Rural areas lead decline in Obamacare policies' enrollment

As enrollment in Obamacare health-insurance policies declines nationwide, rural areas are leading the fleeing, Sarah Melotte reports for The Daily Yonder and its Rural Index.

The Affordable Care Act policies have become less affordable because Congress did not renew premium subsidies that were implemented during the Covid-19 pandemic and extended in the Biden administration.    "People who are no longer eligible for these subsidies have accounted for a disproportionate share of health insurance coverage drops, resulting in increases in monthly premiums for nearly all consumers." Melotte reports.

Melotte looked at the 30 states that used the national marketplace platform for Obamacare policies and found a 12 percent drop in rural counties, defined as those outside metropolitan areas, "representing 29,000 consumers," she writes. "Small metropolitan counties saw a drop of 11%, representing about 154,000 consumers, the next largest decrease in enrollment among all of the county types."

(Charts by Sarah Melotte, The Rural Index)

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

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

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

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

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

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

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

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

After being dropped by their Medicare Advantage Plan, millions of seniors were left scrambling for health insurance

Some rural residents can no longer enroll in Medicare
Advantage Plans.

Privatized Medicare coverage, also known as Medicare Advantage Plans, stopped providing health insurance to residents in counties where profits were too slim or nonexistent. The shift in coverage options has disproportionately affected rural residents, reports Christopher Rowland of The Washington Post.

Over the past 20 years, Medicare Advantage Plans have grown exponentially by offering extra perks and low premiums to seniors seeking health care coverage that provides more benefits than traditional Medicare, but that trend has reversed. Rowland explains, "Insurers sharply retreated from the plans in some regions, saying rising health care costs and reduced government reimbursements have hurt profitability. . . . Hardest hit were a half-dozen rural states from New England to Idaho."

The sudden change "highlights one of the risks for Medicare Advantage beneficiaries, especially in rural areas where options tend to be meager: plans are under no obligation to offer coverage year-to-year," Rowland reports. "When profit margins are threatened, insurance companies can suddenly withdraw coverage."

Many rural counties have been the first to be cut off, leaving residents with traditional Medicare Part B, which has an 80/20 split, as their only option. Many seniors fear their 20% share will leave them with large medical bills.

In 2026, nearly 3 million people, or 10% of Medicare Advantage Plan beneficiaries, were dropped and forced to find other health care coverage, Rowland reports. "That’s a big jump from 2018 to 2024, when the rate of involuntary terminations was below 2% each year."

Rural hospitals will be hurt the most from Minnesota Medicaid cuts

Government action, such as cuts to Medicaid in Minnesota, has an “outsized impact” on rural residents, Sarah Melotte reports for the Daily Yonder.

The Trump administration recently announced its intent to withhold $259 million from Minnesota’s Medicaid reimbursements due to fraud concerns. CMS Administrator Mehmet Oz said Medicaid funds in Minnesota were going to "bogus" centers for autistic children and a behavioral health organization that had bills showing doctors working 24 hours a day for more than 450 days.

Percentage of hospital revenue coming from low-income health insurance programs. (Map by Sarah Melotte, Daily Yonder, data from the Center for Healthcare Quality and Payment Reform, Click to enlarge)

Rural hospitals are disproportionately affected by these cuts. Melotte explains that rural hospitals are more likely to operate with negative profit margins than urban hospitals, and 39 of Minnesota’s 98 rural hospitals have negative operating margins. This means the rate of uncompensated care will increase even more in these rural hospitals.

Some of these hospitals are able to stay open using non-operating revenue, such as taxes or philanthropy, but this isn’t the case for all of them, reports Melotte. More than 100 rural hospitals throughout the U.S. have had to close in the last decade, causing rural residents to have to travel farther to access the care that they need.

One nonprofit in Minnesota that houses people with disabilities reported to Minnesota Public Radio that “any cuts to Medicaid funding will directly result in reduced services.”

Medicaid now accounts for around 19% of discharges in rural hospitals nationwide, Melotte writes. “In communities where hospitals operate on thin margins, even small cuts in federal spending can destabilize entire systems of care.”

The price of hospital services is driving health care costs and insurance premiums to climb nationwide

Patients and employers are impacted by increases health premiums. 
(Graphic by wildpixel/iStock/Getty+ via Conversation CC)

The American public may perceive hospitals as part of their community’s care network, but in reality, many hospitals and specialty clinics are businesses that strive to make a profit. 

As more medical systems in communities of all sizes have consolidated, hospital pricing has become the biggest driver of rising medical costs and steep health care insurance premium hikes.

