As Rural Americans Struggle for Health Care Access, Insurers May Be Making Things Worse

Yves here. Another aspect of why flyover is suffering from falling lifespans: insurers often have “artificial provider deserts” in rural areas: they actually have a few MDs, but they are not in insurer networks. And the picture is likely even worse than this article presents, since as many readers know all too well, insurer lists of in-network doctors routinely include names that are actually not participants, or are included only in a small subset of policies.

By Simon F. Haeder, Assistant Professor of Public Policy, Pennsylvania State University. Originally published at The Conversation

Living in rural America certainly comes with a number of benefits. There is less crime, access to the outdoors, and lower costs of living.

Yet, not everything is rosy outside the city limits. Rural communities face growing infrastructure problems like decaying water systems. And they have more limited access to amenities ranging from grocery stores to movie theaters, lower quality schools, and less access to high-speed internet.

Yet perhaps most daunting are the tremendous health disparities rural Americans face, in terms of both their own health and accessing care.

As a number of my recent studies indicate, these disparities may be exacerbated by insurance carriers and the networks they put together for their consumers.

A Sick System That’s Getting Worse

At the turn of the last century, cities were known to be cesspools rampant with disease. Much has changed since then. Today, health care disparities between urban and rural America have indeed reversed. And they are growing wider.

Part of the problem is demographic. Over the last several decades, many rural areas have lost a large share of their residents. In many areas, the young are moving away, leaving an aging population behind.

Besides being older, those staying behind are poorer and have lower levels of education. To make things worse, they are also more likely to be uninsured. And they tend to be sicker, exhibiting higher rates of cancer, heart disease, stroke and chronic lower respiratory disease. It comes as no surprise that their life expectancy is generally lower as well.

The demographic challenges are made worse by the limitations posed by the health care system. For one, rural areas are experiencing tremendous health care provider shortages. Access is often particularly limited for specialty care. But much more mundane health care services that most of us take for granted, like hospitals – including public hospitals and maternity wards – are also affected.

Politics have made rural access challenges worse in many places. Partisan opposition to the Affordable Care Act has led many states with large rural populations, like Texas and Kansas, to refuse to expand their Medicaid programs or support enrollment in Affordable Care Act marketplaces. This stance is particularly damaging because the program provides a crucial lifeline to rural providers.

A Stark Divide

Rural communities across the country face tremendous health care access issues. And as recent study my colleagues and I did of access to cardiologists, endocrinologists, OB-GYNs and pediatricians shows, insurance plans may further complicate the issue.

Focusing on California, we compared access between plans sold under the Affordable Care Act and commercially available plans. We also made comparisons to a hypothetical plan that included all of the state’s providers. In theory, this would be the plan available to consumers under various Medicare-for-All proposals.

Overall, we found that consumers living in large metropolitan areas faced only very limited access challenges. However, as distance from cities increased, access worsened significantly. Consumers had fewer providers to choose from, and had to travel further to see them.

One of our starkest findings was the existence of what we called “artificial provider deserts” – areas where providers are practicing and seeing patients, but insurance carriers do not include any of them in their networks. Without access to local providers, some rural residents are forced to travel 120 miles or more to reach in-network care.

Our findings hold for both Affordable Care Act plans and those commercially available, which fared only slightly better.

The problems we found in this study extend well past plans sold on the Affordable Care Act marketplaces. Two of my other studies found similar, if not worse problems, for rural consumers of Medicare Advantage plans in New York and California.

More Protections for Rural Americans

There are many reasons for the growing disparities between urban and rural America. Many of these aren’t always easily or quickly remedied through government intervention. Indeed, some may be inherent to living outside of metropolitan areas.

Yet when it comes to health care access, our recent work indicates that decisions by insurance carriers may further worsen the situation. Conceivably, insurers may limit access to providers to push sicker populations to enroll with other insurers.

However, the fault may not exclusively lie with insurers. Rural providers may also demand large fees to enter into contracts with insurers, leading insurers to exclude them from their networks.

While regulating provider networks comes with a slew of challenges, it seems apparent to me that our current approach is not working for Rural America. It is time to rethink how we provide and regulate health care access to millions of Americans living in rural areas.

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  1. Noel Nospamington

    Older Americans in rural flyover areas of the USA are statistically more likely to vote Republican than younger Americans are in large cities.

    How does Medicare factor into this? Does Medicare provide better coverage with a larger network of medical professionals and services, with less co-pays, than private insurance? Since I am not an American, I honestly don’t know.

    Personally I consider the concept of Medicare only being available when one turns a certain magical age to be horribly vicious, since accidents and diseases happen to all age groups. I wonder if these older Americans who have Medicare and support Republicans are basically stating I got mine, and screw everyone else.

