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)

With Social Security and Medicare off the budget-cutting table, Medicaid remains, but has much political support

Protesters in 2017 (Photo by Drew Angerer, Getty Images)

Now that President Biden and Republicans agree they won't cut Medicare and Social Security, the federal-state Medicaid program will be on the table as Republicans try to get concessions for raising the national debt ceiling. But "Medicaid is politically better positioned to weather the storm than ever," Politico's Joanne Kenen reports.

While the House Republican platform for midterm elections was vague about cuts, "and even more vague on health policy, the conservative Republican Study Group’s budget blueprint for the current fiscal year would have restructured Medicaid entirely and cut $3.6 trillion over a decade compared to the current spending trajectory — but there’s no way that Democrats (or even some more establishment Republicans) would accept that," Kenen writes.

Medicaid has "a much stronger constituency" these days because it covers many more people, 90 million, and is "the largest payer of nursing-home care in the U.S, and it’s a lifeline for disabled kids and their families, both very politically sympathetic populations," Kenen reports, citing Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. "More than half of U.S. kids are covered by Medicaid and its sister program the Children’s Health Insurance Program, or CHIP. In some states, more than half of births are covered, and it provides postpartum care, including to minority populations that have disproportionately high rates of maternal death. And it covers long-term care for the poor elderly — or people who became poor after spending most of their savings on long-term care. . . . It’s also a huge payer for mental health and for addiction treatment for opioids, including for kids."

“Medicaid now is touching the majority of families in the country,” Joan Alker, executive director of the Center for Children and Families at Georgetown University in Washington, D.C., told Kenen.

"As if all that wasn’t enough, Medicaid keeps safety net hospitals afloat," Kenen notes." And those hospitals, which treat a large share of poor people in both rural and urban settings, are in an even more precarious financial position than usual after the pandemic. . . . Tom Miller, a health expert at the center-right American Enterprise Institute who has written extensively on what he sees as more realistic conservative approaches to improving Medicaid, including broader use of federally-approved waivers for states, expects conservative Republicans to try again this year — and again overreach and fail."

Open enrollment for Obamacare plans ends Tuesday, Dec. 15; rural customers have more choices than last year

Open enrollment for the Patient Protection and Affordable Care Act marketplace ends Tuesday, Dec. 15 in most states (14 states and the District of Columbia run their own marketplaces and will be open longer). Rural customers, especially those who are suffering side effects of Covid-19 or fear exposure to it, should remember that they may have increased medical expenses in the future because of it.

"The good news for those shopping for their own coverage is that the Affordable Care Act bars insurers from discriminating against people with medical conditions or charging them more than healthier policyholders," notes Julie Appleby of Kaiser Health News. "Former Covid patients could face a range of physical or mental effects, including lung damage, heart or neurological concerns, anxiety and depression. Although some of these issues will dissipate with time, others may turn out to be long-standing problems."

Rural customers don't have as many choices for insurance as their urban and suburban counterparts. "Researchers noted that rural counties have always struggled to secure a range of payer options and 2021 is no exception: while metro-area counties will have 3.1 payers each on average, non-metropolitan counties will have 2.5 payers per county on average," Kelsey Waddill reports for Health Payer Intelligence. But the situation has improved; only 10% of counties will have access to only one insurer in 2021, down from about 25% in 2020.

Biden says Democrats forgot rural Americans: 'We have got to rebuild the middle class . . . especially in rural America'

Biden toured Floyd Valley Healthcare in LeMars, Iowa, in July 2019.
(Photo by Tim Hynds, Sioux City Journal)

Democrats have forgotten rural Americans, and that's part of the reason they voted against them last month. President-elect Joe Biden told New York Times columnist Thomas Friedman.

The topic came up as Biden discussed industrial policy and trade, sensitive subjects in many rural areas.

“I want to make sure we’re going to fight like hell by investing in America first,” Biden said, mentioning energy, biotech, advanced materials and artificial intelligence as areas needing big government investment in research.

“I’m not going to enter any new trade agreement with anybody until we have made major investments here at home and in our workers,” and in education, he told Friedman.

The columnist paraphrased Biden: "And this time, he insisted, rural America will not be left behind. There is no way Democrats can go another four years and lose almost every rural county in America. For their sake and the country’s, Democrats have to figure out what is going on there and speak to rural voters more effectively."

And then he quoted the president-elect directly: “You know, it really does go to the issue of dignity, how you treat people. I think they just feel forgotten. I think we forgot them.”

