Rural healthcare’s grapes of wrath: Too heavy to produce?

People who live in rural America represent a challenging conundrum to healthcare coverage as states and not-for-profit organizations gear up toward a new enrollment period this fall. As National Rural Health Association senior vice president Brock Slabach was quoted in, “the feds are particularly concerned about,” the barriers that Americans living in rural areas face when it comes to signing up for the Affordable Care Act. The main hurdle is of a geographical nature; residents have to travel greater distances to get face-to-face assistance from the so-called navigators and assisters hired to help consumers figure out the enrollment process. Furthermore, Internet access often leaves quite a bit to be desired, turning people off to, although to be fair the federal website even has a CEO now.

For example, in Minnesota consumers sometimes traveled up to 55 miles each way for assistance, according to Minnesota’s Western Community Action navigator Allan Bakke, and some areas are devoid of a stable Internet connection, undermining attempts to use the online healthcare exchange, said  supervising attorney at St. Cloud’s branch of Mid-MN Legal Aid Ralonda Mason. Meanwhile in Virginia, “we’re spread thin throughout the state, but that means in rural areas there are additional challenges in terms of finding the people and getting out to groups,” health attorney at the Virginia Poverty Law Center Jill Hanken said.

Both Minnesota and Virginia have substantial rural populations, and a considerable percentage of those populations live in poverty. Minnesota, though, has the advantage because the stated decided to expand Medicaid as well as set up its own healthcare insurance marketplace. Though MNsure has been technologically impaired by issues such as not letting navigators and consumers use computers in different places in order to log into the application and fill it out over the phone at the same time, exchange’s spokesman Joe Campbell said MNsure is devising strategies to reach farmers and miners, including focused marketing on radio stations and sending representatives to county fairs and farmers markets.

Moreover, states that expanded Medicaid and run their own exchanges usually have more federal resources and self-generated funds to increase enrollment and offer more options to people who live in less accessible areas. Virginia, on the other hand, didn’t expand Medicaid and defaulted to the federally-facilitated exchange. States that use the federal marketplace will have access to $60 million to enable the work of navigators in 2015, but it is not known how much of that sum will be aimed to rural enrollment – by way of precedent, approximately $2.5 million from the Department of Health and Human Services was allocated to rural outreach during the original enrollment period. 

The onset of the Affordable Care Act and the decision not to expand Medicaid has had another effect on healthcare access in rural places. According to the North Carolina Rural Health Research Program (as reported in Reuters), the majority of rural residents in America live in states that did not expand Medicaid; the same states where many of the 24 hospitals that have closed across the United States since 2013 were. “In states that are not expanding Medicaid, we're seeing hospitals close. The finances are just not working out,” Washington and Lee University School of Law professor Tim Jost said.

The U.S. government has always been supportive of small, rural hospitals, designating many of them as ‘critical access’ facilities since 1997, a label that came with extra funds. However, the U.S. Department of Health and Human Services' Office of Inspector General advised the federal government to implement stricter controls on the money that goes to these facilities last year. Additionally, the Affordable Care Act has changed how hospitals are reimbursed for caring for the poor and uninsured. If that weren’t bad enough, “even with community support, investment in quality personnel and equipment, patient activity was not at a sustainable level,” president and chief executive of a recently closed Linden, Texas hospital's owner Good Shepherd Health System said. “The decision to close the Linden facility, while difficult, is one that is occurring across the country.”

Rural communities may be decreasing in size, but those that are left will be miles away from the nearest hospital, so even if more rural residents enroll for insurance coverage, the question would remain as to where they might go to receive the care that they sign up for. Or perhaps they will have to resort once again to Roman charity, as in the indelible ending of the John Steinbeck masterpiece alluded to in the title of this article.