How Will Rural Americans Fare During Medicaid Unwinding? Experts Fear They’re on Their Own

Lambert here: Everything’s going according to plan. As I wrote, summarizing NC’s ObamaCare coverage back in 2016, quoting a post from 2013:

In this series, we’ve been looking at how ObamaCare, through its inherent system architecture, relentlessly creates first- and second-class citizens; how it treats people who should be treated equally unequally, for whimsical or arbitrary reasons. It’s all in the luck of the draw! If you live in the right place or have the right demographic, you go to Happyville. If you don’t, you go to Pain City.

All very much in contrast to simple, rugged, and proven single payer.

Still true today!

* * *

By Jazmin Orozco Rodriguez, a reporter for KFF Health News’ rural health desk based in Elko, Nevada. She explores the ways health issues affect communities in rural areas, including food security, climate change, and agriculture practices. Originally published at Kaiser Health News.

Abby Madore covers a lot of ground each day at work.

A staffer at a community health center in Carson City, Nevada, Madore spends her days helping low-income residents understand their health insurance options, including Medicaid. Her phone is always ringing, she said, as she fields calls[1] from clients who dial in from the state’s remote reaches seeking help.

It’s a big job, especially this year as states work to sort through their Medicaid rolls after the end of a pandemic-era freeze that prohibited disenrollment.

A few dozen specialists work for seven navigator organizations tasked with helping Nevadans enroll in or keep their coverage. Madore said she mostly works with people who live in rural Nevada, a sprawling landmass of more than 90,000 square miles.

Katie Charleson, communications officer for Nevada’s state health marketplace, said it’s always a challenge to reach people in rural areas. Experts say this problem isn’t unique to the state and is causing concern that limited resources will throw rural Americans into jeopardy as the Medicaid unwinding continues.

KFF’s Medicaid Enrollment and Unwinding Tracker shows that 72% of people who have lost Medicaid coverage since states began the unwinding process this year were disenrolled for procedural reasons, not because officials determined they are no longer eligible for the joint state-federal health insurance program.

By late August, federal officials directed state Medicaid overseers to pause some procedural disenrollments and reinstate some recipients whose coverage was dropped.

Experts say those procedural disenrollments could disproportionately affect rural people.

A brief recently published by researchers at the Georgetown University Center for Children and Families noted that rural Medicaid recipients face additional barriers to renewing coverage, including longer distances to eligibility offices and less access to the internet.

Nationwide, Medicaid and CHIP, the Children’s Health Insurance Program, covered 47% of children and 18% of adults, respectively, in small towns and rural areas, compared with 40% of children and 15% of adults in metropolitan counties.

“As is clear from our research, rural communities rely on Medicaid to form the backbone of their health care system for children and families,” said Joan Alker, who is one of the brief’s co-authors, the executive director of the Center for Children and Families, and a research professor at Georgetown’s McCourt School of Public Policy. “So if states bungle unwinding, this is going to impact rural communities, which are already struggling to keep enough providers around and keep their hospitals.”

A lack of access to navigators in rural locales to help Medicaid enrollees keep their coverage or find other insurance if they’re no longer eligible could exacerbate the difficulties rural residents face. Navigators help consumers determine whether they’re eligible for Medicaid or CHIP, coverage for children whose families earn too much to qualify for Medicaid, and help them enroll. If their clients are not eligible for these programs, navigators help them enroll in marketplace plans.

Navigators operate separately from Nevada’s more than 200 call center staffers who help residents manage social service benefits.

Navigators are required by the federal government to provide their services at no cost to consumers and give unbiased guidance, setting them apart from insurance broker agents, who earn commissions on certain health plans. Without them, there would be no free service guiding consumers through shopping for health insurance and understanding whether their health plans cover key services, like preventive care.

Roughly 30 to 40 certified enrollment counselors like Madore work at navigator organizations helping consumers enroll in plans through Nevada Health Link, the state health marketplace, which sells Affordable Care Act plans, said Charleson. One of these groups is based in the small capital city of Carson City, 30 miles south of Reno, where fewer than 60,000 people live. The rest are in the urban centers of Reno and Las Vegas.

