As health care insurance costs continue to climb, farm bureau health plans offer a lower cost alternative

Farm Bill health care plans have been offered in Tennessee
for over 75 years. (Tennessee Farm Bureau photo)

Affordable Care Act subsidies from the pandemic years made purchasing health insurance affordable for many Americans, but those tax credits expired at the end of 2025, leaving many individuals and families "confronting difficult choices because of rising Affordable Care Act premiums and other affordability issues," reports Michelle Andrews of KFF Health News. Farm bureau health care plans often offer a more budget-friendly alternative.

Farm bureau health plans tend to offer less comprehensive coverage and require physical exams to qualify; however, they can still provide substantial savings. Andrews explains, "Plan details vary by state, but they typically share many features of marketplace plans, including coverage of a wide range of services, a broad practitioner network, and a way to file complaints."

Fourteen states "allow health coverage through state farm bureaus, grassroots membership organizations that advocate for the agricultural industry and rural interests," Andrews explains. In general, anyone can join their state farm bureau, which typically costs $30 to $50. "With membership comes the option of buying into the health plan."

To help keep premium costs low, farm bureau health care plans screen their applicants through an underwriting process and will often deny coverage to sicker people. ACA plans have to take anyone who applies. Andrews writes, "In 2026, average ACA premium payments were estimated to increase by 114% for subsidized enrollees."

Because farm bureau plans can turn down people or exempt coverage for expensive or pre-existing conditions, their plans "may be 30% to 50% cheaper than unsubsidized marketplace plans," Andrews reports. For a healthier Americans, a farm bureau health plan presents a viable solutions to spiking premium prices.

Despite their stricter rules, farm bureau health plans are becoming more popular. Andrews adds, "Last year, Missouri was one of four states that passed laws permitting farm bureau health plans." Currently, farm bureau health plan coverage is allowed in Arizona, Arkansas, Indiana, Iowa, Kansas, Mississippi, Missouri, Nebraska, North Dakota, South Dakota, Tennessee, Texas, Ohio and Wisconsin.

Small businesses and their employees could lose health care coverage if ACA subsidies are cut

Farmers and their employees are among those who stand to 
'lose the most' if ACA subsidies are cut. (KFF Health photo)

As the debate over federal Affordable Care Act subsidies stalls efforts to reopen the government, small business owners worry that their employees won't be able to afford health insurance if the subsidies are cut. 

For lawmakers grappling with ACA decisions, any cuts could impact the 2026 Congressional elections.

Small-business owners such as farmers, dentists and barbers are among those "who stand to lose the most should Congress let the additional, generous federal subsidies put in place during the Covid-19 pandemic lapse," reports Amanda Seitz of KFF Health News. 

ACA subsidies cover nearly 24 million Americans -- and almost half of all those enrollees either own a small business or work for one. Collectively, the group "is more likely to vote Republican and overwhelmingly backed President Donald Trump in last year’s election," Seitz writes. But "even Trump’s own pollsters found deep support for the Obamacare subsidies."

According to Seitz, "Nearly 6 in 10 Obamacare enrollees live in a Republican-held congressional district."

U.S. Rep. Marjorie Taylor Greene, a Georgia Republican who is up for reelection in 2026, "broke with her party last month, calling on the GOP to extend the subsidies," Seitz adds. "Greene said in an interview that rising health care costs are the 'No. 1 issue' she hears about from people living in her district."

Threat of medical debt is a top worry for most farming families, says study about household-level farming stressors

Farming families are famously tough and resilient, but they face a host of challenges and fears. One of their top worries is that one of them might suffer an illness or injury that leads to significant medical debt, a recent study found after surveying 900 farm households in 10 states. 

According to the study, recently published in Agriculture and Human Values, more than 90% of farming households had health insurance in 2016, but 55% said they weren't confident they could cope with a major illness or injury without going into debt. That wasn't an unfounded concern, since 20% of farming households surveyed had medical debt of at least $1,000. That indicates that inadequate insurance is a problem for many farming families, according to study co-author Florence Becot. 

"The Affordable Care Act, or ACA, helped make medical coverage available to more Americans and benefitted farmers," Scott Heiberger reports for the Marshfield Clinic Research Institute in Wisconsin. "A provision of the ACA uses income and not assets to determine Medicaid and Marketplace subsidy eligibility, which decouples the family from the assets of the enterprise and addresses the 'land rich, cash poor' conundrum farmers often face. This provision allowed farm families a wider array of health-insurance choices via public health insurance and marketplace options. However, choices in the insurance marketplace can be limited, and health-insurance plans are often confusing. So-called 'skinny' plans – those with lower premiums but very high deductibles and out-of-pocket expenses – offer a weak safety net as people might avoid going to the doctor to limit costs, and a major illness or injury can result in medical debt."