    Perhaps if there was no Medicare, older Americans would be sufficiently motivated, and the USA would soon have single payer universal health care.

    1. marym

      For people who choose “original” Medicare, there are no networks. Anyone can go to any provider that accepts Medicare.

      Individual providers can “opt out” of accepting Medicare at all, or accepting new Medicare patients. I don’t know if there are restrictions or requirements for doing this.

      Medicare Advantage is the privatized version of Medicare. Insurance companies can establish provider networks, additional benefits, and payment provisions (like premiums and copays) just as they do with other types of private health insurance.

      1. Kitty

        Actually medicare advantage (HMO or PPO) models bear no resemblance to Medicare. All restrict members to selected (aka cheaper) providers and from year to year your preferred orthopedist say may not be in network.

        Personally, I prefer Medicare with a Gap policy. No constraints on providers and works everywhere in the country.

    1. marym

      Just a guess, but this may be because private insurance companies (the providers of Medicare Advantage) didn’t find the area to be a profitable market.

      This would be similar to the more general notion of “buying insurance across state lines,” a common proposal from politicians on the right, as an alternative to a universal public plan. Insurance companies would need to be willing to negotiate provider relationships in a particular area, and to comply with any state regulations beyond national requirements, which they may not see as worth the effort for their business.

      1. antidlc

        Last year Georgia enacted legislation allowing insurers licensed elsewhere to sell policies in the state. The expectation was that Georgians would suddenly have a plethora of new policies to choose from as insurers in places like Alabama and Tennessee set up shop in the Peach State.

        1. Letting insurers sell policies across state lines

        “Get rid of the artificial lines and you will have yourself great plans,” said Donald Trump during the first Republican debate.

        Why faulty: Insurers can already do this, for crying out loud. Trump and the other candidates are either being disingenuous or showing their ignorance.

        True facts: Federal law doesn’t prohibit insurers from selling coverage in more than one state. In fact, the Affordable Care Act actually calls for multi-state plans to be made available across the country, and it encourages states to set up “healthcare choice compacts” to facilitate the sale of policies across state lines.

        Not only that, but a number of states have passed laws encouraging insurers in other states to come in and set up shop. So far though, there have been no takers. Here’s why: It would cost insurers millions if not billions of dollars to establish provider networks and everything else involved in selling coverage in a new state, and the insurers would have to comply with the new state’s regulations. And then they’d have to compete with well-established companies with much better name recognition.

        Why, for example, would Blue Cross of Tennessee want to spend a fortune to do business in Georgia only to face formidable competition from Blue Cross of Georgia? It wouldn’t (and hasn’t, even though Georgia has thrown out the welcome mat) because Blue Cross of Georgia has such market domination in the Peach State that it can demand favorable rates from doctors and hospitals, something newcomer Blue Cross of Tennessee, with zero market share in Georgia, couldn’t do. Consequently, the Tennessee Blue wouldn’t be able to offer comparable rates without losing its shirt in Georgia. Insurers are in business to make money, not to lose their shirts to make politicians’ dreams come true

    1. rd

      Rural health care is something that a government needs to want to do, not because it is cost-effective. One the decision is made to do it, then the focus is on how to do it as cost-effectively as possible. That is the Canadian single payer model. Canadian city dwellers expect to subsidize rural medicine as a moral obligation, but they also expect the government-run health care programs to provide good quality care to those far flung regions efficiently, so you get strategic use of tele-medicine, clinics, air ambulance etc. to minimize expensive fixed costs in sparsely populated areas (much of Canada has the population density of Montana).

      This is a societal philosophical choice. Do you view affordable quality health care as a moral obligation or not? The US does not.

      1. Kitty

        Actually in Canada you have to tolerate really long waits. As a bridge player friend reported in November of this year. His knee was really bothering him – 2 years ago. His local provider made an appointment for an MRI – it was a 12 month wait to get it. Then another 12 month wait to see and orthopedist.

        Now waiting for a surgery slot to open up. It Has been months.

        Last ~ 3 years limping around due to knee pain. Unbalanced gait mechanics beating up the knee and hip and low back on the other side

        Long long wait times is a feature of the countries with national/regional team healthcare. Especially an issue in big countries and even UK has serious problems with NHS. No one would ever mistake UK for anything but small.

