The Senate historically has paid special attention to the needs of rural areas, but as the chamber readies its health care bill, there are concerns that the bill would undermine coverage in those places more than anywhere else.

While the exact text of the Senate bill is not yet posted publicly, all signs point to somewhat similar language to the House bill (HR 1628), which would reduce funding for Medicaid compared to current law and impose caps on Medicaid funding. Under the House bill, older people also would face higher premiums — and rural areas tend to be home to a large number of older Americans.

These proposals worry advocacy groups, as rural areas are disproportionately affected by cuts to Medicaid and premium increases. Rural areas already have more uninsured and underinsured people per capita than the rest of the country. In addition, these organizations are expressing frustrations over the increased levels of bad debt to rural hospitals and the need for marketplace changes.

“It’s very polarizing when it used to be one of the health care issues that really brought Republicans and Democrats together,” said Maggie Elehwany, vice president of government affairs and policy at the National Rural Health Association.

Many of the holdout Republican senators are from states with large swaths of rural areas.

“For us in Alaska we’re pretty much the definition of rural, so we’re trying to highlight the issues that impact us and why so much of what we see in the House-passed bill is not helpful for us,” said Sen. Lisa Murkowski, R-Alaska.

Historical Protections

The difference in the dynamic is striking. Senate leaders and committee chairmen over the past two decades traditionally paid special attention to the impact of health care changes on people in small towns and the countryside.

That was particularly true for the Senate Finance Committee leaders when the 2003 Medicare drug benefit and 2010 health care overhaul laws were enacted, Charles E. Grassley, R-Iowa, and former Sen. Max Baucus, D-Mont. Another leader in these efforts was Tom Daschle, D-S.D., who led the Democrats as majority or minority leader until his 2004 electoral defeat.

In 2003, Grassley and Baucus added $25 billion in Medicare funds for rural health providers over a 10-year period to the prescription drug law (PL 108-173). And Grassley helped in pushing for a change added to the Democrats’ 2010 health care overhaul (PL 111-148, PL 111-152) that took steps to shore up rural health care, such as improving pay for doctors in rural areas.

Senators also have championed a range of programs over the years to bolster rural health care, including the critical access hospital program, Medicare dependent hospital program, rural referral center program and sole community hospitals.

To be sure, Grassley and other senators such as Steve Daines, R-Mont., have talked during the current debate about trying to help rural areas. But the overall impact of the legislation would undercut coverage, according to the Congressional Budget Office. And rural areas would be hit particularly hard.

Grassley said, however, that he is concerned about significant problems and a lack of insurers in the Iowa marketplace under Obamacare.

“Obamacare’s unaffordability and collapse in Iowa are causing serious problems. For Iowans in the individual market, including farmers, small business owners and others, they’re hit hard by astronomical Obamacare premium increases. Premiums went up by as much as 43 percent from 2016 to 2017,” Grassley told CQ Roll Call. “Now, because of the way Obamacare is designed, these individuals face tremendous uncertainty and anxiety about even having access to a plan in 2018. Obamacare has failed in so many ways for the people of our state and others, so I’m looking for how to make health care more affordable and accessible.”

Medicaid’s Impact

A major issue would be the bill’s federal cuts to Medicaid, the program for people who have low incomes and have disabilities. The proportion of rural people who qualify for Medicaid is higher than in many cities.

The House bill would slice Medicaid funding by $834 billion over a decade compared to current law, the CBO found. Senate leaders are said to be considering even deeper reductions, although CBO has not released an estimate.

About 23 million people over a decade would no longer have coverage if the House bill becomes law, according to CBO. An increase in the uninsured rate means that more people will visit hospitals for emergency care, and rural hospitals are often not able to absorb this increase in people unable to pay for these services.

Hospitals in small towns depend heavily on Medicaid funding and many have already closed. Rural hospitals in states that have not expanded Medicaid are even more likely to close.

“What’s happening is that they’re exacerbating the rural hospital closure crisis,” said Elehwany.

