'Byzantine' hospital billing practices often leave patients with huge bills; Maine paper's work provides example for U.S.

Kaiser Health News and NPR map based on Urban Institute data

Despite efforts in recent years to increase the transparency of medical bills, millions of Americans are still saddled with medical debt from "unexpectedly huge expenses," partly from "facility fees" charged by hospitals, Joe Lawlor reports for the Portland Press Herald/Maine Sunday Telegram. That's according to a three-month investigation the paper conducted into the "byzantine system of medical billing in Maine," The most rural state. Its findings are broadly applicable.

More than 100 million Americans, or 41% of adults, have medical debt, and they are more likely to live in rural areas, the South, and/or in states that didn't expand Medicaid. The government has attempted to help Americans avoid such debt: The "No Surprises Act," which took effect Jan. 1, 2021, is meant to prevent patients from being blindsided with surprise bills for out-of-network medical treatment. But there are loopholes: Ground ambulances, which can cost thousands of dollars, aren't covered. Another law that took effect that day required hospitals to begin posting the prices for their services online, but few hospitals have complied and fewer still have been fined.

Percentage of those surveyed with below-average income
who said they had serious problems paying or couldn't pay
a medical bill. (Portland Press Herald chart based on
2021 data from the Commonwealth Fund.)

"It has long been standard practice for hospitals to shift uncompensated costs, such as care for uninsured patients who can’t afford to pay their bills, to patients with insurance," Lawlor reports. "But with more patients on high-deductible plans – and insurers sometimes refusing to pay or paying only a fraction of their bills – individuals are picking up more of the tab and bearing more of the financial burden."

Facility fees are another way often cash-strapped hospitals try to stay in the black, Lawlor found. That jibes with a years-long investigation on sky-high emergency room bills by health journalist Sarah Kliff (now at the New York Times, then at Vox). In Maine, "patients are paying hundreds of dollars extra for routine medical tests or procedures simply because the tests are occurring at hospitals," Lawlor reports. "And they may have no idea, because the 'facility fees' are not clearly explained and sometimes hidden on their bills." But one hospital's chief financial officer said facility fees are an "industry standard" because hospitals must cover higher expenses than other medical providers.

Other findings from the Portland Press Herald's investigation:

• "Medical bills are confusing and opaque, and sometimes carry arbitrary and hidden costs" such as facility fees, which can reach hundreds of dollars.
• "The practice of assessing facility fees – sometimes hiding such fees in other charges – increasingly contributes to some patients’ surprisingly large bills."
• Insurance companies sometimes deny claims for unclear reasons that may never be explained. That forces patents to choose between a long fight with insurance or paying huge bills.
• Insurance and procedure costs vary so widely that even patients who carefully compare prices can end up with much higher bills than expected. (See this Kaiser Health News story.)
• Even though Americans have more access to insurance through the Affordable Care Act marketplace, many are still underinsured and risk owing massive unexpected medical bills.
• The high number of underinsured and uninsured people makes the health-care system less efficient and raises costs for providers. The higher costs make even insured people reluctant to seek medical care.
• Everyone agrees reform is needed, but change is difficult because change in one sector often hurts another.
• Reforms like the ACA tend to focus on expanding insurance access instead of addressing root problems with pricing and out-of-pocket costs.
• A single-payer model (not the same thing as universal health-care, though the two are often conflated) could help, but only if the state and federal governments adequately fund it. And there is little momentum right now in enacting such a system, either at any state or national level.

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.

Most local hospitals are not complying with new laws requiring price transparency; how are yours doing?

More than 94% of hospitals surveyed in the Lehigh Valley of eastern Pennsylvania have not complied with a federal rule requiring transparency in pricing, even though the rule has been in effect for nearly a year. That's according to a nationwide survey of 500 hospitals by PatientRightsAdvocate.org and an investigation by The Morning Call in Allentown, Pennsylvania, Leif Greiss reports. The project provides an excellent template for replicating such an investigation in your area.

