Episode 3. Rural Health on Life Support with Joan Alker
Michelle Rathman: Hi everyone. It's great to be back with you again on a new episode of The Rural Impact. I'm Michelle Rathman, and again, just thank you so much for spending some of your time with us today. We are in our third in our, it's our final episode in our series. We're calling Rural Health on Life Support. And if you're following the podcast, we hope that you are subscribing.
You'll note that on our first episode in this series, we welcomed Mr. Allen Morgan, and Alan is the CEO of the National Rural Health Association, and he delivered a masterclass on all things rural health and really, going down that tick sheet of all the challenges that rural health organizations are facing today and as a result, the implications and health outcomes for their communities.
In the second episode we were really privileged to have with us, Dr. Julia Interrante. And Dr. Interrante shared with us a tremendous amount of her research and that of her colleagues around America's rural maternal mortality and mobility crisis. And to say that it's, I think crisis is almost an understatement because we are, we really don't have any end in sight, and today's conversation will help shed some light on why that is so.
But before we dive into that conversation, I do want to deliver some information that's on the positive side because there are some positive things happening. I mentioned in our last episode that there are some programs out there that are born out of policy that are really working to improve the maternal mortality outcomes in this country.
And once such programs come to us through the Department of Health Resources and Service Administration, that's HRSA and I've come to know quite a bit the work that's happening out of the Federal Office of Rural Health Policy. And I just think, again, it's important for us to recognize that there are some good things happening.
And one thing that I think is important and really appropriate for this conversation is the RMOMs Program, and that stands for Rural Maternity and Obstetrics Management Strategies. How appropriate are RMOMs and just, obviously the program was born to address some of these things that we've been talking about.
Maternal mortality and mobility rates are rising rural hospital closures, rural obstetrics programs, closing workforce leaving, and so forth. And of course, all the challenges with social determinants of health and the implications that has for health outcomes. And so, the RMOMs program is designed to collect data on rural hospital obstetric services that builds networks to coordinate a continuum of care.
Again, making sure that we've got prenatal and postpartum care as a part of that package. Postpartum care is critically important. Leveraging telehealth and specialty care is another focus of the program and of course improving financial sustainability. I just want you to know that if you go and we'll put this link on the Rural Impact website, if you go to the pages, it's on HRSA's website.
You can read about the different cohorts and understand how the RMOMS program has helped support them to improve their outcomes. So, there's programs in Missouri, New Mexico, Texas, Minnesota, West Virginia. The new cohort that is going on from September of 22 through August of 26 includes South Dakota, Utah, Maine, and Arkansas.
So again, I'm sharing that with you because I just really want our listeners to understand that while we're really focusing on challenges, there are solutions and my invitation is just to get curious and find what might be working in other states and maybe plant a seed thought that could be your state and your community that's benefiting from some of these policies that are working to address those.
With that said, I am happy to start diving into this last episode, and for that I am so happy to share with you that I had a conversation earlier with Joan Alker. And Joan is the executive Director of the Center for Children and Families and a research professor at the Georgetown McCourt School of Public Policy.
Just so impressive. Her work. I've been following her on Twitter. She's nationally recognized as an expert on Medicaid and children's health insurance program. That's Chip for short, and she's the lead author of CC'S Annual Report on Children's Healthcare Coverage Trends. Joan has been published in dozens and dozens of journals, and she writes so many incredible blogs. I encourage you to follow her. And she provides a lot of commentary on a wide range of issues, including Medicaid, section 1115 waivers, child and family health, the role of Medicaid in rural areas, which we'll really dive into today. And of course, numerous reports on premium assistance for the Kaiser Family Foundation.
So, with that said, it is my pleasure to introduce you to Joan Alker and our conversation focused on Medicaid. Let's go.
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Michelle Rathman: Wow, good morning, Joan. It is really a pleasure to have you here because we have a lot of really rough stuff to talk about, and I can't think of anyone better than you, as we get into the entire subject of Medicaid, something that we know benefits rural places greatly. And yet I think is so misunderstood.