The study matters, Becot and co-author Shoshanah Inwood write, because research on resiliency among farmers mostly focuses on problems such as fires, droughts, or economic trends. Little has focused on family-level concerns such as major illness, divorce, or off-farm employment. It's important to understand those things too, the authors write, because those stressors can lead farmers to sell their land and quit farming, further depopulating rural communities.

High-deductible insurance hurts rural hospitals and patients

High-deductible health insurance plans are hurting the financial health of small, rural hospitals and their patients, Markian Hawryluk reports for Kaiser Health News.

"Plans with annual deductibles of $3,000, $5,000 or even $10,000 have become commonplace since the implementation of the Affordable Care Act as insurers look for ways to keep monthly premiums to a minimum," Hawryluk reports. "But in rural areas, where high-deductible plans are even more prevalent and incomes tend to be lower than in urban areas, patients often struggle to pay."

When patients can't afford to pay, hospitals must eat the cost of treatment; that has contributed to a "substantial" rise in the amount of uncollectible hospital debt in the past few years. "According to the Healthcare Financial Management Association, hospital bad debt increased by $617 million to nearly $56.5 billion between 2015 and 2018," Hawryluk reports. "According to the National Rural Health Association, bad debt for rural hospitals has gone up about 50 percent since the passage of the Affordable Care Act in 2010." Partly because of bad debt, more than 120 rural hospitals have closed in the past decade and many more are on the brink of bankruptcy.

Rural residents often choose these high-deductible plans for several reasons. Consumers tend to shop for insurance based on monthly premium costs, and gamble that they won't get sick and need to pay a deductible. Others may not understand that they will have to pay the full deductible before their insurance covers bills, Hawryluk reports.

Another problem is the lack of choice. "In many rural counties, consumers shopping on their state’s health insurance exchange had little choice. This year, about 10% of enrollees, living in 25% of counties, many of them heavily rural, will have access to just one insurer in their local Affordable Care Act marketplaces," Hawryluk reports.

Maggie Elehwany, vice president of the NRHA, told Hawryluk that the exchanges were meant to provide people with choices, but "There’s no shopping in rural America. You have one choice."

ACA open enrollment has been extended until 3 a.m. ET Wed., but federal officials haven't made a very big deal of it

Open enrollment for "Obamacare" health insurance has been extended until 3 a.m. ET on Wednesday, Dec. 18, because of extensive computer glitches that happened over the weekend.

The original deadline was 11:59 p.m. on Sunday, Dec. 15. The last day is always the busiest, but many people trying to enroll via the website or by phone ran into delays and other issues. Despite the problems, the Centers for Medicare and Medicaid Services said in a statement that more than half a million people were able to enroll on Sunday. According to CMS, "people who already left their names and contact information with the call center on Sunday don’t need to come back and reapply because a representative will follow up with them later in the week," Ricardo Alonso-Zaldivar reports for The Associated Press.

The nonprofit Get America Covered urged the administration to extend the sign-up. The group was founded by ex-Obama administration officials to get the word out about ACA open enrollment after the Trump administration halved the sign-up period and slashed budgets for advertising, outreach and "navigators," people who help others sign up for coverage, Alonso-Zaldivar notes.

Get America Covered co-founder Joshua Peck applauded the extension, but said he worries that the administration isn't doing much to publicize or clarify it. The HealthCare.gov home page still says in big letters that open enrollment is over. A banner with much smaller letters at the top of the page says it has been extended, which could confuse users, Sarah Gantz reports for The Philadelphia Inquirer.

"Senior lawmakers of both major parties are urging the administration to publicize the availability of a redo for seniors who got inaccurate or confusing results using the Medicare Plan Finder. A redesign of the Medicare site produced search results that didn’t automatically rank the prescription drug plan with the lowest total cost first," Alonso-Zaldivar reports.

Peck noted that there were serious glitches on the first day of open enrollment too, and called on CMS to not only extend the deadline and publicize it more, but to also commit to being transparent about what caused the glitches and what the agency has done to ensure they won't happen again, Gantz reports.

Academic journal Health Affairs devotes entire issue to rural health; read a summary of all the studies here

The peer-reviewed academic journal Health Affairs has dedicated its December issue to research about rural health. Here's a quick summary (with links) to the 12 articles. You will have to subscribe or pay to access the full articles (emailing the authors sometimes works too).