“Health insurance premiums in the U.S. significantly increased between 1999 and 2024, outpacing the rate of worker earnings by three times, according to our newly published research in The Journal of the American Medical Association Network Open,” write economic experts Vivian Ho and Salpy Kanimian from Rice University in Houston, Texas, for The Conversation. 

Using federal information and data from the Kaiser Family Foundation, Ho and Kanimian found that “the cost of hospital services increased the most, while the cost of physician services and prescription drugs rose more slowly.”

Many hospitals, including those with nonprofit designations, often aggressively price their services and care well above their costs, Ho and Kanimian point out.

“One study found that for nonprofit health systems, the greatest pay increases between 2012 and 2019 went to hospital CEOs who grew the profits and size of their organizations the most,” Ho and Kanimian explain. In contrast, any emphasis on charity care by those systems was not linked to CEO pay. 

Ho and Kanimian suggest a way to help “ensure that nonprofit hospitals make the health of their local communities a top priority by requiring their boards to disclose their executive compensation guidelines for salary and bonuses, similar to the information that for-profit health care companies disclose to their stockholders.” Such a shift could help communities push for better care and lower costs for patients as determinants of executive pay and bonuses. 

Some economists suggest that “hospital prices should be regulated. This approach involves capping prices for health care services at the most expensive hospitals and restricting price growth for all hospitals,” Ho and Kanimian write.

If Congress doesn't extend enhanced health care tax credits, 4 million rural Americans could face steep premium hikes

Average health care premium comparison before and after ACA credits for 10 'farm states.'
(Robert Woods Johnson Foundation graph)

Without the Affordable Care Act's enhanced tax credits, roughly four million rural Americans could see significant increases to their health care insurance premiums. Last year, the Health and Human Services reported that 17% of individuals who purchased insurance through the ACA marketplace were rural residents, reports Chris Clayton of Progressive Farmer.

While Washington lawmakers focus on eliminating programs that could use American tax dollars to pay for health insurance for illegal immigrants, "there is less talk about how much rural America relies on those tax credits," Clayton explains. "The tax credits have been a major driver for reducing the number of uninsured Americans."

In 2024, the Robert Wood Johnson Foundation reviewed "enrollment of Medicaid and marketplace policies in ten 'farm states,'" Clayton reports. "In that study, eight states -- all but Iowa and Kentucky -- showed more than 5% of residents were enrolled in ACA marketplace policies."

Without ACA enhanced tax credits, health insurance premiums may be out of reach for many rural Americans. According to the article, an individual making $35,000, with enhanced tax credits, would pay a health care premium of $1,033 per year. Without ACA credits, the premium jumps to $2,615 annually, representing a $1,582 increase.

"Overall, the enhanced tax credits saved rural enrollees an average of $890 per year, about 28% more than their urban counterparts," Clayton reports.

Half of rural hospitals lose money; consultancy estimates 418 could close, citing Medicare Advantage as big issue

Map by Chartis Center for Rural Health, labeled by The Rural Blog

Rural hospitals are in more trouble than ever, and 418 of them are “vulnerable to closure,” according to a study of their finances by Chartis, a Chicago-based health-care consultancy that specializes in tracking the business of rural health. (Here's its list of top 100 rural and community hospitals.)

The Chartis Center for Rural Health says rural hospitals are entering "a startling new phase of this crisis as rural hospitals fall deeper into the red, 'care deserts' widen throughout rural communities, and the increasing penetration of Medicare Advantage could further disrupt rural hospital revenue."

The top warning signal cited in the study is that half of rural hospitals are losing money, up from 43 percent a year ago. That news is especially bad for independent rural hospitals, 55% of which are in the red, while only 42% of rural hospitals affiliated with groups are operating at a loss. "Nearly 60% of rural hospitals are now affiliated with a health system," Chartis reports.

Most people on Medicare now have Medicare Advantage, private insurance plans that get lump sums from Medicare to cover members and look for ways to attract customers while limiting claims. "Medicare Advantage now accounts for 35% of all Medicare-eligible patients in rural communities," Chartis reports, saying Advantage plans' share of rural residents has risen 48% since 2019. 

Chartis map, labeled by The Rural Blog; click to enlarge

That's a problem for rural hospitals designated as "critical access" because Medicare Advantage plans' net reimbursement to such hospitals "is often lower for similar services than that of traditional Medicare because Medicare Advantage does not follow cost-based reimbursement" as traditional Medicare does for such hospitals, Chartis reports. Insurance companies negotiate those rates with hospitals, and in many rural areas, hospitals are at a negotiating disadvantage because few insurers operate in their service areas.