Michelle Rathman: Or maybe the misinformation is, another way that we could put it. And Joan, again, thanks for joining us today. I'm really excited to have you here.
Joan Alker: Thanks so much, Michelle, and it's great to call attention to this critical issue of the intersection of rural health and Medicaid.
Michelle Rathman: Absolutely. So, let's start here because your organization does a tremendous amount of research and want to benefit, and I follow you on Twitter and I will say I wish there was a different choice than to like what you're saying, because it's awful, but it's so important. I've been watching you just for, quite some time now.
Michelle Rathman: But first, let's just talk a little bit about what the Center for Children and Families is, where you're housed, what your mission is, and just a little bit about your work and that of your research team.
Joan Alker: Sure. So, the Center for Children and Families is housed at Georgetown University. We're part of the McCourt School of Public Policy. We're a smallish team, just under 20 folks now. And we're all basically foundation funded, so we don't accept any government funding. We don't accept any industry funding either.
Joan Alker: So pretty much all our funding is from foundations, and our mission is to ensure that children and families have access to high quality, affordable health coverage. And we really do that by providing data and evidence to influence the discussion about public policy and working in partnership with many folks around the country to try to improve health policy, which as all your listeners know, needs a lot of improvement.
Michelle Rathman: Yeah. The tagline of this show is all rows to quality of life are paved by policy. And I don't talk about the politics, although that does fuel the policy. And so again, I think it's fitting to have you here because we're in our third and final episode of our first series Rural Health on Life Support.
Michelle Rathman: And anyone who works in the rural space, whether you're a critical access hospital, CEO, or community health a center CEO or a leader in the rural space, families, individuals, moms, we know that access to healthcare in frontier and rural areas, we're not expanding.
Michelle Rathman: We're shrinking. With that we're also leaving quite a few families behind because of this conundrum that we're in with respect to Medicaid expansion and now the unwinding. But we'll get there. So just talk to us a little bit about why Medicaid is increasingly important for kids and families and small towns.
Michelle Rathman: You've done an a, a really great job. There was a paper that I have in front of me, Medicaid and Small Towns in Rural America, A Lifeline for Children, Families, and Communities. It's nice to say it, but I think you could put some really important context to that.
Joan Alker: Yeah, so this is an area that we've done a lot of work in the last five years, and I think that it was a common misconception that Medicaid was more important for cities and urban areas. And, in fact, when you analyze the data, and frankly, this has only become more true in the last few years, the role that Medicaid plays in providing health insurance coverage is even more important in rural areas than it is in metro areas.
Joan Alker: And I'll just give you some recent data that we updated some work that we've done with the University of North Carolina. And I should say this is using census data. It's even a little bit of an undercount, but we find that as of 2021, 47% of children in rural areas were covered by Medicaid, as compared to 40% of children in metro areas. So, you can see a pretty big disparity there. And those numbers, again, are actually a little bit low overall. For adults, 18% of adults in rural areas are covered by Medicaid versus 15% of adults in metro areas. So, over the last 10 years, Medicaid has become an increasingly important source of coverage in this country.
Joan Alker: It is. Now a larger insurer than Medicare, for example, and as its role has grown nationwide, it's grown even more in rural areas.
Michelle Rathman: Well, it's just interesting that you say that because I also have a paper that was released by one of your colleagues, Edwin Park, if I may say, and the headline is "House Republican Study Committee Budget Plan, Again Includes Draconian Medicaid Cuts." And if I may I read this again this morning and I've, read the paragraph several times just to let it sink in, which goes as follows, "Facing such drastic reductions," and we'll get into that, "under federal Medicaid funding, states will have no choice but to institute truly draconian," I hate that word, "cuts to eligibility benefits and provider reimbursement rates." So, we know the, we know it's essential, critical in fact, and so if you wouldn't mind just touching base on what some of those cuts could look like in the face of a time where we know we need more robust Medicaid coverage.