• U.S. health care spending increased 4.6 percent, to $3.6 trillion, in 2018, driven by accelerating Medicare and private-insurance spending. The increased spending was influenced by the reinstatement of the health-insurance tax. The total number of uninsured people increased by 1 million for the second year in a row, to reach 30.7 million in 2018. Read more here.
• Rural U.S. areas have had an overall higher death rate than urban areas since the 1980s, and the gap continues to widen. A 2016 data analysis found that rural mortality rates exceeded urban mortality rates in all but three states. The gap is mostly because of socioeconomic deprivation, physician shortages, and lack of health insurance. State laws that affect Medicaid access, health infrastructure and socioeconomic conditions can affect rural mortality rates. The study suggests state and policy efforts to lower rural mortality rates. Read more here.
• Rural mothers and their babies are at a higher risk of dying or experiencing life-threatening complications during childbirth, especially African Americans, Native Americans and Alaska Natives. Read more here. The Daily Yonder also has an excellent write-up of this study.
• Increasing staffing in rural community health centers can help improve behavioral health care, which includes treatment for mental health and substance abuse. The overall staff-to-patient ratio for behavioral health staffers in community health centers rose 66% between 2013 and 2017; staffing in urban centers grew 49%. Most of the added staff were clinical social workers and other licensed mental health providers, not psychiatrists or psychologists. Read more here.
• Rural residents have worse health outcomes; understanding why could inform policy proposals to close the rural-urban gap. A nationwide analysis of Medicare beneficiaries with one or more complex chronic conditions showed that such patients make up 61% of rural beneficiaries and 57% of urban beneficiaries. Rural residents had a 40% higher rate of preventable hospitalization and a 23% higher mortality rate than urban patients. Read more here.
• Rural counties with majority African American or Native American populations have the highest rates of premature death in the U.S., and are much higher than rural counties with majority white populations. Read more here.
• A 2017 law allowed nurse practitioners and physician assistants to get waivers to prescribe the opioid abuse treatment drug buprenorphine (brand name Suboxone), but there hasn't been much data about how many rural NPs or PAs have obtained such waivers. The researchers confirmed a sizeable jump in the numbers of rural clinicians who have obtained waivers. Read more here.
• Rural residents may pay more for private health insurance because they have smaller risk pools with more high-risk residents. However, the number of insurers competing in rural areas wasn't found to be a major factor in how much premiums cost. Read more here.
• Rural hospitals have been closing at an increasing rate over the past decade. That has not only reduced access to care, but has cut the number of rural physicians; when a rural hospital closes, the doctors who worked there may decamp to an urban hospital. Read more here.
• In 2017, President Trump halted the cost-sharing payments used to help low-income people with ACA Marketplace insurance. Researchers found that rural residents who were eligible for the tax credits were able to access Marketplace plans that were more affordable than those accessible to their urban counterparts, but rural enrollees without subsidies had some of the least affordable premiums for Marketplace plans. Read more here.
• Rural hospitals that affiliated with a group between 2008 and 2017 saw a significant decrease in on-site diagnostic imaging technologies, the availability of obstetric and primary care services and outpatient nonemergency visits, but saw a significant increase in operating margins. In short, joining groups may have kept some rural hospitals afloat, but reduced access to medical services for nearby residents. Read more here.
• Fewer rural residents apply to or get into medical school. Read more here, or read the more in-depth write-up on this study we did last week.

House Agriculture Committee chair, seeking re-election in most pro-Trump Democratic district, draws strong GOP foe

Minnesota's Seventh District
(National Atlas map via Wikipedia)

House Agriculture Committee Chair Collin Peterson of Minnesota, whose represents the Democratic-held district with the largest 2016 majority for President Trump, has drawn a strong Republican opponent in former state Senate President and Lt. Gov. Michelle Fischbach.

"Trump won it by 30." Minneapolis StarTribune columnist Patrick Coolican notes. "She'll have a huge supply of money from national Republican groups, including presumably the anti-abortion network her husband is part of as executive director of Minnesota Citizens Concerned for Life."

Fargo's KFGO notes, "David Hughes has also announced to seek to the Republican nomination to challenge Peterson. Hughes has challenged Peterson twice before."

Rep. Collin Peterson

If Peterson seeks re-election, he will have "the advantage of name recognition, and his perch as chair of the Agriculture Committee during a time of deep uncertainty about the farm economy given the trade conflict with China. He'll frame the race as a risk of giving up the gavel to the district's most important committee."

The Star Trib's Jeremy Olson reports, "Peterson has maintained popularity and strong support from farmers and rural voters in his district. Peterson is considered a Blue Dog Democrat with conservative positions on abortion and same-sex marriage. He voted against the Affordable Care Act that was championed in 2010 by his own party and President Barack Obama, but also against Trump’s legislation in 2017 that would have repealed it."

