Obamacare & You: Coverage, care scarcer in rural areas - LivewellNebraska.com
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Obamacare & You: Coverage, care scarcer in rural areas

LINCOLN — Nebraska is faring better than the nation when it comes to health insurance, but access to coverage may depend on where you live.

While the number of uninsured is highest in Omaha and Lincoln, many rural Nebraska counties have larger proportions of residents who lack coverage.

Nebraska’s uninsured rate of 13.3 percent is lower than the national average and those of all its neighboring states, except Iowa. But a closer look shows the rates are far higher in many rural Nebraska counties, including eight where at least 20 percent of the population is uninsured.

Blaine County, in central Nebraska, has the state’s highest rate of 23.2 percent, according to the U.S. Census Bureau’s 2011 Small Area Health Insurance Estimates survey, the newest available data.

The number of insured people is in the spotlight because of the Affordable Care Act, which requires people to get insurance or face fines. While groups are encouraging people to get insurance, the effort has faced a host of problems, most notably the federal government’s troubled enrollment website. There also have been complaints about soaring premiums for some people and concerns about the many states, including Nebraska, that have rejected Medicaid expansion, which was viewed as a key part of the federal effort.

The higher percentage of uninsured in rural Nebraska reflects the fewer large employers in those areas and a reliance on farms and mom-and-pop businesses that can’t afford coverage. The areas also have fewer health care providers, forcing residents to drive farther for routine checkups and treatment.

The combination of those factors means rural residents are more likely to skip preventive screenings and early treatment, which is often cheaper and more effective.

“It has a stressful impact on communities when you don’t have insurance,” said Roger Wiese, the executive director of the North Central Health Department in O’Neill. “If you’re diagnosed with cancer, it tends to be at the latter stages. That’s probably one of the biggest impacts: being able to get preventive services.”

Wiese said he drives his own children at least 75 miles for routine checkups with an orthodontist, or schedules appointments when the specialist drops in at a local office.

“The more rural you get, the more frontier you get, the fewer options that are available,” he said. “I don’t want to make it sound like rural areas have no health care, because we do. But there are some needs that are unfilled here.”

By contrast, the six counties with the lowest uninsured rates — Washington, Sarpy, Seward, Cass, Hamilton and Saunders — are all located near a large Nebraska city. Except for Hamilton County, each has a population greater than 12,000. The state’s lowest uninsured rate came in Washington County, part of the Omaha metro area, where just 8.9 percent of people lacked insurance.

Unpaid medical bills and debt are two of the largest unmet needs for clients of Central Nebraska Community Services, a Loup City-based nonprofit that works with low-income residents. Many clients in the 21-county area are working in low-wage jobs with little or no insurance, and a sudden health problem often wipes them out financially, said Laura Hilty, the group’s resource development specialist.

Nebraska ranked 36th last year in the number of physicians per capita. The state had nearly 220 physicians for every 100,000 residents, according to the Association of American Medical Colleges.

Health insurance coverage in rural areas was a major theme in this year’s legislative debate over whether to expand Medicaid coverage under the Affordable Care Act. The expansion measure, which stalled under Republican opposition, would have allowed an estimated 54,000 low-income, childless adults to qualify.

Supporters argued the expansion was especially crucial for rural residents without coverage, saying it would reduce the cost of uncompensated care that is passed along through higher premiums to the insured. Opponents, including Gov. Dave Heineman, argued the measure would become a financial burden for the state and could overwhelm health care providers who are already in short supply.

Even without the expansion, many rural doctors are still treating the uninsured or underinsured and absorbing the cost, said Dr. Rowen Zetterman, a spokesman and past president of the Nebraska Medical Association.

Zetterman said expanding Medicaid would encourage patients to seek preventive care, such as mammograms, Pap smears and colonoscopies. Adding new, Medicaid-covered patients would also generate revenue that would help doctors expand their practices and hire health coaches, medical technicians and other workers, he said.

“To me, it’s unconscionable that we have as many uninsured as we do in as wealthy a country as we are,” Zetterman said. “Healthy people tend to work harder, do more and do things that benefit the state and the country. We ought to do everything we can to make everybody as healthy as they can, and we know that the uninsured tend to be less healthy.”

Because they lack large employers, many of Nebraska’s most rural communities aren’t well-served by a health insurance system that relies so heavily on employer-based coverage, said Jon Bailey, research director of the Lyons-based Center for Rural Affairs. Bailey said many families have simply opted out of coverage or bought into bare-bone plans that are more expensive.

“In any place where you have a remote population, you seem to have this issue come up,” Bailey said. “It doesn’t appear that the data have really changed much over the years. This is a reasonably consistent problem.”

Like other states, Nebraska splits costs for the federal-state Medicaid program. The federal government has agreed to pay 100 percent of the cost for new recipients through 2016, at which point its share would begin ratcheting down to 90 percent.

The lack of coverage in rural Nebraska has led many farmers or spouses to seek jobs that offer insurance benefits, said Roger Furrer, executive director of Community Action of Nebraska, a nonprofit that helps low-income families.

“Basically, the farming and ranching is happening during their overtime,” Furrer said. “It takes additional time away from the families, and from what they’re really passionate about — farming and ranching.”

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