The rule, enacted under the authority of the Affordable Care Act, requires hospitals to post on their websites a list of standard charges for all services, as well as negotiated rates with insurers, among other things, Greiss reports. But two Lehigh Valley hospitals, for example, instead provide a price estimate tool on their patient portal apps, and users must provide personal information including their full name and insurance number to access those estimates. Users must fill out a request form and wait for a quote from the billing department if their insurer is not listed on the website. That could force them to wait for hours or days while suffering a medical issue, and the quote is still only an estimate.

"Cynthia Fisher, founder and chairperson of PatientRightsAdvocate.org, said unlike consumers in most other industries, patients have historically been left in the dark when it comes to the cost of care until after services are rendered, something that wouldn’t happen when booking a hotel or shopping at the grocery store," Greiss reports. "However, she said the point of the Hospital Price Transparency rule is to allow patients to know what they would pay ahead of time based on the hospital and insurance provider, opening a new door for competition among hospitals and insurance providers."

Pandemic roundup: ACA enrollment booming; what we don't know about 'long Covid'; National Guard opening vax clinics

Here's a roundup of recent news about the pandemic and vaccination efforts.

As more people get vaccinated, more Americans are relaxing social-distancing precautions and returning to normal life, according to a new poll. Read more here.

More than 200,000 people have signed up for health insurance plans under the Affordable Care Act's online marketplace during a special enrollment window that President Biden opened, which one health policy reporter says is "a sign that those who lost insurance during the pandemic remain in desperate need of coverage." Read more here.

The National Guard is opening coronavirus vaccination clinics in rural counties to increase access to underserved areas. Read more here.

Vaccination sign-ups prove daunting for speakers of other languages. Read more here.

Visually impaired people face extra difficulties in getting vaccinated. Read more here.

Communities and organizations are working to get the vaccine to homebound people. Read more here and here.

A 70 percent vaccination rate doesn't ensure herd immunity, some experts caution. Specifically, if residents in some areas can't or don't get vaccinated and social distance, they can harbor the coronavirus and allow it to mutate and spread to other areas. Read more here.

American adults gained an average of half a pound for every 10 days spent under stay-at-home orders, according to a new study. Read more here.

What we know and don't know about "long Covid," or symptoms—sometimes debilitating—that persist for months after catching the virus. Read more here.

Affordable Care Act health-insurance marketplace has been reopened for three months; here's what you need to know

Because so many have lost their health insurance after being laid off or are finding it difficult to afford their current plan, President Biden has reopened the federal health insurance marketplace for three months to allow people to buy or change their plan. 

"The Biden administration is promising to spend $50 million on outreach and education to get the word out about the new special enrollment period," Michelle Andrews reports for Kaiser Health News. "That’s critical, experts said. Although the number of people signing up for Affordable Care Act plans has generally remained robust, the number of new consumers enrolling in the federal marketplace has dropped every year since 2016, according to KFF, corresponding to funding cuts in marketing and outreach."

KHN has a detailed explainer with info about the new open enrollment period, which opened Monday. Click here to read it.

What to know as ACA lawsuit is argued in Supreme Court

The Supreme Court heard oral arguments Tuesday "in a case that, for the third time in eight years, could result in the justices striking down the Affordable Care Act," Julie Rovner reports for Kaiser Health News. However, initial reporting on the oral arguments indicates that the court is unlikely to do that.

"The case, California v. Texas, is the result of a change to the health law made by Congress in 2017. As part of a major tax bill, Congress reduced to zero the penalty for not having health insurance. But it was that penalty — a tax — that the high court ruled made the law constitutional in a 2012 decision, argues a group of Republican state attorneys general. Without the tax, they say in their suit, the rest of the law must fall, too."

The court could rule in a number of ways, Rovner notes: It could declare the whole law unconstitutional, refuse to decide the case on the grounds that the plaintiffs don't have the legal standing to sue; rule that, by eliminating the penalty but not the rest of the mandate, lawmakers didn't intend to coerce citizens, so there's no constitutional conflict; or that, without the tax, the requirement to have health insurance is unconstitutional but the rest of the law is legally sound.

Many rural conservatives dislike the ACA because they insist that the open-market premiums are too expensive. But some aspects are popular, including Medicaid expansion in many states and protections for pre-existing conditions and a requirement that insurers provide coverage to everyone who wants it. "But throughout the attempts to eliminate the ACA, politicians who oppose the law have promised that people with preexisting conditions will still be able to access health insurance if the law is overturned," Lauren Peace reports for Mountain State Spotlight. "But that’s easier said than done."