Rural hospitals struggling most in states where lawmakers declined Medicaid expansion under the Affordable Care Act

People living in the most politically conservative areas of rural America are seeing local hospitals “founder and close” because their state lawmakers opposed expanding Medicaid under the 2010 Patient Protection and Affordable Care Act, says a story by a GateHouse Media reporting team. Of the 106 rural hospitals that have closed since 2010, 77 are in states that haven't expanded Medicaid.

“Fiercely conservative and inherently distrustful of the federal government, state politicians balked at picking up 10 percent of the Medicaid expansion cost [as of 2020] and repeatedly expressed fears that Washington bureaucrats would renege on generous Obamacare funding, leaving states to cover an ever increasing share of the healthcare burden,” Michael Braga, Jennifer F. A. Borresen, Dak Le and Jonathan Riley reported for Gatehouse.

John Henderson, who heads The Texas Organization of Rural & Community Hospitals, told GateHouse he supports the Medicaid expansion his state did not accept. “The irony to me is that we’re paying federal income taxes to expand coverage in other states. We’re exporting our coverage and leaving billions of dollars on the table.”

Hospital closures affect “farmers and farm workers, small business owners and their employees, the old and infirm,” the story notes. “More than half of all rural hospitals in Mississippi, South Carolina, Georgia and Oklahoma lost money from 2011 through 2017. In Kansas, the bloodletting was even more widespread. Two out of three rural hospitals in the state operated in the red during the seven-year period. Five were forced to shut down.”

The GateHouse reporters analyzed financial data from 2,200 rural hospitals to see which ones are losing money and could close under the financial strain. The reporters also looked at academic studies and interviewed hospital officials and other experts in the field. They wrote:

Rural America is in the midst of a deep and prolonged crisis that resulted in 106 hospital closures since 2010. Nearly 700 more are on shaky ground, and nearly 200 are on the verge of collapse right now, according to reports from Massachusetts consulting firm iVantage Health Analytics and the Sheps Center for Health Services Research at the University of North Carolina in Chapel Hill.
Hospitals faring the worst are mainly in states that refused to expand Medicaid. Those states account for 77 of the 106 closures over the past decade. They also are home to a greater percentage of money losing facilities and lower collective profit margins.
“At the bottom of the pack is Kansas, where Gov. Sam Brownback’s conservative politics reigned for eight years. Seventy of its 109 rural hospitals lost money from 2011 through 2017, and seven ranked among the 20 worst performing rural hospitals in the country. Hospitals in nearby Oklahoma did not perform much better, and the same can be said for many states in the Deep South.
But one state, whose residents only recently voted to expand Medicaid, bucked the national trend. Thanks to sacrifices made by urban hospitals and their willingness to work with their small town counterparts, rural hospitals in Utah were among the most profitable in the country from 2011 through 2017. Only 14 percent lost money during the period and not one was forced to shut down.”

Appeals court sounds likely to uphold ruling against ACA; Democrat says the law 'is the future of rural health care'

"A panel of federal appeals court judges on Tuesday sounded likely to uphold a lower-court ruling that a central provision of the Affordable Care Act — the requirement that most people have health insurance — is unconstitutional," reports Abby Goodnough of The New York Times. "But it was harder to discern how the court might come down on a much bigger question: whether the rest of the sprawling health law must fall if the insurance mandate does."

The law "is the future of rural health care," said Andy Beshear, the Democratic nominee for governor of Kentucky and one of 21 Democratic attorneys general who intervened in the Texas lawsuit that led to a federal district court ruling that the entire 2010 law violates the Constitution.

Without the law and its expansion of Medicaid to people earning up to 138 percent of the federal poverty level, many more rural hospitals would be in trouble, Beshear told Kentucky Health News, because they would not only get less revenue but have to write off the cost of care for people who wouldn't be able to afford health insurance.

Beshear is the son of former Gov. Steve Beshear, who expanded Medicaid under the reform law. His opponent is Republican Gov. Matt Bevin, who initially campaigned on repealing the expansion but now wants to require work or other "community engagement" from "able-bodied" people covered by the expansion. Most of them work, but Bevin has argued that the benefits keep some from working.

In Tuesday's oral arguments, "Two appellate judges appointed by Republican presidents peppered lawyers with blunt questions while the third judge, appointed by President Jimmy Carter, remained silent," Goodnough reports. "The two Republican appointees, Jennifer Walker Elrod, appointed by President George W. Bush in 2007, and Kurt Engelhardt, appointed by President Trump in 2018, seemed particularly skeptical of the Democratic defendants’ argument that Congress had fully intended to keep the rest of the law when it eliminated the penalty for going without insurance as part of its 2017 tax overhaul."

