The New York Times points out that the PPACA tends to work to the disadvantage of the rural poor:
As technical failures bedevil the rollout of President Obama’s health care law, evidence is emerging that one of the program’s loftiest goals — to encourage competition among insurers in an effort to keep costs low — is falling short for many rural Americans.
While competition is intense in many populous regions, rural areas and small towns have far fewer carriers offering plans in the law’s online exchanges. Those places, many of them poor, are being asked to choose from some of the highest-priced plans in the 34 states where the federal government is running the health insurance marketplaces, a review by The New York Times has found.
but I don’t think that they quite appreciate what a problem the healthcare exchanges present to the rural poor. Reliable, high speed Internet connectivity, when available at all in rural areas, tends to be quite pricey. Of all of the people in the country the rural poor are the least likely to have high speed Internet and if you take all of the problems with the Healthcare.gov web site and multiply them times ten that’s probably about what accessing the site via a dial-up connection will be.
Presumably, for some this is more a feature than a bug. The rural poor aren’t their constituents.
Still, for somebody like Illinois Sen. Dick Durbin (the second highest ranking Senate Democrat), it’s going to present a problem. Illinois is already one of the states in which the PPACA is likely to produce substantial premium increases in the individual insurance market and these other issues with the legislation will aggravate the situation. I expect the upstate/downstate gap to be greater than ever in the 2014 midterms.
I grew up in the rural midwest. Lots of poverty there. No one in Washington gives a rat’s tuches about the rural poor. Most of the “coasters” (as our nation’s capitol is on the east coast, our s**tty representatives in DC are coasters, whether they represent the flyover country they come to disdain or not), think that the poor in rural flyover country are nothing but white trash redneck methheads, so why should they bother?
I noticed last week that Kentucky has a very consolidated healthcare insurance market. The largest provider for individuals has 83% of the state’s market, and the second largest provider has between 5% to 17%. I wonder how much that has contributed to some of the success that state’s exchanges has reported.
Rural people have fewer choices in absolutely everything: schools, restaurants, car dealers, grocery stores, movie theaters and yes, doctors. It’s part of being rural. If you want a lot of choices, don’t live in the middle of nowhere. Also if you live in the south there’s humidity, and in the north it gets cold, and the sun rises in the east most days.
Interesting graph here: http://dish.andrewsullivan.com/2013/10/24/when-will-most-sign-up-for-obamacare/ It shows enrollment rates/time for RomneyCare.
Rural areas also have connectivity problems, whereas you often can’t get cable, and tree canopies create problems for satellite reception. People I know in N CA have to go into town with their laptops to hook onto a cafe’s wifi, which could be a daunting experience if these lengthy maze issues continue. Another issue for rural America is how small family practices will survive, continuing to be able to service these areas.
There’s an irony that seems to be intrinsic in social progressive programs, whose primary goals are to benefit the poor, needy, disenfranchised. Because, at the end of the day, the people who ultimately end up suffering the most are the poor, needy, disenfranchised.
re Illinois; I don’t know that the insurance issues will galvanize regional political divisions as much as pensions and education. Downstate (like Wyoming) tends to have lower uninsured rates that the big cities anyway, though perhaps because of Medicare and Medicaid:
Chicago — 27% uninsured; 23% public insurance
Chicago Suburbs — 15% uninsured; 13% public insurance
Downstate — 14% uninsured; 20% public insurance
Map here: http://whitepapers.mchc.com/july-2012/illinois-uninsured-by-county/
@michael reynolds
… If you want a lot of choices, don’t live in the middle of nowhere. …
“Let them eat cake.”
The important thing is that the rich liberal’s health insurance costs have decreased. This will come in handy for the injuries caused by patting yourself on the back.
@jan
There is no irony. These are hustlers working for their own benefit. The crap about helping the poor is to make them feel better about screwing people.
If the do-gooder is benefiting from the do-gooding, you have a hustler not a saint. Mother Teresa was living in the same conditions as the people she was trying to help. Rich liberals are also living in the same conditions as the people they are trying to help.
Tasty,
I actually think many liberal “do-gooders” believe that their ideology is compassion-based, and therefore has the higher ground – results showing they’re wrong, be damned!
Krauthammer is an interesting case in point, of a liberal-turned-conservative, simply because empirical evidence proved that it was small government policies which helped improve the lives of people, especially those below the poverty level, than liberal big government ones.
@jan
They are hustling you. They are like the parent of a child star. They are helping themselves, but they claim their child is important. Bullshit.
Notice how they will phrase the justification. When charged with hurting the poor, etc., liberals will counter that conservatives are hurting them more.
Liberals go out of their way to not see the horror their programs cause.
Tasty:
It’s not a case of let them eat cake, it’s a case of choose-your-own-adventure. Why do you think people move to cities and their suburbs? Should we listen to people complain about how noisy and congested cities are? Or how dull and predictable suburbs are? If you live in the middle of nowhere, guess what? You’re in the middle of nowhere. Do you have a local symphony hall and a sushi place? Not so much.
