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The Patient Protection and Affordable Care Act (PPACA), colloquially known as Obamacare, was signed into law by President Obama on March 23, 2010, and along with it the federal government has touted a string of successes for access to healthcare insurance and healthcare services from 2010-2020. Perhaps the greatest success outcome to date is that 17 million more consumers gained access to health insurance since the core of the PPACA took effect in 2013 (according to the RAND group study). 

Not everyone, however, has benefitted, as some 600,000 people who had individual coverage before passage of the PPACA ended up uninsured. In fact, the PPACA has left rural and underserved communities, healthcare systems, and vulnerable populations more financially fragile, especially minority families that still face racial and socioeconomic disparities even if they are insured. Additionally, while the PPACA increased insurance availability for the economically challenged by expanding Medicaid eligibility to more people based on their income level, it hasn’t panned out as initially thought and planned.

The law originally intended for all states to expand Medicaid, but the U.S. Supreme Court ruled in 2012 that states could choose not to do so – and has a result, many went that route, worried about lack of long-term program sustainability and conditioning recipients to not emerge from the assistance programs. As a result, 22 states currently have not expanded the program, putting rural America at even greater risk.

One of the largest impact drivers of rural healthcare is the “hospital setting,” and while millions of people have benefitted from the PPACA, rural hospitals continue to face reimbursement cuts and regulations that many hospital administrators and board members say have caused more harm than good. Since the PPACA was passed, more than 55 rural critical access hospitals have closed.  

Perhaps no one has sized up the PPACA’s rural impact more strikingly than one of the key architects of the president’s healthcare law, Ezekiel Emanuel, who has drawn attention to the massive impact rural healthcare closings are having on the totality of rural healthcare’s existence. 

“The fact that 56 rural hospitals shutting down is not enough – it’s astonishing,” He was quoted as saying. Frighteningly, Emanuel cited that over the next few years, 1,000 hospitals could be in jeopardy, potentially leaving 1,000 American communities farther away from care. 

The results of many studies and polls are indicating that while healthcare reform in this country has been a necessity for a long time, the PPACA isn’t the answer, and instead it has created more disruption to care and communities, from patients to providers to taxpayers.

Originally, insurance exchanges were supposed to create greater competition and drive down costs, but they haven’t worked within the unique rural setting. Being uninsured was already a “rural kind of thing,” with one in six Americans defined as rural, but one in five uninsured classified as rural.

In 2014, competitiveness didn’t exist, with 58.3 percent of rural communities only citing one or two plan options; 23.7 percent of rural counties (versus 5.5 percent of urban counties) had only one plan option; and over three-quarters of urban plans had three or more choices of coverage.

Affordability has been another prickly area. The PPACA mandates were supposed to create greater efficiencies and opportunities, but in many cases they resulted in people buying an expensive policy that was more than what was wanted, needed, or within budget affordability.

While residents of rural counties face slightly lower median premium costs for all levels of coverage than do urban counties, many saw their insurance premiums go up 30-58 percent, because the old plan that worked for them was no longer available within the new slate of post-PPACA offerings.

Co-ops have also been a bitter pill for consumers. Failed co-ops received nearly $1 billion in taxpayer loans, entered the consumer marketplace claiming lower-cost insurance offerings, but then had to fit within stringent guidelines of mandates and restrictions, leaving them to languish. Eight of the 23 healthcare co-ops in the nation have collapsed in the past several months. Insurance co-ops in Iowa, Kentucky, Louisiana, Nebraska, Nevada, New York, Oregon, Tennessee, and Wyoming have already or are closing their doors because they have lost immense amounts of money. This leaves at least half a million people losing their insurance coverage. Those co-ops that are keeping their doors open are hiking their rates anywhere from 43-58 percent so they don’t succumb to the same unsustainable business model.

Not getting to “keep their plan if they liked it” and the PPACA illusion of coverage is not only leaving rural residents without affordable coverage, but placing access to care in total jeopardy. While approximately 30 percent of the U.S. population lives in rural areas, these areas account for 60 percent of all trauma deaths, and knowing that, the PPACA has jeopardized individuals and now critical access hospitals, creating a domino effect. Originally, the language of the Patient Protection and Affordable Care Act speculated that the number of bankruptcies due to medical debt (surpassing mortgage loans and credit card debt) would be significantly lowered, citing Medicaid expansion, insurance subsidies, more market competition within insurance exchanges, and approved coverage despite pre-existing conditions as eases to the system. With medical expenses growing at a rate well above inflation, however, 78 percent of all people that filed for medical bankruptcy actually had insurance (according to a GiveForward study). The study found that co-pays, co-insurance, travel to and from medical facilities, lost wages, daycare, high deductibles, and expensive COBRA coverage were actually drivers of bankruptcy. If individuals are filing for medical bankruptcy, it is no surprise that many rural hospitals across the nation also are filing for bankruptcy protection. If their patients don’t have money and hospitals aren’t able to collect compensation for the care that they currently provide patients at no cost, the prospects of closure can become very real.

So again, while many have benefitted, many more have struggled, and continue to do so. It remains to be seen if the Feb. 29 Centers for Medicare & Medicaid Services (CMS)-issued final report of proposed changes to address the 2017 enrollment period, PPACA exchanges, health plans, and co-ops will produce the significant positive changes desperately needed within the system. Additionally, in a presidential campaign year, when there is great continued PPACA support on one side and ideas of “repeal and replace” on the other side, it is difficult to know where equity and the balance of healthcare reside.

Will political parties ever come to the center to talk about the future of American healthcare and healthcare delivery, or what truly represents what consumers/constituents want and need to create sustainable change for healthier communities and individual positive health outcomes?

Will there ever be a model of affordability that’s truly for all? All of this broadens the deeper conversation and debate happening in academic symposiums, on news channels, and in coffee shops: whether healthcare truly is a privilege earned or a right. One thing is for sure, however: doors need to be opened to provide for the future of our healthcare.

We all are counting on it.

About the Author

Janelle Ali-Dinar, PhD,  is the chief operations officer at MedFirst Partners and a senior rural health expert at Healthcare Solutions Connections. She has more than 10 years of experience in rural health policy, legislation, strategy, and operations, having served on the National Rural Health Association’s national rural congress. Dr. Ali-Dinar is also an NRHA Rural Fellow.  

Contact the Author 


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