"Despite such pointed questioning, the hearing did not clearly foreshadow how the panel will rule," reports Amy Goldstein of The Washington Post. The newspaper also reports that Senate Majority Leader Mitch McConnell refused to say whether he supports the lawsuit, but focused on coverage of pre-existing conditions, which has also been the focus of Democrats. “I think the important thing for the public to know is there is nobody in the Senate not in favor of covering pre-existing conditions,” the Republican leader told reporters at the Capitol. “And if it were, under any of these scenarios, to go away, we would act quickly on a bipartisan basis to restore it.”

7 rural hospital CEOs in N.C. call for Medicaid expansion

CEOs from seven rural hospitals in North Carolina met with Gov. Roy Cooper and state Health and Human
Services Secretary Mandy Cohen (center) Wednesday to support Medicaid expansion. (Photo by Taylor Knopf)

CEOs from seven rural North Carolina hospitals told Gov. Roy Cooper and Health and Human Services Secretary Mandy Cohen on Wednesday that expanding Medicaid would help them stay open, Taylor Knopf reports for North Carolina Health News.

Though the issues the hospitals face vary, there are many similarities: they're having a hard time recruiting doctors and other medical professionals, all of them have thin operating margins, and their budgets are increasingly strained because rural patients rely more heavily on emergency departments for care; many of those patients can't pay or are uninsured, so the hospital must eat the cost of care for those patients, Knopf reports. The CEOs also said that, because poor patients don't have access to urgent, primary or preventative care, problems that might have been dealt with relatively quickly and cheaply become expensive issues when the patients finally seek care at the emergency department.

"The consensus was that Medicaid expansion wouldn’t solve all their problems overnight, but they agreed it would go a long way to relieving pressure on their emergency departments and create a healthier patient population," Knopf reports.

The CEOs have reason to worry: six rural hospitals have closed since 2010, while 104 rural hospitals closed nationwide in the same time frame. Eighty percent of those nationwide closures happened in states that didn't expand Medicaid, Knopf reports. 

Greg Tung, a health economist from the University of Colorado, told Knopf that his research found that Medicaid expansion has helped hospitals stay open, and especially rural ones, which tend to be in more danger of closing. Helping a rural hospital stay open helps the local economy too, he said: "Rural hospitals are anchor institutions in their communities. They are kind of a pillar of the local community and the local economy, they provide a lot of skilled, well-paying jobs for that area . . . So when a rural hospital closes, it has a disproportionately large impact on that community, especially in comparison to an urban hospital closure."

Cooper said Medicaid expansion could pass in the state House right now if the Republican leadership allows it to come to a floor vote, but was less confident about it passing the state Senate. Some state Senate Republicans worry that the federal money to support Medicaid expansion might disappear, but Cooper said that hasn't happened so far in other states because it's such a popular measure. "They couldn't kill it," Cooper said, 

Judge blocks Ky.'s bid to make 'able-bodied' adults on Medicaid work, volunteer, get training or drug treatment

A federal judge threw out Kentucky's plan for changes in Medicaid, casting doubt on efforts in several other states to require "able-bodied" adults on the program to work, volunteer, take job training or get treatment for substance abuse.

Kentucky is one of four states where the U.S. Department of Health and Human Services has approved Medicaid work requirements. "Seven others — Arizona, Kansas, Maine, Mississippi, Ohio, Utah, and Wisconsin — have proposals waiting for approval," Dylan Scott of Vox reports.

U.S. District Judge James Boasberg of Washington, D.C., said in his ruling that HHS Secretary Alex Azar "never adequately considered whether" Kentucky's plan "would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid." The state had estimated that its Medicaid rolls would have 95,000 fewer people in five years than without the plan, partly due to non-compliance with its rules and reporting requirements.

Boasberg sent the issue back to HHS for review. State Health Secretary Adam Meier issued a statement calling the ruling "very narrow" and saying the state would work with the Centers for Medicare and Medicaid Services "to quickly resolve the single issue raised by the court so that we can move forward."

"However, other issues may stand in the way," Al Cross writes for Kentucky Health News. "Boasberg said he didn't have to rule on some issues raised by the plaintiffs because Azar's omission was enough to invalidate the waiver."

