Access to Health Care for the Uninsured in Rural and Frontier America

An Issue Paper Prepared by the National Rural Health Association -- May 1999

INTRODUCTION

The number and percentage of Americans without health insurance continues to increase. Census Bureau figures released in September 1998 showed that 43.2 million Americans (16.1 percent of the population) now lack health insurance. Rural and frontier populations are more severely affected. Despite having a higher percentage-18 percent vs. 15 percent in urban areas-of people 65 and older who qualify for Medicare, rural America still has a 20 percent higher rate of uninsurance than its urban counterpart. This greater degree of uninsurance-and underinsurance-is a result of having a higher percentage of people who are self-employed, work for small businesses, do seasonal work, or fail to apply for Medicaid.

There is a great variation in the degree of uninsurance from state to state, with states in the Southwest and Southeast having the highest percentage of uninsured people. There is also a large disparity in the degree of uninsurance by ethnic group. Twelve percent of non-Hispanic whites are uninsured, compared with 21.5 percent of blacks and 34 percent of Hispanics (Bureau of the Census).

Providers are able to serve the uninsured on a pro bono basis to the extent that other revenues cover fixed costs and provide enough margin to absorb the extra costs of caring for nonpaying patients. When managed care plans reduce payments to providers, the cushion used to provide care to the uninsured and underinsured disappears. To date there has been less penetration of managed care in rural areas than in urban settings. But those rural providers who have contracted with managed care organizations have been subjected to cost reduction strategies such as steep discounting from fees.

Rural health care providers are in a different position from their urban counterparts in regard to serving the uninsured. Patients cannot be so easily turned away in the rural setting where the selection of providers is much more limited. Many rural regions of the country do not have safety net providers eligible for public grant dollars to help underwrite the costs of caring for the uninsured. Where rural providers-such as Rural Health Clinics-are able to receive cost-based payments (which include fixed costs), even that alternative is being threatened.

Policy issues and questions confronting the NRHA with respect to the uninsured and underinsured in rural and frontier areas can be divided into incremental or comprehensive approaches. Incremental strategies include such items as 1) defining and supporting new safety net providers; 2) obtaining new sources of funding care for the indigent, such as state monies; 3) providing new services, such as facilitating access to specialists; 4) working with new networks; 5) changing reimbursement formulas; and 6) increasing enrollment into existing and new insurance programs.

A comprehensive strategy for financing, such as universal coverage for all Americans, could contribute significantly toward solving access and financial problems for the uninsured-and lead to massive simplification of health care financing. However, even if universal coverage becomes a reality, other access issues (such as geographic, cultural and provider availability barriers) will still need to be addressed, especially in rural and frontier America.

The NRHA's recommendations to improve the status of the rural uninsured and underinsured, in summary, are:

• while continuing to support federal, state, local and community rural health initiatives, the NRHA supports the goal of universal health coverage and access to care for all;
• continuing to strengthen the rural health infrastructure;
• requiring accountability of managed care organizations to respond to local needs in rural areas; and
• eliminating unfavorable rural-urban disparities in health care financing and recognize the need to reimburse rural providers adequately for government programs.

DESCRIPTION OF THE PROBLEM:
THE UNINSURED AND HEALTH CARE IN AMERICA

Numbers of Uninsured and Underinsured
Despite so-called "incremental" attempts at health care reform after the failure of President Clinton's comprehensive health care plan in 1994, the number (and proportion) of Americans without health insurance has continued to grow. From 37 million uninsured in 1993, the number increased to 41.7 million in 1996. Census Bureau figures released in September 1998 estimate 43.2 million people were uninsured in 1997. The growth of managed care in the '90s, which some proponents hoped would create savings that would have allowed more coverage for the uninsured, has actually contributed to an increase in the numbers of the uninsured. At the same time, the number of Americans who are underinsured-estimated at 31 million in 1996, but likely many more-has increased dramatically.

