Proposed cuts to Medicaid funding will have a devastating impact on the nation’s rural hospitals, but Tennessee may suffer the most.
With nine rural hospitals closed since the Affordable Care Act (ACA) was signed into law in 2010, more could face the chopping block if either of the two proposed Republican Party-backed health care bills are approved, according to Carole R. Myers, PhD, RN, a nursing and associate professor and health care policy instructor at the University of Tennessee in Knoxville.
“There have been nine rural hospitals closed in Tennessee (compared) to 11 in Texas, which leads the nation,” Myers said. “But Texas is much bigger. Tennessee leads the country in the rate of rural hospital closings.”
Tennessee is the “canary in the coal mine” for rural hospitals across the country, she said.
Myers was a speaker July 6 at the “Tractorcade for Rural Health” event in downtown Nashville organized by an ad hoc group called Protect Rural Tennessee. The action was linked to the National Farmers Union’s opposition to the Better Care Reconciliation Act, the US Senate version of the similar bill previously approved by the House, the American Health Care Act (AHCA).
Both bills are designed to replace the ACA, also known as Obamacare, and would effectively end Medicaid as an open-ended guaranteed government benefit based on need by changing the method of federal funding to the program. They would also phase out the ACA’s expansion of Medicaid under the ACA in those states that adopted it.
“The current situation in Tennessee, precipitated in part by not expanding Medicaid, will be exacerbated if the ACHA replaces the ACA,” Myers said. “The AHCA changes Medicaid from an entitlement program to a block grant program. This change will be devastating to Tennessee. Benefits in entitlement programs are guaranteed to eligible individuals. Entitlement funding is based on need and is open-ended.”
According to Myers, the proposed AHCA funding for Medicaid block grants would be capped at levels significantly below current funding.
In a recent op-ed piece in Nashville’s the Tennessean newspaper, Myers and former University of Tennessee graduate student Madison Kahl described a bleak future for rural health care in the state. Kahl recently graduated after completing an honors thesis on Medicaid expansion.
“The portrait of rural Tennesseans and communities reveals deep-rooted disparities,” the two wrote, citing the following:
Seventy-eight of Tennessee’s 95 counties (82 percent) are rural. A report from a task force convened to look at issues impacting rural communities noted that 17 rural counties rank in the bottom 10 percent of counties across the country in unemployment, poverty rates, and per capita market income; an additional 35 counties rank in the bottom 25 percent.
More than 1 in 3 Tennesseans live in rural counties. Citing the Rural Health Reform Policy Research Center, the authors write that “rural residents tend to be older, more are uninsured, and they have higher rates of chronic diseases. They also have higher death rates, lower life expectancies, and higher rates of infant mortality.”
Cuts to the Medicaid program will mean less money to pay rural hospitals.
The column notes: “An analysis of financial data derived from the Tennessee Joint Annual Reports on Hospitals by the Tennessee Justice Center revealed that 28 of the remaining 61 rural Tennessee hospitals are at risk for closures or severe cuts based a three-year average of losses.”
According to the Tennessee Hospital Directory, 35 rural counties (83 percent) have only one hospital, and 80 percent of Tennessee’s rural, at-risk hospitals are the only one in the county.
Hospital closures also can have a profound economic impact on rural communities. Myers calls hospitals “economic powerhouses” and often a county’s single largest employer.
“The loss of a hospital is not just bad for health outcomes—it can precipitate the collapse of the local economy,” the authors write. “Without adequate funding rural health and health care disparities will become more severe and the closure of rural hospitals may herald the death of a community.”
Myers, who spoke most forcefully in defense of Medicaid and rural hospitals, was joined at the protest by two former elected officials. But it was a young woman named Meredith who put a human face on the dangers being raised by Medicaid cuts.
Meredith is a mother of three who lives in Westmoreland (population: 2,300) in Sumner County and suffers from a congenital disease that also affects her children. Under Obamacare she was able to obtain insurance through Blue Cross/Blue Shield until the company dropped out of the ACA market.
“It has been absolutely terrifying for me and my children,” she said. “I lost every one of my comprehensive health team at Vanderbilt Medical Center (in Nashville). Are my children’s lives worth that little?”
She had to resort to using medical clinics in the county. Now her children are covered by CoverKids, free health coverage for pregnant women and children who do not qualify for Medicaid.
“There are so many people in my shoes and I talk to them every day,” she added. “There are so many children in my children’s shoes and I talk to their mothers every day.”
In 1994, Tennessee was the first state to be granted a federal waiver to, in effect, operate the Medicaid program as a state function known as TennCare. This involved enrolling 800,000 Medicaid recipients in managed care programs and opening enrollment to 500,000 Tennesseans who could not get private health insurance because of preexisting conditions or were deemed uninsurable but not eligible for Medicaid.
Tennessee officials believed their own press releases and thought with local control they would be able to implement a workable program and have money left over. It didn’t work out that way.
After the first year of operation the state closed enrollment to those who were uninsurable for reasons other than preexisting conditions. Various cutbacks and program changes continued and in 2005 the state cut back further, removing 190,000 participants, imposing limits on the number of prescription medications participants could receive, and reducing other benefits.
There was opposition to the cuts then, but it mainly took on a religious character. When the state legislature met to vote on gutting the program, some supporters of TennCare stood in the hallways leading to legislative chambers as legislators filed in. In hopes of changing minds at the last moment the protesters read aloud from the Bible while “Amazing Grace” was played in the background.
At the “Tractorcade” protest, which attracted about 40 people, there was no talk of health care as a basic human right or of the parasitic nature of the for-profit health care industry, which is the foundation of the ACA and will be under any Republican plan.
Organizations like the Democratic Party front-group “Indivisible” had no one at the protest, but planned a separate action that afternoon. The Democratic Party has no solution to the health care crisis as they support the private insurance companies that have both profited off of Obamacare and pulled out of markets when they have not.
The Democrats have signaled their willingness to work with the Republicans to “fix” the ACA, which will only mean more attacks on the affordability and quality of health care and access to it. As the WSWS has continually stressed, health care is a social right that must be fought for and defended by a political struggle of the working class, not by pressuring the two big-business parties.
Michelle Armstrong from Fairview, Tennessee, attended the protest. Armstrong, who grew up in a rural community in upstate New York, came dressed as a skeleton and was willing to endure the hot afternoon to make her point with the sign: “Trumpcare Will Kill.”
“We are not a poor country and we can afford to give people good health care,” she said. “This is not a joke, not a game. We’re talking about people’s lives.”