What's good for Big Ag isn't always good for rural America, 'Food and Farm File' columnist opines

Farm, ranch, and commodity groups are no longer preaching or practicing unity, creating a farm-nonfarm divide in rural America, opines Alan Guebert in his "Food and Farm File" column: "That culture of togetherness hasn’t aged well in the age Big Ag and Big Agbiz. American farm and ranch groups, like urban and political America, are now less social and more tribal. Many tightly grip a 'we’re-right, you’re-wrong' view of farm and food technology, policy and their customers."

Guebert notes that the National Pork Producers Council moved its headquarters from rural America to Washington, D.C., and says major livestock and meatpacker groups have supported legislation that would hurt rural areas. For example, groups, such as the National Cattlemen’s Beef Association, asked the U.S. Department of Agriculture to withdraw proposed rule changes to the Farmer Fair Practice rules that "would ensure packers cannot retaliate against producers who show their contracts to legal counsel.”

Guebert writes, "Why would any livestock group oppose a sensible, necessary rule that allows American cattle and hog growers to 'show their (meatpacker) contracts to legal counsel' without fear of retaliation?" NCBA "said the rules would lead to meatpackers paying one price for all U.S. cattle." Guebert says "that’s an absurd and ridiculous claim with no factual basis—other than a study NPPC and NCBA bought and paid for—that went unchallenged by other commodity groups, unanswered by USDA, and uncommented on by any member of congressional ag committees."

Also, one of the biggest farm groups in the U.S., the American Farm Bureau Federation, quietly endorsed a House plan to repeal the Patient Protection and Affordable Care Act, Guebert notes. "AFBF offered neither a replacement plan for the millions of Americans—many in rural America—who would lose insurance coverage under the repeal nor any suggestion to improve the ACA if it remained. Moreover, the AFBF announcement didn’t mention that several of its state affiliates own and operate regional, rural-focused insurance companies who might benefit, some handsomely, if the entire ACA was repealed and no federal replacement took its place."

"There was a time when what was good for rural America was good for farmers and farm groups," Guebert writes. "We’ve now flipped that to read: What’s good for farm groups might be good for farmers and rural America. That change, subtle as it seems, seems to change everything. Many farm and commodity groups are often viewed as anti-customer, anti-environment, and anti-neighbor bottom-line grubbers. Are they?"

Kansas legislature falls short of overriding governor's veto of Medicaid expansion

The Kansas House on Monday fell three votes short of overriding Republican Gov. Sam Brownback’s veto of a bill to expand Medicaid in the state, Peter Hancock reports for the Lawrence Journal-World. Expansion would have extended Medicaid coverage to an additional 150,000 people. The vote meant that the bill never returned to the Senate.

The final vote was 81-44, the same vote that passed the measure in February. Two lawmakers that voted against the bill in February voted in favor of overriding the veto, but two lawmakers who supported the bill, changed their votes for the veto override, Hancock reports. One who switched to favor the bill said he voted to help struggling hospitals in his district.

Brownback, a critic of the Patient Protection and Affordable Care Act, "argued in his veto message that expanding Medicaid would burden the state with what he called 'unrestrainable' costs," Hancock writes. He also argued "that the bill 'funnels more taxpayer dollars to Planned Parenthood and the abortion industry." A Catholic Democrat noted that all four Kansas bishops support expansion.

Kansas legislature votes to expand Medicaid, but governor may issue a veto and make it stick

The Kansas Senate on Tuesday passed a bill to expand Medicaid expansion in the state, Hunter Woodall reports for The Kansas City Star. By a vote of 25-14 the Senate passed "a bill that would expand coverage of KanCare, the state’s privatized Medicaid program, to roughly 150,000 people in the state," most of them rural residents. The bill now goes to the desk of Republican Gov. Sam Brownback, who is against expansion, but "has not said whether he will veto the legislation."

Lawmakers already are preparing for a possible veto override, Woodall writes. "Brownback will have 10 days from the time he gets the bill to decide whether to veto it, sign it or let it become law without his signature. If Brownback does veto the bill, it will take 84 votes in the House and 27 votes in the Senate to override his veto."

"The bill was supported by a majority of Republicans in the Senate, though by a narrow margin," Woodall writes. "Sixteen Senate Republicans voted for the bill, while 14 voted it down. Many conservative Republicans strongly opposed the legislation, though that opposition wasn’t enough to defeat the bill. Expansion proponents will need to flip at least two of the 14 conservatives in the Senate to a yes vote to override a veto. That may be a tough task, as conservative lawmakers were already saying after the vote that they would not be flipped and were hopeful the Senate, or even the House, could defeat a veto-override effort."