Also, "Medicare Advantage may not cover all the services traditional Medicare does, including swing beds, which provide skilled nursing care for patients and are often a strong source of revenue stability for rural hospitals," Chartis notes. "Rural providers may not be equipped to efficiently navigate administrative requirements for payment introduced by Medicare Advantage, such as prior authorizations, which can lead to increased denials."

Since 2010, "167 rural hospitals have either closed or converted to a model that excludes inpatient care," Chartis says. The firm says its estimate that 418 are “vulnerable to closure” is based on "a new, expanded statistical analysis" of their finances, gleaned from cost reports they file with Medicare.

When to get which vaccine and how to get insurance to pay for it has some Americans ditching vaccines

Illustration by Molly Ferguson, Stat

If it's too hard to understand or to get done, many people will opt out -- as is the case with adults attempting to get vaccines.

"Alison Buttenheim was floored by a sign she saw in her doctor’s office when she went to get the first jab of the two-dose shingles vaccine to protect her against painful flare-ups of varicella zoster," reports Helen Braswell of Stat. "The notice read: 'Medicare patients cannot receive Tdap or zoster vaccines here. They need to obtain [them] at their pharmacy. If they receive it here, they need to pay out of pocket.' In this instance, patients could receive vaccines covered by Medicare as treatment, but not as a preventative measure. For instance, if a person stepped on a nail, Medicare would pay for their tetanus shot; however, if a patient is getting a tetanus booster to maintain protection, Medicare would not cover it.

Buttenheim, a professor of nursing at the University of Pennsylvania who studies vaccine acceptance and hesitancy, "knows that any amount of difficulty in the immunization process can deter people from getting vaccinated. She couldn’t believe her eyes," Branswell explains. "To stay abreast of what to get and when and where to get it almost requires would-be vaccine recipients to have advanced degrees. Buttenheim recently found herself shelling out $160 for her latest Covid booster. She told Branswell, "We’re absolutely making it too hard."

Branswell reports, "Some of that may be due to vaccine hesitancy but more of it is likely due to the sheer difficulty of knowing what to get, when to get it, and how to get insurance coverage for the various shots, said Saad Omer, a vaccine expert who is dean of the Peter O’Donnell Jr. School of Public Health at the University of Texas Southwestern." Omer told Branswell: “Beyond the cacophony of pro-vaccine and anti-vaccine arguments on X (formerly know as Twitter), most of the country doesn’t actively think about vaccines, period."

Labor costs, drugs and inflation push health care costs up; painful pricetag will be felt by employers and workers

Wall Street Journal graph, from WTW data

Many Americans will see higher health-care coverage costs during fall open-enrollment periods. "Health-insurance costs are climbing at the steepest rate in years, with some projecting the biggest increase in more than a decade will wallop businesses and their workers in 2024," reports Anna Wilde Mathews of The Wall Street Journal. "Costs for employer coverage are expected to surge around 6.5% for 2024, according to major benefits consulting firms Mercer and Willis Towers Watson.

Coverage pricetags will be painful for employers, families and individual participants. Employers "already average more than $14,600 a year per employee," Mathews writes, "driving up health-insurance costs that are among the biggest expenses for many American companies and a drain on families' finances. . . . For people who have individual insurance plans sold under the Affordable Care Act, premiums are also expected to rise by about 6% next year, according to public insurance filings analyzed by health-research nonprofit KFF."

"Among the factors leading to the faster health-insurance cost growth are hospitals' higher labor costs and heavy demand for new and expensive diabetes and obesity drugs," Mathews explains. "The employer-plan increases are expected to strike businesses of all sizes. . . . For several years, health-coverage costs nationally increased relatively slowly, partly because the pandemic chilled doctor and hospital visits. Yet hospitals have had to hike wages for nurses and pay more for other expenses."

Some companies will increase employee costs, bumping up co-pays and deductibles to cover premium costs, but other businesses will opt to pass the expense onto customers. Mathews reports, "Many employers are expected to take on the lion's share of the increase, partly due to a labor market that remains tight in many sectors, benefits consultants said." Inflation has also made its way into the equation. Tim Stawicki, the chief healthcare actuary at Willis Towers Watson, told the Journal: "The inflation we saw a year ago is finally making its way into the [health care] contracts. It's like a delayed reaction."

