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Rural Health Care

N.C. Attorney General Approves Sale of Rural Hospital System, But with Added Protections

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North Carolina Attorney General Josh Stein in Asheville last Wednesday posing with members of the Health Equity Coalition after announcing his approval of the sale of Mission Health to HCA. Photo: Deborah Miles

Citizens were concerned. They voiced those concerns. And it appears their voices were heard.

When it was announced in August that Nashville-based HCA Healthcare had reached a deal to purchase Mission Health, many residents of Western North Carolina – most particularly those in the region’s rural communities – had trepidations about ceding control of their health care future to an outside operation.

Mission Health is based in Asheville, a city of 90,000 and the economic hub of otherwise largely rural Western North Carolina. It’s a not-for-profit health care system – the only one managed in the region – covering 18 counties. In addition to its flagship medical center, Mission Hospital in Asheville, Mission owns five smaller hospitals in the surrounding rural counties. 

HCA is a for-profit system that owns 178 hospitals in 20 states. The asset purchase agreement stipulated that a newly formed foundation called the Dogwood Health Trust would manage the proceeds of the sale, with an objective to use social determinants of health to improve the health and well-being of the communities Mission Health now serves.

The $1.5 billion deal was contingent on the approval of North Carolina Attorney General Josh Stein. Stein deliberated for some five months, and last week announced that he was granting that approval, but with the addition of significant provisions to preserve the delivery of health care services throughout the whole of the region – provisions that were agreed to by HCA and Mission Health.

“It really feels like we all pulled together to do some good things for the people of Western North Carolina,” said Risa Larsen, one of many of the region’s residents who advocated for more protections. “We’re overwhelmed with the fact that what’s in the new agreement way exceeded our expectations.”

Heightened Oversight

In the original draft of the agreement between HCA and Mission, HCA committed to providing services at the smaller regional hospitals for five years. That commitment has now been extended to 10 years.

The revision also provides more explicit language on exactly what services must be provided.

Further, HCA is prohibited from closing any facilities or discontinuing services unless agreed upon by both a hospital’s local advisory board and an independent monitor. That monitor will also regularly review whether HCA is maintaining its overall commitments.

Jay Nixon, the former governor and attorney general of Missouri who was brought in by citizen advocates as an advocacy consultant while the attorney general deliberated over the proposed sale, said the addition of this independent oversight is a significant development. Advocates feared that a local advisory board would alone be insufficient protection, given that half of its members would be appointed by HCA, the other half by Mission.

Nixon, who, as Missouri’s attorney general, challenged HCA in the courts, is also encouraged by the enforcement powers the agreement vests in the attorney general’s office, and in measures added to maintain transparency.

According to the agreement letter, Dogwood Trust will hold public meetings “to discuss the needs of the region and to obtain input on the priorities for addressing the social determinants of health” in Western North Carolina.

Dogwood will hold an open meeting with the public each year and will provide an annual report detailing how it’s using its funds

“General Stein and his staff stepped up to the challenge,” Nixon said, “and I believe the citizens of the region were a very positive, direct force in assisting him and his team in dramatically improving this agreement and raising the clear opportunities that the region will have for decades to come.”

Committing to Diversity

Equally important to advocates was regional, ethnic and gender diversity on the proposed 15-member Dogwood Health Trust board.

Dogwood has committed to having no more than five members from any one county by Jan. 1 of next year and no more than four members from any county by 2021. This is good news for those who feared the board would be Asheville-centric, removed from the concerns of its rural neighbors. The Dogwood board must include at least one member from each of the five regions with a hospital by Jan. 1 of next year.

And in a commitment letter to Stein’s office, Dogwood chair Janice Brumit wrote that the foundation would take into consideration ethnic and gender diversity as part of the its “commitment to be fully and fairly representative of western North Carolina.”

The revised agreement gives the local foundations that oversee the individual hospitals more flexibility in pursuing their own health care initiatives. And the local foundations and Dogwood Health Trust will have the right to bid on hospitals if they’re put on the market or closed.

The deal also stipulates that Dogwood will commit $25 million over five years to addressing opioid use disorder.

“Access to healthcare is truly a life or death issue,” Stein said in a press release announcing the agreement. “I am satisfied that this new agreement protects healthcare in western North Carolina, ensures that the full value of Mission’s assets will continue to be used for public purposes, and requires that the Dogwood Health Trust will be independent and representative.”