Joan Alker: Perennially, we see these kinds of large proposals to cut Medicaid to terminate the entitlement. The last time we had a real battle around this was when President Trump came into office and tried to repeal the Affordable Care Act. And while they were in the neighborhood, they also tried to cut Medicaid very dramatically and take away the guarantee of coverage that's really the bedrock of the Medicaid program. Fortunately, that proposal was defeated along with the efforts to appeal, the Affordable Care Act. But this keeps coming up and up and when you do see and, we're certainly a nonpartisan organization and work with anybody who'd like to work on making policy better on both sides of the aisle. Unfortunately, it does tend to be that Republicans are the ones here in Congress who propose very large cuts to Medicaid. And that would be really disastrous for rural areas.
Joan Alker: I think any provider who's working in the Medicaid space and has patients or Medicaid will tell you they're getting paid too little for those patients, not too much. So, the thought of cutting Medicaid, which is really a lean program, and it's not to say that there aren't savings, sure. Are there some savings we could get out of, for example, high drug costs?
Joan Alker: Yes. Sure. But fundamentally, Medicaid on a per person basis is the leanest program in our healthcare system. And that's really important to keep in mind when you're thinking about rural areas where you have so many folks dependent on Medicaid. The providers really would be devastated by serious cuts to Medicaid.
Michelle Rathman: I work in the rural health space and right now we're having an extremely challenging time. I think so many years ago when I started this work, we thought, rural hospitals, critical access in particular they’re solid. They get this cost plus 1% reimbursement, but that as the costs go up for healthcare, they're not coming down.
Michelle Rathman: And then you decrease the rate, in which providers are actually paid for their services, what do you foresee? If we stay on this track, what happens if we're connecting the dots. We've got the unwinding, which we'll talk about in a moment, and then we talk about potential drastic cuts in Medicaid investments.
Michelle Rathman: That's the word I like to use. What do you foresee happening for providers who are already looking for the exit doors?
Joan Alker: Yeah. So fortunately, I think for now there won't be any dramatic federal cuts in Medicaid. I'm confident that President Biden is not going to let that happen on his watch. I think the real challenges are the Medicaid unwinding, which we'll talk about. There are huge challenges in those 10 states that continue not to expand Medicaid.
Joan Alker: They're mostly in the south. They're leaving a great deal of money on the table that could be supporting their rural healthcare providers. And then of course, who knows what the future holds, and state budgets may be in tougher shape next year as a lot of the Covid-19 related funding starts to be pulled out, both in Medicaid and other aspects of the state budget.
Joan Alker: I am worried next year between the unwinding and, some of the challenges that state budgets may be facing. A lot of those states gave tax cuts over the last few years rather than building up their reserve funds. So, I don't see any immediate big federal cuts coming, but nonetheless, there are a lot of things to worry about.
Michelle Rathman: Yeah, I mean that state level, we tend to not pay attention to that enough. I get a little frustrated when I talk to people, and I ask them what's going on in their state. So, Joan, just let me so our listeners understand. We, I think we were sitting at 11 states that did not expand and now we're sitting at 10.
Michelle Rathman: Correct? Now that North Carolina got on board if you will. So, we still have 10 states. And before we move on to the whole very depressing subject of the unwinding. Last episode we focused on rural maternal mortality and morbidity. And I take a look at a paper that you all did.
Michelle Rathman: Alabama women need, need Medicaid expansion, one in six women aged 18 to 44, lack health insurance and faced many barriers to good health. And one in six that almost 16% of Alabama women of reproductive age lack health insurance. I know you can't figure out the why so much. But it's the implications.
Michelle Rathman: We want better health outcomes for women and infants without that insurance coverage. Let's talk a little bit about some of those outcomes that you're seeing in your research. The, you some great key findings.
Joan Alker: Yes. We have a maternal mortality crisis in this country, especially for black women, and the statistics are really, really disturbing. Alabama does have the third highest maternal mortality rate in the country. Mississippi's and other state that has an extremely high rate that has not expanded Medicaid and it's just almost beyond belief that we would let our women of reproductive age go without health insurance.