Over-the-counter Narcan on shelves next week; overdose reversal spray may cost too much for many who need it

Photo by NEXT Distro, Unsplash

Over-the-counter naloxone nasal spray, or Narcan, will hit drugstore shelves next week. The lifesaving spray reverses opioid overdoses but used to require a prescription. “Big-box outlets like Walgreens, CVS, Walmart and Rite Aid said they expected Narcan to be available online and on many store shelves early next week,” report Jan Hoffman and Noah Weiland of The New York Times. “Narcan is already a staple for emergency personnel and street outreach teams. Now scientists and health officials hope Narcan will eventually become commonplace in public libraries, subways, dorms, corner delis and street vending machines.”

Walgreens announced that it will sell a two-pack of Narcan for $44.99, and the spray qualifies as a medical expense for health savings accounts and flexible spending accounts, according to the Flex Spending Store. But at $45 for two doses, the treatment may be out of reach for some that need it the most. “When Narcan was available only by prescription, public and private insurance readily covered it. But those plans typically restrict coverage of over-the-counter drugs,” the Times reports. “Some state Medicaid programs have already announced that they will cover Narcan when it becomes available over the counter. Those states include Missouri, California, Massachusetts, Washington, Rhode Island and Oregon.”

Where retailers display Narcan, such as behind the counter, could also prevent people from picking it up. “Behavioral health experts say that customers may be reluctant to ask store workers for Narcan, fearing raised eyebrows and dismissive comments—marks of the pervasive stigma surrounding drug use and addiction,” Hoffman and Weiland explain. “Rite Aid, Walgreens, Walmart and CVS also said that Narcan could be purchased next week through their online sites, offering greater privacy.” Brendan Saloner, an addiction policy expert at Johns Hopkins, told the Times: “Stigma will always be there, but I think there’s been a sea change in how the public perceives naloxone over the last decade, and many more people are willing to carry it.”

Narcan won’t be the only company in the overdose reversal OTC field; the drug’s price will likely fall with market competition and some insurance companies may offer coverage. The Times reports, “CVS is encouraging customers to ask for Narcan at the pharmacy counter ‘so our pharmacy teams can check a patient’s insurance plan for potential savings on prescription naloxone products,’ a spokesman said. . . . Earlier this summer, the Food and Drug Administration gave over-the-counter approval to RiVive, a naloxone spray expected in early 2024. RiVive, manufactured by Harm Reduction Therapeutics, is intended as a low-cost product largely for outreach groups."

Pregnancy riskier for rural women without health insurance

Illustration by Alexis Jang, The New York Times

The physical demands of pregnancy are risky, and "Women and birthing people in rural America are at higher risk of adverse maternal-health outcomes, including maternal morbidity and mortality . . . One possible factor: lower enrollment in health insurance," the University Michigan reports on a study by researchers there. "Residents of rural communities had lower rates of continuous health insurance before, during and after pregnancy compared to those in urban cities."

Lead author Dr. Lindsay Admon said in the news release, "Being uninsured during the time of pregnancy has been associated with less adequate prenatal and postpartum care, which decreases opportunities to address risk factors affecting health outcomes for both the birthing person and baby. . . . Our study suggests that uninsurance disproportionately affects rural residents during pivotal stages of pregnancy."

To flesh out disparities, "Researchers analyzed survey data from 154,992 post-partum individuals in 43 states in 2016-19, including roughly 16 %, or 32,178, rural residents," the release says. "They compared rates of those without any insurance or had gaps in coverage between rural and urban residents during preconception, at the time of birth, and postpartum."

Admon noted, “Rural inequities persisted regardless of age, marital status or insurance type. But these differences were even more significant among specific racial and ethnic groups." The release says: "In each of the three periods, rural residents who were non-Hispanic white, married, and with intended pregnancies experienced greater odds of less adequate or consistent insurance compared to their urban counterparts. They were also less likely to have commercial health insurance during any of those times."

Insurance that extends past 60 days after birth also needs review, the release says: "This lack of coverage the year after pregnancy is especially worrisome, Admon says, since rural residents without postpartum insurance in the study were more likely to be older than 35 and have obesity or chronic hypertension compared with uninsured urban residents." Admon added, "We need to explore policies that help increase insurance enrollment during all phases of pregnancy and that account for rural differences . . . Health insurance is critical to accessing quality healthcare and improving maternal health in the U.S. We hope these findings help inform policies that address rural–urban inequities in maternity care access and maternal health across the country."