Vermont's health care experiment could serve as a national model, especially in rural areas

Vermont, one of the nation's most rural states, has launched an ambitious "experiment that could transform the delivery of health care nationwide," Michael Ollove reports for Stateline. The state is replacing the traditional "fee for service" system where doctors and hospitals are paid for each procedure, treatment or test they provide in favor of a "pay-for-performance" system. Studies have shown that pay-for-performance is more successful in rural areas, because fewer competing insurers and hospitals make it easier to coordinate the system.

"Under Vermont’s plan, to be phased in through 2022, health plans would pay doctors and hospitals based on how well they care for their patients and contain costs, rather than on the volume of services they provide," Ollove writes. "Some health care plans, public and private, have been experimenting with 'pay-for-performance' systems for more than a decade. But Vermont’s experiment is the most ambitious, aiming to cover 70 percent of the state’s residents (excluding those who are in out-of-state employer-sponsored plans), whether they are beneficiaries of Medicare, Medicaid or commercial health insurance."

Organizations "that choose to participate in Vermont’s experiment would join one of two 'accountable care organizations,' or ACOs, which are groups of doctors, hospitals and other providers who combine to coordinate the care of their patients," Ollove writes. "At the beginning of each year, Medicare, Medicaid and Blue Cross Blue Shield (Vermont’s dominant private insurer) would pay the ACOs a per capita amount to cover the care of each patient. Participating providers would earn financial rewards for staying under budget, and for meeting standards of high-quality care."

"The ACOs have agreed to limit spending growth to about 3.5 percent a year for the five years of the experiment. (The national growth rate for health spending in 2015, the last year for which data is available, was 5.8 percent.)," Ollove writes. "As a reward for staying under budget, ACOs would receive up to three percent of the amount they were budgeted. If they miss the targets, they would have to pay a penalty of up to three percent." The model doesn’t count spending on prescription drugs.

"Because payments will be based on the health outcomes of patients, the architects of Vermont’s all-payer model think doctors and hospitals will provide services they forgo under a fee-for-service system because they are not paid for them. Some of those services will not only benefit patients, but save money in the long run," Ollove writes.

Another key is that all "providers in the ACOs will use the same electronic health record system, allowing for seamless communication between hospitals, practices, home health agencies and nursing homes. The single system will make it easier for providers to share what works best for each patient." (Read more)

Fact-checking Trump speech: economy, pipelines, health care, immigration, coal, manufacturing jobs

Washington Post photo by Jonathan Newton

President Trump's address to Congress Tuesday night contained plenty of factual errors. We only have room here for a few fact checks. If you want to re-publish them, we encourage you to look at reports from The Washington Post, The New York Times, NBC News, PolitiFact.com and FactCheck.org.

NBC's Chuck Todd, Mark Murray and Carrie Dann write on First Read that Trump's biggest whopper of the night concerned the economy when he said: "Ninety-four million Americans are out of the labor force. Over 43 million people are now living in poverty, and over 43 million Americans are on food stamps. More than 1 in 5 people in their prime working years are not working. We have the worst financial recovery in 65 years." NBC says while some figures are true "others are highly misleading."

For example, 93 percent of people not in the labor force say they don't want a job. David Freedlander of The Daily Beast noted on Twitter that of the 94 million not working, 44 million are retired, 15.3 million are disabled. 13.3 million are taking care of a family member and 13.2 million are in school.

The Times and Post both say Trump "cherry-picked" data on the economy "to reinforce his argument that he’s walking into the White House with the economy in a near-shambles, as Philip Bump of the Post writes. Trump's description of “the worst financial recovery in 65 years” is true, Bump writes,m but "we also had the worst economic situation since the Great Depression." NBC noted that Trump failed to mention that he inherited a country with a low unemployment rate of 4.8 percent and rising household income.

Pipelines: Trump said the Keystone and Dakota Access pipelines will create "tens of thousands of jobs." Times reporter Coral Davenport noted that most of the jobs will be temporary: "A 2014 State Department environmental review estimated that Keystone would support 42,000 temporary jobs over its two-year construction period — about 3,900 of them in construction, the rest in indirect support jobs, such as food service. It estimated that Keystone would create about 35 permanent jobs."

Trump also said, "I’ve issued a new directive that new American pipelines be made with American steel.” Post fact-checkers Glenn Kessler and Michelle Ye Hee Le write, "Workers in Arkansas have already built about half of the high-strength line pipe needed for the project, some 333,000 tons. TransCanada said in 2013 that it had already purchased all of the steel pipe it needed for the Keystone XL, with the rest coming from a Russian-owned plant in Canada, Italy and India. Experts say the plant in Arkansas (owned by an Indian company) is the only one in the U.S. that could build the pipe—and it gets its steel from India."