Are you under the impression that pre-Obamacare people in rural areas had it great when it comes to medical care? They don’t have trauma centers, they don’t have 20 different radiologists, they don’t have a wide variety of doctors and dentists, and they never did. I choose to live in a bedroom community and when I need something serious done in the medical line I drive to San Francisco. Ditto if I want to buy a taco after 9 PM. Choices, consequences.
@michael reynolds
It’s not a case of let them eat cake, it’s a case of choose-your-own-adventure. …
You are making my point. Like Marie Antoinette, it never occurs to you that they may not be able to move, and if they were to move, their social/economic support will not be available.
If somebody is poor, they do not have a lot of extra money for moving. They probably cannot be without a job while they search for another. More than likely, their childcare comes from a relative. At least, they have family and friends in their shitty circumstances.
Your attitude is no different than the Tea Party. Conservatives make the same argument, but they do not pretend to be saving the world.
Some people are born into or fall into shitty circumstances, and most of them would prefer better. I am sure that they are rejoicing about the lowered health insurance of their betters.
Your compassion is more worthless than a bucket of warm spit.
Tasty:
You keep trying to peg me as a limousine liberal, and you keep ignoring reality in the process. And accusing me of not imagining something is ridiculous.
1) I’m a poor kid who grew up in trailer parks. I’m 59 and didn’t have two dimes to rub together until I was in my late 30’s.
2) I have a very good imagination. Which is why I’m no longer poor.
But by all means, ignore facts and stick with your narrative.
@michael reynolds
Your being able to get out of a shitty situation and to prosper is admirable, and it is an example of what a person can achieve. It is not luck as you like to portray it. Luck is sitting in your trailer with the lottery ticket you sent your son/daughter to the store to buy, and it is a winner.
What you did is extra-ordinary, and few people in your circumstances will be able to do the same. If it were easy, everybody would do it. You and your Tea Party brethren share the philosophy that the poor should stop being poor.
I do not think that you are a “limousine liberal”. I think that you are a compassionless asshole with the same philosophy as those you castigate.
Also, being poor has gotten a lot worse since you left the trailer park. The poverty programs instituted by liberals have insured that few are able to make it out of poverty. Of course, this means less competition for middle and upper income liberals is a happy coincidence.
Finally, the “I lived in a trailer park” line does not make you compassionate any more than the “black friend” and racism.
Tsty:
Literally no idea what you think you’re talking about. I suspect you don’t, either.
Rural poor are covered under the Medicaid expansion–unless their state has refused the money.
Are you under the impression that pre-Obamacare people in rural areas had it great when it comes to medical care? They don’t have trauma centers, they don’t have 20 different radiologists, they don’t have a wide variety of doctors and dentists, and they never did.
Michael,
Why does this sound so condescending and out of touch?
Granted, rural populations don’t have the sizable menu of choices as metropolitan areas do. However, they do have care facilities (small clinics/medical centers) and doctors with whom people have cultivated trusting and comfortable relationships with. The effect this messy government intrusion will have, in continuing to fund these existing services, remains to be seen. Nonetheless, if one doctor packs his/her bags up, because they are unable to make a go of it under the complex. fiscally restrictive conditions posed under Obamacare regulations, such a loss will be of greater magnitude than a doctor calling it quits in a big city. This is because every professional member of a smaller community is a valued and oftentimes irreplaceable place holder.
I’m kind of surprised, though, at the specificity of your empathy and concerns for medical access. There is such a generalized consideration in your empathy — the unidentified poor — who you seem to go in a tailspin over regarding who you think is entitled to entitlements. However, when circumstances worsen for other people, because of the way these entitlements are designed, you seem detached and heartless.
“Rural poor are covered under the Medicaid expansion–unless their state has refused the money.”
Most of the rural poor (and the sickest of the rural poor) live in states that have refused the Medicaid expansion (states dominated by Republicans). Having or not having a high-speed connection is meaningless for those folks. See, Where Poor and Uninsured Americans Live.
sam: Most of the rural poor (and the sickest of the rural poor) live in states that have refused the Medicaid expansion (states dominated by Republicans).
That’s right. The law was written so that states would cover the poor under Medicaid, with the federal government providing most of the money, but the Supreme Court nixed that provision. That decision left it to the states to decide whether to participate.
Dave Schuler: Presumably, for some this is more a feature than a bug. The rural poor aren’t their constituents.
The law made provision, and does make provision, for the rural poor, most of whom live in red states. That undercuts your characterization.
jan: However, when circumstances worsen for other people, because of the way these entitlements are designed, you seem detached and heartless.
The federal law isn’t the problem, but decisions made at the state level.
I have been spending a lot of time overseeing the rehab of a house close to a small hospital in a small rural hospital so I can have staff live there a week at a time to provide care at the place. I just helped with getting a Level 4 trauma certification for the Hospital. There are some problems with the ACA that will affect the rural poor, but overall it is a plus in states that participate with the Medicaid expansion.
Critical hospitals in rural areas have been able to get higher fees from Medicare. That is going away. While it may be harder to apply for ACA insurance, they have always had that problem. Since internet access is obtainable, I suspect it will be a net plus.