In West Virginia, for example, more than a third of the state's people under 65 have medical conditions that would have made it difficult to get affordable private insurance before the ACA, Peace reports. Patrick Morrisey one of the attorneys general pressing the case, won re-election last week over a Democratic challenger who supported preserving the ACA. Morrisey has not yet proposed a plan to replace the Medicaid money and other federal dollars the law brings into the state, but promised in a January 2020 interview with MetroNews that, should the ACA be overturned, "people will be protected if they have pre-existing conditions."

In essence, "The ACA offers three tiers of protections. Preventing the denial of coverage is just one," Peace reports. "But requiring insurance companies to cover everyone regardless of medical history doesn’t mean by itself that coverage will be affordable, or prevent insurers from charging some people more if they have conditions that are expensive to treat."

Biden was sometimes off base in drive-in town hall on CNN

Joe Biden held a socially distanced, drive-in town hall on CNN Thursday night. "Biden tends to stick close to the facts but occasionally gets carried away with some over-exuberance," Fact Checker Glenn Kessler and Salvador Rizzo report for The Washington Post. Biden didn't make nearly as many false claims as President Trump did at his own town hall, he told a few "whoppers," they report.

Biden claimed that if Trump had "had done his job from the beginning, all the people would still be alive. All the people — I'm not making this up. Just look at the data." But there is no data to support this. Even if Trump had moved rapidly to contain the spread of the pandemic in January, some people would likely have died, as has happened even in countries that have been praised for their handling of the pandemic, Kessler and Rizzo report. In South Korea, which has a population of 51.2 million, there were 377 deaths. The U.S. has about 331 million people, nearly 6.5 times more than South Korea, but its death toll of around 200,000 is over 530 times higher than South Korea's. 

Biden said he wrote an article for USA Today in January saying "We've got a pandemic. We've got a real problem," but that overstates what he said in the Jan. 27 piece. Kessler and Rizzo say he should be commended for focusing early on an issue most Americans weren't concerned about, but didn't say a pandemic was coming. He said it was a possibility and would "get worse before it gets better." 

During the town hall in Moosic, Pa., Biden said the U.S. should expect another 215,000 to die from the coronavirus by January, and said that 100,000 of those would live if people simply wore masks. Those numbers are accurate, according to projections from the Institute for Health Metrics and Evaluation at the University of Washington, Kessler and Rizzo report.

Biden noted that the Trump administration is trying to nullify the Patient Protection and Affordable Care Act, and said 100 million people with pre-existing conditions would see their insurance premiums go up if that happens. About 102 million people had pre-existing conditions in 2018, Kessler and Rizzo report. but premiums would not necessarily go up for all if Trump wins in court. 

Biden alleged that television journalists said that he would be the first person without an Ivy League degree to be elected president. "No reporter said that," Kessler and Rizzo report. "Ronald Reagan, elected in 1980, was the last president who did not go to an Ivy League university."

Rural African-Americans in Ga. fear reopenings will leave them more vulnerable; pattern could show up in other states

Washington Post map; click on it to enlarge.

Georgia Gov. Brian Kemp allowed some businesses to reopen Friday, but African-Americans in hard-hit rural areas say it's too soon, and worry they will suffer the worst fallout, since they appear to be more susceptible to the coronavirus. "They fear the restart will spike new infections, particularly in the southwest region, with some of the highest death rates in the nation," report Reis Thebault, Andrew Ba Tran and Vanessa Williams of The Washington Post. "In these small, interconnected towns, where everyone seems to know everyone else, each death reverberates."

Jeff Zeleny reports for CNN, "The reopening of some Georgia businesses, which started including restaurants on Monday, was at odds with White House Task Force guidance for states to first have a 14-day decline in coronavirus cases. After initially signaling his support for Kemp, Trump criticized the move after his medical advisers voiced strong concern."

