Rural Missourians to Face Unique Challenges if ACA Repealed

Jan 23, 2017

Many of the medical supplies at the rural Good Samaritan Clinic in south-central Missouri have been donated from hospitals.
Credit Jennifer Moore

Hours after his inauguration, President Donald Trump signed an executive order indicating that a repeal of the Affordable Care Act, also known as "Obamacare," is imminent. A repeal could mean different things to those living in cities and those in rural areas. 

To see how a repeal of the ACA could affect Missouri’s poorest and sickest counties, I took a little road trip.

The Good Samaritan Clinic in Mountain View, Missouri sits a two-hour, straight shot east of Springfield on Highway 60.

The clinic hugs the border of Howell and Shannon Counties. According to the US Census Bureau, the percentage of people without health insurance in Shannon County is nearly twice the US average.

Areas like this one don’t typically attract large employers—and many smaller businesses, like farms or mom-and-pop cafes, often don’t provide health insurance.

The Good Samaritan Care Clinic provides medical care every Monday night to the uninsured population of south-central Missouri.
Credit Jennifer Moore

Shari Noble is the administrator of this clinic, which offers medical and dental care to the uninsured population—at no cost to the patients.

It’s open once a week—on Monday nights—and the waiting room is often full.

“We know that we have had some patients that have received coverage through the Affordable Care Act, and we know that mainly by the decrease in numbers that we’ve seen,” Noble said.

The clinic saw a decline in patients in 2014 then again in 2015. 

Before the ACA was implemented, Noble used to turn away patients every time the clinic's doors were open.

Some of those former patients qualified for insurance on the ACA marketplace, or exchange.

Noble said most patients the clinic sees are the working poor who fall in the coverage gap:  they make too much to qualify for Medicaid, but often not enough to pay the insurance premiums on the exchange—even with subsidies thrown in.

“But even at that—you know, if you’re living on a very limited income, and you do get assistance, just paying an additional one hundred dollars a month for insurance that you weren’t paying before might seem like an insurmountable thing you can’t do.  So a lot of them have chosen not to sign up for insurance. And they just pay the penalty on their income tax return. [They] take it out of their refund,” Noble said.

She says many patients drive 40 or 50 minutes to get here. And that more people would come—but they don’t have a way to get to the clinic.

Sheri Noble is the administrator of the Good Samaritan Care Clinic, which sits near the county line of Howell and Shannon Counties in south-central Missouri.
Credit Jennifer Moore

“Just Monday night, we had a gentleman [who] has been here in the past, but it’s been about two years since he’s been real consistent in following with us. Transportation was an issue. He lost his job and didn’t have money even to buy gas to get here. Normal blood sugars usually run below 120, especially for patients who have not been diagnosed with diabetes. This gentleman was running, on average, about 450,” she said.

Noble is convinced she will see an increase in patients at the Good Samaritan Clinic if the Affordable Care Act is repealed and replaced with something that doesn’t provide more coverage to low-income Missourians.

To prepare, she’s pushing the recruiting of volunteer medical staff, including physicians, dentists and nurse practitioners. She says some doctors drive from Springfield every six to eight weeks.

Leaving the clinic, I drive down a country highway to get a sense of the economic tapestry that makes up this area. I’m almost immediately surrounded by woods. Some of the houses appear to be pretty dilapidated—a couple are patched together by tarps.

The Centers for Disease Control and Prevention released some grim statistics this week:  if you live in rural America, you might want to reach for your vitamins. A CDC study shows rural Americans are considerably more likely to die from all five leading causes of death in America than their urban counterparts.  Among those health conditions are heart disease, cancer, and respiratory disease.

One of the researchers for the CDC, Ernie Moy, says that’s because rural Americans have higher rates of cigarette smoking, high blood pressure, and obesity. They’re also less active.

This is relevant to the repeal of Obamacare because the ACA made it impossible for people to be denied health insurance because of pre-existing conditions, like diabetes or lung cancer.

And since rural areas show higher rates in many of these chronic health conditions, this population—and their care providers—could be affected disproportionately.

That means rural hospitals and clinics may take more of a hit.

A higher percentage of rural patients didn’t have insurance before the ACA, so a repeal would mean they are more likely to seek what’s referred to as “charity care” from hospitals.

Last week, the Missouri Hospital Association released data on the amount of charity care and bad debt hospitals experienced from serving uninsured or underinsured patients. The data from 2015, the second year of the ACA, shows that for the first time in over a decade, charity care was reduced.

“And so even without Medicaid expansion, as a hospital community, we saw a reduction in the individuals who are using hospitals are their only venue for care,” said Dave Dillon, a spokesman for the Missouri Hospital Association.

Rural Americans are also just an older population on average.

Jen Bersdale heads the group Missouri Health Care for All, which joined groups across the nation in staging protests over the potential repeal of Obamacare.

She said people tend to forget that the ACA addressed the coverage gap some seniors were experiencing with their Medicare prescriptions.

“And the Affordable Care Act provided for a gradual closing of that ‘donut hole.’ It’s almost closed now. But if they were really to just repeal the law, like they would like to do, that ‘donut hole’ comes right back into place,” Bersdale said.

Republican lawmakers in Washington, D.C. maintain that the law former President Obama championed is overreaching, too costly, and burdensome.

The new Congress in Washington, D.C. is expected to debate and perhaps vote on the repeal and potential replacement of the Affordable Care Act in the next few weeks.

Jennifer Moore is Missouri State University’s Journalist-in-Residence and a KSMU contributor focusing on public affairs journalism.