, including farmers, small business owners and others, they’re hit hard by astronomical Obamacare premium increases. Premiums went up by as much as 43 percent from 2016 to 2017,” Grassley told CQ Roll Call. “Now, because of the way Obamacare is designed, these individuals face tremendous uncertainty and anxiety about even having access to a plan in 2018. Obamacare has failed in so many ways for the people of our state and others, so I’m looking for how to make health care more affordable and accessible.”
A major issue would be the bill’s federal cuts to Medicaid, the program for people who have low incomes and have disabilities. The proportion of rural people who qualify for Medicaid is higher than in many cities.
The House bill would slice Medicaid funding by $834 billion over a decade compared to current law, the CBO found. Senate leaders are said to be considering even deeper reductions, although CBO has not released an estimate.
About 23 million people over a decade would no longer have coverage if the House bill becomes law, according to CBO. An increase in the uninsured rate means that more people will visit hospitals for emergency care, and rural hospitals are often not able to absorb this increase in people unable to pay for these services.
Hospitals in small towns depend heavily on Medicaid funding and many have already closed. Rural hospitals in states that have not expanded Medicaid are even more likely to close.
“What’s happening is that they’re exacerbating the rural hospital closure crisis,” said Elehwany.
About 51 percent of residents in rural West Virginia, 47 percent in Alaska, 38 percent in Maine and 37 percent in Nevada rely on Medicaid, according to a June report from the Georgetown Health Policy Institute. The report found that in non-expansion states, the uninsured rate for adults in small towns and rural areas is 21 percent, almost double the 11 percent uninsured rate in expansion states.
The health law provided states that want to broaden Medicaid eligibility with higher federal matching rates for that population. Thirty-one states and the District of Columbia opted to expand. The Center on Budget and Policy Priorities found that in eight states with Medicaid expansion, more than a third of enrollees live in rural areas.