Due Diligence

Risa Larsen said the wait for Stein’s decision had been anxiety-inducing; the outcome, sweet.

“We really appreciate the hard work that the attorney general, his office, Mission, HCA and Dogwood Health Trust have done,” Larsen said. “I mean, good night, they’ve been working hard. The 10-year commitment on the rural hospitals, the more explicit language about the services, the independent monitoring – I never would have thought that would happen.”

“I’m delighted,” said Highlands Mayor Pat Taylor, who’s been at the forefront of the effort to secure more protections.

Asked if he saw any holes in the agreement, Taylor said, “Not anything that can’t be addressed and worked out. This is a complicated process, so I know there are going to be some problems and some holes. But I think we have a good foundation now to all work together to provide good health care for this region.”

“It’s important to take a deep breath,” Nixon said, and assess the task ahead. Western North Carolina will now have “a $1.5 billion foundation specifically to address health outcomes in the region while not taking away any of the hospitals or institutions.”

“But the public is going to have to stay involved,” he cautioned. “You saw in this situation, I believe, that an involved public – an informed citizenry that respectfully, in essence, petitioned their government – was a positive force for goodness here.”

“This is how it’s supposed to work. This is what democracy is supposed to look like,” Nixon avowed, praising Stein’s office for its openness and availability to all parties involved. “But I do think that folks are going to have to continue to stay vigilant.”

“Everybody played a part in moving this to a better place,” he concluded, “but everybody needs to continue to play a part in making sure it delivers the maximum of its capacity.”

Rural Health Care

Medicare for All, Most, Some? How Far Will Rural Voters Go with a Public Option?

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A Medicare for All rally in 2017. Photo: Molly Adams/ Flickr, Creative Commons

The healthcare debate among Democratic candidates highlights a fundamental question within the party about the proper role of government. Rural voters will have a hand in helping determine which direction the Democratic Party takes.

Medicare for All. Medicare for Most. Medicare for Some. Medicare at 50.

Democratic presidential candidates are offering a range of ways to structure a mandatory or optional public health insurance program. With rural voters, the challenge may be creating a policy that goes far enough without going too far.

Fifty-five percent of rural voters favor a Medicare for All plan, according to a July Harvard/Harris poll. But other rural residents, like Iowa farmer Ron Rossman, think a mandatory program would go too far for the rural voters he knows.

Rossman equated Senator Bernie Sanders’ Medicare for All proposal (also supported by Senator Elizabeth Warren and entrepreneur Andrew Yang) with socialism. “With health care and all that, socialism early in my lifetime was associated with communism, and we grew up with all that kind of thinking,” Rosmann told Senator Warren, according to the Chicago Times. “Rural people have long memories.”

Veteran political reporter David Yepsen, host of the “Iowa Press” TV, said Iowa is a good place to see how various healthcare proposals go over with rural voters.

“What you’re seeing here is a good microcosm of an argument going on in the Democratic Party all over the country,” Yepsen told the Chicago Times. “They’ve got to find candidates who can do better in rural areas. Now, do you do that with a moderate message or a more progressive message? That’s still to be determined, and Iowa is a good place for that type of testing ground.”

So what do the various public-option proposals mean?

The plans can be broken down into five different options:

  • Medicare-for-all – a single-payer program for all U.S. residents, which would move all Americans to a government-run health insurance program.
  • Medicare for America –a national health insurance program that keeps private insurance and would allow U.S. residents opt-out of the national plan with qualified private coverage.
  • Medicare-X-Choice – the existing Affordable Care Act altered to offer coverage individuals could opt into.
  • Medicare at 50 – Medicare coverage for U.S. residents starting at age 50
  • Medicare State Option – a buy-in option approved by individual states that would offer coverage through the Affordable Care Act marketplace.

Since the 2016 election, the idea of Medicare for All, or single-payer healthcare, has expanded to include several other options that would transition the country into a system that allows for expanded healthcare coverage.

Sen. Bernie Sanders (I-Vt.) introduces the Medicare for All Act of 2017. Photo: Public Citizen/Flickr, Creative Commons

Several members of Congress have submitted bills that would reflect these options. Most notably, Sanders’ bill would create a national health care system paid for by taxes that would replace all private insurance, Medicare and Medicaid and Children’s Health Insurance Program, or CHIP benefits. Sanders pointed to the current system as broken and needing to be replaced with something that would provide health care for every American.