Though African-Americans make up about 30 percent of Georgia's population, they account for more than half of its covid-19 deaths. The death rate is especially high in rural counties with majority-black populations, the Post reports. Part of that is because of systemic inequalities: Georgia did not expand Medicaid under the Patient Protection and Affordable Care Act, so its low-income residents are less likely to have health insurance; African Americans are more likely to have underlying health conditions that make them more vulnerable to the virus, and ate more likely to work in industries with a greater risk of virus exposure, the Post reports.

Rural areas have less access to nearby hospital care, and rural health-care providers have a harder time accessing testing and personal protective equipment, the Post reports. Georgia, as a whole, ranks 40th in terms of how many tests are available per person.

Two funerals in Albany turned southwest Georgia into a pandemic hot spot in early March. City Commissioner Demetrius Young told the Post that residents will continue to die at disproportionate rates without better testing and virus tracking, and worries that reopening businesses will be disastrous. "To open up businesses where it’s impossible to practice social distancing — hair salons, nail salons, theaters — people are like, what? You want to put everybody in a closed room, and that’s supposed to be okay?" Young said. "For black folks, it’s like a setup: Are you trying to kill us?"

Andrew Pavia, head of the pediatric infectious diseases division at the University of Utah School of Medicine, told the Post that Georgia's rural death-rate disparity, especially among African-Americans, may be happening in other states: "It’s a perfect storm for risk of death when the virus lands in these poor, more rural communities."

Rural Tenn. hospital reopens; new owner blames hospital closures on Southern states' refusal to expand Medicaid

Cumberland River Hospital in Celina, Tenn. (Cookeville Herald-Citizen photo by Ben Wheeler)

Rural hospitals have been closing at alarming rates over the past decade, so it's always good news when one reopens. That's what happened this week in Celina, Tenn., where Cumberland River Hospital reopened, a year after it was forced to close for lack of a buyer. But it's been a rocky road.

Cookeville Regional Medical Center, two counties away, owned the hospital, which served as a major employer for the county of 8,000. Johnny Presley, a physician assistant who owns three health clinics, recently purchased the hospital and has already opened the emergency room and a daytime clinic, Ben Wheeler reports for the Herald-Citizen in Cookeville.

Celina in Clay County, Tennessee
(Wikipedia map)

Presley said he is trying to find more staff so the hospital can start treating more serious cases, but it's difficult to find employees for a rural hospital. He said it has also been hard to bring in money during the pandemic when hospitals aren't doing many elective procedures and the cost of supplies has increased greatly. "It's a double-edged sword," he told Wheeler. "Unless the government steps in and bails out hospitals in general, I don't see how any facility overcomes this."

Presley, who is running an uphill campaign for U.S. senator in the Aug. 6 Republican primary, "blamed hospital closures across the South on the refusal by members of his party in states like Tennessee to expand Medicaid insurance coverage, an option under the Affordable Care Act," Richard Fausset and Rick Rojas reported April 9 for The New York Times. Rural hospitals in such states are far more likely to close, according to a 2018 Government Accountability Office report.

"The governors of the Southern states did not take this seriously enough," Presley told the Times. "I think we’re really going to suffer through this pandemic." Last year The Daily Yonder and Kentucky Health News contrasted the fate of the hospital with its neighbor in Kentucky, which expanded Medicaid.

Some state legislatures tackle rural health access problems

Stateline map; click to enlarge it.

As state legislatures begin their 2020 sessions, more are grappling with how to increase access to medical care in rural areas.

Most rural areas have significantly worse health outcomes than cities and suburbs. Rural mortality rates for the top five causes of death (heart disease, cancer, accidents, low respiratory disease and stroke) and the gap has been growing at least since 2009, Michael Ollove reports for Stateline. Rural areas also have higher suicide rates. And though urban areas have a higher overall rate of deaths from drug overdoses, rural areas have higher overdose rates for some drugs, such as methamphetamines and oxycodone. Rural women are also more likely to die from a drug overdose than their suburban and urban counterparts.

The health gap has multiple reasons: poverty (which reduces access to health insurance and nutritious food), higher rates of smoking and obesity, and lower rates of exercise. Another big reason: "Since 2005, at least 163 rural hospitals have closed, more than 60 percent of them since 2012. Nineteen rural hospitals closed in 2019, the most in a year," according to the Rural Health Research Program at the University of North Carolina, which tracks rural hospital closures, Ollove reports. Rural health clinics are faring poorly, too: 388 clinics closed between 2012 and 2018, leaving 4,245 in operation.