America remains the only industrialized country in the world that does not offer health care coverage to all its citizens. Yet the United States spends 40 percent more (as a percentage of gross domestic product) and 75 percent more (on a per capita basis) than any other country on health care (Organisation for Economic Co-operation and Development, 1998). Our country now has the highest percentage of uninsured-16.1 percent in 1997-since the passage of Medicare and Medicaid in the '60s. This growth in the number and percentage of the uninsured is even more startling given that the late '90s have been a time of unparalleled economic prosperity for America.

Distribution of the Uninsured
The geographic and ethnic distribution of America's uninsured is uneven and varies widely. This unevenness correlates with multiple factors including employment patterns, poverty, the organization of medical care systems, and political differences among states. The state-by-state percentage of the uninsured in 1997 varies from lows of 7.5 percent in Hawaii and 7.9 percent in Wisconsin to highs of 24.5 percent in Texas and 24.4 percent in Arkansas. The southern states, both in the Southwest and Southeast, with a high percentage of poorer ethnic groups and unorganized labor, have a much higher percentage of uninsured.

Equally maldistributed is the percentage of uninsured by ethnic group. The 1997 Census Bureau figures show that 34 percent of Hispanics lacked insurance compared with 21.5 percent of blacks and 12 percent of non-Hispanic whites. Age discrepancies also are remarkable. There were 10.7 million uninsured children in 1997.

Characteristics of the Uninsured
The Kaiser Family Foundation 1998 monograph Uninsured in America documents that:

• Eight in 10 uninsured Americans are workers or dependents of workers.
• Nearly eight in 10 uninsured Americans have family incomes above the poverty level.
• Most (55 percent) of the uninsured state the major reason they don't have insurance is because they can't afford it.
• The uninsured have greater problems getting needed care-particularly those in poor health.
• The uninsured and those who have had gaps in coverage are likely to go without or postpone health care.

Trends Relating to Uninsurance and Underinsurance
Trends in the late '90s that have led to increasing numbers of uninsured include:

• The increasing cost of health insurance, especially for individuals and small businesses.
• Decreasing employer coverage of dependents.
• More persons choosing not to purchase health insurance when offered by employers because of the high cost.
• Decreasing proportion of employees who are covered because more are part time or seasonal.
• Welfare reform that has resulted in fewer people on Medicaid.
• Diversion of resources to the pursuit of market-based approaches and profits.

Recent "incremental" reforms, such as the Kennedy-Kassebaum Act, the Children's Health Insurance Program (CHIP) and a variety of state efforts, such as guaranteed issue insurance and portability, have so far done little to halt the increasing numbers of Americans without health insurance.

RURAL AND FRONTIER FACTORS RELEVANT TO UNINSURANCE

Data from a 1997 study by the Agency for Health Care Policy and Research indicate that the rate of uninsurance is more than 20 percent higher in rural areas than in urban areas (for 1996, 19.8 percent vs. 16.3 percent). While uninsured spells for all geographic areas are increasing, rural uninsured have longer periods without insurance. The factors contributing to this disparity include the higher percentage of self-employed people, small businesses and agricultural enterprises in rural areas.

Rural and frontier people often are employed only seasonally or in part-time work. Because of the nature of many rural economies, which are based on agriculture, mining, fishing or timber, rural employers are less likely to provide health insurance. Rural and frontier people also are more likely to be self-employed or to work for small businesses than their urban or suburban counterparts. Additionally, people who work for small businesses that do provide health insurance often make relatively larger contributions to insurance premiums, especially for dependents, and have higher co-pays than people employed in larger urban enterprises. Moreover, selling and servicing policies to small businesses and individuals is more labor intensive for insurance companies, which then pass these costs onto consumers through increased premiums.

People from rural or frontier areas also are less likely to enroll in Medicaid. They usually have less knowledge about the program and are less accessed by outreach programs and other social services.

Rural and frontier areas have a higher percentage of elderly people with Medicare coverage. This higher proportion slightly offsets the much higher proportion of working age people, ages 18 to 65, who lack insurance.