Joan Alker: It's, really kind of shocking. I at this point, I've just got to say that it's politics, right? And, frankly at this point, it's not partisan politics. Because it's a fight within the Republican party. We have many red states that have expanded Medicaid. So, it's a fight within the Republican party.
Joan Alker: This is not a partisan issue anymore. And for those that are sort of clinging onto this knee jerk, Anti-Obama Care, anti-Medicaid, whatever it is, it's coming at a huge cost for their citizens and their providers who serve them. Having Medicaid expansion is not going to solve the maternal mortality crisis that we face as a country.
Joan Alker: This is a very embedded set of issues. However, it is absolutely necessary. There is no state that will lead the way in addressing this crisis without expanding Medicaid because the way that our country is structured health insurance, as I like to say, is the price of admission to our system.
Michelle Rathman: This is so true.
Joan Alker: And if you don't have a ticket you're not going to get in and see a good show.
Joan Alker: So, there are two issues here. We've got to get folks covered so that they have the ticket to admission. And then the second piece is we got to make sure they see a good show. And that's where a more, more complicated set of issues will come in with respect to addressing maternal mortality and morbidity.
Joan Alker: However, like I say being uninsured has so many negative consequences. And anybody who has been pregnant myself included, knows that first, you want to go into that pregnancy being as healthy as you can be. You want to get your chronic conditions under control. Get yourself in the best condition you can be because it's tough being pregnant and you go to the doctor a lot.
Joan Alker: And postpartum. It's also taking a long time to recover from that. So, we want women to be healthy before, during, and after pregnancy, and that's where Medicaid expansion comes in because we don't want these women just to be covered while they're pregnant.
Michelle Rathman: Yeah, it is. Dr. Interrante really focused on this as well because we are, we're, like, we're saying the, when you. Are discharged if you are like on that fast track, 24-hour plan and then you're on your own. And so, we are talk about as a nation, we talk in theory about how important it is to have healthy babies and healthy children, and yet we are not willing to invest in that which is required.
Michelle Rathman: And your numbers. Speak volumes. What almost 50% of our nation's rural, small-town children are insured through Medicaid. When you bring up a really good point I, think it leads into the next subject, which is health equity. I, read something the other day that really jar was jarring and I.
Michelle Rathman: I, don't think I could ever be surprised, but sometimes I find myself shocked actually. There is something that came out of the state of Indiana where public health officials were leaving, they attended their resignation because they're not allowed to use the term health equity anymore.
Joan Alker: Hmm.
Michelle Rathman: And it's as if the word doesn't exist or means something.
Michelle Rathman: And so, I'd like to focus on health equity for a few moments. What are some of the examples of how Medicaid and CHIP, which for those of you who are, don't unwind the acronyms is Children's Health Insurance Program promotes health equity for rural children and adults and access to prenatal and postnatal care, or, those are equity issues, are they not?
Michelle Rathman: And then, as you said, going into a pregnancy, all those chronic conditions that are directly related to those determinants, which are also challenging for many individuals, too many individuals to access in this country.
Joan Alker: Yeah, there's huge implications for health equity. From all the big Medicaid issues the day. I personally think the Medicaid unwinding is a huge health equity issue. Overall, we know that last year we started with just over half of the children in the country. When you use the enrollment data, the census data, as I said, as a little bit of an undercount 54% of all children in the country are insured through Medicaid.
Joan Alker: And that number, we don't know the precise number, but we know that it's higher for black and brown children. We're talking a very, solid majority of black and brown children are being insured through Medicaid. And I want to just stop for a minute and say, why is this why have we come to a point in the country where half of children in rural areas.
Joan Alker: The majority of children of color are being insured through Medicaid. And I think there's a couple of important answers to that question. First of all, on the positive side as a country, we've made a greater commitment to covering children and as a consequence, state. Who really are the ones that drive a lot of the variation that we see.