  2. lyle

    If you look in the Texas Almanac you find that in a large number of rural counties, the number of deaths far exceeds the number of births, Partly this is due to in a county with 3000 in population not having any obgyns practicing in the county.. Take for example Kimble, Edwards and Real counties in Tx. If you look up obgyns in the various phone directories you find none. Note that Edwards and Real counties have less than 2 people per square mile, and Kimble outside of the county seat is the same. So folks go to Uvalde, San Angelo, Kerrville or San Antonio for births. However it has almost always been this way in the near frontier counties. Note that looking at web sites will cover hospitals for these areas up to 80 miles away. There are still areas in the US such as the ones cited that have always been at frontier population levels, Note that even for an ambulance there might be one on duty in the County and it might take up to 45 mins to get to an incident. (let alone look at Brewseter co tx (where big bend park is)). Of course in these areas one needs access to a car to live.

    This situation is just because there are not enough folks in the county to support the infrastructure and hever have been. In ca if one looks east of the Sierra or in Nv one will find the same situation in a lot of areas.

    1. lyle

      Let me give another example De Baca county New Mexico which has 1700 (2016) people in 2234
      square miles. The county seat has only a clinic no hospital, Folks have to go to Clovis or
      Santa Rosa for a hospital and for Level 1 trauma to either Albuquerque, or Lubbock, Tx..
      This is common in the west, from the county seat it is 45 mi to Santa Rosa and 60 to Clovis NM.
      Medicine with such low population levels is essentually impossible to support. (indeed for much
      shopping you have to go to Albuquerque which is about 165 miles away. Of course in both NM
      and Tx, one is used to the concept of having to drive large distances for much.
      Of course the issue relates mostly to small county seats further east losing medical services, where for example a hospital closes. But further east of course a 40 mile drive one way will get one to a significantly larger place. Of course one major solution is to endorse telemedicine. Perhaps setting up a clinic in an old hospital building. There could be either a nurse or an emt to take vitial signs etc for the telephysician (many devices can already send results remotely). If you have read about Scottsburg In which has a major opiates problem, although only 30 mi from Louisville Ky, but troubles getting services for them. Here telephysiciatry would make sense.
      Or in NM again look at the folks on the reservations in the NW corner of the state, again a long distance.
      The whole issue is party a function of young adults prefering the big city so that the rural population is aging as is also true at least in Japan.

      1. pretzelattack

        it’s young folks desperately looking for jobs mainly, imo. even if they didn’t prefer cities, which younger rural folks have done for a long time, there just aren’t anywhere near enough jobs.

    2. Kitty

      Absolutely correct – time for mobile clinics. We even have one veterinarian with a mobile clinic. If we can do it for dogs, horses & cows it should be made to work for people.

      As a kid in a rural area the public health doctor & nurse showed up each fall to do an exam of each child – looking for vision, hearing, signs of malnutrition, immunizations, head lice, heart & lungs. Nothing fancy – we are talking about the 1950′. But everyone checked at no cost to families.

      Immunization issues was very simple – diptheria-tetanus-whooping cough & small pox. Polio did not come along until I was in 4th grade – that was also done by public health doctor & nurse.

  3. Susan the Other

    It is their very reason for existence that insurance companies reduce risk to their own bottom line. Hence the necessity for a social mandate that they get out of medical insurance for good. They are slimeballs. They have no place anywhere if they cannot provide everywhere. Above and beyond that, rural America can benefit from high-speed internet; local distribution of medical supplies – local manufacture would be good too. And for doctors? Lotsa doctors appreciate a rural existence. It would be an excellent idea to ban, forbid and sentence to death all private equity funders who buy into rural hospitals just to gut them. They deserve a profound lack of medical attention if anyone does. And if rural living is contributing to the survival of the planet, even more so. And to that end, we should do a little analysis. Too rural interferes with the natural rehabilitation of the environment which is very important – it needs room to breathe and rejuvenate. But for rural but still within the sphere of a commercial center there should be an obligation of the medical mandate. It might be good to put humans on a reservation for a while. So maybe a medical mandate for the environment as well.

    1. Clark

      Susan the Other — Nicely put in a short and appropriately venomous paragraph! I’m sure this has been stated many times on NC, but the “insurance model” is singularly not effective for dealing with medical needs. …. And can we prevent PE from sucking the life out of rural America without action from Congress?

      1. Xrystia

        +1 A comment on the article. I’m really disappointed that the author has adopted the neoliberal term “cosumer”. I am a patient who needs a doctor/physician to address my medical issues. I do not consume healthcare. I am amazed how quickly neoliberal terminology permeates medicine. Doctors are now providers and patients are consumers. Words carry ideology and this change is very powerful. I’m sad that I see no resistance to “consumer of healthcare”

      2. pretzelattack

        or perhaps “can we prevent pe from sucking the life out of rural america with the eager support of congress?”

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