Not Just a Debate
Health-care reform is paramount to rural Americans

This was the pullout feature of a two-part report on failing health-care infrastructure in rural areas before the ACA was signed into law. I reported and wrote both pieces. Read the overview article.


RURAL CLEAR LAKE, Iowa — Six hundred-plus pages of correspondence — about five pounds’ worth — weigh heavily on Chris Petersen, Iowa Farmers Union president and owner of a sustainable livestock operation with his wife, Kristi. The letters, stacked in yellow folders on the kitchen table, track the couple’s three-year odyssey since being dropped by their private health insurer.

“When you have a personal experience, it turns you into a hell-raising person,” Chris Petersen said. “The trouble is, we don’t have enough people speaking up when they’ve had bad experiences, because until the voices that vote outnumber campaign contributors, nothing is going to change.”

His is a political lesson millions of Americans are learning firsthand as industry pressure threatens another generation of reforms. Although legislation in the past year has gone further than at any time in the last century, key cost-control and accessibility measures remain at risk. And all rural residents — but particularly farm families — will be among the greatest losers should they fail.

“Self-employed people are some of the most vulnerable in our health-care economy — and that’s the dilemma of our farmers,” said Merlin Friesen, a Nebraska Farmers Union member and part-time emergency room doctor. “It’s one of the highest risk professions behind coal mining, and that accounts for a large percentage of the farm business we see.”

A recent multistate survey found that 90 percent of all farmers have health insurance, but large numbers are covered under individual plans, resulting in higher costs and less stability. In Missouri, for instance, farmers who purchased single plans spent on average $2,117 more each year than their counterparts with group coverage.

Regardless of insurance type or plan, rural residents generally bear greater out-of-pocket costs, paying for, on average, 40 percent of all their health expenses. The result is that rural adults are more likely to delay or forego necessary care, yet they still report high levels of medical debt. This is particularly acute for farmers, one of every five of whom has burdensome monthly health-care bills.

Petersen is such a patient.

As is typical among farm families, the Petersens were on-again, off-again with health insurance starting in the mid-1970s, often relying on off-farm jobs for coverage. While employed as a school bus driver, he was diagnosed with a nickel-sized hernia, a slight inconvenience compared to the downtime even such minor surgery would require while running a farm and working full time.

With their two kids out of the house and still in good shape themselves, things changed for the couple in 2000, when they were able to afford private insurance. Five years later, their agent suggested they switch to a company with lower co-pays and a better record of claims payment. The two were approved, despite Petersen’s ongoing hernia and his wife’s lifelong heart murmur — conditions disclosed during the application process. Each month, $700 automatically was deducted from the couple’s checking account.

Just shy of a year later, Chris Petersen was pre-approved for hernia surgery, recovering without a hitch. When bills began arriving, he called his insurance agent and was assured that the company simply was slow in paying the claim. Months later, being hounded by collection agencies for the full cost of surgery and postoperative care, he received the first of what would become hundreds of letters: The insurance company determined that Petersen’s hernia was a pre-existing condition and denied the claim. It issued a new policy covering his wife only.

Within months, following pre-approved heart tests, Kristi Petersen’s claim also was denied and she was dropped. The company’s stated reason: discrepancies between medical records and insurance forms, paperwork filled out nearly two years earlier by their agent listing Kristi as one inch taller and a dozen pounds lighter than on the day of her tests.

Between 1999 and 2008, insurance premiums rose by 119 percent, compared to a 29 percent increase in inflation. These skyrocketing rates have struck rural areas particularly hard — and the impact extends beyond individuals and families who call such places home.

In the current recession, like other modern downturns, the rural economy is shedding jobs at a pace faster than the rest of the nation — and fewer and fewer of those remaining offer health benefits. Of the 45 million Americans living without health insurance the vast majority are rural residents, as are an additional 25 percent with bare-bones plans that don’t adequately cover expenses. The effect extends beyond higher premium prices and diminished overall care.

Over the past 25 years, nearly 500 rural hospitals have closed for lack of funds, and another 2,200 areas now suffer from acute physician shortages. Today, 65 million Americans live in areas with too few primary-care providers — 50 million of whom are rural residents. As a result, millions of unnecessary dollars are spent each year transporting urgent-care patients across miles of countryside, resulting in many surpassing the 30-minute threshold in which the nature and necessity of care explodes in price.

Rural patients increasingly are being seen, even for routine health needs, at regional health facilities, where costs are substantially higher. The average cost per day for care in these hospitals is $7,000; the price is down around $1,100 for community-based care.

“Farmers are getting eaten at both ends,” said Friesen. “The health-care economy is so expensive and unattainable, and farm policy is eating the small farmers at every turn. It makes it increasingly impossible for a small operator to make an income off of farming.”

Over the next 14 years, the Petersens will make $200 monthly installments for medical care they paid thousands in premium costs to cover. Now deemed uninsurable by the private market, the two also spend $1,300 a month on coverage through the Iowa Comprehensive Health Association, a safety net for those who can’t get insured elsewhere. But with his $2,500 annual deductible, Petersen can afford just one of the four annual diabetes and blood pressure checks recommended by his doctor.

“This is not health care; this is sick care, and not even comprehensive sick care,” he said. “We’re taking a bad situation and making it worse, which costs the system even more.”

With Senate and House negotiations under way — and final passage in both chambers still outstanding — what will arrive on the president’s desk is unknown. But one thing is clear: Without significant cost controls and expanded access to primary care, farm families like the Petersens will continue to be plowed under so long as profits — not concern for people — drive our nation’s health-care system.