The whole idea of decreased competition is interesting. I have written to multiple economists, including health care economists and it is a difficult issue to understand as there are many competing incentives. Most rural hospitals have just one specialist of every kind. In theory, absent competition, they should be able to charge a fortune. In fact, they do not. They participate with the insurance carriers. The insurance carriers have no competition in the areas. They should be able to charge a fortune. They have not. I think it comes down to not being able to get blood out of a stone.
Steve
“Literally no idea what you think you’re talking about.”
Sure you do, Michael. Tasty just shoved you into a corner you could not escape. You can’t tell us about free will and owning the personal choices we make………….and then endlessly tell us government should be in out knickers constantly fixing all sorts of perceived ills………….especially if its good for New Yorkers or San Franciscans…but if you live in Mississippi you are probably too stupid to matter.
@michael reynolds
Your references to being poor and living in a trailer park do not give you a pass on being compassionless. They are only relevant to the extent they give you insight into the hardships of the poor. You have either forgotten or had a different experience.
Your no longer being poor is admirable, but it is relevant for the insight. Again, you have either forgotten or had a different experience.
Your being a “rich liberal” is really not accurate. You are a rich conservative pretending to be a liberal. You have much in common with those you castigate.
I would expect @Drew to say that the poor should just move, and he claims that he is just a poor farm boy from Iowa. The big difference is he is not claiming to be Mr. Compassion.
Your not understanding my point is not surprising, but I believe this is through a willful ignorance.
Red Barchetta: but if you live in Mississippi you are probably too stupid to matter.
Again, ObamaCare did address the issue of the rural poor.
@Drew
I am not taking a shot at you. I am only pointing out that Mr. Liberal is not that different from you. Walks like a duck, talks like a duck, shits like a duck, it is highly likely that it is a duck.
Relevant
It’s actually my experience that rural places don’t have any specialists. At best, they have a roving specialist who comes by for one week a month. That was the case for my urologist. When we needed a maternal fetal medicine doctor? Three hour drive (219 miles away). Four hours (250 miles) for the next one after the first one took leave. Pediatric cardiologist was 2.5 hours (175 miles) away. Fortunately, a pediatric orthopedist was only two hours (130 miles) away. That’s despite being in a relatively affluent rural county.
Like Michael says, it’s sort of bundled in with rural living.
My big concern is obstetrics. My wife’s former employer out there was one obstetrician away from having to cease obstetrical support and has been one obstetrician away from that for the past four years. It’s the only hospital in a tri-county area two-thirds the size of New Jersey. It’s one thing to drive 2 or 3 hours to visit a specialist. It’s another to do it while you’re in labor.
There is also a big problem recruiting and retaining emergency room and hospital personnel. The economics aren’t really all that favorable. I was under the impression that with the exception of OB the hospital end was a money-loser that the clinic subsidized.
@Trumwill, I think the OB stuff is a problem in a lot of places. I live in a 200,000 pop. metro area with a lot of healthcare and a medical school, and I still think part of the welcome to women moving to the area is to keep their annual visit with their last doctor because the wait for new patients is so long.
Our state has a program in which it helps pay doctors to go to rural areas, and the reason I know about this program, is that I helped a doctor, who decided not to stay to get the state to agree to the proper repayments. One concern I would have is whether such programs work well with the specialists.
Most rural areas don’t have access to on-site permanent specialists. Usually you have to go to the county seat, or the nearest larger city for such appointments. Even emergency events are initially addressed at small medical centers, giving treatments that stabilize a patient for transfer, via medivac, out to a larger medical provider. For example, in N. CA we are enrolled in two medivac services, as preventive measures should a family member require more complex, lifesaving care.
However, even fledgling medical centers, similar to the one in our area, fiscally struggle to remain open, as it is. Our’s already heavily depends on outside fund-raising galas, donations etc. But, this may not be enough, should more be taken out of the government till because of ACA implementation.
As I have relentlessly been saying, we just don’t know or understand all the unintended consequences of how this so called cost-cutting HC reform will actually impact every community, every individual across the board, across the country. It’s vastly more comprehensive, invasive, and erratically applied than I initially even realized. Everyday, a new twist, a new reading of growing ramifications of this unread law become more disturbing to me.
Tasty
You can take a shot. After all, I invite them for the sake of the thread.
@Trumwill-Small (rural) hospital economics is interesting. In the past, few belonged to networks. They had no purchasing power and paid high prices for everything. Many money losers can become income generators once they join a network, so the hospitals can, sometimes, make money.
The problem of getting staff to live in those areas is tough. Six figure employees dont generally want to live in an area where the average house sells for $50,000. (We paid $53k for ours that I am fixing up. Not a single 90 degree angle in the place, sigh.) Most of these small places have existed by hiring whomever they could get to agree to live close by. Often people unable to find work elsewhere. What we are trying is to have people live there a week at a time, our mid levels, and have a small core of docs drive back and forth. It means that I can have Ivy league trained guys capable of treating almost anything there on a daily basis. Much higher quality staff. The downside is that the medical literature shows that familiarity does lead to better outcomes. It is a balancing act. I hope we are getting it right.
Steve