About 51 percent of residents in rural West Virginia, 47 percent in Alaska, 38 percent in Maine and 37 percent in Nevada rely on Medicaid, according to a June report from the Georgetown Health Policy Institute. The report found that in non-expansion states, the uninsured rate for adults in small towns and rural areas is 21 percent, almost double the 11 percent uninsured rate in expansion states.

The health law provided states that want to broaden Medicaid eligibility with higher federal matching rates for that population. Thirty-one states and the District of Columbia opted to expand. The Center on Budget and Policy Priorities found that in eight states with Medicaid expansion, more than a third of enrollees live in rural areas.

Republicans plan to phase out the higher federal payments for expansion. Senators have floated a number of ideas to lessen the blow of the cuts. Majority Leader Mitch McConnell of Kentucky has advocated for a three-year phasing out of the enhanced funding while moderate Republicans have pushed for a seven-year glide path.

“The idea is that we need to work some things out so that states that are rural states that have expanded Medicaid like Alaska and there are states that are rural states that didn’t expand Medicaid like Wyoming and the question is how do you make sure that’s balanced? Not all rural states are the same,” said John Barrasso, R-Wyo., the No. 4 Senate Republican.

Of the 52 Republican senators, Barrasso notes that 20 senators are Republicans in states that expanded and 32 are from states that did not.

A former Senate Republican committee aide who worked on health issues doesn’t think that rural health care is completely forgotten but more lost in the shuffle of other issues.

The former staffer points to increased attention to the opioid epidemic and how that affects more rural areas than urban ones. For example, Sen. Rob Portman, R-Ohio, has said he will not vote for the bill without added opioid funding.

However, critics of the bill such as hospital officials and physicians, say that reducing federal support for Medicaid would undercut addicts’ access to treatment since the program is the nation’s largest funder of mental health and substance use treatment.

Some senators dispute the notion that they are less focused on protecting rural health care than in the past.

“I have a list of things and so does Sen. [John] Thune, and so does everybody else in rural areas. And those of us on the Ag committee are weighing in, and we just want to make sure that we still have adequate health care, more than that really,” said Sen. Pat Roberts, R-Kan.

Political Ads Targeting Republicans

Last week, grassroots advocacy group Save My Care launched radio ads in four states — Alaska, Maine, Nevada and West Virginia — dissuading their respective senators from supporting the health care bill because of how it could affect rural areas.

The ads highlight the House bill’s changes to Medicaid including cutting the growth rate.

Save My Care’s ad targeting West Virginia Sen. Shelley Moore Capito, highlights how the Senate bill also could result in patients losing access to opioid abuse treatment and emphasizes the dangers of lifetime limits on coverage that could be allowed under waivers in the House bill.

On Sunday, the Community Catalyst Action Fund also launched ads airing in Nevada, Alaska, Arizona and West Virginia, all states with significant rural populations.

“I’m raising my kids and working two jobs. Without these services I couldn’t manage caring for my parents too. Just one vote in Congress could break us. Across Alaska, Medicaid provides critical services to thousands of seniors,” says the narrator in the ad targeting Murkowski.

Insurance in Rural America

Critics say the Senate bill, if it is similar to the House version, would increase premiums in the short term, particularly in rural areas.

“There’s a lot of evidence that older people are going to face much higher premiums than they do now and get less assistance. And in many rural areas there’s a disproportionate amount of the older population,” said Tim Jost, a professor at the Washington and Lee University School of Law.

Jost said the House bill’s impact is clear because it would change Obamacare subsidies, which are more generous in high-cost areas such as rural places, to tax credits that are not adjusted for costs.

“If you have premium tax credits that are the same across the entire country, then places where premiums are higher are going to be hit a lot harder,” said Jost.

Sen. Ted Cruz, R-Texas, said Tuesday the bill would not reduce premiums to a level he can accept. “If it is going to pass, the bill is going to need to make meaningful steps to lower premiums,” said Cruz.

When asked if the Senate bill would lower premiums for rural residents, Murkowski said, “It’s hard for me to answer questions about what’s been done and what has not been done when we don’t know what the product is.”