Despite high rate of uninsured, rural West Texans not flocking to Obamacare

AUSTIN - Time is running out to buy medical insurance for this year under the Affordable Care Act, better known as Obamacare. However, though Jan. 31 is the deadline and millions of Americans have signed up for coverage since the current enrollment period began on Nov. 1, don't expect a big rush in rural West Texas.

While 11.2 million Americans had enrolled by the end of 2015, including 1.1 million in Texas, and in two years the state's uninsured rate has fallen from 25 percent to less than 20 percent, enrollment figures show the uninsured rate in rural areas remains almost as high as in October 2013, when marketplaces created by the ACA began offering coverage.

"Our association does not have any hard data, but as we talk to the rural hospitals, the sense that they continue to share with us is that any increase in the number of insured under the exchanges is very minimal," said Don McBeath, director of government relations at the Texas Organization of Rural and Community Hospitals.

"This is not an issue just in Texas, it is nationwide," said McBeath, who was Lubbock County Judge from 1991 to 1998.

Fewer choices, higher prices

A Stanford University study released last February explained why, compared to their urban counterparts, most rural residents are not signing up for medical insurance under the ACA.

"Small rural coverage regions under the Affordable Care Act have fewer insurers to choose from and higher prices relative to similar rural markets that get grouped in with larger urban markets nearby," the report states.

"Small and rural regions appear to attract fewer entrants," wrote Michael J. Dickstein, an assistant professor of economics, in a policy brief for the Stanford Institute for Economic Policy Research. "Insurers also charge higher premiums to rural residents."

Moreover, a study the Baker Institute for Public Policy at Rice University and the Episcopal Health Foundation published in August found that the insured population in Texas "remains primarily Hispanic, middle-aged, with low incomes and no college degree."

That's the profile of a growing number of rural counties in West Texas.

In Bailey, Crosby, Deaf Smith, Floyd and Parmer counties - to name a few - Hispanics are now the majority group and an average of 25 percent of them live below the poverty line of $24,250 a year for a family of four, according to U.S. Census Bureau figures.

"The lowest-income families, who are likely to have worse health status, have no access to subsidies," Vivian Ho, chair in health economics at the Baker Institute and a professor of medicine at Baylor College of Medicine, said in the report.

"The ACA intended to give the poorest individuals Medicaid coverage, but Texas has not elected the Medicaid expansion offered by the law," Ho said.

Elena Marks, president and CEO of the Episcopal Health Foundation and a nonresident health policy fellow at the Baker Institute, agreed.

"Not surprisingly, the lowest-income adults comprise an increasingly large percentage of the uninsured, because most of them were ineligible for coverage opportunities in the marketplace," Marks wrote. "The ACA offered coverage to this group through optional Medicaid expansion, but Texas has not expanded Medicaid."

Rural hospitals get some help

McBeath said though the high percentage of people with no medical insurance is a major concern for rural hospitals because many of those facilities continue to struggle financially, for now medical institutions are holding their own, thanks mainly to new money for Medicaid payments the Texas Legislature approved last year.

The 84th Legislature restored $58 million of the approximately $75 million for Medicaid payments to rural hospitals the lawmakers cut in the 2011 session when they tackled a $27 billion shortfall. The restoration of most of the funding was critical because most insured patients at rural hospitals are on Medicaid or Medicare.

Medicaid is the joint federal and state program that helps qualifying low income people pay for long-term medical and custodial care while Medicare is the federal insurance program for people 65 and older.

"It is fair to say that rural hospitals continue to struggle," McBeath said. "But I do believe sincerely that the extra Medicaid payments that (state Rep.) Four Price took the lead in (restoring) will take the pressure off. We didn't get 100 percent, but what we got helps."

Price, an ACA critic and chairman of a House subcommittee that deals with health care funding, said though he is relieved rural hospitals are holding their own, the high percentage of uninsured patients those institutions care for is one of his top concerns.

"I am always concerned about the adequacy of health care in rural communities, not only maintaining what is available now but improving it for those communities as well," Price, R-Amarillo, said. "The Affordable Care Act has not been affordable."

In many states, more than half of the plans offered through the HealthCare.gov, the federal online market place, have deductibles of $3,000 or higher, a New York Times review found.

"Having access to health care and having access to health insurance are two different things," Price said "You can have insurance coverage but not access and you can have access but not insurance."

Some options out there

Rep. Garnet Coleman, who served in a now-defunct advisory group President Barack Obama created when the then-Democratic controlled Congress approved the ACA in 2010, said though he is concerned about some problems the uninsured face when trying to get coverage, people could help themselves greatly if they shop around.

"Look for the policies that are less expensive and have lower deductibles," Coleman, D-Houston, advised. "Also, even if somebody is re-enrolling, look for policies that are less expensive in terms of premiums and the deductible.

"So, it is very important that people shop for the best price, for the lowest deductible and for the best network of hospitals, doctors and providers," Coleman stressed. "This is tough. It's a tough deal, but it is better to be safe than sorry.

"Having insurance is very important because you never know what's going to happen and you need treatment."

Enroll America, the nation's leading health care enrollment coalition, reminds the uninsured population that those who choose to remain uninsured could face a fine of $695 or 2.5 percent of their annual income, whichever is greater.

"The good news is that financial help is available to help you pay for your plan," Enroll America said in a Jan. 1 news release. "In fact, as of September 2015, over 838,000 Texans were enrolled in coverage through the Marketplace, and 85 percent of them received financial assistance to make their monthly payments affordable."

enrique.rangel@morris.com

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