“It is unacceptable to me and to many Americans that 87 million people in the United States are uninsured or under-insured,” he said in a policy statement on July 17. “Americans pay twice as much per capita on healthcare than any other country while our life expectancy continues to go down and our healthcare outcomes lag behind other major countries.”

Sanders’ plan is supported by Warren and tech entrepreneur Andrew Yang. (Sanders’ proposal became a flash-point differentiating candidates’ approaches during the September 12 debate.) All three candidates say Medicare for All is the only way to ensure Americans have access to healthcare, and view healthcare as a right, as opposed to an option.

And at a town hall forum on CNN this year, Warren said it would be, and should be, the least expensive option, “What’s key is to get everyone to come to the table on this … and to figure out a way to get medical coverage for everyone at the lowest cost possible.”

For Yang, the issue is one of ensuring that the healthcare system is working for Americans and not bankrupting them even if they have insurance.

“Access to quality healthcare is one of the most important factors in overall well-being, and yet America is one of the few industrialized nations not to provide healthcare for all of its citizens,” Yang’s campaign website says. “Through a Medicare for All system, we can ensure that all Americans receive the healthcare they deserve. Not only will this raise the quality of life for all Americans, but, by increasing access to preventive care, it will also bring overall healthcare costs down.”

Other candidates support a Medicare for All option, but also would support rethinking the whole healthcare system in America. These candidates vary wildly in their support of alternative pieces of legislation, and other ideas for the system. Some advocate lowering the age for which Americans qualify for Medicare to 50. Others say individuals and companies should have the option to buy into Medicare.

At the “Linking Together: March to Save Our Care” Rally at the U.S. Capitol on June 28, 2017, Sens. Kamala Harris and Cory Book, along with other Democratic leaders, rallied to support the Affordable Care Act and criticize Republican Party efforts to repeal Obamacare. Photo: Mobilus In Mobili/Flicker, Creative Commons

Senator Cory Booker (D-NJ) and Kamala Harris (D-CA) have endorsed many different plans.

On its website, Booker’s campaign said “Cory believes that health care is a human right and that Medicare for All is the best way to safeguard that right for every American. On the path to Medicare for All, we must act with urgency for people across the country who need quality, affordable health care. This plan will immediately address one part of the broken system as we move toward guaranteed health care for all Americans.”

But his stance has also been that he supports all the legislation previously introduced, and would be willing to entertain systems that provide Medicare for Most.

Harris said on her web site a new healthcare system should be based on the current Medicare system, as it’s a system that’s accessible for all Americans.

“Kamala’s plan for Medicare for All expands on the progress made under Obamacare, immediately offers an improved Medicare buy-in, and transitions the country to a Medicare system we are all in so that we can take on insurance and drug companies. Her plan will reduce costs, keep options for public or private Medicare plans, and ensure a smooth transition,” her campaign said on its web site. “Medicare works. It’s popular. Seniors transition into it every day, and people keep their doctors and get care at a lower cost. Let’s not lose sight that we have a Medicare system that’s already working.”

South Bend, Indiana, Mayor Pete Buttigieg said he would like to see a “Medicare for All Who Want It” plan.

“The health care system we have today is both unjust and inefficient. For the first time since World War I, life expectancy is falling. If you’re uninsured, you’re paying too much for health care. If you’re insured, you’re still paying too much. This burdens hard-working families, especially in communities of color, the most. Other developed countries provide universal coverage for less than what Americans currently pay — and with better results. The American people should not have to settle for less,” Buttigieg’s campaign said on its web site. “This plan makes a Medicare-type public option available on the exchange and invites people to buy into it: if corporate insurers don’t lower costs to deliver something dramatically better than what is available today, competition will create the glide path toward Medicare for All.”

Former Housing and Urban Development Secretary Julian Castro said that while he supports Medicare for All, he doesn’t think we should eliminate private insurance completely, instead giving Americans the option to buy into Medicare or private insurance if they choose to do so, depending on what the final system is the winner. Castro hasn’t specifically endorsed any of the options presented as solutions to healthcare coverage, but has said that he feels healthcare should be a right for Americans.