Joan Alker: They're covering children on average, at higher income levels than they are adults. So even states that are covering adults through the Medicaid expansion, which goes up to 138% of the poverty level, the average for children through Medicaid and CHIP is, two, two and a half times the poverty level, 250% times the poverty level.
Joan Alker: And some states are higher than that. So, there's a greater availability of Medicaid and for low and moderate wage working families. There just is not a lot of affordable dependent coverage from their job. And I think this is a critical aspect of the issue for rural areas. The structure of the labor market is just not likely to lead ever. In my opinion, this medic, the role of Medicaid is here to stay for rural communities because to have the kinds of employers that are offering very comprehensive health coverage for people's children, right? We're not talking about what they offer for the worker themselves, which sometimes that's nothing or very inadequate, but for their children.
Joan Alker: My coverage at Georgetown University, which is obviously a good employer, my dependent coverage is expensive. Even here at Georgetown University. So, for these low wage workers, it's just very hard for them to find affordable employer sponsored coverage, and that's why Medicaid plays such a critical role for children and especially children of color, and especially children living in rural areas.
Joan Alker: Rural areas, as you know, tend to be poorer than urban areas in general and sicker. And so, all of these factors mean that Medicaid's role is so important and that all of these big questions like the unwinding that we're going to get to have huge health equity, implications, they will implicate people of color, families of color, and folks living in rural areas as well.
Michelle Rathman: You bring up so many great points and I, know neither one of us can answer the question. Why? We know. We fundamentally, we know why. There is something within the mindset, within the culture wars that we find ourselves in that. There are enough people in positions of power to say, yeah, it's okay that we're sacrificing these individual lives for whatever gain it might be.
Michelle Rathman: And I fundamentally I disagree with that position because I ask what percentage of the people in your county are deserving of life-saving care? If you answer less than a hundred percent, we need to have a different conversation because we're not valuing an individual having any assemblance of quality of life.
Michelle Rathman: And one of the things I said earlier, what I really appreciate about your work and your commitment is to educating all of us through social media. Good, bad, or indifferent is a very powerful tool to spread good information as much as misinformation, but yours is good. And you talk a lot about the Medicaid unwinding and in a report from February of this year of the headline read, Child Uninsured Rate Could Rise Sharply if States Don't Proceed with Caution.
Michelle Rathman: Now that was in February. Here we are at the end of June. I don't want to assume everyone understands what unwinding is, so we hear the term, but could you just give us a 101 on what unwinding is and then we'll talk about some of the implications of that?
Joan Alker: Sure. So as part of one of the early COVID-19 relief packages that Congress passed, and former President Trump signed anybody who was enrolled in Medicaid or became enrolled in Medicaid during the public health emergency and was eligible for Medicaid. They could not be terminated unless they raised their hand and said, I don't want Medicaid anymore.
Joan Alker: So, what this did was it really put an end to what we see in normal times, quote unquote, which is particularly for children that. They're probably still eligible, but they lose coverage because the renewal process trips up their family. And of course, other folks who in states, for example, that haven't expanded Medicaid, if you're a child or you turn 19, you lost your coverage, you may not be eligible as an adult.
Joan Alker: And. Certainly we have folks whose income went up from the depths of the pandemic, and so they're over income now. So basically, nobody could be terminated from Medicaid unless they wanted to be essentially. So, what we're seeing now is that states starting April 1st, they could begin that process of terminating coverage.
Joan Alker: States have 14 months to go through this process. And so May, 2024 will be the end of the process. And states essentially are checking eligibility for everybody on their Medicaid program. And we're talking 90 million people here. So, this is a huge exercise at a time where states are understaffed.
Joan Alker: And so, this is a very heavy lift. And then we've got the politics of it where we've got some states who clearly want to kick as many people off as quickly as they can. There's just no other way to say it and some who don't. And in some states, we can come back to this. Have really made lemons from lemonade of the pandemic and envisioned a brighter future in their Medicaid program.