Immigration: Trump said, “By finally enforcing our immigration laws we will raise wages, help the unemployed, save billions and billions of dollars and make our communities safer for everyone.” Kessler and Lee write, "Trump exaggerates the impact of illegal immigration on crime, taxpayer money and jobs. Extensive research shows noncitizens are not more prone to criminality than U.S.-born citizens. The vast majority of unauthorized immigrants are not criminal aliens or aggravated felons." Several studies have shown that immigrants are less likely to commit crimes than people born in the U.S., Richard Perez-Pena reported in January for the Times.

Health care: Trump said, "Obamacare premiums nationwide have increased by double and triple digits." Times reporter Robert Pear notes that double-digit increases in premiums have been common for many years. "President Trump cited Arizona's 116 percent increase; it is the only state that experienced a triple-digit hike. Premiums for a popular group of health plans sold on HealthCare.gov rose this year by an average of 25 percent, according to the Obama administration. While subsidies are available to people with low and moderate incomes, people who do not qualify for financial assistance must bear the full cost."

Jobs and trade: Trump said, "We've lost more than one-fourth of our manufacturing jobs since Nafta was approved." Times reporter Binyamin Appelbaum writes, "The U.S. has lost a lot of factory jobs since 2000, but the biggest reason is technological progress, not foreign competition. America's manufacturing output is at the highest level in history—it just doesn't take as many workers to make stuff anymore. Some jobs have been lost to foreign competition, but studies assign a modest role to NAFTA."

Coal: Trump said he ended a regulation that threatened "the future and livelihoods of our great coal miners." Davenport writes, "There is no evidence that the rule threatened a significant number of coal mining jobs, or that rolling it back will create new ones. No credible studies have shown that rolling back major regulations on coal pollution will contribute to a major increase in coal-mining jobs."

Repealing Medicaid expansion could put more rural hospitals at risk; Tenn. senator says not to worry

Repealing the Patient Protection and Affordable Care Act could lead to an increase in the number of vulnerable rural hospitals, Shawn Radcliffe reports for Healthline. A report by the Chartis Center for Rural Health found that in states that expanded Medicaid in 2014, 36 percent of rural hospitals had a negative operating margin in 2015, compared to 47 percent in states that didn’t expand the program. When it comes to the worst category of operating margins (less than negative 5 percent) 18 percent were rural hospitals in Medicaid-expansion states, compared to 30 percent in non-expansion states.

The North Carolina Rural Research Program says 80 rural hospitals have closed since 2010, and Chartis lists 673 rural hospitals as being vulnerable, Radcliffe reports.

Before Medicaid expansion, hospitals still treated uninsured patients, but weren't paid for the care provided, Radcliffe notes. "By increasing the number of people with health insurance, the Medicaid expansion directly benefitted rural hospitals." Dr. Daniel Derksen, director of the Arizona Center for Rural Health, told Healthline that in states that expanded Medicaid, “we saw two important trends—reduction in uncompensated charity care and a reduction in the number, or the velocity, of the rural hospital closures."

Rural hospitals in the 19 states that chose not to expand Medicaid were more vulnerable, Radcliffe writes. Of the 80 hospitals listed by the North Carolina Rural Research Program 60 are in states that didn't expand Medicaid, led by 13 in Texas, seven in Mississippi, six in Tennessee and Georgia and five in Alabama. (Kaiser Family Foundation map: Medicaid expansion states)

Republican Sen. Lamar Alexander of Tennessee, chairman of the Senate health committee, told Politico last week that Congress will not only continue the Medicaid expansion, but broaden it.

Paper reveals its county, home to a big university, is high in poverty and low in upward mobility

Greg Townshend, recently released from prison,
found work in Boone County through a statewide
program for at-risk youth. (Daily Tribune photo)

The Columbia Daily Tribune in Columbia, Mo., has published a series examining poverty in surrounding Boone County, which it says is "one of the worst counties in the country for socioeconomic mobility," which measures an individual's upward or downward movement on the economic ladder.

"Data show that if you’re born into poverty in Boone County, you’re more likely to die in poverty than in most other counties," Jodie Jackson Jr. reports in a story that looks at a job skills program that helps people earn a living wage.

Stories in the "Left Behind" series look at how Boone County residents face obstacles in getting access to health care, finding affordable housing, moving up the economic ladder, being able to afford to have children, the link between crime and poverty and how expanding Medicaid could benefit the poor in the county and the rest of Missouri.

"Children who live in low-income households in Boone County face challenges moving up the income ladder, according to a 2015 national study conducted by Harvard University researchers," Brittany Ruess reports in a story that looks at the county's lack of economic mobility. "The study shows that Boone County has the second-worst economic mobility in Missouri and is better than only 17 percent of counties in the country."