UPDATE, July 3: Writing for The Commonwealth Fund, Sara Rosenbaum has "three takeaways" from Boasberg's ruling:  "1. Work requirements may not be unlawful per se, but any Medicaid waiver demonstration conducted under Section 1115 of the Social Security Act must be carefully assessed for its impact on people’s health care coverage. Providing health insurance, after all, is Medicaid’s reason for being.  2. Where Medicaid’s fundamental purpose and statutory protections are concerned, expansion beneficiaries stand on equal footing with 'traditional' populations. Judge Boasberg spends considerable time debunking what has become an especially contested aspect of the debate surrounding the Affordable Care Act (ACA)’s Medicaid expansion population: namely, that these individuals are somehow less worthy . . . 3. Comprehensive, high-quality evidence is the heart of lawful administrative decision-making."

Vote today in Va. will make state 33rd to expand Medicaid; at least two referenda already set in other states for Nov. 6

"Virginia is on the verge of expanding Medicaid after years of partisan battle," Alan Suderman reports for WRC-TV in Washington, D.C. "The GOP-controlled General Assembly is set to pass a state budget Wednesday that's expected to expand Medicaid eligibility to about 400,000 low-income adults."

The House has already passed legislation expanding Medicaid to people in households with incomes up to 138 percent of the federal poverty level, "and Democratic Gov. Ralph Northam is a strong proponent," Suderman reports. "Wednesday's upcoming vote will mark the end of a more than four-year battle over expanding the publicly funded health care program for the poor in Virginia. The fight led to a standoff over the state budget in 2014 and again this year."

Virginia will become the 33rd state to expand Medicaid under terms of the 2010 Patient Protection and Affordable Care Act. A petition has been certified in Utah for a referendum on the issue there, and a petition in Idaho is nearing certification. UPDATE, June 4: Montana will have a referendum Nov. 6 on extending its Medicaid expansion, which if not extended will expire in 2019, reports Sara Kliff of Vox.

States that expanded Medicaid tended to improve most in latest scorecard of health system performance

States that expanded Medicaid showed the greatest improvement in health-system performance from 2013 to 2016, according to a scorecard released today by The Commonwealth Fund, which says it advocates for high-performing health systems but takes no position per se on the Patient Protection and Affordable Care Act, which enabled expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level.

A chart with the report shows the improvement and decline of each state across 37 indicators that measure access to care, quality and efficiency of care, health outcomes and income-based health care disparities. (Click on the chart to view a larger version.)

Among the nine states that improved on the most indicators, only Oklahoma has not expanded Medicaid. It did show a big drop in its smoking rate, to 19 percent from 26 percent. Commonwealth Fund President David Blumenthal said in a telephone press conference that the state's second largest city, Tulsa, "has a very aggressive, citywide health-improvement program." Researchers for the fund noted afterward that Oklahoma's improvement in the percentage of people without health insurance, to 20 percent from 25 percent, "is certainly better than nothing, but it doesn’t come close to the improvement that states like Arkansas, Kentucky or New Mexico, that did expand Medicaid, saw."


The overall rankings of health system performance placed Oklahoma next to last, behind Louisiana, where the expansion of Medicaid did not some until 2016 and thus was not reflected in the report. Hawaii, Massachusetts, Minnesota, Vermont, and Utah were ranked highest overall. In the rankings, California and Oregon rose the most, jumping nine and 10 spots, respectively.

Rural hospitals in states that expanded Medicaid have been six times less likely to close than in states that didn't

Rural hospitals in states that expanded Medicaid were six times less likely to close than those in states that didn't, according to a study published in the January edition of the journal Health Affairs. "Richard Lindrooth, a professor at the Colorado School of Public Health and lead author of the study, says hospitals saw more people showing up to hospitals with that insurance — so Medicaid payments increased. That helped the hospitals' bottom line," John Daley reports for NPR.

Lindrooth and his team of researchers at the University of Colorado examined national hospital data and local market conditions from the four years leading up to the Patient Protection and Affordable Care Act (2008-2012) and the two years after the act took full effect with Medicaid expansion (2015-2016). They found that about half the hospital closures in non-expansion states could have been averted through Medicaid expansion. Expansion-state hospitals had more insured people, so they made more money and provided less free care, reducing cost margins, he told Daley.

Jason Clecker, CEO of Delta Memorial Hospital in rural western Colorado, said Medicaid expansion helped his hospital's finances. Between 2011 and 2016, the number of Medicaid patients seen in his hospital increased from 10 percent to 20 percent, and since the hospital had to provide less free care, it saved more than $3 million. "Our bad debt decreased significantly, and the uninsured rate decreased significantly," Cleckler told Daley. "It's pretty remarkable, and I would venture to say that most hospitals, even ones with a lower percentage of Medicaid, have experienced a similar story."