Case histories of the rural uninsured can help illustrate the real problem. Following are a few examples that illustrate the plight of the uninsured. These cases come from one day's practice in the fall of 1998 at a community health center in Idaho.

• A 55-year-old man demonstrates massive obesity, uncontrolled diabetes and leg ulcers that are healing very slowly because he lives alone in the mountains in a house with no running water or electricity.
• A 50-year-old woman, who works at a fast-food restaurant, has had ovarian cancer and has diabetes. She can't afford the yearly abdominal ultrasound exams she needs for her cancer or strips to measure her blood sugar. Additionally, she can't afford to buy health insurance because she has pre-existing conditions.
• A 40-year-old man, currently unemployed and a recent medical school drop-out, delays getting care 18 hours for a severe gaping hand laceration because he knows going to the emergency room would cost him a fortune.
• A 41-year-old woman with diabetes and hypertension lost her Medicaid coverage three months ago and ran out of medications. She comes in as a new patient with a blood pressure of 160/110 and a blood sugar of 400.

MANAGED CARE AND ITS RELATIONSHIP TO THE UNINSURED
IN RURAL AND FRONTIER AMERICA

Managed care-or managed cost-has had much less impact on rural and frontier America than in urban areas. Although there have been some rural community-based experiments in managed care, the general wisdom in the early '90s was that a managed care organization required a certain critical population mass (originally pegged at 300,000) to be viable. Managed care also has been less prevalent in rural America because federal capitation rates for Medicare have been substantially lower in rural vs. urban areas.

There are examples of safety net providers, such as Community and Migrant Health Centers, that have had their insured patients taken away from them through the aggressive marketing efforts of health maintenance organizations (HMOs) and other managed care organizations. Some safety net providers have seen losses of patients when employers, trying to cut costs, have switched their employees to HMOs. The result has been a decrease in third-party revenues to offset the cost of uncompensated care for the uninsured. In some areas where there are Rural Health Clinics, their federally qualified health center (FQHC) status-and financial viability-has been threatened by Medicaid managed care plans that may not reimburse at FQHC rates. Yet managed care-as opposed to "managed cost"-has great potential to help the uninsured in rural communities, possibly by strengthening the role of primary care.

Managed care-or cost-as a whole has had little or no positive effect on the uninsured in the past few years. Two recent studies, one from the Center for Studying Health System Change and another from the Urban Institute, have shown an increased number of uninsured associated with a higher degree of Medicaid managed care or HMO penetration. Managed care-or cost-has often diverted attention, energy and resources away from the problems of the uninsured. With decreased reimbursement, health care providers, especially hospitals, are left with far fewer resources to cover the costs of caring for the uninsured.

MEDICARE, MEDICAID AND THE UNINSURED

Motivated to cut costs, both federal and state governments have been promoting the shift of Medicare and Medicaid beneficiaries to managed care. The Balanced Budget Act of 1997 created new options in the Medicare program, including preferred provider organizations (PPOs), medical savings accounts (MSAs), enhanced fee-for-service, and provider sponsored organizations (PSOs). The same legislation changed the calculation of payment for Medicare risk contracts, removed the requirement that Medicare HMOs include commercial enrollees and established access standards (Mueller, 1997). These changes in the Medicare program may encourage, in time, more widespread offering of-and subsequent enrollment into-managed care plans. The legislation also removed the requirement that states obtain a waiver before limiting the choice of Medicaid beneficiaries to a single HMO (Mueller, 1997).

There has been some turmoil in the transition of Medicare to managed care. On Jan. 1, 1999, managed care organizations dropped 440,000 Medicare enrollees from their plans. Rural populations were disproportionately affected, perhaps because of the lower capitation rates in rural areas. It is uncertain whether these abrupt changes negatively impacted continuity of care for the affected Medicare beneficiaries.