The Tribune, which the Waters family recently sold to Gatehouse Media, also is trying to get readers involved in the series by asking them to share their stories through social media or email.

Tennessee teacher goes viral after using Christian values to question lawmaker about repealing ACA

Cookeville, Tenn. high school French teacher Jessi Bohan has gone viral after a town hall meeting Thursday at Middle Tennessee State University in which she used Christian values to challenge Rep. Diane Black, a Tennessee Republican, over concerns that the Patient Protection and Affordable Care Act will be repealed, Greg Sargent reports for The Washington Post.

Bohan said to Black: “It’s my understanding that the ACA mandate requires everybody to have insurance, because the healthy people pull up the sick people. As a Christian, my whole philosophy in life is to pull up the unfortunate. The individual mandate, that’s what it does. The healthy people pull up the sick. If we take those people, and we put them in high risk insurance pools, they’re costlier, and there’s less coverage for them. That’s the way it’s been in the past, and that’s the way it will be again. So we are effectively punishing our sickest people.”

Black said, "About 20 million people did actually come into the program who were uninsured. You don't want to hurt one group of people to help the another. We can help both groups at the same time," Jen Hayden reports for the Daily Kos. Bohon responded: "How many of those people were in states where they played a political game with people's lives?" Black, who appeared flustered, declined to continue, saying "I'm going to pass this one."

Bohan, who made the 90 minute trip to the town hall in Mufreesboro, said she purposely "framed the question the way she did because she is irked by politicians who say they are Christian but advocate for policies that don’t, in her view, reflect the faith’s principles—the looming repeal of the ACA, which could leave millions uninsured without a viable replacement," Helaine Olen reports for Slate.

Bohan, who grew up as one of three children of a single mom in rural Grundy, Va., a small Appalachian coal-mining town near the border with Kentucky, told Olen, “We were the poorest of the poor. We had no car, we were on welfare.” She said her mother “raised me with the belief that Jesus loves poor people, he loves the oppressed, he loves the most vulnerable and I will tell you that’s a lesson that stuck with me. I don’t go to a fancy church, I don’t really have a good grasp on the literal interpretation of the bible. I believe in the central message of Jesus, which was pull up the people.”

Rural Wisconsin, which surprisingly went for Trump, anxiously waits for an economic revival

President Donald Trump narrowly won Wisconsin—where Barack Obama won in 2008 and 2012—largely on the strength of several rural counties that turned from blue to red in 2016, Claire Galofaro reports for The Associated Press. "They voted for Trump for an array of reasons, and the list of grievances they hope he now corrects is long and exacting: stagnant wages, the cost of health care, a hard-to-define feeling that things are not getting better, at least not for people like them."

While Trump has talked of a U.S.-Mexico border wall and plans to ramp up immigration enforcement, those issues are of little concern in Crawford County (Wikipedia map), one of the oldest and poorest counties in Wisconsin, Galofaro writes. In Crawford, where Obama in 2012 beat Mitt Romney 52.8 to 46.1 percent, but in 2016 Trump easily beat Hillary Clinton 59.2 to 37.4, residents "are still watching and they are waiting, their hopes pinned on his promised economic renaissance."

"Jim Bowman, director of the county's Economic Development Corporation, says some of the economic anxiety here is based not on measurable decay, but rather a perception that life is decaying," Galofaro writes. "There are plenty of jobs, but it's hard to find one that pays more than $12 an hour. Ambitious young people move away. Rural schools are dwindling, and with them a sense of pride and purpose."

Mark Berns, who owns a small-engine repair shop that he can barely keep open, told Galofaro, "If you ask anybody here, we'll all tell you the same thing: We're tired of living like this. I just hope we get the jobs back and the economy on its feet, so everybody can get a decent job and make a decent living, and have that chance at the American dream that's gone away over the past eight or 10 years. I'm still optimistic. I hope I'm not wrong."

Like many others, Marlene Kramer, who voted twice for Obama, voted for Trump because of the hope that a change could be better, Galofaro writes. Kramer, 54, has worked for 40 years, all hard jobs, and now works at a sewing shop where the biggest benefit is getting to sit, instead of being on her feet all day. She said the Patient Protection and Affordable Care Act hasn't helped her, with her and her husband "stunned to find premiums over $1,000 a month. They opted to pay the penalty of $2,000 until Trump, she hopes, keeps his promise to replace the law with something better."

Repealing ACA could hinder treatment for opioid addiction, epidemic in Appalachia, rural areas

President Trump's pledge to repeal the Patient Protection and Affordable Care Act could have dire effects on drug-treatment programs, especially in Appalachia and other rural areas plagued by the opioid epidemic, Christine Vestal reports for Stateline. An estimated 1.6 million previously uninsured addicts in the 31 states that expanded Medicaid gained coverage since 2014.