Availability of navigators and their outreach tactics vary from state to state.

In Montana, which is larger than Nevada but has one-third the population, six people work as navigators. They cover the entire state, reaching Medicaid beneficiaries and people seeking help with coverage by phone or in person by traveling to far-flung communities. For example, a navigator in Billings, in south-central Montana, has worked with the Crow and Northern Cheyenne Tribes, whose reservations lie relatively nearby, said Olivia Riutta, director of population health for the Montana Primary Care Association. But officials struggle to reach northeastern Montana, with its Fort Peck Reservation.

Having navigators in rural communities to help people in person is an ongoing challenge the country faces, said Alker. But the unwinding circumstances make it an especially important moment for the role navigators play in guiding people through complex insurance processes, she said.

This became clear following a recent survey regarding what consumers encounter when independently searching for health coverage on Google. “The results are really concerning,” said survey co-author JoAnn Volk, a research professor and the founder and co-director of the Georgetown University Center on Health Insurance Reforms.

The researchers found that former Medicaid enrollees looking for health plans on the private market face aggressive, misleading marketing of limited-benefit products that don’t cover important services and fail to protect consumers from high health costs.

Researchers shopped for coverage using two profiles of consumers who were losing Medicaid coverage and were eligible for a plan with no premiums or deductibles on the ACA marketplace.

The team reported, though, that none of 20 sales representatives who responded to their queries mentioned that plan, and more than half pushed the limited-benefit products. The representatives also made false and misleading statements about the plans they were touting and misrepresented the availability or affordability of the marketplace plans.

The sales reps and brokers quoted limited plans that cost $200 to $300 a month, Volk said. Such an expense could prove unaffordable for consumers who may still be low-income despite being ineligible for Medicaid.

“If they can’t get to a navigator, I would not trust that they would get to their best coverage option in the marketplace, or to the marketplace at all, frankly,” Volk said.

Making a difficult problem more challenging, the federal government does not require states to break down Medicaid disenrollment data by county, making it harder for experts and researchers to track and differentiate rural and urban concerns. The Center for Children and Families does so with data from the Census Bureau, which Alker pointed out won’t be available until next fall.

A data point that will be important to watch as states continue the redetermination process, Alker said, is call center statistics. People in rural areas rely more heavily on that method of renewing coverage.

“Call abandonment rate” is one such statistic. CMS defines it as the percentage of calls that drop from the queue in two separate measures — calls dropped up to and including 60 seconds, and calls dropped after 60 seconds. In August, the agency sent a letter to the Nevada Department of Health and Human Services about its rate: An average of 56% of calls dropped in May, the first month after Nevada’s unwinding began.

The agency “has concerns that your average call center wait time and abandonment rate are impeding equitable access to assistance and the ability for people to apply for or renew Medicaid and CHIP coverage by phone and may indicate non-compliance with federal requirements,” said Anne Marie Costello, deputy director of CMS.

In the letter, Costello also cited the 45% of Medicaid enrollees whose coverage was terminated for procedural reasons in May.

All 50 states received letters about early data, but only Idaho, South Carolina, Texas, and Utah had higher disenrollment rates than Nevada, and no state had a higher rate of call abandonment.

Officials at Nevada’s Division of Welfare and Supportive Services said its call center, staffed by 277 family service specialists, receives more than 200,000 calls a month. A spokesperson said the phone system offers self-service options whereby customers can obtain information about their Medicaid renewal date and benefit amounts by following prompts. Because those calls aren’t handled by a case manager, they are considered “abandoned,” the spokesperson said, raising the rate even though callers’ questions may have been fully addressed.

People shopping around for coverage after a lapse might go into a panic, Madore said, and the best part of her job is providing relief by helping them understand their options after disenrollment from Medicaid or CHIP.

When people find out the wide range of free services navigators like Madore offer, they’re shocked, she said.

“They’re unaware of how much support we can provide,” Madore said. “I’ve had people call me back and they say, ‘It’s my first time using insurance. Where do I go to urgent care?’”


[1] Hilariously, I first read “calls” as “culls.”

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Louis Fyne

    (in my neck of the woods) the market is clearly speaking as the dominant local hospital systems have bought all their rivals servicing great/good demographics.