Meanwhile, welfare reform measures have resulted in a reduction of people on Medicaid and an increase in the uninsured. Even if a state's intent was to retain Medicaid for people dropped from the welfare rolls, many ex-welfare recipients failed to understand that they could temporarily continue on Medicaid. Additionally, there are 14 states, mostly poor and rural states, that provide no access for the "medically needy" under Medicaid.

Some states, such as Tennessee and Oregon, have experimented with the expansion of Medicaid managed care to cover the uninsured-with mixed results. Tennessee's TennCare expanded eligibility massively but ran into problems of access. Oregon's plan had grand objectives, did manage to increase employer coverage and fill gaps for many of the underinsured, but has problems of access, notably in rural areas. Currently, in at least 12 states, managed care organizations that previously sought Medicaid contracts are fleeing Medicaid because they are losing money.

Because of the problems discussed above and because of the more scattered populations and smaller number of providers in rural and frontier areas, these usually have been the last to be converted to Medicare and Medicaid managed care. For similar reasons, the effects of "incremental" programs to help the uninsured, such as the positive CHIP program, guaranteed issue insurance, or other provisions of the Kennedy-Kassebaum Act, are likely to reach rural and frontier residents last. There have already been examples of a state-based CHIP program being given to a managed care organization that has then proposed implementing the program in rural areas last-a clear disadvantage for rural children.

RURAL PROVIDERS AND THE RURAL UNINSURED

Rural and frontier providers are in a very different situation than their urban counterparts with regard to the uninsured. There can be no shifting of responsibility, especially in the smallest towns where there may be only one hospital and a handful of providers-or even a solo clinician. Providers in a small rural community usually do not have the option of refusing care to anyone.

While old-time rural clinicians tend to be more independent-minded and less likely to accept managed care, provider demographics are changing in rural America. Rural facilities are increasingly affiliating with larger entities, often networks or urban hospitals, and the close-knit ties of community may be changing. As health care increasingly becomes bigger business even in small communities, the uninsured may not be so welcome. With increasing managed care pressure to contain costs and increasing regulation as well as greater pressure to conform to quality assurance standards, rural hospitals and health care providers will find themselves with little margin to be squeezed and less willingness and ability to provide uncompensated care.

POLICY ISSUES AND QUESTIONS

There are policy issues for the NRHA with regard to the uninsured and the underinsured in rural and frontier America. In certain ways, rural and frontier areas are different from the rest of America, but some of the policy questions apply to all Americans. Although comprehensive approaches have been generally avoided for political reasons since the failure of Clinton's plan in 1994, strategies for the NRHA to pursue could be either incremental or comprehensive.

Incremental Policy Strategies Specific to Rural and Frontier America
Numerous regulations, geographic definitions, special programs, special reimbursements and partial solutions by government and foundations have been tried in an attempt to improve access to care for rural and frontier Americans, seemingly with little success. The regulations are becoming increasingly complex-especially with the expansion of managed care and the increasing complexity of the new Medicare options. However, it may be possible to improve these incremental measures (e.g., CHIP) to increase their positive impacts. Even if universal coverage were enacted, it would still need to be decided how to improve infrastructure, distribute resources, design benefit packages, etc.

Some incremental policy strategies or questions that should be considered include the following.