More than 33,000 people died in 2015 from opioid overdoses, a 16 percent increase over 2014, while prescription overdose deaths have quadrupled since 1999, says a study by the Centers for Disease Control and Prevention. In 2014 Ohio had the most opioid overdoses and West Virginia the highest rate, says a separate study by CDC. Both expanded Medicaid.

ACA "offered states the ability for the first time to provide Medicaid coverage to adults without children, with the federal government paying most of the bill," Vestal writes. "That change, and the law’s mandate that all insurers cover addiction treatment at the same level as medical and surgical procedures, has allowed states to ensure that low-income people can get the care they need, said Linda Rosenberg, CEO of the National Council for Behavioral Health, which represents nonprofit addiction treatment organizations." (Stateline map: Six of the 10 states with the highest opioid death rates voted for President Trump)

"Although a plan for replacing the federal health law has yet to be announced, House Republicans and Trump have proposed shifting Medicaid to a block grant, in which a capped amount of money would be allocated to each state to provide low-income health care services," Vestal writes. "By putting more of the cost burden on states, the shift is projected to save the federal government $1 trillion over 10 years. But most states would be unable to come up with the extra money and would have to scale back efforts to get more people into treatment, said Lisa Clemans-Cope, a researcher with the Urban Institute, which analyzes health care policy."

"Because addiction is a chronic, lifelong disease, a cut in Medicaid funding would stymy states’ efforts to reduce the number of people who are addicted to heroin and other opioids and at risk for drug overdoses," Vestal writes. "Not only would low-income adults already in treatment be in jeopardy of losing coverage for their continuing care, but budget-strapped states likely would be unable to help others get out of homeless shelters and jails and into treatment."

Repealing Obamacare would have biggest impact on rural areas, medical-school professors write

Repealing the Patient Protection and Affordable Care Act would have the biggest impact on rural areas, which typically have higher rates of chronic illness, obesity, drug overdose, alcoholism, mental illness and suicide, opine Margaret Greenwood-Erickson and Mahshid Abir for Bridge, published by The Center for Michigan. Greenwood-Erickson is national clinician scholar and clinical lecturer, and Abir is a professor, at the University of Michigan medical school.

"Taken as a whole, Medicaid expansion through the ACA has resulted in critical gains toward improving rural population health by expanding insurance coverage and stabilizing rural hospitals," Greenwood-Erickson and Abir write. "The repeal of Medicaid expansion and collapse of the individual insurance market, which could occur as part of repeal of the ACA, could threaten strides the country has made in advancing the health of rural America." (Kaiser Family Foundation map: Medicaid expansion states)

"One option forward would be to encourage states to apply for special waivers, or 1115 waivers, which allow states a more flexible implementation of Medicaid expansion," Greenwood-Erickson and Abir write. "For some states, this allows them to expand coverage under Medicaid in a way that is more attuned to each state’s unique demographics and values. For example, alterations range from healthy behavior incentives that reduce premiums in Iowa to permitting higher cost-sharing than is otherwise allowed under federal rules for non-emergency use of emergency rooms in Indiana."

"We do not yet know how the debate over ACA repeal and replace will play out," Greenwood-Erickson and Abir write. "Yet, we do know that some of the proposed alternatives could result in real harm to rural states, the most obvious being a repeal of Medicaid expansion. Further, block grants have been discussed as a method to control Medicaid costs. These are grant programs from the federal government that give states annual fixed amounts to spend on a specific program, but they can result in neglect of rural populations. As block grants limit the amount of money states have to spend on vulnerable populations, they may overlook national objectives, such as caring for rural and poor communities."

Medicaid expansion greatly increased coverage, especially in rural areas, study finds

Medicaid expansion under the Patient Protection and Affordable Care Act greatly increased access to health care for Americans, especially in rural areas, says a study by researchers at Indiana University, published in The Journal of Rural Health. Researchers, who used data from the Census Bureau's American Community Survey from 2011-15, found that expansion "increased the probability of Medicaid coverage for targeted populations in rural and urban areas, with a significantly greater increase in rural areas, but some of these gains were offset by reductions in individual purchased insurance among rural populations." 

"Medicaid expansion increased the probability of having 'any insurance' for the pooled urban and rural low-income populations, and it specifically increased Medicaid coverage more in rural versus urban populations," says the study. "There was some evidence that the expansion was accompanied by some shifting from individual purchased insurance to Medicaid in rural areas, and there is a need for future work to understand the implications of this shift on expenditures, access to care and utilization." 