Beto O’Rourke, the former Texas Representative, said that he would support Medicare coverage through private insurers, as well as allowing people the option of buying into Medicare.

“We need universal, guaranteed, high-quality health care so that every single American is healthy enough to go to school, work a job, start a business, raise a family, and live up to their full potential,” O’Rourke’s campaign said on its website. “Each day that we fail to deliver on that promise is another day that Americans will be forced to split their pills, to postpone seeing a doctor, to make the impossible choice between paying rent or paying their premiums. Beto’s plan would dramatically reduce out of pocket expenses and eliminate deductibles for Medicare participants—and it would ensure everyone who wants to enroll in Medicare can do so, without eliminating employer-sponsored insurance. That’s because Beto believes health care—including reproductive and mental health care—is a right, not a privilege.”

The last of the three candidates who debated on September 12th has supported keeping the Affordable Care Act as a way to provide more healthcare coverage to Americans.

Former Vice President Joe Biden said he supports taking the existing law and fixing it as a pathway toward universal coverage.

“Because of Obamacare, over 100 million people no longer have to worry that an insurance company will deny coverage or charge higher premiums just because they have a pre-existing condition – whether cancer or diabetes or heart disease or a mental health challenge. Insurance companies can no longer set annual or lifetime limits on coverage. Roughly 20 million additional Americans obtained the peace of mind that comes with health insurance,” Biden’s campaign said on its website. “As president, Biden will protect the Affordable Care Act from these continued attacks. He opposes every effort to get rid of this historic law – including efforts by Republicans, and efforts by Democrats. Instead of starting from scratch and getting rid of private insurance, he has a plan to build on the Affordable Care Act by giving Americans more choice, reducing health care costs, and making our health care system less complex to navigate.”

Senator Amy Klobuchar (D-MN) agreed.

“Amy supports universal health care for all Americans, and she believes the quickest way to get there is through a public option that expands Medicare or Medicaid. She supports changes to the Affordable Care Act to help bring down costs to consumers including providing cost-sharing reductions, making it easier for states to put reinsurance in place, and continuing to implement delivery system reform. And she’s been fighting her whole life to bring down the cost of prescription drugs,” her campaign said on its website.

While the plans vary, most all of the major candidates agree that medical insurance coverage for all is an important issue that must be addressed by the federal government.

This article was originally published by The Daily Yonder.

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Rural Health Care

North Carolina’s Most Remote Clinic?

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Ocracoke Health Center is likely North Carolina's most remote clinic. It can take as much as four hours to get to the next nearest health care facility, and that's if the ferries are running or a helicopter can make it to the island. Photo: Rose Hoban

The Ocracoke Health Center is one of those vital institutions that keeps the island going, but that doesn’t always translate into fiscal health.

Despite being a business leader in a busy tourist town, Cheryl Ballance sometimes has had to tell summer guests not to come to Ocracoke.

Cheryl Ballance works in her office at the Ocracoke Health Center. She said the clinic’s payor mix consists of about a third of patients who are uninsured and pay on a sliding scale, including paying next to nothing. The rest of her patients are about 20 percent Medicaid, about 20 percent Medicare and the remaining 30 percent are insured. Photo: Rose Hoban

“Sometimes, we’d get calls from people who said they were nine months pregnant with a high-risk pregnancy, wanting to know if we had resources for them,” Ballance said. “I’d tell them, ‘Oh, you really need to look at the map.’”

Ballance, the longtime head of the Ocracoke Health Center, has seen and heard it all from tourists and from the thousand-or-so year-round residents on the 13-mile long island, which lies south of Hatteras Island on the Outer Banks. The health center is an important place on the island’s map, as it’s the only place to get consistent health services. The center does not turn anyone away, insured or not.

Supplementing the remote island’s health care is Gail Covington, a mobile nurse practitioner, who provides services in homes on Ocracoke and Hatteras islands, and who does not take insurance.

“On a summer holiday weekend, we have this blossom of you know, maybe 10,000 people who show up,” Ballance said. ”I think it’s probably like seven to 8,000 during the week.”

Despite the center’s importance to the life of Ocracoke, the past few years have been challenging financially. Ballance said she’s making a go of it, but it’s difficult to keep providing high-quality care on a shrinking health care dollar in one of the most remote and sparsely populated parts of the state.