Cleckler also said Medicaid was a "mixed bag" for rural health care providers, since reimbursement rates are sometimes very low. Because of that, some providers won't accept or limit the number of Medicaid patients they'll accept.

Farmworkers getting older; many have chronic ailments and spotty health coverage; production in California slows

Farmworkers harvesting in California, the No. 1 agricultural state (Photo from University of California, Davis)

As immigration from Mexico slows, "Harvesting U.S. crops has been left to an aging population of farmworkers whose health has suffered from decades of hard labor," Sarah Varney of Kaiser Health News reports for the Los Angeles Times. "Older workers have a greater chance of getting injured and of developing chronic illnesses, which can raise the cost of workers' compensation and health insurance."

Federal data show that the average age of a farmworker in the U.S. is 45, and that fewer have migrated from Mexico in recent years. "Researchers point to a number of causes: tighter border controls, higher prices charged by smugglers, well-paying construction jobs and a growing middle class in Mexico that doesn't want to pick vegetables for Americans," Varney reports.

Varney gives several examples of injuries and ailments that can result from working in the fields. "Many farmworkers don't have health insurance and pay what they can for medical care. Those who have immigration papers rely on Medicaid," she writes. "Only workers with legal status agreed to be interviewed for this story. Most farmworkers, however, are not working in this country legally, and their health coverage is spotty. They are employed by subcontractors who are supposed to offer them health insurance, but seven years after the passage of the Affordable Care Act, there's no good accounting for how many employers are complying with the law."

Farmer Brent McKinsey told Varney, "You start to see your production drop, but it's difficult to manage because there aren't the younger people wanting to come in and work in this industry." McKinsey "says farmers are trying to mechanize planting and harvesting to reduce their labor needs. But machines can only do so much, McKinsey said. You can replace the human hand in a factory, perhaps. But out here, the fields are bumpy and the winds are strong, and you need people to bring the plants to life."

Update: Va. House race ruled a tie; Republican wins random drawing, preserving GOP majority

UPDATE, Jan. 4: Republican David Yancey won a random drawing for the seat.

Election officials recounted ballots.
(Associated Press photo by Ben Finley)

UPDATE, Dec. 21: The winner of the race is in question after a three-judge panel would not certify the recount that ruled Democrat Shelly Simonds the winner by one vote. The panel said that a questionable ballot should be counted for Republican David Yancey, rendering the vote a tie. The ballot in question contained a mark for both Simonds and Yancey, but the voter drew a line through Simonds' name, which the judges believed indicated that they intended to vote for Yancey. Republicans challenged the recount in court yesterday, saying that the voter in question had voted for every other Republican on the ballot and had intended to vote for Yancey, The Washington Post reports.

"Virginia Board of Elections Chairman James Alcorn said on Twitter Thursday that the board will met Dec. 27 to break the tie," The Associated Press reports. "By law, the winner's name will be drawn at random by an elections official."

In a stark reminder that every vote can count, "a recount in a Newport News district appears to have flipped the outcome and moved the House of Delegates to a 50-50 split between Republicans and Democrats, ending 17 years of GOP control," David Seidel and Mallory Noe-Payne report for NPR.

Democratic challenger Shelly Simonds will beat Republican incumbent David Yancey by one vote our of more than 23,000 cast, if a recount court certifies the results today. If so, neither party will have a majority in the House of Delegates, which will necessitate a power-sharing agreement not seen in the state since the 1990s, NPR reports. The final vote tally was 11,608 for Simonds and 11,607 for Yancey, Jessica Estepa reports for USA Today.

Simonds' victory is the final word in an election where Virginia Democrats erased a 32-seat GOP advantage in the House of Delegates. Republicans had controlled 66 of the chamber's 100 seats, NPR reports. Republicans have conceded the seat to Simonds, pending court confirmation. Democrats hope the power-sharing under a Democratic governor will lead to an expansion of Medicaid under the Patient Protection and Affordable Care Act.

Medicaid expansion expanded coverage by 8.5% in rural areas, 4.1% in urban areas, study concludes

The expansion of Medicaid under the Patient Protection and Affordable Care Act resulted in larger coverage gains in rural areas than urban ones, suggesting that any roll-back of the program would hurt rural America the most, according to a recent University of Louisville study.

The study, published in The Journal of Rural Health, found the percentage of low-income residents who signed up for health insurance through the expansion was greater in rural regions compared to urban ones: an 8.5 percent increase, compared to a 4.1 percent increase, respectively.

Joseph Benitez, who led the study as an assistant professor in U of L's School of Public Health and Information Sciences, said that even with the Medicaid expansion, cost-related barriers weighed more heavily on rural residents related to things like transportation to a medical provider. He said that can be problematic for individuals who live in health provider shortage areas.

