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Medicaid can be a rural health lifeline

Rural providers and populations are unique in many ways, with fates that increasingly depend on expanding public insurance

Rural health providers may feel burdened by a confluence of policy and financing trends. But one opportunity, depending on the state, can help with sustainability.

Expanded Medicaid eligibility, the missing if not final link for universal health insurance in many states, is already starting to show signs of reducing uncompensated care costs for about half of the states in the country.

Now, there’s new evidence that expanding Medicaid to childless adults can keep hospital inpatient and outpatient units alive, with insured patients accessing acute care, tests and procedures, in some cases for the first time.

Marguerite Burns, a professor of population health at the University of Wisconsin, Madison, studied the impact of a pre-Affordable Care Act Medicaid expansion, from 2009, when Wisconsin offered its Medicaid, or BadgerCare, coverage to 60,000 childless adults. (Due to imited funding, the state had to turn away another 100,000 who were eligible.)

In a study for Health Services Research, Burns and colleague examined Medicaid claims and enrollment data from the Marshfield Clinic, a two hospital system with 48 community care centers in rural Wisconsin, across two different groups of childless adults, new Medicaid enrollees previously treated in Marshfield’s safety net program and new enrollees who were largely not accessing the healthcare system.

About two thirds of the cohort had at least one chronic illness diagnosis after enrolling in Medicaid, including hypertension, diabetes, depression and substance abuse disorders. After the new population groups were covered by Medicaid, the Marshfield Clinic saw fairly significant increases in many, though not all, clinical areas.

For those patients who were previously accessing Marshfield’s safety net program, preventive care visits increased by 26 percent, while inpatient hospital admissions rose by more than 50 percent. The other group, the uninsured who weren’t using Marshfield’s safety net program, also brought large increases in outpatient and inpatient visits, compared to their reported utilization before Medicaid enrollment.

But the researchers did not find evidence of a change in emergency department visits after the expansion, in either group — adding to a somewhat conflicting body of evidence on the issue of whether expanded Medicaid and insurance generally makes individuals more likely to use emergency care.

“These baseline differences between urban and rural populations in care use might alone suggest that the effects of a public insurance expansion may differ from the experience of urban populations,” the researchers wrote. “This possibility is further supported by the intriguing observation that the disparity in care use between insured and uninsured rural residents is present but attenuated compared to city-­dwellers.”

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