Rural Nebraska’s stake in Medicaid expansion

Rural Nebraskans are at a distinct disadvantage in their ability to access health care coverage. Combined with the limited availability of health care providers and facilities, this disadvantage grows as consideration is given to the socioeconomics of health care access. Rural populations are older, have fewer financial resources and have more health concerns than the general population.

Moreover, a high percentage of rural employment is in the small business sector. When coupled, these factors limit access to health care coverage and place a greater proportion of rural residents in the “coverage gap.” Ultimately this inability to access adequate health care coverage not only places individuals in peril, but also the rural communities they call home.

Nebraskans in the state’s rural counties have much to gain with the state’s expansion of Medicaid coverage. Of the state’s residents that are estimated to be in the Medicaid coverage gap, nearly 36 percent live in rural counties. These uninsured residents account for nearly 4.24 percent of the total rural population.

When the data on Nebraska’s uninsured is disaggregated, rural and completely rural counties have higher average percentages of uninsured than metro counties. The average percentage of uninsured between the ages of 18 and 64 in completely rural counties, or counties with urban populations under 2,500, is 15.76 percent. In Kimball County 23.8 percent of the working age residents of are uninsured. This percentages balloons in Blaine and Hayes counties where more than a quarter of residents between the ages of 18 and 64 do not have insurance. While in Thurston County nearly 40 percent of residents are uninsured. Yet in metro counties, the average percentage of uninsured adults of working age is 11.74 percent.

These higher percentages in rural counties matter not only because of the number of rural Nebraskans who are left uninsured, but also for those in their communities who are left to shoulder higher insurance premiums and the radiating effects of uncompensated care on health care systems.

Rural employment’s influence

Those who go without insurance are not just faceless data points. They are hard working Nebraskans, trying to take care of themselves and their families as residents in our state’s rural communities. Those in the gap include a daughter trying to care for an elderly parent while working at the local grocery store, the neighbor who lost his job at the local manufacturer, just two years short of retirement, and the new college graduate who has to come home to a small town to work on the family farm. These are our family members, friends, and neighbors who live and work alongside us working to care for their families and their communities, and yet they cannot access the health care they need.

Even for rural residents who are employed, insurance coverage is not always a benefit that is extended or accessible because of income limitations. Data from the Census Bureau finds that the percentage of the employed who are uninsured is greatest in Nebraska’s most rural counties at 12.32 percent, exceeding the state’s average of 11.42 percent in this category of the uninsured.  For example, in Deuel and Sheridan counties, these percent of the employed without insurance is 17.7 percent and 18.7 percent respectively. And again, in Thurston County more than 27 percent of those who are employed do not have insurance coverage.

Rural Nebraska’s economy is built almost exclusively on small businesses and their employees. Small businesses with fewer than 500 employees account for more than 97 percent of the businesses in the stat. Of Nebraska businesses with 50 or fewer employees, often the economic anchors of small towns across the state, only 18.8 percent offer insurance coverage. This situation leaves workers to pay steep premiums and other out­-of-pocket costs for health insurance coverage or simply forces workers to forego coverage all together. Often this leaves many hardworking Nebraskans in the Medicaid coverage gap.

All rural residents bear the burden

Failing to expand access to health insurance forces health care providers to provide uncompensated care, placing entire rural communities in peril. A Kaiser Family Foundation report found that 37-percent of households with incomes below $50,000 reported difficulty in paying medical bills. To compare, Nebraska’s median household income is $54,384.Low and middle-incomes, coupled with limited access to employer provided insurance coverage, expose many Nebraska families and health care providers to financial risks beyond access to care. Without a insurers or individuals paying for care, providers have to write off the costs as bad debt or charity care. Providers and insurers ultimately shift this cost to all patients and policyholders – raising costs for all Nebraskans.

Beyond increased premium costs passed onto consumers is the burden faced by rural and critical access hospitals. Fourteen percent of rural hospitals’ gross revenues come from Medicaid payments. For many hospitals, the ability to provide services to Medicaid patients allows them to remain viable. Yet, it is estimated that Nebraska’s failure to expand Medicaid will continue to result in a $1.6 billion in loss hospital reimbursements between 2013 and 2022.

When rural hospitals remain open on very narrow margins or ultimately face closure, it is not only residents in “coverage gap” that are left without access to care – it affects the whole community. When a hospital closes, beyond the loss in basic health care access, an economic and social void is left in a community.While Medicaid expansion does not offer the solution to all of the challenges before rural hospitals, it stands to play a part in their continued viability.

Initiative 427

With Initiative 427, Nebraskans, rural and urban alike have a voice in deciding the future of  health care coverage access for 90,000 of our neighbors. Much weighs in vote for Nebraskans and our hospitals, and our communities and our state. We encourage voters to vote yes on Initiative 427 and help insure the good life for all Nebraskans.