Results suggested "that rural childless adults, compared to urban childless adults, experienced a 1.9-percentage-point larger increase in the probability of having Medicaid as a result of the expansion," says the study. "Rural childless adults experienced a 1.5 percentage point larger decline in the probability of having individual purchased insurance. (IU graphic)

About 1.4 million rural residents signed up for insurance through federally managed marketplace

About 1.4 million rural Americans purchased health care last year through the federally managed marketplace, about 10 percent more than in 2015, says a study by the RUPRI Center for Rural Health Policy at the University of Iowa. That represents 40 percent of the potential market outside metropolitan areas. Michigan, North Carolina and Wisconsin had non-metro enrollment rates above 50 percent.

Researchers found that about rural areas in about half the states, mostly in the Midwest, had higher enrollment growth. (RUPRI graphic: 2015-16 Health Insurance Marketplace enrollment rates as a percent of the potential market, by metropolitan and expansion status.)

"The study compared 2015 and 2016 data from the 36 states with non-metro counties whose individual insurance marketplace is managed through the federal system," Tim Marema reports for the Daily Yonder. "The states that weren’t part of the study either managed their own marketplaces or had no non-metro counties."

Overall, metro areas had a higher rate of enrollment, 48 percent, but the gap has narrowed, says the study. Researchers found that "six of the eight states with the highest differentials (states in which metropolitan enrollment substantially outpaced non-metropolitan enrollment) were non-expansion states: Florida, Georgia, Kansas, Mississippi, Oklahoma, and Texas all showed large enrollment differences, as did Pennsylvania and Arizona in the Medicaid expansion group."

Marema writes, "Though a lower percentage of potential market purchased insurance in states that didn’t expand Medicaid, those states had a greater year-to-year increase in enrollment. That may be because private insurance was the only option for more residents in those states that didn’t expand Medicaid."

"The study noted that counties that had a concentration of residents who lived at 100 to 200 percent of the poverty income (defined as $24,300 for a family of four and $11,880 for individuals) had better enrollment rates than other counties," he writes. "The scholars theorized that was because lower-income residents are eligible for greater subsidies to help them pay for their insurance, so the insurance was a better deal."

Lawmakers ask feds to investigate black lung; Obamacare repeal could be obstacle to benefits

Progressive massive fibrosis in underground miners
 with more than 25 years experience (Coal Workers’
 Health Surveillance Program, Ky.,Va.,W.Va,1974–2015)

Reports that black-lung disease among coal miners in Central Appalachia is significantly higher than federal records show has led to requests for more accurate reporting of the disease, Howard Berkes reports for NPR. Sen. Bob Casey (D-Pa.) and Rep. Bobby Scott (D-Va.) want the National Institute for Occupational Safety and Health, the U.S. Department of Labor Coal Mine Workers' Compensation Program, and black lung clinics funded by the Health Resources and Services Administration to work together do a better job obtaining counts of progressive massive fibrosis, the most progressive form of black lung.

Scott and Casey sent NIOSH a letter asking it to lead a study of complicated black lung cases identified by its own national testing program, by the Coal Mine Workers' Compensation Program and by HRSA, which doesn't require its clinics to report cases of progressive massive fibrosis, Berkes reports.

An NPR survey of black lung clinics across Appalachia—11 responded—found 962 cases "of what is also known as 'complicated' black lung so far this decade," Berkes writes. "In roughly the same time period, NIOSH reported just 99 cases nationwide." A report by the federal Centers for Disease Control and Prevention found that an Eastern Kentucky radiologist contacted NIOSH about finding 60 active or former coal mining patients in Pike County from Jan. 1, 2015 to Aug. 17, 2016 that were consistent with progressive massive fibrosis.

Another concern is that repeal of the Patient Protection and Affordable Care Act could make it difficult for coal miners to get benefits for black-lung disease, Eric Boodman reports for Stat, the national health-and-science website of The Boston Globe. The 2010 reform law "shifted the burden of proof from the miners onto the mining companies." Before the law, 19 percent of black lung disease claims were successful. In 2015, 28 percent of claims were successful. The law says someone who spent at least 15 years in the mines and can prove they have breathing issues ... is presumed to have black lung "unless a company can prove otherwise," reports Angela Reighard of WYMT-TV in Hazard, Ky.

Obamacare changes could make it more difficult for miners to get compensation for black lung

Impending changes to federal health laws could make it difficult for coal miners to get benefits for black-lung disease. "That’s because buried in the Affordable Care Act are three sentences that made it much easier to access these benefits," Eric Boodman reports for Stat, the national health-and-science website of The Boston Globe. If those sentences are repealed, "Miners will be back to where they were in 2009, when it was exceedingly difficult to be awarded compensation for black lung."