Partly because of hospital closures, rural areas have a hard time attracting and keeping medical professionals. "Nearly 80% of rural counties are short on primary-care doctors, and 9% have none, according to the National Rural Health Association’s Policy Institute," Ollove reports. "The shortage of providers is likely to only get worse. More than 25% of primary care physicians in rural areas are 60 or older, compared with 18% in urban areas.

Though Medicaid expansion and the Patient Protection and Affordable Care Act have helped many rural residents get health insurance, rural areas are still grappling with these systemic problems. "Many states are focused on making improvements, both large and small, to address the deficiencies," Ollove reports. "Among the ideas: creating private-public partnerships to increase access to care, sending mobile medical units into remote areas, expanding telemedicine and encouraging young people in rural communities to go into health professions."

Several Republican-run states are fielding initiatives to expand Medicaid, which would increase rural coverage and thus rural hospitals' revenue. "Some states are trying to help rural hospitals deliver preventive care and chronic illness management beyond their walls, improving the collective health of the community while reducing health care costs," Ollove reports.

Pennsylvania, for example, has an initiative in which it guarantees 13 participating rural hospitals the revenue they'll receive in the coming year and rewards hospitals for keeping patients healthy and out of hospitals. The hope is that hospitals will be better able to focus on prevention and treatment without having to worry so much about the budget, Ollove reports.

"Brock Slabach, senior vice president of the nonprofit National Rural Health Association, said big ideas are needed to truly change the trajectory of rural health. The good news is that because of scale, rural areas are promising places to test out innovations in the delivery and financing of health care." But, he told Ollove, "we don’t have the luxury of having years to spend finding solutions."

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.

Rural and safety net hospitals brace for federal funding cuts

Rural and other safety-net hospitals are bracing for a body blow. Most are already operating on thin  profit margins, which sometimes disappear, and now they're facing cuts in funding for charitable care. Funding for such programs was expanded under the the Patient Protection and Affordable Care Act, but it had an expiration date. Unless Congress votes to protect that funding within the next few weeks, hospitals nationwide will lose it, Michael Ollove reports for Stateline.

"The federal money reimburses hospitals for the care they provide to people who can’t afford to pay and offsets the cost of care that hospitals provide to Medicaid patients that Medicaid does not cover. The federal cuts amount to $4 billion this year and $44 billion through 2025," Ollove reports. "The hospitals’ total loss of funding could be even more significant because the program includes state matching funds. If state cuts are commensurate with federal ones, the overall reduction would go from $4 billion to more than $7 billion in 2020."

Disproportionate-share hospitals, which have a larger than average share of Medicaid patients, increasingly rely on such funding to stay afloat. DSH payments totaled $18.2 billion in 2014, covering more than half of the uncompensated care costs for hospitals that received the money. "By 2019, the total DSH allotment was $22 billion, 57 percent of which came from the federal government; the rest came from state governments," Ollove reports. 

The ACA was meant to reduce hospitals' charitable care expenditures by expanding Medicaid and affordable private insurance; that's why it had a built-in DSH funding decrease. But things didn't go according to plan, Ollove notes: the Supreme Court ruled that states didn't have to expand Medicaid (19 haven't), and Congress rolled back the individual mandate to purchase insurance.

"Those actions, which likely kept millions in the ranks of the uninsured, undercut the premise of the cutbacks in DSH payments: Hospitals needed the money after all. Congress took notice. Four times, it voted to delay the cuts, and in September passed a continuing resolution that would keep funding at 2019 levels through Nov. 21, Ollove reports. "Still, the U.S. Centers for Medicare and Medicaid Services last month issued rules for states on how to calculate the DSH cuts."

A House bill would cut the DSH reductions by $16 billion in the next three years, but the Senate hasn't produced a similar bill, Ollove reports.

