How the GOP's Medicaid Politics Are Hurting Rural Southerners: An Index of Harm


©Jenny Warburg

A protester at a 2013 Moral Monday action in North Carolina. The state's General Assembly rejected federal funds to expand Medicaid—funds that would have given coverage to 500,000 state residents without insurance. 

This index was originally published by Facing South, a website of the Institute for Southern Studies.

Date on which Adam O'Neal, the Republican mayor of Belhaven, North Carolina, arrived in Washington, DC after walking 273 miles from his hometown to draw attention to the recent closure of his community's only hospital and to call for Medicaid expansion under the Affordable Care Act to prevent more such closures: 7/28/2014

Date on which Belhaven's hospital, Vidant Pungo, closed after a failed effort by the town to take it over: 7/1/2014

Number of days after the closure that a local resident died when she suffered a heart attack and had to wait an hour for a helicopter to take her to the nearest hospital: 4

Amount in unpaid care Vidant Pungo had provided since 2011 to patients lacking health insurance: more than $2 million

Number of rural U.S. hospitals that have closed since last year alone: 22

Number of those closures that were in states which blocked Medicaid expansion because of opposition from Republican governors and/or Republican-controlled legislatures: 20

Number of rural hospitals that have closed in Alabama in the past three years: 10

Number of rural hospitals that have closed in Georgia since 2000: 9

Of the 13 states in the South, number that have refused to expand Medicaid to date: 10*

Percent of rural hospital revenues that come from the government-financed Medicaid and Medicare programs for low-income and elderly patients: 60 to 80

Average percent loss that rural hospitals operate at because they treat higher rates of poor, uninsured and under-insured patients: 8.3

Percentage points higher that a University of North Carolina study found a community's unemployment rate was a few years after a rural hospital's closing, with one factor being industrial employers' reluctance to locate to an area without a hospital to treat workplace injuries: 1.6

Amount by which the UNC study found per capita income fell, in current dollars, following a rural hospital's closure: $1,000

The Urban Institute

Chart from "Who Are the Remaining Uninsured as of June 2014?" by The Urban Institute

Percentage points by which the portion of uninsured Southerners increased from September 2013 to June 2014 -- a time when other states were implementing or getting ready to implement Medicaid expansion: 8.4

Number of other U.S. regions where the portion of uninsured residents increased over that same period: 0

Rank of the South among U.S. regions with the highest rate of uninsured residents: 1

Percent of Southerners who remained uninsured as of June 2014: 48.9

Factor by which that exceeds the average percent of people lacking insurance in the other three U.S. regions: almost 3

Month in which the Florida Medical Association, a politically conservative trade association for the state's doctors, passed a resolution endorsing Medicaid expansion: 7/2014

Number of Florida residents who would benefit from Medicaid expansion: 1 million

Amount the refusal to expand Medicaid will cost in penalties to Florida employers because their lower income employees will be unable to get coverage: $145.7 million to $218.6 million

Figure spending by the National Federal of Independent Business (NFIB) for a recent ad campaign urging the Florida legislature to reject Medicaid expansion: 6

Amount the NFIB, which gets funding from conservative groups affiliated with the billionaire Koch brothers and Republican strategist Karl Rove, spent in 2010 as the chief litigant in a lawsuit that unsuccessfully sought to challenge the Affordable Care Act: $2.9 million

Estimated number of Americans who will die every year as a result of states' decision to reject Medicaid expansion: between 7,115 and 17,104

* Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas and Virginia have refused Medicaid expansion. The only Southern states that have approved expansion are Arkansas, Kentucky and West Virginia.

(Click on figure to go to source. Chart from "Who Are the Remaining Uninsured as of June 2014?" by The Urban Institute; for a larger version, click here.)


OFF TODAY'S EXACT TOPIC -- but another potential major problem?

In Illinois elderly patients on both Medicare and Medicaid are being forced into narrow networks under one insurance company (e.g., Aetna, Blue Cross, Cigna, Humana, Ilinicare, Meridian).

They may be lucky enough to keep their personal care provider — but he or she is stuck referring them to specialists on the network. PCPs usually refer patients to a physically contiguous medical group: in the same hospital or office building. What happens if PCPs are forced to refer the elderly (the sick elderly) to addresses all over town?

Old people see a lot of specialists. The older — and more infirm; the more unable to shuffle all over town by themselves — the more specialists they need to see. Some of the medical deflation we are going to see here may not be a healthy trend at all.

This is just speculation on my part — as I learn more I will add or subtract.

The enormous resources that many Republicans have poured into attacking Obamacare have lulled many of us on the left into forgetting that the Affordable Care Act was no more than a political compromise between middle-of-the-road Democrats and right-of-center Republicans. It was never designed to overhaul the United States healthcare landscape and, as this article shows so well, under the ACA certain types of inequalities have not only been perpetuated but have expanded. I've written a bit more about this in "Health Insurance Roulette: The House Always Wins."

Insurance is a financial product, not a health care service. It's purpose is to level load payments to cover rare, but expensive events. It adds to the total cost, but protects from catastrophic bankruptcy in the event of disaster. Competition and innovation are the only ways to lower prices. Both are illegal or punished in health care. When competition is legal and the patient (not the insurer or the employer) is paying the bill and becomes the customer, change will happen... rapidly. Until then...

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