Joan Alker: But nonetheless we are seeing a lot of folks lose coverage, not because they've been determined ineligible, but because they have not successfully completed the renewal process. And that's very problematic. We can talk more about that in a minute, but I just want to call out one thing for your listeners.
Joan Alker: Medicaid is run by states and federal government plays a really important role. Sets the rules, gives a lot of money out. But states are running these eligibility systems and we've always had this problem in Medicaid. If you think about Medicare, right? Everybody knows you turn 65, you're eligible for Medicare.
Joan Alker: You can go to medicare.gov, you can call the number. You're going to get enrolled in Medicare, and as a consequence, we have 99% participation in Medicare. That's not true in Medicaid. We always have people in, particularly children who are eligible for Medicaid, but they're not enrolled because maybe their families don't know, or they've lost coverage because the paperwork was too confusing or too scary.
Joan Alker: So, during the pandemic, we actually got to a place where we didn't have a lot of those red tape losses as we call them, where we didn't have these variations from state to state. We saw much more robust participation from those who should always be eligible. So that's the concern here. We've got two groups of folks.
Joan Alker: One are going to be over income and they're eligible for something else, and hopefully they will find that something else, either the marketplace or employer coverage. But then we have a second group who are still eligible for Medicaid. And they're not going to find another source of coverage. They're going to become an insured, and that's much more likely to happen to children.
Joan Alker: So, this is a really very serious red alert right now for children and families, particularly in rural areas, because children are covered at higher rates in those areas.
Michelle Rathman: Oh my gosh you, bring up two, two things that come to mind, in particular. Number one, just in terms of navigators when I think about. Early days when I was working in with a hospital down in Georgia when ACA enrollment came about, and this is an interesting little story here. The person I was working with at the hospital, their responsibility was to set up community meetings to explain the ACA.
Michelle Rathman: And she chose a stock photography of a person with a like distressed headache. And they called it Obamacare. And I said, you know, so and so. When you present it like that, it's negative. So, let's talk about the positivity here. So, my question to you is how do we or who, what entity children aren't going to learn how to.
Michelle Rathman: Figure this out. Like kindergarten class, we can take a break instead of recess, we're going to do Medicaid enrollment for you. Who's navigating this state by state? So, you said they're lean, they're understaffed. If there's someone spending time unwinding, where are the resources that you can think of that are spending time being deliberate about ensuring that people are able to access, navigate, complete the paperwork?
Michelle Rathman: Is that just nonexistent?
Joan Alker: Yeah, that's a great question. Of course, it's going to vary state by state community navigators, and assistors, to the extent that communities have them and a lot of rural communities don't, they are they are there to help. They're particularly probably going to be pretty good at helping people enroll in the marketplace and get subsidized coverage there.
Joan Alker: That's sort of their specialty and that's important. But again, that's not the ballgame for children especially. So, one of the things that we've been saying to really get to families, and this is where we need governors and state legislators to really commit to, let's not lose families who should be getting our health coverage through Medicaid.
Joan Alker: Let's make that commitment. We don't want to see our uninsured rate go up. And really this has to be an all-hands-on deck effort with all the systems that interact with families, right? So, schools, childcare centers, churches, community groups and providers of course, play a very important role, pediatricians, rural health clinics, hospitals, they will come into contact. And another key place I think is pharmacies. A lot of folks are going to find out that they've lost their coverage because they go to pick up a prescription. Maybe they're going to pick up their child's asthma inhaler, or they're going to get a service.
Joan Alker: And we've heard this story already a lot, which is that they didn't know they lost coverage. They never got a letter. They had no idea they had lost their Medicaid and they show up for a doctor's appointment or to get a prescription, to go to physical therapy and they're told they have no coverage. So those this really has to be an all-hands-on deck with leaders playing a key role, but a broader vision here, because this is such a huge, this is the biggest event ever to hit the Medicaid program. The Congressional budget office has projected that we will have 6 million more uninsured people when this is over.
