The Affordable Care Act was supposed to expand Medicaid nationwide, but the Supreme Court’s decision to allow states to opt out of Medicare expansion has had dramatic, deadly consequences. New data shows that rural hospitals in states that chose not to expand Medicaid under the Affordable Care Act are struggling at worse rates than in the rest of the country.
According to an investigation by the Pittsburg (KS) Morning Sun and GateHouse Media, 72 percent of rural hospital closures since 2010 happened in states that didn’t expand Medicaid. Hospitals in Kansas are in the worst shape: 64 percent of its hospitals are losing money. Five of its rural hospitals have closed, and the margin of profitability is -0.1 percent. (Earlier this year, a bill to expand Medicaid failed in the Kansas Senate by just one vote.)
The decision to expand Medicaid or not isn’t the only factor affecting hospital profitability. Iowa, which expanded its Medicaid program in 2014, hasn’t seen any hospitals close, but 29 percent of its hospitals were losing money between 2011 and 2017. Kentucky expanded Medicaid, but four of its hospitals have closed, 34 percent of the remaining hospitals are losing money, and the margin of profitability is just 0.9 percent. Five percent of Kentuckians are uninsured, but the state is ranked 47th in poverty rate. Poorer people tend to be sicker, and thus need more care.
But in some states that didn’t expand Medicaid, the numbers are very stark. Tennessee has seen twelve hospitals close since 2010. Texas, the state with the highest uninsured rate in the country, has seen 17 hospitals close. In Oklahoma, a state with just 3.9 million residents, seven have closed.
Medicaid expansion makes a big difference for these rural hospitals simply because when more people are uninsured, more of their care goes uncompensated. People without insurance might avoid going to primary care doctors that they can’t afford (or don’t have the time or transport to get to), but if they have a heart attack or a stroke, or the unexplained cough they have turns out to be untreated cancer, they’re eventually going to end up in hospital. And when they do, if they’re uninsured, the hospital has to treat them without anyone paying for the cost of doing so.
Earlier this year, the Washington Post profiled a rural Oklahoma hospital where staff were working without pay for 12 or 16 hours shifts to care for its patients. In January, a woman in Houston, MS, died after an asthma attack. The nearest hospital, which her cousins drove her to, had closed its emergency room.
Rural hospitals do not have to wither and die; their fate doesn’t need to turn on whether or not they’re ‘profitable.’ It does not need to be this way. Without universal healthcare—specifically, healthcare that is entirely free at the point of access, so that everyone can access it as and when they need it, not just when they’re already dying—this will never happen.
Some things are good even if they’re not profitable, and it’s long past time for America to apply that very basic concept to the life and death of its people.