“Any efforts by the government to roll back Medicaid expansion will certainly disproportionately affect the ability of rural residents to gain affordable coverage and access to care,” Benitez said in a news release.

Health-insurance deadline in most states is tonight; your current plan may not be the best for you

Photo by Joe Raedle, Getty Images

The deadline for signing up for health insurance under the Patient Protection and Affordable Care Act is midnight tonight in most states. People now on ACA plans will be automatically re-enrolled, but are advised to check their options because changes in the insurance market and government subsidies mean that re-enrolling under the same plan is not the best option for some people.

"As of last week, nearly 4.7 million people had signed up for a 2018 health plan through HealthCare.gov, the online federal insurance marketplace that serves consumers in 39 states," Noam Levey reports for the Los Angeles Times. "Several million more are estimated to have signed up through marketplaces in 11 other states and the District of Columbia. The pace of enrollment has actually been quicker this year than last, according to federal data. And enrollment by new customers is up nearly 17 percent."

Despite the record pace of signups early in this year's enrollment period, overall signups are not expected to match last year's total of 9.2 million, because the Trump administration cut the enrollment period to six weeks from three months and cut almost all funding for advertising and outreach.

The law requiring almost all Americans to get health coverage or pay a penalty on tax returns would be repealed by the tax legislation pending in Congress, but under the last version available, it would not affect tax returns that will be filed in 2018 for 2017.

"Some consumers who miss the cutoff could be surprised to learn they have the opportunity to enroll later," notes Michelle Andrews of Kaiser Health News. "People are entitled to a special enrollment period when they have specific changes in their lives, such as losing other health insurance, getting married or having a child, or when they have a change in income that affects their eligibility for premium tax credits or cost-sharing reduction subsidies. Those special enrollment periods generally last at least 60 days."

Ala. election makes Obamacare repeal less likely

Jones and wife Louise.(Photo: Bastien Inzaurralde, W.Post)

Alabama Democrat Doug Jones' narrow win yesterday over Roy Moore for a U.S. Senate seat will make Republican efforts to repeal and replace the Patient Protection and Affordable Care Act even more difficult.

"Up until now, the Senate GOP's 52-seat majority allowed the party to lose two votes on a health-care bill, with tie-breaking help from Vice President Pence. That’s an important number, because the two most moderate Republicans – Sens. Lisa Murkowski of Alaska and Susan Collins of Maine – have been regarded as nearly impossible to bring on board," Paige Cunnningham reports for The Washington Post.

While it may seems unlikely that Republicans will renew their push for ACA repeal before the 2018 midterm elections, "Behind the scenes, some GOP lawmakers are also convinced they should return to the effort once taxes are out of the way; after all, repealing Obamacare is something they relentlessly promised when a Democrat was in the White House," Cunningham writes. "The GOP idea is to pass a new budget resolution for next year, giving them another way to avoid attracting Democratic support for a controversial health-care measure by seeking just 50 votes for it."

In the meantime, Jones isn't waiting until January to make use of the bully pulpit; in his victory speech last night he called on Congress to "go ahead and fund that CHIP program before I get up there." He refers to the Children's Health Insurance Program, which expired without reauthorization Sept. 30 and covers 9 million children from low- and mid-income families who cannot afford health insurance.

Rural areas face confusion as ACA enrollment opens

Open enrollment for health insurance under the Patient Protection and Affordable Care Act begins tomorrow, but many people, especially in rural areas, may face confusion about how to sign up. That could lead to fewer people being covered by health insurance. "Much of the cutbacks and confusion, health-care advocates said, follows President Trump's constant disparagement of the law.

Congress was not able to pass a repeal or replacement law, so the administration may be knocking the legs out from under the law in other ways. The Department of Health and Human Services slashed the ACA advertising budget by 90 percent, which means there are many fewer messages to tell people when open enrollment is, or whether they qualify. HHS also cut by 40 percent grants to pay navigators, which are regular citizens trained to help people sign up for ACA plans.

The Trump administration has also decreased overall access to the plans, trimming open enrollment from three months to six weeks. The enrollment website, www.Healthcare.gov, is also being taken offline for maintenance for 12 hours almost every Sunday during open enrollment, even though weekends are generally a convenient time for people to apply.

"Most recently, Mr. Trump announced plans to cut off subsidies that reimburse insurance companies for assistance they are required to provide to low-income customers who struggle with co-payments and deductibles. The cuts resulted in a crazy quilt of premiums for 2018 that differs radically from the pattern of the last four years, which will upend expectations of consumers in many states," Abby Goodnough and Robert Pear report for The New York Times.