    One might not have noticed if your doctor is a truly independent practitioner, but every since Obamacare started, the hustling hospital chains have vertically-integrated: family care generalists, specialists, cancer wards, MRIs, diagnostics, outpatient care, even health clubs—-all in one campus.

    One-stop shopping for large insurance groups like your city government, school districts, unions, etc.

    You can tell which hospitals (like many rural ones) are the proverbial lepers (ie, lackluster w/profits)—-they are the ones not getting acquired or acquiring.

    Next recession + current wave of (deserved) labor wage inflation among frontline health care workers is going to push the marginally profitable hospitals into bankruptcy/liquidation.

    And there isn’t going to be a rush to replace the outgoing hospitals.

    1. redleg

      One big advantage for single payer is eliminating profit incentives from clinic/hospital decisions. Rural hospitals and clinics would stop closing because of profitability issues. There might be other reasons to close them, but lack of profit wouldn’t be one of them.
      I can’t comprehend how twisted someone’s values have to be to think that financial profit off of people’s health is desirable.

      1. Piotr Berman

        A single payer system also needs to calculate cost effectiveness of dispersed hospitals and clinics. For example, Russia is consolidating rural health care in fewer facilities, so you may have a village with one registered nurse, and everything else requires a helicopter (perhaps the only solution for a village of 700 people in roadless taiga.) But in this case you can organize transportation services at reasonable cost, not like in USA where a helicopter ride can be billed for 50,000 and a van ride above 1,000.

        Larger benefits of single payer is that you do not have dropping the enrollment, bureaucracy that identifies which enrollments should be terminated and restored, and more frequent issues, what procedures should be covered with clerical staff of hospitals and insurance companies fighting each other, and so on.

        1. GramSci

          Does the Cuban Health Care System rely upon helicopters?

          I wonder how much helicopter insurance will cost?

          1. Piotr Berman

            Even in Virginia they rely on helicopters in a case of very specialized surgery (the location of a horror story with 700,000 bill, including 50,000 for the helicopter). In Boston, NYC etc. you can have all types of care available in the metro area, but it can be impractical in rural Nebraska, Nevada or Chukotka to assure them all in reasonable driving distance. (In extreme cases, like in Arctic, you do not have a road. Supplies in winter come over ice and frozen snowy ground, in summer by boat, no traffic in Spring and Fall).

            On the question of insurance, yeah, it is most cost effective for medical companies to abandon remote areas, but social and economic calculus is different.

  2. ambrit

    I despair at the lack of Public Hospitals. Louisiana has the Charity Hospital system, cemented in by Huey Long. Long was a genuine populist of the old style “give the people something to secure their votes” type. He met an appropriately Neo-liberal end. He went and was helped to die.
    There are plenty of “random acts of violence” in America today. Eventually, someone or someones will figure out the ‘value’ of “targeted acts of violence.” The old style Anarchists understood this a century ago. Since everything seems to be following hundred year cycles, why not the “A” Team as well?

    1. Mary McCurnin

      Charity Hospital closed in New Orleans after Katrina. It was flooded in the basement and repaired fairly quickly. But it never reopened. The right used Katrina to kill Charity Hospital, take away the first public housing in the United States, and make the school system even more non-functional.

  3. Michael Fiorillo

    As coincidence would have it, the requirements changed on the very same day the Trump indictment parade began, with #McResistance liberals swooning at the prospect of Stormy Daniels rescuing Our Democracy.

    The juxtaposition of the two seems significant, illustrating where Lawfare (and the TDS- triggered magical thinking underpinning it) meets Democrat inability to provide for people’s needs without administrative (i.e., PMC jobs programs) bloat.

    No wonder so many people hate them. People may not follow the details and intricacies, but they intuit how they’re being lied to… and there are few things worse than sanctimonious liars.

    1. chris

      Yes. It makes me question the title of this article because I doubt experts in this field care about rural Americans. Or any Americans for that matter.

      I’m sure we’ll all be shocked when we have another national health emergency and the US is sicker than imagined and does fsr worse than any other estimates.