Some anti-abortion states consider extending Medicaid to likely increasing number of pregnant women

Viola's House in Dallas provides housing and services to young,
expectant mothers. (Photo by Allison V. Smith, The Washington Post)

After Roe v. Wade was reversed, many states further restricted abortion. Now some of them are thinking cause and effect, and considering extending Medicaid coverage to pregnant women, reports Molly Hennessy-Fiske of The Washington Post.

Usha Ranji, associate director for women’s health policy at the Kaiser Family Foundation, told Hennessy-Fiske, "There’s a discussion among Republicans and those who are anti-choice about, 'What should we be doing to support mothers?'"

Texas is one red state with coverage and care dilemmas: "The limits on Medicaid coverage after the emergency insurance lapses hinge on Texas’s long-standing rejection of the Affordable Care Act, which included provisions for expanded Medicaid," Hennessy-Fiske writes. "And it has set up an uncomfortable dynamic: While Texas and nearly a dozen other red states have resisted expanding Medicaid for those who are pregnant, many of them have also restricted access to abortion, leading to more new mothers needing coverage."

Steve Aden, general counsel and chief legal officer for Americans United for Life, told Hennessy-Fiske, “On our side, there is an awareness and a very strong move after Roe’s overturn toward caring for women. I think the whole movement is looking for ways to implement policy on the state level to support the increasing number of women who will have children.”

John Seago, president of Texas Right to Life, told Hennessy-Fiske, “We want Texas to be abortion-free, but we also want Texas to be pro-life. We want these mothers to be healthy and to have access to the care they need.” The group wants postpartum coverage: “Don’t call it Medicaid expansion, just ensuring insurance for moms up to a year after birth.”

Hospital industry analysis: Problems that triggered 136 rural hospital closures in 2010-21 appear to be getting worse

"Low reimbursement, staffing shortages, low patient volumes, regulatory barriers, and Covid-19 disruptions all played a role in the shuttering of 136 rural hospitals between 2010 and 2021, including a record 19 closures in 2020," John Commins reports for HealthLeaders, citing a report from the American Hospital Association, And, the report says, "Those problems appear to be worsening as rural hospitals contend with rising costs for labor, drugs, supplies and equipment, threatening care access for rural Americans." Key takeaways from the report include:

• 35 percent of all U.S. hospitals are rural. That includes critical-access hospitals, frontier hospitals, and sole community hospitals.
• Rural hospitals are often their community's largest employer, and drive the local economy.
• Rural hospitals support 1 in 12 rural jobs nationwide.
• AHA wants Congress to extend subsidies under the Medicare-Dependent Hospital and Enhanced Low-volume Adjustment programs. Both programs are set to expire Sept. 30.

Rural communities lost 10% of their retail pharmacies in the last 20 years, and most were independents', not chains'

Change in count of independent pharmacies, 2003-21: rural in red, micropolitan
(10,000-50,000 city pop.) in green (RUPRI Center for Rural Health Policy Analysis)

"Rural America is losing pharmacies, especially independently owned drug stores that are mainstays of rural communities," Liz Carey reports for The Daily Yonder. "Challenged by slow payments, decreasing reimbursements from insurance companies and Medicare, and growing competition, nearly 600 independent rural pharmacies have closed since 2003, a study from the RUPRI Center for Rural Health Policy Analysis at the University of Iowa found. During the same period, the number of franchise pharmacies fell by about 70, while chain pharmacies like CVS and Walgreens grew by about 90 stores."

In that time frame, the number of rural retail pharmacies fell 9.8% while the number in metro counties grew 15.1%. "Of the retail rural pharmacies, independently owned pharmacies declined by 16.1%, while the number of independently owned metropolitan pharmacies increased by 28.2%," Carey reports. "There were 3,698 independently owned rural pharmacies in 2003. By 2021, there were only 3,102. Nearly half of the pharmacies located in rural areas are sole, independently owned retail stores, researchers said."

Negotiated pricing is a major reason for the closures, said one of the study's authors. When pharmacies' costs go up, reimbursements from insurance providers, Medicare and Medicaid sometimes don't keep pace. Delays in those reimbursements are a problem too. "Additionally, competition from not just the chain pharmacies, but mail-order pharmacy services works against the independent retail store," Carey reports. "Another challenge, researchers said, is the aging rural population, and the difficulties handling these more complex patient cases."

'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.