Michelle Rathman: Oh my gosh.
Joan Alker: And it's scary. It's really scary.
Michelle Rathman: It's, a nightmare, Joan, because I say uninsured, people still need healthcare. And in the space that I work in, we're talking about when you have no coverage, and you can't show up for your well child visits and. Or sick visits, or you can't have therapy, or you have to postpone.
Michelle Rathman: Maybe not a lifesaving surgery, but something nonetheless is very important. You're going to show up in an emergency room more than likely. We don't have, in rural America, we don't have convenient cares on every corner they require payment. Go figure. And so, what's going to happen, the domino effect.
Michelle Rathman: Of those who, 6 million people, uninsured. What do you think, if you could speculate, which is probably not a stretch, what's going to happen to our already vulnerable systems of health serving these communities? It's insane.
Joan Alker: Yeah, it's scary, particularly in rural areas which are already suffering from provider shortages and a heck of a lot of pressure. On, the healthcare systems. We were talking earlier about the values question, right? Should we care that people are uninsured? Okay. I, yes, I would like that. But leaving that aside, there are many practical reasons why we're all in this together.
Joan Alker: People have healthcare needs, and they don't go away because they're uninsured. And it's like a balloon. If you press the balloon on one side, it's going to pop out on the other side. What we lose when people are uninsured are a few things fundamentally. First of all, we put families and people at economic risk because everybody knows that one trip to the emergency room when you're uninsured.
Joan Alker: One big event a child falls down, breaks their wrists, that can literally bankrupt a family. And these things happen a lot when, you have children. I children are relatively cheap to cover, but they do need regular healthcare. And I can certainly say I never went to the ER so much as when my kids were little.
Joan Alker: Any of these events could literally set a family back for years with medical debt, which is the leading cause of bankruptcy in this country. So that's number one. But number two is that what you lose when folks are uninsured is you lose regular access to primary and preventive care. And that's just foolish. We know that chronic conditions that adults and children have, things like hypertension, diabetes, asthmas, very, very common amongst children. These are treatable conditions. Depression is another really important example, particularly for maternal health. These are treatable conditions, but you've got to have access to regular medication to regular outpatient services so that you don't get worse, right? And some people are out there saying why should we care about these people losing coverage? Because then they can just get back on if they're still eligible. I just wrote a blog about this and I, reject that argument for a bunch of reasons.
Joan Alker: It's no way to run a railroad. To kick people off and then say, well, they can come back in when they're sick. Don't we want to keep them healthy? That's better for them and it's better ultimately for our healthcare costs.
Michelle Rathman: Well, it's such in conflict with the healthy people, 2030 health. It's it, it's so in conflict with what we talk about. We talk about the need for wellness and for people to be healthy. And yet we put up so many roadblocks. So, in the last few minutes that we have because I could have this conversation with you all day, I you're a very, busy person, but, As the tagline suggests, we do want to connect the dots between policy and rural, whatever is the subject that we're talking about.
Michelle Rathman: And you alluded to earlier why should people care? And I, get this I, people say, why do you care so, so much? And I said I'm, wired that way. I've been in this industry and I, but I do care about, all that which affects the health and wellbeing of anyone in any one of our communities.
Michelle Rathman: That's just the profession I've chosen. But what message do our listeners need to be sharing with their policymakers with respect to Medicaid for those who live in one of the 10 remaining states that have made a policy decision not to expand? And then likewise you're, as you're reporting the figures of how many people have been unwound based on procedural issues and so forth, because it's not just for the individual's health, but it is, there is an economic impact to those communities as well. So, let's, give our listeners a few nuggets of how they can advocate, even if in fact it doesn't directly impact them. Meaning they are, they have another pathway for being insured. So, what are some things that we need to be having them talk because our lawmakers are out there Politicking for all sorts of things against things.