  4. chris

    It seems insane that during a time when we still don’t understand the level of excess deaths occurring in the country we’re taking Healthcare away from people.

    And why has no one answered the question of why we still have excess deaths following the major time period of the pandemic? People can’t die twice. If the pandemic allegedly culled the morbid and sick, then shouldn’t we be seeing a marked decrease in deaths because all of the people who were most likely to die in the last three years are already dead? Where are all these morbidly sick people coming from to maintain such a high rate of excess deaths?

    And if we don’t understand this, why would be make it ever harder for people at risk to get healthcare? I know the answer to that question but it’s horrible. I suppose the only question I should ask is, how soon after these people are all too sick to work should we expect to see articles from these same experts lamenting how people don’t want to work and that they’re a drag on the economy?

    1. playon

      From the link you posted on excess deaths — “Please note that these datasets will no longer be updated after September 27, 2023”. But of course…

    2. redleg

      Rephrasing Lambert’s Rule of Neoliberalism:
      When life is viewed as a marketable commodity, it will be used until all financial value is extracted and then be discarded.
      Of course healthcare is pulled right when it’s needed, as that’s when the financial value turns negative.

  5. Lexx

    I live in a ‘house proud’ neighborhood, in a college town at the northern end of a blue state. Poverty exists in Colorado and it’s not hidden…even I’ve noticed. My measure therefore as we crossed the west to the Pacific coast is what kinda shape is the house in? Is there any evidence that someone lives there?

    I grew up here (PNW), some of what I’m seeing is normal. Some of the residents prefer to live like the moss covering the trees deep under their canopy. Now decades later and while living in another sub-culture, all I see is desperate poverty or a damn good imitation. Those ‘cabins in the woods’, once family homes, are falling down with disrepair, and access to health care of any kind is far away.

    So many of them, we’re talkin’ millions and the rural West emptying out. It isn’t just those foreign-owned condos in Vancouver where the lights don’t come on at night because no one comes home to turn them on. If the question is about affording the electric bill, then it’s just a matter of time and there’s less of it than I thought..

  6. Billy Bud

    Go long, deer rifles and ammo. Rural people will know what to do.
    Good advice for city slickers as well.
    As to 2A “resistance is futile” against Bidens DOJ, military, etc…how long did it take 1,000 law enforcement and trained agents, dogs, aviation, to find the escaped convict who had zero knowlege of the area he fled into?
    Wasn’t it like almost a week?

    The PTB would be wise to let Trump run, win and try and fix the mess.

    1. JonnyJames

      DT, many folks’ personal Lord and Savior, won’t do a damn thing to make the collapsing USA any better. No matter how much people want to believe, the fairy tales just won’t come true. He didn’t do anything in the four years he had, except cut taxes for the oligarchy (and himself) with the help of the so-called opposition.

      But JB and DT are the best US “democracy” can do, the kleptocratic kakistocracy cannot produce any better.

  7. Mark Gisleson

    My only medical checkup since moving back to Minnesota was at the nursing home across the street. Not a healthcare clinic, but they do see patients on a long-term care basis.

    Most nursing homes could easily double as rural healthcare clinics and almost every community has a retirement home or some kind of public building that doctors and nurses could use to see rural patients.

    This bizarre modern notion that a hospital has to be some kind unnavigatably complex tech haven with byzantine billing practices is frankly weird and has really put me off American healthcare. Like our government, American healthcare should be smashed into a million pieces. It’s the only way we’ll ever get good healthcare (or governance).

    1. Lexx

      The one primary care doc I’ve had that offered concierge services (maybe ten years ago) closed his practice and went to work in Denver for a chain of nursing homes. It paid him much better than his private practice. At the time it seemed ludicrous to me to pay more out of pocket in addition to our insurance. Now I wish we’d taken him up on his offer. Perhaps he would have stayed and I’d be in better shape under the care of a physician i didn’t have to share with thousands of others..

      We’re considering again private primary care when Husband retires and wondering if it will still be possible, never mind affordable. Perhaps we could lure one out of an old folks home; we’ll be officially old by then.

  8. playon

    We live in a predatory culture where it’s perfectly legal to prey on the weak and less fortunate. $$$ uber alles.