• New types of safety net providers for rural and frontier areas beyond the current community health centers, free clinics and well-known charity organizations. This measure could help ensure the availability of resources to provide uncompensated care for the medically indigent.
• New grant monies or incentives for providers who provide more uncompensated care than other providers, or a subsidy for providers who see more than their share of Medicare and Medicaid patients. As a starting point, the recommendations of the Medicare Payment Advisory Commission (1999) could be adopted, leveling the playing field in the disproportionate share payment program.
• Increased resources made available, either on a federal or a state level, to strengthen and adapt the emergency safety net, which is especially important in rural areas.
• The definition of "safety net provider" should be more broadly defined to include not only those providers who provide indigent care and have a sliding fee scale, but also providers serving remote geographic areas, locations that serve culturally diverse populations, and areas with a limited number of providers where no patient can be turned away.
• A concerted state-by-state effort to get state funds to subsidize care for the indigent, especially in rural and frontier areas where access to care is more problematic.
• Expansion of tax options, including a broad-based national (vs. state-by-state) medical indigency tax, or use of the tobacco settlements to pay for indigent care.
• Special recognition that certain populations, especially in rural and frontier areas, require special services including transportation, meeting sociocultural access issues, or improving access to specialists. Special funding to meet these special needs should be provided for all rural and frontier residents.
• Community-based solutions for the uninsured, aimed at covering entire communities and based on pilot projects.
• The creation of a more widespread use of local taxing districts to fund indigent care.
• The expansion of hospital-based or organizational-based (AHA, AMA, foundations, etc.) programs to serve indigent populations. Examples include the American Hospital Association's "Campaign for Coverage" or the Robert Wood Johnson Foundation-funded "Access Project."
• Determine the effect on the uninsured, if any, of facilitating 1115 Medicaid waivers. Consideration should be given to reintroducing more safeguards in the granting of 1115 waivers.
• Requiring that all providers, including health plans, assume some responsibility for indigent care to a reasonable extent. Health plans should be required to contract with providers who provide uncompensated care.
• Adequate funding for outreach efforts to educate and enroll rural and frontier people in programs such as CHIP and Medicaid for which they may be already eligible.
• Better data on the uninsured and underinsured and about how their care is being provided. Geographic and cultural, as well as economic factors, should be included in any analysis.
• Including provisions in new programs (such as CHIP) designed to improve access to care for the uninsured, such as:
  • Preferential consideration for safety net providers and other professionals who traditionally provide uncompensated care in the community.
  • State plans should not be approved unless they ensure that statewide implementation will occur in a timely manner. Care should be accessible to all sectors of the medically indigent population that are intended to benefit from the program.
  • Coverage of support services that help ensure comprehensive care such as social work, transportation, nutrition and health education. The issue of the scarcity of these resources in rural areas should be addressed.
  • Ensure that reimbursement rates reflect real costs of services to help offset the costs of providing uncompensated care.
  • Require presumptive eligibility and 12 months' continuous eligibility in programs for the medically indigent.

Comprehensive Policy Strategies Specific to Rural and Frontier America
If Americans should decide that every U.S. resident should have health insurance and implement such a sweeping change, financing of health care would be greatly simplified. With a well-designed system, financial barriers for the uninsured and the underinsured would be eliminated. Rural and frontier populations would especially benefit because of their higher rate of poverty as well as the larger number of rural and frontier people who are self-employed, work for small businesses, or do seasonal work. However, there would still be many policy concerns beyond insurance status.

Some of these additional policy concerns that would affect rural and frontier people are mentioned in the "incremental" section above. Expressed as policy, global concerns beyond the issue of universality include the following.

• Obtaining equal reimbursement levels for rural and urban health care services, including for managed care plans.
• Solving problems created by geographic, cultural and other rural-specific barriers.
• Providing necessary adequate infrastructure in sparsely populated areas, including special services such as telecommunications, small emergency hospitals, EMS services, continuing education, etc.
• Implementing reasonable regulations that ensure quality and safety, and modifying regulations that are inappropriate for rural and frontier areas and that curtail access in those areas.
• Implementing data systems that would allow rational planning.
• Integrating management and delivery systems to make them more efficient and able to deliver adequate and cost-effective services to rural and frontier residents.
• Integrating all of the above with a comprehensive financing system.
• Encouraging innovative new solutions to improve health services and access for rural areas, such as networks, more local autonomy, increased emphasis on initiatives to strengthen public health and promote prevention and lifestyle modification.

Providing access to health care for the rural and frontier uninsured involves more than providing health insurance. But if it were possible to have a comprehensive system of health insurance covering every American, the savings gained from such a system-such as from lower administrative costs and the elimination of monies diverted to support insurance companies-could be used to help meet the special needs of rural and frontier and other underserved populations. However, even a patchwork system that provided universal coverage would be an improvement over the current system.