“I respect them,” Biden added, and indicated that he plans to prove it by going after the novel coronavirus and effectively distributing vaccines in “red and blue areas alike.”

Noting that he visited 15 rural hospitals and the trouble they have staying open, Biden said the federal government can “end the rural health care crisis right now by building on Obamacare, assuming it survives at all, with a public option [and] automatically enroll people eligible for Medicaid. There’s strong support for that — and particularly [from] people in rural states, like Texas and North Carolina, that reject expansion. We can boost funding. . . . The biggest problem is there’s not enough reimbursement for them to be able to keep open.”

He told Friedman that many rural hospitals and clinics that could benefit from telemedicine lack broadband connectivity. “We should be spending $20 billion to put broadband across the board,” he said. “We have got to rebuild the middle class,” but “especially in rural America.”

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

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

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

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

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

Rep. Collin Peterson

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

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

Study finds reasons for lack of health-insurance competition, high cost in rural America; story has link to interactive map

Map by The Daily Yonder with data from Kaiser Family Foundation; for an interactive version click here.

A key goal of the Patient Protection and Affordable Care Act — to increase access to health insurance by fostering competition among insurance companies — is not as effective in rural America as it is in metropolitan areas, a new study finds.

The impact of market-focused strategies is diminished by the lack of competition among health insurers in rural areas, Liz Carey reports for The Daily Yonder. And rural areas are less competitive in the insurance market because of many complex factors – not just population density, the study concluded. The study could be valuable to policymakers who need a better understanding of how rural markets work. The Yonder has an interactive, county-by-county map.

The study by the Institute for Rural Health Policy Analysis in the Rural Policy Research Institute “looked at insurer participation data across three market-based health insurance programs — the Federal Employees Health Benefits Program Medicare Advantage and Health Insurance Marketplaces (HIMs, which the Affordable Care Act created),” Carey writes.

The researchers wanted to see if competition affected decisions to purchase health insurance. “The study found that, in areas that had been dominated by a smaller number of insurers in the past, the Affordable Care Act’s health-insurance marketplaces for individual policies had lower enrollment.” Population density alone does not lower health-insurance enrollment, but an area’s previous lack of competition did predict lower enrollment rates.

Abby Barker of the Rural Policy Research Institute, told the Yonder, “I think you could say that population density, and some of those other population-related measures … are expected to be significant. But what we added is this measure of competition that shows that another explanatory factor is how concentrated the market is and has been over time. The methods don’t really identify which is more important, but the contribution of this work is to say that prior market concentration matters. In my view, it suggests that policies that rely on competition to achieve certain access/affordability goals, really have to be intentional about overcoming this sort of inertia that tends to exist. Once certain insurance issuers are established in a particular geographic region, it’s a little harder for new ones to come in.”

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

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

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

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

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

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

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

Biden unveils rural policy plan that aims to help farmers, strengthen ACA, bring green jobs, and fund broadband

Former Vice President Joe Biden, so far the leading Democratic presidential candidates in polls, has announced a plan for rural America that "includes investment in clean energy, payments to farmers to protect the environment and creating low-carbon manufacturing jobs in rural communities," Stephen Gruber-Miller and Robin Opsahl report for the Des Moines Register. "The rural plan builds on Biden's climate plan and the health-care plan he released Monday, which would involve adding a public option to the Affordable Care Act so people can buy into government health insurance."

Biden made the announcement Tuesday in Manning, Iowa, telling the crowd of about 230, "Rural communities power the nation. They feed our bodies. They fuel our engines. They are the stewards who protect our lands." Gruber-Miller and Opsahl report that the plan would:

• Double the maximum microloan available to new and beginning farmers to $100,000
• Foster development of regional food systems by working with small- and mid-sized farmers to deliver fresh produce and other products to schools, hospitals and other institutions
• Increase research funding for land-grant universities to create new technologies and seeds that are owned by the public
• Increase payments to farmers for practices that protect the environment so the American agriculture sector reaches net-zero emissions
• Strengthen antitrust enforcement through the antitrust laws and the Packers and Stockyards Act to help farmers and ranchers who are being hurt by market concentration
• Expand bio-manufacturing to create a low-carbon manufacturing sector in every state in the country, including bringing manufacturing jobs to rural areas
• Invest $400 billion in clean energy and research and deployment, including researching next-generation cellulosic biofuels
• Invest in wind and solar energy to meet a goal of a 100 percent clean-energy economy and net-zero emissions by 2050 or earlier
• Invest $20 billion in rural broadband infrastructure and triple broadband grant funding, which Biden's plan says has the potential to create more than 250,000 new jobs"

The Rural Blog reports major statements by presidential candidates about rural policy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diabetes is disproportionately rural; in last 2 decades rates have declined across U.S., except in the the rural South

Mortality rates from diabetes have improved in most of the country over the past 20 years, but have remained almost unchanged in the rural South, according to a newly published study from the School of Public Health at Texas A&M University.