Michelle Rathman: So how do we get this one to rise to the top of their radar screen? How do we get them to snap out of some of this culture stuff and get more in tune with the need to support Medicaid robust expansion and being much more mindful about how people are being, out that they're no longer insured.
Michelle Rathman: I just can’t imagine
Joan Alker: Yeah.
Michelle Rathman: being in those shoes.
Joan Alker: Right. So let me speak broadly to that question. As you say, we've got a lot of focus right now on children and families in the political dialogue, for better or for worse. And I think first of all, everybody, every family in a rural community, is, I bet, touched by Medicaid. Okay. If they're not being covered themselves, they know somebody, their sister, their cousin, their friend, their neighbor, right?
Joan Alker: When you're talking about children and families, everybody's going to be touched by Medicaid. And so first of all, sharing the word. That you're going to have to get your Medicaid checked. So, take action. Make sure you still have your Medicaid coverage. Call the hotline. Look, at your state's website.
Joan Alker: Check and make sure that you are still keeping your Medicaid coverage. So that's like to me number one most important message.
Joan Alker: But with respect to state legislators. And we have some maps now on our website, which is CCF as in Frank, ccf.georgetown.edu. You can look up your county for rural counties to see what percent of kids, what percent of adults are covered by Medicaid, and it's a lot probably for your county, but talk to your legislators and say, look, this, we need a commitment from our leaders to make sure in particular that children are protected in this process, families are protected if you want to protect children.
Joan Alker: We hear a lot of talk about protecting children these days. Let's make sure that we don't end up with more uninsured children. And we need commitments from governors and state legislators to make that happen. It is absolutely starts at the top and they send that message down to the eligibility teams.
Joan Alker: They've got to be out there making that commitment and using their bully pulpit to say they're going to protect children from losing their health insurance. That's what it comes down to. So, I strongly encourage folks to raise this issue. This is affecting every part of the country. It's going to affect rural areas, and now is the time we are going to see coverage losses really stack up this summer and over the next few months.
Joan Alker: So now is the time to raise this issue.
Michelle Rathman: And I shudder to think about any research that would be done to follow those children through their lifetime that were not insured and what their outcomes might be. And we shouldn't even be thinking that way, but we have to, and we have to connect those dots. I will say one idea that I had as you're talking Joan, is I think rural health organizations are in a unique position and we talked about faith-based organizations and communities and community leaders.
Michelle Rathman: I'm headed out to another state working and we're holding a community visioning session to talk about being a healthier county and what that looks like. So, I think real health organizations can lead a discussion and not worry about being stuck in a political conversation. But moreover, talk about what it actually means for the health and wellbeing of their community and the vitality of their local resources.
Michelle Rathman: And I think school superintendents should be there and community leaders. My gosh. I'm going to continue following you. We are going to put up the links for this conversation for the Center for Children and Families. We'll make sure it's up on the Rural Impact website. Joan, I just cannot thank you enough for taking the time.
Michelle Rathman: We will be following you and if you are not following Joan on and on Twitter, I really suggest that you do Joan Alker. Give us your handle again, because I want to make sure people follow you and see what those numbers are.
Joan Alker: it's @JoanAlker1 one, so it's j o a n a l k e r one. Depressing as it is. I will keep tweeting the numbers to show state by state what we know so far.
Michelle Rathman: Well, we really appreciate it, and again, to all of you, we so appreciate you joining us for another episode of The Rural Impact.
Michelle Rathman: We're going to start a new series next time around on rural food insecurity. Very important subject. We know it's tied to health, but there are so many bigger implications to that.
Michelle Rathman: I also want to make sure that I thank Brea Corsaro, our associate producer and Sarah Staub. She's mad creative and she handles all the graphics and the editing of this podcast, and a special thanks to Jonah Mancino for the original music that he's provided to us. Again, you can follow us on Twitter, YouTube, LinkedIn, it's all the same, The Rural Impact, and we'll talk to you the next time.
Michelle Rathman: Thank you for joining us. Take good care. These are not light subjects, but we hope we've enlightened you.