RECOMMENDATIONS

• The NRHA reaffirms its position on universal access to health care: "Whereas the NRHA continues to support both new and ongoing rural health initiatives, the association also reaffirms its commitment to effective health care reforms that will provide access to comprehensive health care for all people living and working in America. Because rural populations are disproportionately affected by both the lack of health insurance coverage and access to quality, affordable and appropriate care, the NRHA supports the goal of universal health coverage and access to care for all."
• The NRHA supports continued strengthening of the rural and frontier health infrastructure that is crucial for adequate access even if the financing barriers are eliminated for the uninsured and underinsured.
• The NRHA feels that managed care organizations that enter a rural or frontier area should be held accountable for addressing the problems of the uninsured and the underinsured in that area. Further, these organizations should work toward securing the presence of safety net providers while promoting the integration of community and financial resources.
• The NRHA continues to advocate for elimination of unfavorable rural-urban disparities in health care financing, as well as reasonable reimbursement for government programs. Present reductions, as seen with the Balanced Budget Act, and future reductions in reimbursement to rural providers will significantly reduce their capability to provide care for the uninsured.

REFERENCES

American Hospital Association (1998). Campaign for Coverage: A Community Health Challenge. Summer 1998 Report.
Bureau of the Census. (1998, September). Report on the Uninsured in America.
Carrasquillo, O., et al. (1999). Going Bare: Trends in Health Insurance Coverage, 1989 through 1996. American Journal of Public Health, 89(1), 36-42.
Coburn, A., et al. (1998). Urban-Rural Differences in Employer-Based Health Insurance Coverage of Workers. Medical Care Research and Review, 55(4), 484-496.
Cunningham, P. (1998, June). The Effects of Market Factors on Access to Care of Uninsured Persons. Presentation, Center for Studying Health System Change.
Duncan, RP. (1995). Changes in Health Insurance Coverage Within Rural and Urban Environments-1977 to 1987. The Journal of Rural Health, 11(3), 169-176.
Kaiser Commission on Medicaid and the Uninsured (1998, June). Uninsured in America: A Chart Book.
Kassab, C., et al. (1996). The Influence of Insurance Status and Income on Health Care Use Among the Non-metropolitan Elderly. The Journal of Rural Health, 12(2), 89 -99.
Kilborn, P. (1997, August 1). Illness is Turning Into Financial Catastrophe for More of the Uninsured. The New York Times.
Kilborn, P. (1999, January 3). Oregon Falters on a New Path to Health Care. The New York Times.
Kilborn, P. (1999, May 1). Tennessee Talks of Rolling Back Health Plan for "Uninsurables." The New York Times.
Kilborn, P. (1998, July 6). Largest HMO's Cutting the Poor and Elderly. A Managed Care Retreat. The New York Times.
Kuttner, R. (1999). The American Health Care System-Health Insurance Coverage. New England Journal of Medicine, 340(2), 163.
Marsteller, J, et al. (1998). Variations in the Uninsured: State and County Level Analyses. (Monograph). The Urban Institute.
Mueller, K, et al. (1997). Lengthening Spells of Uninsurance and Their Consequences. The Journal of Rural Health, 13(1), 29-37.
Mueller, K. (1997). Rural Implications of the Balanced Budget Act of 1997: A Rural Analysis of the Health Policy Provisions. (RUPRI Policy Paper 97-10). Columbia, MO: Rural Policy Research Institute.
Pear, R. (1998, August 9). Government Lags in Steps to Widen Health Coverage. The New York Times.
Rural Information Center Health Service, National Agricultural Library (August 1998). Facts about the Rural Population of the United States.
Seccombe, K. (1995). Health Insurance Coverage and Use of Services Among Low-Income Elders: Does Residence Influence the Relationship? The Journal of Rural Health, 11(2), 86-97.