What Gov. Sam Brownback gets wrong about rural health care in Kansas

With concerns mounting about access to medical services in rural areas, Kansas Gov. Sam Brownback has asked for a task force to address the challenges.

That’s a good move, if late. The hospital in Independence, Kan., closed last year, and others are on the ropes.

But by apparently ruling out expansion of Medicaid eligibility, Brownback is asking his solutions group, to be assembled by Lt. Gov. Jeff Colyer, to ignore the most accessible and obvious remedy.

In his State of the State speech, when he announced the effort, Brownback launched a simplistic attack on President Barack Obama’s signature health care reform law.

“KanCare is working. Obamacare is failing,” he said.

KanCare is the state’s revamped Medicaid program that handed off responsibility for caring for low-income, disabled and frail elderly Kansans to three managed care companies. How well it is working is in dispute.

Brownback went on to accuse the federal health reform law of harming rural hospitals and rural health care.

“It was Obamacare that cut Medicare reimbursements to rural hospitals,” he said. “It was Obamacare that caused the problem.”

Here, too, the governor is reducing a complex situation to an unsophisticated political attack.

Many rural hospitals were in trouble long before Congress passed the Affordable Care Act in 2010. Doctors and patients — especially those with insurance — have been gravitating toward larger hospitals in more populous areas. A move toward outpatient services also has taken a toll.

The Affordable Care Act did lower Medicare reimbursement rates for services provided by hospitals. Hospitals agreed to the cuts because they anticipated seeing more patients with private insurance and also a sizable uptick in patients covered by state Medicaid programs.

But some states, including Kansas and Missouri, have refused to increase Medicaid eligibility. That leaves hospitals to forfeit some of their Medicare reimbursements but still pick up costs for uninsured patients in the Medicaid coverage gap.

At the same time, the federal government is phasing out Disproportionate Share Payments, which compensate hospitals for serving higher numbers of uninsured patients.

Hospitals also have been hurt by a reduction of Medicare funding that has nothing to do with the Affordable Care Act. Unable to agree on government spending in 2011, the U.S. Congress passed the sequester, which mandated steep, automatic cuts.

For hospitals in Kansas and elsewhere, that meant an additional 2 percent reduction in Medicare reimbursements — a big hit for hospitals on the margin.

When Colyer convenes his task force, he’ll find plenty of expertise on the subject of rural health access. Hospitals and health care experts in Kansas and beyond already are looking toward a landscape in which traditional hospital services give way to online consultations, more reliance on nurse and dental practitioners, and other innovations.

The Kansas Hospital Education and Research Foundation, an offshoot of the Kansas Hospital Association, is experimenting with two models that would refocus the mission of rural “critical access hospitals” away from inpatient stays and toward outpatient and emergency care.

But nearly everyone in the trenches agrees that Kansas can’t continue to pass up Medicaid expansion, which would provide insurance coverage for about 150,000 persons and bring about $360 million in federal funds into the state’s medical network.

“KanCare expansion is an important factor in the survival of rural communities — it’s an economic issue,” Dave Martin, the city manager for Fort Scott, Kan., wrote in a recent opinion piece.

The cash-strapped Mercy Hospital Fort Scott is projected to gain about $2.5 million a year if Kansas would expand Medicaid eligibility, Martin said.

“Instead of using that money to help rural health care providers, the Kansas Legislature has refused to accept nearly $1 billion in federal funds for Medicaid expansion over the past three years,” he wrote.

Brownback, in his speech, said his administration welcomed diverse views on rural health but indicated his mind was made up.

“Let’s be realistic,” he said. “Congress recently voted to defund expansion. We cannot rely on yet another Obamacare false promise.”

What the U.S. Congress passed was a “repeal and replace” vote, which Obama promptly vetoed. Detractors have spent the last six years predicting that the Affordable Care Act would go away as a result of an election or a legal decision.

That hasn’t happened, and the fundamental tenets of the act will be very difficult to dismantle at this point.

It is Brownback and like-minded lawmakers who need to be realistic.

The Affordable Care Act demanded changes that make up part, but not all, of the stresses confronting rural hospitals.

But the law also presented an opportunity for hospitals, rural and otherwise. That opportunity is Medicaid expansion, and it’s past time for Kansas to take advantage of it.

This story was originally published January 22, 2016 at 6:08 PM with the headline "What Gov. Sam Brownback gets wrong about rural health care in Kansas."