Closed and at-risk rural hospitals are more common in the 14 states that haven't expanded Medicaid

Rural hospitals all over America are struggling, but "closures and at-risk hospitals are heavily clustered in the 14 states that have not expanded" Medicaid under the 2010 Patient Protection and Affordable Care Act, Michael Ollove reports for Stateline. "Those state decisions not to expand have deprived rural hospitals, which already operate with the slimmest of margins, of resources that could be the difference between survival and closure."

At least 95 rural hospitals have closed since 2010, according to the Center for Health Services Research at the University of North Carolina. Another 600 or more are at risk of closing, "according to an oft-cited 2016 report by iVantage Health Analytics," Ollove notes. The center told Kentucky Health News that 35 to 38 percent of rural hospitals are losing money.

Medicaid has been expanded in 36 states and Washington, D.C. About 4 million more people would qualify if the program were expanded in the remaining states, according to a 2018 Kaiser Family Foundation analysis. That includes 1.2 million in Texas alone, and rural hospitals in Texas are especially endangered; 21 have closed in the past six years, leaving 160 still open. "An Urban Institute study in 2014 estimated that not expanding Medicaid would deprive Texas hospitals of $34.3 billion in federal reimbursements over 10 years," Ollove reports.

But expansion is not a silver bullet. It could "prop up inefficient and wasteful hospitals," said Michael Cannon, director of health policy studies at the Libertarian-leaning Cato Institute. And some rural hospitals could stay solvent if locals approve increased property taxes, Ollove reports. Moreover, rural America would still face many health care issues even if Medicaid were expanded in all states, since rural areas tend to have an older, sicker and less-insured populace.

Analysis: Individual Obamacare premiums higher in rural areas due to lack of competition among hospitals

Health care premiums on individual Affordable Care Act marketplace plans tend to be higher in rural areas, according to a new study by the Urban Institute with support from the Robert Wood Johnson Foundation.

The disparity has grown over the past several years; benchmark premiums in 2016 were 9 percent higher in rural areas ($26 more per month) and 10 percent higher in 2017 ($39 more per month). Some of the greatest rural-urban cost disparities were in Nevada, Colorado and Illinois.

"Lack of provider competition largely, if not predominantly, drove this disparity, the analysis says. Rural areas generally have fewer providers than urban areas to begin with, and the unyielding trend of consolidation is creating an even tighter market," Rose Meltzer reports for Fierce Healthcare. "As The Atlantic reported earlier this year, rural hospitals increasingly face a difficult choice: Be acquired or leave the community with no hospitals at all. In rural areas where the local hospital is the predominant employer, as is often the case, closure can mean economic ruin. And hundreds of rural hospitals are at risk of being shuttered, according to the National Rural Health Association" along with the dozens that have already closed in recent years.

The study's lead author, Erik Wengle, says reinsurance programs can help stabilize rural insurance polls in the long run, and says a permanent federal reinsurance program could help states but would likely have to be established through legislation.

Voters approve animal-space rules in Calif., Medicaid expansion in Idaho, Utah and Neb., recreational pot in Mich.

Voters not only chose officeholders yesterday but decided a host of ballot initiatives.

Colorado voters rejected, 57 percent to 43 percent, a proposal to increase the minimum distance from buildings and waterways for oil and gas drillers. John Aguilar of The Denver Post has a report.

California voters passed Proposition 12, requiring farmers to provide more space for egg-laying hens, breeding pigs and veal calves. "California businesses will be banned from selling eggs or uncooked pork or veal that came from animals housed in ways that did not meet these requirements. Prop 12 also bans the sales from other states not meeting California’s standards. The changes must happen by 2022," KOVR-TV in Sacramento reports. That could have a huge impact on the nation, as it did in 2008 when California passed a similar measure that barred farmers from keeping those animals in cages so small they could barely move. "Since then, supermarket shelves have filled with cage-free egg varieties. Corporations like McDonald’s, Costco and Taco Bell have committed to using cage-free products," the station reports.

The largely rural states of Idaho, Nebraska and Utah voted to expand their Medicaid programs under the Patient Protection and Affordable Care Act. That will extend coverage to about 325,000 people who make less than 138 percent of the federal poverty level. Since the poverty line in 2018 is, for example, $12,140 for an individual and $25,100 for a family of four, that means individuals making $16,146 and families of four making $33,250 will qualify for Medicaid, Sarah Kliff reports for Vox.