As the seventh-highest cause of death in the nation, diabetes continues to be a significant health challenge in the U.S. "Rural Healthy People 2020," a decade-long report of rural health goals published by the university, identifies diabetes as the third most important public health issue in rural areas, where diagnosis rates can be as much as 17 percent higher than in cities and suburbs. As of 2015, 30 million Americans have diabetes and another 84 million were pre-diabetic, Rae Lynn Mitchell reports for Texas A&M's health news publication.

The study's lead researcher, Assistant Professor Timothy Callaghan, told Mitchell that diabetes is most likely more common in rural areas because of a lack of education about it, different training for health-care professionals, and/or lack of access to care. He cautioned that the study does not establish cause and effect.

The research studied publicly available data from the National Center for Health Statistics and the Centers for Disease Control and Prevention from 1999 to 2016.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

Oregon voters OK health taxes to keep Medicaid expansion

In a special election Tuesday, Oregon voters approved a tax on hospitals and health-insurance plans to continue funding the state's Medicaid expansion. It's the first time a state has approved such a measure by referendum, and "the second time that the Medicaid expansion has won at the polls: Maine voters in November overwhelmingly supported bringing the Medicaid expansion to their state," Sarah Kliff reports for Vox. The tax could raise as much as $320 million over two years.

The referendum almost didn't happen, since last spring Oregon legislators considered ending Medicaid expansion to balance the state's budget. That would have made the state the first in the country to repeal an expansion. But the Democrat-controlled state legislature voted to pass a 1.5 percent tax on premiums collected by health insurers and a 0.7 percent increase on the tax rate collected from some hospitals, Elon Glucklich reports for The Register-Guard in Eugene. In response, some Republican state representatives gathered enough signatures to put the taxes up for vote through Oregon's referendum process.

About 62 percent of Oregon voters favored Measure 101, with more than 1 million votes cast; much of rural Oregon voted against it. The referendum's success "may catch the eye of other states with difficult budget situations as a way to bring in additional revenue," Kliff reports.

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

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

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

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

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

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

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

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

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

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

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

New projection says reauthorizing CHIP will save money in the long run; lawmakers say they're close to a deal

A new projection from the Congressional Budget Office says that reauthorizing the Children's Health Insurance Program for 10 years would save the government $6 billion. CBO says a five-year extension would cost the government $800 million, down from earlier estimates of $8 billion.

CHIP provides insurance to 9 million children whose parents make too much to qualify for Medicaid but can't afford private insurance. The CBO's projection is anchored on the repeal of the Patient Protection and Affordable Care Act's individual mandate in the recently passed tax overhaul.

"To summarize the CBO’s complicated line of reasoning that led to this outcome, no mandate means fewer people will enroll in the Obamacare marketplaces, meaning fewer low-income folks will get federal subsidies," Paige Cunningham reports for The Washington Post. "Some of those people leaving the marketplaces would instead enroll their kids in CHIP. And on the federal government’s end, paying for CHIP coverage is actually cheaper overall than funding subsidies for private marketplace plans. So the government, the argument goes, would actually save money on CHIP in the future."

With such a projection, Cunningham writes that it would be "truly shocking" if Congress doesn't renew CHIP soon. Lawmakers in both parties say they've almost resolved the disagreement and could reauthorize the popular, bipartisan law as soon as next week. The measure could be attached to a short-term government funding bill that must pass before Jan. 19, Peter Sullivan reports for The Hill.

House Energy Committee Chairman Greg Walden (R-Ore.) told reporters he didn't think paying for the five-year extension would be a problem, but said whether CHIP is added to the spending bill next week is up to the leaders who are negotiating what goes in it, Sullivan reports.

The deal will come not a moment too soon. The Centers for Medicare and Medicaid Services said the stopgap funding already provided to CHIP may not last through the end of March, Cunningham reports. Several states, such as Virginia and Alabama, have sent letters to parents warning them that the program will end soon unless Congress funds it.

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

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

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

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

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

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

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

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

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

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

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

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

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