Before the 2010 law, "to qualify for benefits, miners had to prove not only that they were disabled because of breathing problems, and that they had coal workers’ black lung, but that their disability was caused by their years in the mine," Boodman writes. That was “almost impossible,” Phil Smith, a spokesman for the United Mine Workers of America, told Boodman: “The vast majority of people were denied benefits. People would take these cases through the black lung court system and they would be denied because the companies could sow the shadow of a seed of a doubt.”

The reform law "shifted the burden of proof from the miners onto the mining companies," Boodman writes. "If a miner has spent 15 years or more underground and can prove respiratory disability, then it is presumed to be black lung related to mine work, unless the company can prove otherwise." Before the law, 19 percent of black lung disease claims were successful. In 2015, 28 percent of claims were successful.

The coal industry has opposed the provision. Bruce Watzman, vice president of the National Mining Association, told Boodman, “Our concern back then, which continues today is that … compensation is not based on occupational disease, but rather this is becoming a supplemental pension program, and that was not what it was ever intended to be." (Read more)

Feds estimate that 1.1 million more people will sign up on Obamacare exchanges in 2017

About 1.1 million more people are projected to sign up for health insurance on the Obamacare exchanges for 2017, according to the U.S. Health and Human Services Department. The agency estimates that 13.8 million people will sign up in 2017, compared to 12.7 million in 2016, Toni Clarke reports for Reuters. Officials said "average monthly enrollment in 2017 is estimated at 11.4 million people, up from 10.5 million people in 2016."

"Enrollment has been about half of what was initially expected and some large insurers this year have said they were losing too much money on the exchanges because of that and the fact that enrollees are older and sicker than expected," Clarke writes. "Aetna and UnitedHealth Group have largely pulled out of the exchanges for 2017."

Officials said "there are 10.7 million uninsured people who are eligible for the exchanges but unenrolled," Clarke writes. About 40 percent of those people are 18 to 34 years old. (Read more)

More than 650 mostly rural counties will have only one Obamacare exchange option in 2017

Residents in more than 650 counties, mainly rural, will only have one insurance option when shopping for Affordable Care Act health insurance in 2017, Anna Wilde Mathews and Stephanie Armour report for The Wall Street Journal. "The entire states of Alaska and Alabama are expected to have only one insurer on the health law’s signature online marketplaces next year, according to state regulators. The same is expected to be true in parts of several other states, including Kentucky, Tennessee, Mississippi, Arizona and Oklahoma, state regulators said."

In 2016 the number of counties with only one option was 225, "when the state of Wyoming, among other areas, already had just one ACA marketplace competitor," Mathews and Armour write. "Of the counties in jeopardy of having only a single exchange insurer next year, 70 percent have populations that are mostly rural," according to Cynthia Cox of the Kaiser Family Foundation. She said "disclosures of new market entries or further pullbacks will change the totals in coming months. Filings in many states aren’t yet public, and insurers can tweak their approaches until September." (WSJ graphic)

"UnitedHealth Group Inc. said last month it would leave all but a handful of the 34 states where it sold exchange plans this year amid losses; Humana Inc. is also pulling out of some areas," Mathews and Armour write. "Others are sticking around: Anthem Inc. has said it would continue selling exchange plans in its current 14 states. Aetna Inc. will remain in its 15 states and has said it may enter more, and Cigna Corp. plans to extend beyond the seven states where it currently sells exchange plans. Premera Blue Cross said all of its subsidiaries would stop selling ACA marketplace plans in a dozen largely rural counties in its home state of Washington. It will also pull out of Oregon, where it has used the LifeWise brand."

Insurance companies say rural areas have "fewer, less-competitive health-care providers that weren’t willing to strike the payment deals the insurer sought," Mathews and Armour write. "A new analysis by Inovalon Inc., a health-technology firm, shows why rural areas are often less inviting for insurers. Using a health-insurance claims database that includes about two million exchange enrollees, Inovalon found that rural residents racked up significantly higher medical costs than urban enrollees in 2015." (Read more)

Congress and the Obama administration are doing little to help struggling rural hospitals

Hospitals in rural areas continue to close or struggle to remain open, leaving an aging population with few resources to seek medical care, Shannon Muchmore reports for Modern Healthcare. The problem, especially bad in states that refused to expand Medicaid, is getting little help from Congress, where bills have been introduced but have little chance of passage. The Obama administration hasn't helped either, proposing "tightening the definition of a critical-access hospital and cutting their reimbursements, which are currently slightly higher than other hospitals." (Photo: Page Memorial Hospital in Virginia's Shenandoah Valley is in danger of closing because of Medicare cuts and the state's refusal to expand Medicaid)

"While the Affordable Care Act has allowed millions to gain access to health insurance, rural hospitals continue to face reimbursement cuts and practice-of-medicine regulations that administrators say do more harm than good. In the U.S., nearly 2,000 hospitals are rural and 1,333 qualify as critical access," Muchmore writes. Travis Clark, president of Page Memorial Hospital in Virginia's Shenandoah Valley, "said the federal government has helped hospitals such as his in the past. But they are now in need of special programs and grants that will allow rural providers to do more than just survive." In Shenandoah Valley the population over age 65 has increased 28 percent in the past decade and the poverty rate is up 21 percent.