Montana rejected an initiative to increase taxes on tobacco products to keep funding its Medicaid expansion. Montana's legislature expanded Medicaid in 2015, but only funded the program for four years. In July 2019 the expansion will end without a reauthorization of funds, and the initiative was an attempt to head off a possible reauthorization fight, Kliff reports. The initiative failed in part because of heavy opposition from the tobacco industry; Altria Group, which includes Philip Morris, spent more than $12 million, Kelly Gooch reports for Becker's Hospital Review.

Marijuana was also on several ballots. Michigan became the 10th state to legalize recreational marijuana while North Dakota said no to the idea. In both states, the winning side got about 60 percent of the votes, Michael Grass reports for Route Fifty.

Medicinal marijuana was on the ballot in two states. In Missouri, voters had three initiatives to legalize medical cannabis and tax its sales. The differences were the level of tax and what the revenue would be used for. The one that passed, with 66 percent of the vote, will tax sales at 4 percent and use the revenue to pay for services for veterans, German Lopez reports for Vox. It also allows people to grow marijuana at home, which the other two did not.

Utah also legalized medical marijuana with 53.2 percent of the vote though the Church of Jesus Christ of Latter Day Saints opposed the measure in favor of a legislative approach. "To some, the vote seemed largely symbolic, since top lawmakers are busy constructing a different model for delivering medical cannabis to Utah patients. State legislators were expected to overwrite Prop 2 if it succeeded at the ballot box and approve their own cannabis act if it failed," Bethany Rodgers reports for The Salt Lake Tribune.

Voters in Florida automatically restored voting rights to former felons, affecting some 1.4 million residents," the National Conference of State Legislatures reports. "In Louisiana, voters instituted a five-year waiting period for felons to seek political office." NCSL has resources on felon voting rights.

In West Virginia, 52 percent of voters passed a measure that could limit access to abortion. "In 1993, the state Supreme Court interpreted the state constitution to say that medically necessary abortions could not be denied to the poor. That meant state Medicaid funds would have to pay," WSAZ-TV reports. "With the passage, this language will be added to the state constitution: 'Nothing in this constitution secures or protects a right to abortion or requires the funding of abortion.'"

Fact Check: Trump wrong about 'Medicare for all,' school violence funding; ad criticizing Tenn. Republican spins facts

Here's another installment of a series we are running weekly until Election Day, in which we list some of the most relevant items from FactCheck.org and other nonpartisan fact checkers. We encourage you to subscribe to their alerts, which you can do here, and republish their findings, which FactCheck lets anyone do for free with credit to them.

In President Trump's Oct. 10 op-ed for USA Today about 'Medicare for all' proposals, "almost every sentence contained a misleading statement or a falsehood," Glenn Kessler writes for The Washington Post's Fact Checker column. Kessler presumes the president must know that most of his claims have already been debunked by Fact Checker, since Trump links to two of them in his op-ed, but chose to ignore the facts. Trump is correct that the plan promoted by Sen. Bernie Sanders, I-Vt., would cost the federal government $32.6 trillion over 10 years, but doesn't mention that overall national health expenditures might not increase because costs for individuals and state governments would go down. Kessler does a point-by-point debunking of Trump's claims in the op-ed; it's too long for us to detail here, but well worth the read. Read more here.

A TV ad criticizing Rep. Marsha Blackburn, R-Tenn., spins the facts about her votes on health-care issues, Lori Roberts reports for FactCheck.org. Majority Forward, an organization affiliated with the Democratic super PAC Senate Majority, launched the ad in early October to help Blackburn's Democratic challenger, former Tennessee governor Phil Bredesen. The ad claims Blackburn voted in 2012 to "give members of Congress health care for life," but lawmakers had already received a health insurance retirement benefit. "There was a possibility at the time that lawmakers could have lost the benefit, but that never happened," Roberts reports. The ad also says she voted in 2017 to take away maternity coverage, but that's not necessarily true. Her vote to repeal and replace the Patient Protection and Affordable Care Act would have meant that some states would no longer require insurers to offer maternity coverage, but insurers could still keep that coverage. Similar claims are likely being made against other Republican House members.

