The border between Kentucky and Tennessee runs just over 340 miles in a nearly straight line. It doesn’t waver to follow natural divides, such as rivers or high mountains. It is an entirely artificial designation indicating only a difference on governance.
But oh, what a difference governance can make. On one side of that straight line, rural health care is doing well. On the other, it’s undergoing something close to a collapse.
{mosads}The roots of that collapse run deep and speak to important aspects of what kind of country we want to be. When President Ronald Reagan signed the Emergency Medical Treatment and Active Labor Act (EMTALA), mandating that hospitals treat desperately ill people without regard for whether they could pay, it was a triumph of humanity over economics. Congress and the president acknowledged that health care has a moral component above other goods and services, and that the market could not be relied upon to fulfill that moral obligation.
The passage of the EMTALA had relatively mild effects on hospitals in wealthy communities, where almost everyone is insured. But in poor areas with large numbers of uninsured, it dropped an existential burden on already frail medical centers.
Because poverty rates in farm communities are higher than in cities, the cost of Reagan’s unfunded mandate fell hardest on rural hospitals. In addition, the increasingly capital-intensive nature of high-tech medicine favored big hospitals benefiting from economies of scale. Over time, that double whammy increased the fragility of hospitals in America’s small towns until, according to The National Rural Health Association, more than 700 rural hospitals were at risk of going out of business.
The Affordable Care Act’s Medicaid expansion was intended not just to provide more humane treatment for the uninsured, but to ensure that the hospitals serving the working poor would remain viable. North of the Tennessee border, Kentucky’s former Democratic governor enthusiastically embraced and supported the expansion, providing insurance to hundreds of thousands of people, mostly in rural areas. To the south, in Tennessee, the Republicans in charge abandoned Reagan’s humanity in favor of small-government ideology. They refused billions in federal aid, leaving the welfare of their constituents to market forces that are, literally, amoral.
The results, only a few years later, are dramatic. Before the ACA, the uninsured rate on Kentucky’s side of the border was 16 percent; Tennessee’s was 15 percent. According to a Kaiser Family Foundation study, after the ACA Kentucky’s rate has dropped to 7 percent, while Tennessee’s has remained high, at 13 percent. (The national average is 10 percent.)
There is no explanation for the difference that the Kentucky-Tennessee border makes except the two states’ different approaches to the health of their citizens. If Tennessee had accepted the Medicaid expansion and its uninsured rate had fallen as far as Kentucky’s, its health care system would be serving 400,000 fewer uninsured patients. In rough terms, hospitals and clinics would have almost $750 million more to cover operating expenses.
Since the passage of the ACA, 10 Tennessee hospitals have gone out of business, versus only four in Kentucky. (Adjusted for population, Tennessee’s closure rate is about 50 percent more than Kentucky’s.)
When a rural hospital closes, it impacts not just the area’s health, but its economy. Studies have shown that after a hospital closes, unemployment rises and wages fall. The sense of place the hospitals support weakens, with all the social pathologies that accompany the loss of a sense of community.
“Our politicians are blind to these people,” says Dr. Garrett Adams, who founded the Beersheba Clinic to provide health care in Tennessee’s rural mountains. “It’s like the population nobody cares about.”
In a rational world, our two states would look across the border and adopt the policies most beneficial to their citizens. In fact, nothing of the sort is happening. Kentucky’s new Republican governor is ignoring the lessons of Tennessee and busily hacking away at the state’s successful ACA adoption — which will cost at least 100,000 people their health insurance and cause rural hospitals to close. In Tennessee, Republican resistance to the ACA is so entrenched that adopting the successful policies of the state next door isn’t even under consideration.
The great irony of this is that the counties most adversely affected by Republican policy are counties that typically vote heavily Republican. The hospitals that go out of business, the patients who go untreated, the small businesses that fold as communities collapse are part of the Republican base. One would imagine that would be of concern to Republican politicians on both sides of our long, straight border. It’s not.
John Yarmuth (D) is U.S. representative for Kentucky’s 3rd Congressional District. Mariah Phillips is a teacher and a Democratic candidate for Congress in Tennessee’s 4th District.