WASHINGTON – Uncertainty over the future of health care policy has some experts worried that people in rural communities may lose coverage and rural hospitals will be at risk of closing.

Rural areas could be deeply affected by changes that President Donald Trump and the Republican Congress are considering to the Affordable Care Act, said speakers at the National Rural Health Association’s annual conference on Tuesday.

For instance, more people in rural areas got coverage by the Obama administration’s expansion of Medicaid, than in cities, said Bruce Bowden, a National Association of Counties health care lobbyist.

Of 11 million people insured through Medicaid expansion, 21 percent live in rural areas, he said.

Congress and the Trump administration are moving toward repealing President Barack Obama’s signature health care law but haven’t yet decided how to replace it.

Whether that includes preserving Medicaid for people who made too much money to qualify for the program before the expansion “is a big question mark,” said Maggie Elehwany, the rural health care group’s vice president for government affairs.

Also raising concern among rural health care providers is House Speaker Paul Ryan’s plan to cut costs by expanding Medicare Advantage.

That program, which funnels Medicare funds to private insurers, does not pay hospitals as much as traditional Medicare, said Jason Barb, partner of BKD, an accounting and consulting firm that works with rural hospitals.

That could mean another hit for rural hospitals already struggling with other federal cuts.

Eighty rural hospitals have closed since 2010, and another 673 are considered vulnerable, according to the Rural Health Association.

“We face a very complex, multi-threat environment,” said Tim Size, executive director of the Rural Wisconsin Health Cooperative, a group of 40 hospitals.

The Affordable Care Act’s problems are exacerbated in rural areas, said Cynthia Cox, an insurance reform expert at the Kaiser Family Foundation.

While people in 62 percent of metropolitan counties have a choice of three or more carriers of individual insurance, 41 percent of rural counties just one insurer.

Premiums rose in urban areas last year by 20 percent, to $351 per month, she said. Rural areas, with a disproportionate number of people with medical conditions, saw rates rise by 30 percent to an average of $423 per month.

Republicans in Congress said at the conference that repealing the Affordable Care Act is a chance to fix the problems.

“Increasing choice and competition is the key to lowering cost and increasing access to care,” said Sen. Dean Heller, R-Nev.

Rep. Evan Jenkins, R-W.Va., said the Obama administration, by comparison, had a “lock-down attitude” and was not open to changing the law.

Changes are coming, he said.

“Wanting no change or fix is a non-starter in Washington,” he said.

But Bowden, of the National Association of Counties, said changes that result in a rise in the number of uninsured could hit taxpayers..

Counties help pay for medical care for people do not have insurance, he said, and county governments already spend one-fifth of their budgets on health care.

Medicaid’s expansion under the Affordable Care Act, he noted, lowered the percentage of uninsured getting mental health care nationally from 20 percent in 2013 to 5 percent in 2015.

Alyene Senger, a policy analyst for the conservative Heritage Foundation, said changes are needed to deal with Medicare’s ballooning deficit.

Size, however, said policies that lead to the closure of rural hospitals will hurt communities.

“It means a loss of jobs, a loss of pride in the community,” he said, adding that survivors still feel like “we’re being attacked by a government that thinks rural hospitals don’t matter.”

Kery Murakami is the Washington, D.C. reporter for CNHI’s newspapers and websites. Contact him at kmurakami@cnhi.com.

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