At an event for law enforcement officials, Trump said his administration's STOP School Violence Act had provided "historic levels of funding to improve school safety" and "hire more officers." But this is untrue, because the new law doesn't fund school safety at "historic levels," Eugene Kiely reports for FactCheck.org. The act, which was signed in March, was funded with $75 million shifted from an existing school safety program. "But a single program created in the late 1990s and since disbanded, called COPS in Schools, provided as much as $180 million in fiscal year 2000, according to a 2017 government report. That’s $260 million in 2018 dollars," Kiely reports.

A green light for work requirements may trigger expansion of Medicaid in conservative Republican states

"Republican lawmakers in a half-dozen states are launching fresh efforts to expand Medicaid, the nation’s health insurance program for the poor, as party holdouts who had blocked the expansion say they’re now open to it because of Trump administration guidelines allowing states to impose new requirements that program recipients work to get benefits," Jeff Stein reports for The Washington Post.

That includes efforts in Utah, Wyoming, Idaho, North Carolina, Virginia and Kansas, though it's unclear whether enough conservatives will support expanding Medicaid at all, or whether Democrats will support doing so with work requirements attached. Ten states have already filed requests for work requirements; Kentucky was the first state to have them approved. 

Republican-friendly versions of the program could increase Medicaid's reach into the 17 conservative Republican states that didn't expand Medicaid under the Affordable Care and Patient Protection Act, albeit with reduced benefits.

ACA sign-ups set record pace for first week of enrollment

"More than 600,000 people signed up last week for health insurance under the Affordable Care Act, significantly beating the pace of prior years as consumers defied President Trump’s assertion that the marketplace was collapsing," Robert Pear reports for The New York Times.

Sign-ups averaged more than 150,000 per day last week, compared to 77,600 per day during the first week of enrollment in 2015. About 23 percent of the enrollees last week were new to the marketplace and didn't have insurance through the federal exchange this year.

The ACA has been much in the news lately after President Trump slashed its advertising budget to the bone, cut off cost-sharing subsidies to insurers, and halved the amount of time for open enrollment. But Matthew Slonaker, the executive director of the Utah Health Policy Project, told Pear that "Perhaps there's no such thing as bad publicity. All the talk about health care in the year since the election has been good advertising for the Affordable Care Act."

And Obama administration official Lori Lodes, who is also the founder of insurance education nonprofit Get America Covered, told Pear that people visited Healthcare.gov because they were anxious and confused about coverage, and found that plans were cheaper than they expected.

"Health policy experts said that unhealthy people with the greatest need for insurance tended to sign up in the first weeks of the open enrollment period while healthy people, who are needed to stabilize the market, were more likely to sign up near the final deadline. It is, they said, too early to predict total enrollment for 2018," Pear reports.

After Sept. 30 deadline, here's what the 2018 ACA marketplaces look like

Sept. 30 was a critical deadline for many of the moving parts in the nation's health insurance system. We've covered in another piece what's going on with the Children's Health Insurance Program, which expired on that date without reauthorization. But beyond that, the Senate had to muster the votes to repeal the Affordable Care and Patient Protection Act if it wanted to accomplish it with a simple majority vote; and insurers had to file plans for their 2018 plans by that date.

The Graham-Cassidy bill failed to pass, but a new budget resolution suggests that Republicans may still try to repeal key portions of the ACA in the coming years.

Because insurers didn't know what the health insurance laws would be in 2018, and because President Trump threatened to withhold subsidies to help pay for low-income plans, insurers played musical chairs all summer: withdrawing from some marketplaces and filling others. At several points, rural areas in different parts of the country were left without an insurer to provide individual marketplace plans.

Now that the dust is clearing, we can see what the 2018 ACA marketplaces will look like. Bloomberg has been an invaluable source throughout the summer, with a continuously updated blog with news of insurers' moves and county-level maps of coverage. The most important thing to note is that all counties will be covered by an insurer, and most counties will have multiple insurers to choose from.

Click here for an animated map showing how marketplace coverage changed over the summer. And below is the final county-level map of insurance coverage for 2018:

Bloomberg map