"Maggie Elehwany, vice president of government affairs for the National Rural Health Association, said significant Medicaid cuts in the past few years have been suffocating rural hospitals," Muchmore writes. "Since 2010, 55 rural hospitals have closed and that rate is escalating. More than 280 report being at the edge of closure. In 2013, more than one-third of rural hospitals were operating at a deficit, she said."

"The worst financial hits have come from cuts to Medicare's bad-debt program and disproportionate-share hospital payments," Muchmore writes. "Sequestration, which slapped a 2 percent across-the-board cut on Medicare payments, hit rural areas with their older populations especially hard. Rural hospitals rarely have the option of shifting costs to the privately insured. The 20 states that have not yet expanded Medicaid eligibility under the ACA tend to be more rural states with Republican governors. These states also have residents who tend to be older, poorer and sicker, Elehwany said."

Uninsured rates are down, but hospitals struggle to collect big deductibles from newly insured

Federal health reform has decreased the number of uninsured Americans and charity cases at hospitals, it has also led to an increase in the number of high deductibles they can't collect, a particular problem in rural areas where hospitals are already struggling financially, John Lauerman reports for Bloomberg Business.

The nation's uninsured rate has dropped from 15.7 percent in 2009 to 9.1 percent today. That would be good news if a Centers for Disease Control and Prevention survey hadn't revealed "that in the first nine months of 2015, about 36 percent of the U.S. insured were covered by high-deductible or consumer-directed health plans that can require considerable out-of-pocket payments, compared with about 25 percent in 2010," Lauerman writes. As a result, companies like Community Health Systems Inc., which "operates 195 hospitals in 29 states and is the U.S.’s second-biggest for-profit U.S. hospital chain." earlier this month "revised its fourth-quarter 2015 provision for bad debt up by $169 million—and said that 40 percent, or about $68 million of that amount, was from patients being unable to pay deductibles and co-payments."

"Patients are unlikely to pay medical bills that are greater than 5 percent of household income, according to the Advisory Board, a consulting firm to hospitals," Lauerman writes. "Median household income in the U.S. is at about $53,000, suggesting that when out-of-pocket charges exceed $2,600 hospitals can forget about collecting," said Washington-based analyst Spencer Perlman.

"Rural hospitals have been hit particularly hard," he writes. "Minnesota has long had high rates of care coverage, and many employers have switched to high deductible offerings, according to Joe Schindler, vice president of finance for the Minnesota Hospital Association. Last year, bad debt rose by 20 percent to $425 million at the association’s 140 member hospitals." Schindler told Lauerman, “We have 39 hospitals that have negative margins and the majority of them are rural. They have less of a financial cushion to absorb the losses of bad debt.” (Read more)

Stories about the problems of rural hospitals led The Rural Blog's readership list in 2015

Stories about the problems of rural hospitals led the list of most-read topics on The Rural Blog in 2015. Of the 60 blog posts that were viewed at least 250 times by TRB readers, eight excerpted stories about rural hospitals, and some related items also had high readership.

The most-read item on the topic was one on Aug. 4 about the struggles of rural hospitals in Alabama, Oklahoma and Nebraska, perhaps appealing because it dealt with three states. Close behind was one published the day before, about a community's reopening of a southwest Virginia hospital that a chain had closed. Next in line was a Feb. 19 report on how the Syracuse Journal in Kansas had held the local hospital accountable in the face of claims by its fired administrator about "negative press."

We said in that item, "With many rural hospitals in financial trouble, rural news media need to cover their activities. Some handle hospitals with kid gloves, because they are such important local institutions, often run by well-regarded local people. But in many cases the accountability for these institutions is fuzzy, and rural news media are in a position to increase accountability."

Other well-read reports on rural hospitals included a March 18 item about hospitals facing federal reimbursement cuts for high readmission rates; one the day before reporting that 48 rural hospitals had closed since 2010 and 283 more were in trouble; an April 17 item noting that four of the 10 closures in Texas were due to a fraud case; and a July 24 item quoting an expert advising rural hospitals to strengthen their connections to their communities.

Some related reports also had high readership, such as a Jan. 16 item about the shortage of doctors in rural areas and one on June 9 about a national survey of rural stakeholders, which found that their top concern was access to health care, being limited partly by the closing of rural hospitals.