    1. Synoia

      Twas always thus. Except the Powers were really frightened by the return of the WW II veterans, many of whom who could shoot straight, were disciplined in combat, and identify an enemy.

    2. Ashburn

      Speaking of preying on the weak and unfortunate, how about that scam artist, Bernie Sanders, who collected millions from the desperate, weak, and unfortunate, while proclaiming M4A and then endorsed Hillary in 2016 and then repeated his scam in 2020 by endorsing Joe Biden. I can’t help but believe his betrayal of all he proclaimed to support is partially responsible for the very noticeable increased militancy among the NC commentariat.

      For me, the healthcare issue along with declining life expectancy in this country becomes even more explosive as a political issue when contrasted with our endless, wasteful, and murderous wars around the globe.

  9. jrkrideau

    This is mad. In my Canadian province, one goes to the local Gov’t Services Office with some proof of residency and gets a medical card. Last time I renewed my (expired) card it took seven minutes as I was early and had an appointment.

    One can also renew a driver’s licence, licence plate, or get a new birth certificate but that last one is hard to do.

    1. edwin

      I don’t know what the procedures are now, but in the past you could renew OHIP retroactively – after your emergency room visit. I don’t think they liked that but it made more sense than the hospital trying to collect from someone with no money.

      I thought it was interesting that originally the health cards were issued without a picture or expiry date. Apparently there was enough sharing with friends/family from down south way that that was changed.

  10. Susan the other

    Single payer is based on the right of everyone to have good healthcare. Just the complacent act of allowing anyone to be “cut from Medicaid” for any reason whatsofucking ever is extremely harmful. It should be made illegal and punishable by prison time. Just like any other felony. It would also be appropriate to fine and/or imprison any legislator or government functionary who failed to protect the health of anyone. One obvious solution to this long-running nightmare is to allow other countries to export healthcare to us. Cuba. Mexico. The EU. Russia. China. Let’s have some good old competition. Anything beats the disgusting plate of options we have been given. There is no excuse for this mess. It is so sickening it is making us sick. Sick of our own country.

    1. redleg

      Looking at this as a person and not an investor, single payer is the only thing that makes sense in terms of risk pool and bargaining power.

      Looking at this as an investor, it’s the one thing that kills the system.

      And if my comment comes off as implying that investors are inhuman, well, if the shoe fits…

  11. Boomheist

    I think – might be wrong, here – this article’s reference to “navigators” means SHIP or State Health Insurance program – advisors, which are groups of trained volunteers located in every one of the 50 states established to offer non-biased advice regarding Medicare and Medicaid. I happen to be such a counselor located in Washington State, have been for a year and more, still new at this. My work is located in Pierce County which is an urban-suburban county with some rural pockets at the edges, and everything in this article rings absolutely true, from what I ahve seen. What is often overlooked, or not mentioned, is the enormous assumption everyone makes that everyone is computer literate and can use online services to do research, sign up for medical plans, etc. This is often not the case, especially in rural areas which have poor web connectivity anyway. A big problem, which is a system problem, and one not mentioned very much, is that the proliferation of phone trees and messages constantly directing you to go to http://www.whatever.whatever to solve your problem means that you have enraged frustrated callers who simply cannot get in touch with a real human being unless they wait, wait, wait, some times foir over two minutes, until a phone option FINALLY says something like, “If you want to speak to a human being press this number”; that is, if you can even find such an option these days.

  12. jobs

    Reading articles like these I’m becoming more and more convinced we only still have Medicaid because it’s such a great upward wealth transfer mechanism.

  13. Eudora Welty

    I remember reading some details about Obamacare when it first started in around 2010. The monthly fee you paid was based on a comparison to the poverty level. That shocked me in 2010. I thought I was paranoid and possibly completely loopy to be shocked that the standard was the “poverty rate,” as though that was going to become a common measure. Now most people are moving toward the poverty level! I was right to be pessimistic! It has been a downward slide. I listen to Trump’s appearances, and I hear people speak to him so respectfully, “President Trump,” as though he is a savior when we have direct evidence that he doesn’t know how to govern. He must be laughing to himself … “You knew I was a snake when you..”

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