McCaskill: Missouri’s Rural Hospitals May Be At Risk Of Closure If Obamacare Is Repealed

May 2, 2017

President Donald Trump and Republican leaders in Congress are promising to take another vote this week to repeal the Affordable Care Act, otherwise known as Obamacare. But Sen. Claire McCaskill says rural hospitals in the state could be forced to close if the health reform measure is repealed.

McCaskill says she met with leaders of several of Missouri’s rural hospitals earlier this year, and many of them say Missouri’s failure to expand Medicaid has had a harmful impact on their financial health.

KCUR’s Dan Margolies recently spoke to McCaskill, a Missouri Democrat, about her concerns. The audio version has been edited for length and clarity.

You recently asked the Government Accountability Office to review the closures of rural hospitals and federal programs aimed at addressing the problem. Why is this of particular concern now?

Well, we have, first, more than 2 million Missourians live in rural areas of our state. And 41 percent of our state's hospitals are in rural areas. We know that they are under particular stress right now, particularly in states like Missouri that have refused the money that has been offered them for their Medicaid program under the Affordable Care Act. We know that there’ve been 78 rural hospitals closed, including three in Missouri. We know that 74 percent of those hospitals were actually in states that refused to accept the Medicaid money that was offered by the federal government back to the federal taxpayers in those states. 

So I want to make sure that we understand all of the public policy reasons that are contributing to the closures of rural hospitals as the Republicans are trying to revamp the health care delivery in this country. I want to stay very focused on those folks, those 2 million Missourians who their medical care is more difficult to get, it is more expensive and frankly, just on the economic side, these hospitals, in most instances, are the No. 1 employers in these communities. And their health, the health of these hospitals, is very important to the health of rural Missourians.

So as you just pointed out, senator, Missouri is one of 19 states that have opted not to expand Medicaid under the Affordable Care Act. What effect has that had on rural hospitals in the state?

Well, there's no question that it has had a dramatic impact. Rural hospitals are more dependent on, first of all, Medicare because the populations tend to skew older. And they're more dependent on Medicaid because many of the people in rural Missouri, because there is no other hospital, they are taking in a lot of the Medicaid patients. And then frankly, they take in a lot of uninsured because of the gap in Missouri of people who make too much money. ... They're too poor to get on the exchanges and definitely not poor enough to get on Medicaid. So because the exchanges were designed assuming states would take the money, take their own tax dollars back, to help with health care. 

That’s what’s so hard for me to understand, that the folks in Jefferson City, because they wanted to make a political point about Obamacare, they have steadfastly refused to accept Missourians’ own federal tax dollars – the same tax dollars they accept for highways, they accept for all kinds of economic development grants, they accept for all kinds of purposes – but they’ve refused to accept these dollars for people’s health care. And that is why the rural hospitals in Missouri are under more stress than hospitals in states that expanded Medicaid.

So I hope this GAO report will not only talk about that, but also talk about other reasons why rural hospitals are in such danger right now in terms of their ability to keep the doors open.

You mentioned earlier that three rural hospitals in Missouri have closed. How many rural hospitals in Missouri are at risk of closure?

I think that they would tell you many of them. Forty-six of the 50 counties in our state that have above average mortality rates are in fact in rural areas. And we know that almost half, over 40 percent of the state's hospitals, are in rural areas. We've now lost hospitals in Farmington, in Osceola, and down in Reynolds County. I talk to hospital leaders all the time and I've particularly spent time talking to leaders of rural hospitals in places like West Plains and Houston and other small communities across our state. And they are very worried. They're particularly worried if the Republican plan for health care involves even more Medicaid cuts that for a state like Missouri that never expanded, that then would be looking at additional cuts. That is really problematic.

And by the way, the plan the Republicans are talking about is going to make insurance much more expensive for, particularly, people between the ages of 55 and 65 that live in rural communities. So it’s going to be a double whammy if the House bill that’s being contemplated actually ever makes it to the president’s desk.

And how likely do you think that is?

I can’t tell you at this point. You know, when I went around the state recently on town halls and I was in rural communities, and I would explain in places like Hannibal that an average 60-year-old man who is making around $30,000 as a small farmer, his premiums on the exchange would go from, currently, about $2,400, $2,500 a year, to as high as $13,000 a year. That was shocking to the people that were at my town halls in these communities outside of Kansas City and St. Louis. And what people have to realize is that their plan allows older people to be charged five times as much as younger people, and it’s based on how much insurance premiums are where you live. And insurance premiums are higher in rural Missouri. So it’s going to be particularly devastating to rural Missouri if the Republicans and President Trump have their way with what they’re trying to do.

And what we should be doing, frankly, is just fixing the problems in the Affordable Care Act, shoring up the individual markets, expanding Medicaid in Missouri. We could improve the number of people that actually have insurance in our state and make it more affordable for everybody else, because everyone who shows up without insurance at the emergency room, we all pay the bills through our insurance premiums. It’s not like that money comes from the fairy. The money for people who show up and who we take care of in America that don’t have insurance, we just pay it indirectly rather than directly.

Final question: You're up for reelection next year in a state that Donald Trump carried by more than 18 percentage points. How do you like your chances?

You know, I am very comfortable in the role of underdog. I don't think there's any question that I'm an underdog. But I've been there before. And I think it just means I've got to work even harder to make sure I'm listening carefully, showing respect to all Missourians. One of the things that's been frustrating to me is that some of my friends and frankly, some of my colleagues from much more liberal states, like California and New York, they have a tendency to talk about people who voted for Donald Trump in a derisive tone, kind of looking down their nose at them, like somehow they're not smart. I couldn't disagree more. I think the people who voted for Donald Trump wanted a disruptive president, they wanted somebody who was really going to shake things up, because the system hasn't been working for them. It has been rigged against them; those people who are working two and three jobs and feel like every year they get further and further behind.

So I want to make sure I show up, I show respect, I listen, and then Missourians have to decide: Do they want a check and balance, do they want a state where both parties are represented, or do they want a state where there’s no check and it’s all one party? I kind of think Missourians like the idea that we have two parties represented in important places like the United States Senate, and I’m hoping that will show next November at the polls. But we’ll see.

Dan Margolies is KCUR’s health editor. You can reach him on Twitter @DanMargolies.