Two convicted for rural-hospital lab-billing scam in 3 states

"Two Miami men were convicted Monday for conning vulnerable addiction treatment patients, rural hospitals and health insurance companies out of $1.4 billion in a health-care fraud scam that spanned Florida, Georgia and Missouri, according to authorities," Omar Rodriguez Ortiz reports for the Miami Herald. "Jorge Perez, 62, and Ricardo Perez, 59, were found guilty of conspiracy to commit health-care fraud and wire fraud, five counts of health-care fraud, and conspiracy to commit money laundering of proceeds greater than $10,000."

To help rural hospitals stay open, Medicare and some insurers reimburse them for laboratory services at higher rates. The defendants exploited that through Jorge Perez's company EmpowerHMS: "They promised to save the rural hospitals from closure by converting them into laboratory testing sites, but instead billed health-insurance companies for fraudulent laboratory testing worth hundreds of millions of dollars in a sophisticated and years-long billing scheme," Ortiz reports. "The plot made it appear that the rural hospitals themselves did the laboratory testing when, in most cases, it was done by testing laboratories controlled by others, the department added." When insurers began questioning the billings, the company would move on to another hospital and leave the one they had used for scams in the same or worse financial shape.

It's only the latest such scheme Jorge Perez has been involved in. A Kaiser Health News investigation in 2019 detailed how Perez and his company, EmpowerHMS, used hospitals in Arkansas, Kansas, Missouri, Oklahoma, Tennessee, and more to perpetrate billing scams. Most of the hospitals EmpowerHMS managed or owned have shut down.

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.

New laws could save Americans from more than 12 million surprise medical bills this year

"In the first two months since a new federal law started blocking unexpected medical bills, consumers have avoided two million would-be surprise medical bills — and it could potentially be over 12 million unanticipated bills this year," Andrew Keshner reports for MarketWatch. "This is according to estimates released Tuesday on the early impact of the 'No Surprises Act' from the Blue Cross Blue Shield Association and AHIP, a health insurers’ trade association."

The law, signed by former President Trump in December 2020, "took effect on Jan. 1 and it prevents patients from getting blindsided by medical bills — and saddled with more medical debt — for out-of-network medical treatment. In recent years, one in five people undergoing elective surgery wound up with unplanned bills, researchers said in February 2020," Keshner reports.

The law is most helpful in emergency situations where patients don't have the time or ability to ensure their health-care plan covers needed doctors and services. However, though the law limits surprise billing for air ambulances—which mostly serve rural areas—ground ambulances are not covered, and unexpected ambulance charges can cost thousands of dollars.

About half of emergency ground ambulance rides result in out-of-network charges for people with private insurance, according to a Kaiser Family Foundation study. But fewer than half of U.S. adults have enough money in the bank to cover a an unexpected expense of $1,000, according to a recent Bankrate survey.

Rural residents benefit most from enhanced ACA subsidies, and have highest risk of losing coverage without them

"Rural residents were the most likely to benefit from enhanced subsidies for Affordable Care Act coverage and face the greatest danger of losing coverage if those benefits expire after this year, a new study finds," Robert King reports for Fierce Healthcare. "The study, released by the Robert Wood Johnson Foundation Tuesday, comes as healthcare groups are making a major effort to get Congress to renew the boosted subsidies. ACA enrollment grew to a record-setting 14.5 million people this year, thanks in part to the higher subsidies."

This year's federal poverty threshold for a single person is $13,590, but people whose earnings put them over 400% of the poverty line ($54,360 for an individual) may still have a hard time affording decent health care. Through the ACA, such people have qualified, for the first time, for enhanced subsidies on their insurance premiums. If the tax credits that fund those subsidies are allowed to expire, "Rural residents will have few if any policies to choose from that are both affordable and comprehensive," said Kathy Hempstead, a RWJF senior policy adviser.

Rural residents generally pay higher premiums than their suburban and urban peers for a number of reasons, according to Urban Institute researchers working in collaboration with RWJF. They compared average premiums for benchmark plans on ACA exchanges and found that they were higher in rural areas than in urban areas in 34 states, averaging about 10% more, and "18 of them had average rural premiums more than 10% higher than the average urban premium. In addition, 12 of those states had rural premiums more than 20% of their urban counterparts," King reports. Illinois had the largest disparity, with rural residents paying an average of $217 more for their monthly premiums than their urban counterparts.

Health-care provider and insurance groups wrote an open letter to Congress this week urging them to make the enhanced subsidies permanent, King reports. "Our country continues to work through the economic and public health implications of Covid over the past two years, including rising inflation which is forcing families to pay more at the grocery store and gas pump," said the letter. "We cannot add to these burdens by putting the healthcare of 14.5 million current marketplace enrollees, and millions of future enrollees at risk."

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