Seasonal Work, Yearround Expenses

One issue for Ballance is about a third of her patients are uninsured, even as they work two, three, even four gigs at a time during tourist season, when there’s work to be had.

“The people who support this whole resort are people who are only employed, if they’re lucky, somewhat in April, May, June, July, August, and if we don’t have hurricanes September and October,” she said. “Then by November, everything is closed.”

“They’re making a year’s worth of income during that five to six month period.”

Some workers do leave the island in winter, Ballance said. Maybe “they have a friend that lives out in the mountains, ‘Can you come up here for three weeks, we’re really busy, you can help us at ski lodge?’”

But for many people on the island, funds begin to dwindle in the lean months of the late winter, especially as unemployment checks peter out. It’s something familiar to Erin O’Neal, the clinic’s chief operating officer, who used to work in restaurants when she’d come home from school.

“Anybody who’s waiting tables, and you got a lot of that, or cleaning rooms, aren’t a high hourly rate, their unemployment is gonna be the lowest,” O’Neal said, noting how the law changed to shorten the number of weeks someone can draw an unemployment check. “And if there was a storm, and they drew on their unemployment during that time, they’ve already used part of their weeks before they’ve even gone out with their season. So it’s an even longer extended period of time with no income, it’s really hard for people.”

The flip side is that winters give the clinic’s doctor, Erin Baker, time to dig into problems.

Dr. Erin Baker has been at the Ocracoke Health Center for six years and she’s settled in on the island. She’s the facility’s only physician. Behind her is a telehealth kiosk. Photo: Rose Hoban

“In the summertime, she’s clipping those visits for the residents,“ because the clinic is hopping, Ballance said. “But she spends a lot of time, time you’re never going to get anywhere else … in the winter.”

Getting Away Has a Cost

The isolation that tourists crave also poses challenges for the locals.

When Vince O’Neal was a kid on Ocracoke, his only medical encounters were with the school nurse or his grandmother, a midwife who delivered the island’s babies for decades. That was before the clinic started in 1981.

“We did not have any kind of medical services here until that clinic was built,” said the 59-year-old restaurant owner, and, by his reckoning, eighth-generation Ocracoker.

Otherwise, it was off the island to the doctor, a trip that could take hours, or even a whole day.

Merrian Midgett checks in the prescriptions that came over via courier on the Hatteras morning ferry. There’s no pharmacy on Ocracoke, so if a patient needs medications, they come from Hatteras, that is, if the ferry’s running. Photo: Rose Hoban

Access to emergency care from Ocracoke has gotten better over the years. There are always emergency medical technicians on the island and helicopter service to Vidant Medical Center in Greenville or to the Outer Banks Hospital in Nags Head, but there’s no pharmacy and no lab.

Getting off the island takes hours by ferry to the mainland and then to the nearest hospital or an hourlong ferry ride to Hatteras from the northern end of the island and another 90 minutes from there to Nags Head.

So much depends on the ferry. If the weather turns stormy or foggy, the ferries don’t run. Even when they do, getting to a specialist off the island or to the dentist can mean getting up at 3:30 a.m. to get the 5 a.m. Hatteras ferry run. Prescriptions? They come by courier from Hatteras every afternoon.

But if a tourist gets a stingray barb in their foot or a severe sunburn, the center is where they turn.

“We have people who have been coming here for years,” O’Neal said. “They come every season … they’re already in our system.”

Quality on a Thin Budget

Many of the clinic’s child patients are covered by Medicaid, but Ballance said there’s uncertainty about that payment stream too, as the program gets set to transform from a fee-for-service to managed care payment regimen, where clinics such as OHC get paid a set monthly fee in return for providing all of a patient’s needs.

“We want to sign with every (managed care) provider,” Ballance said. “But I don’t want to sign and then I get, you know, 20 percent less reimbursement. I want to get the same reimbursement, like I get with Blue Cross Blue Shield right now.”

Merrian Midgett greets patients as they come into the Ocracoke Health Center. Photo: Rose Hoban

OHC has achieved the benchmarks required to be a “quality provider” for BCBSNC, which comes with enhanced payment. But achieving the benchmark to become a quality provider has meant extra work.

“We’re almost at that breaking point. I mean, we’re really on the brink, that we have to hire another person,” she said, noting that the cost of living on Ocracoke can make it challenging to recruit year-round workers. “We don’t earn resort income, but we pay resort prices to live here.”

Even the well-paying patients haven’t been as profitable. Traditionally, the clinic has been happy to treat tourists, who do often have jobs – with insurance – that pay enough for them to come to the island for a vacation. But commercial reimbursements haven’t been keeping pace.

“We barely do a margin in our busy season, June, July and August,” Ballance said.

If it weren’t for the funds the center gets for being a “federally qualified” health center, the fundraising and foundation grants, there’d be no way to keep health care going on the island.

“Health care is vitally important for the island, both to meet the needs of the local community and the tourist population,” said Helena Stevens, who heads the Ocracoke Civic and Business Association. She said her organization supports all of Ballance’s fundraising efforts, such as a seafood dinner later this summer.

She wouldn’t even speculate what losing the clinic would mean to the island.

Erin O’Neal (L) and Cheryl Ballance (R) stand in front of the Ocracoke Health Center, which opened in 1981. Photo: Rose Hoban

This article was originally published by the Daily Yonder. It was co-published by North Carolina Health News with the Ocracoke Observer, which has a version in their August print edition. It is reprinted here with permission.

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Rural Health Care

Complex Factors Create Lack Of Health-Insurance Competition In Rural Areas

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The small city of Hazard, Kentucky. Photo: AP Photo/David Stephenson

If policymakers use market-based approaches to solve healthcare access problems, they need a better understanding of how rural markets work, says one researcher.

A lack of competition among health insurers in rural areas has reduced the ability of market-based approaches to increase insurance enrollment, a new study says.

The Affordable Care Act of 2010 sought to improve the health-insurance access in part through fostering more competition among insurers. But rural markets have less competition than metropolitan ones, so the impact of market-focused strategies is diminished, according to a study by the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis.

The study looked at insurer participation data across three market-based health insurance programs — the Federal Employees Health Benefits Program (FEHBP), Medicare Advantage (MA) and Health Insurance Marketplaces (HIMs – which were created under the Affordable Care Act). Researchers aimed to see whether the competition within an insurance market affected an individual’s decision to purchase health insurance.

That information is key in determining whether market-based health-insurance helps increase enrollment rates in rural areas where population is less dense.

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.

“This finding suggests that an underlying level of competition, based upon historic and/or institutional factors, plays a role in [the Affordable Care Act health-insurance marketplace’s] success or lack thereof in rural places,” the study said.

The study also indicates that a lack of population density doesn’t lower health-insurance enrollment. Rather, the region’s previous lack of competition predicted the lower enrollment rates.

The study used data from the three health insurance programs, as well as the “Herfindahl Index,” which measures market concentration.

Data showed that insurer participation began to decrease in 2017, across the country, but most especially in rural counties and in states that did not expand Medicaid.

Focusing on counties with population densities below 100 people per square mile, the study found that counties that continued to attract insurers tended to have lower prior-year Herfindahl indexes, meaning the counties previously had market competition.

“Over the first four years of [health-insurance marketplace] operation, 2014-17, there was significant entry and exit of insurers in both urban and rural counties,” the study found. “In 2017, data began to show signs of weakening insurer participation, especially in rural counties and in states that did not implement Medicaid expansion.”

The study concluded that a complex set of factors, not just population density, made rural areas less competitive.

“Years of evidence across three market-based health insurance programs clearly indicate that rural places are less competitive,” the study found. “Our findings suggest that while this is due in part to the limitations of small populations, low population density, and fewer available providers, other factors are also at work.”

Those other factors can include things like “the presence and type of hospital systems, the policy environment at the state level, the entrenchment of certain insurers who were early entrants to the private market, the payer mix and even the specific geography in terms of terrain and infrastructure.”

Abby Barker, with RUPRI, said in an email to the Daily Yonder that the study points to the need for a re-evaluation of how rural areas are different than urban areas.

“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.”

Policies should address the specific needs of rural areas in the future, she said.

“This brief didn’t really examine the urban county data, but I think implicitly our message is that rural places DO have the potential to be different in terms of how much we can rely upon the market model to work well, at least in certain rural places, at least without recognition that rural places may require something explicit in a market-based policy to mitigate these types of issues,” she said.

This article was originally published by the Daily Yonder.

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