Stanford University economist Neale Mahoney, director of the Stanford Institute for Economic Policy Research and a former healthcare policy adviser to two White House administrations, outlined several proposals being discussed by policymakers as the November midterm elections approach.
Mahoney said the immediate priority for many healthcare economists is reversing federal Medicaid reductions and restoring enhanced Affordable Care Act premium tax credits. He estimated that Medicaid changes, including additional paperwork requirements, could eventually cause approximately 7.5 million people to lose coverage.
He also emphasized that insurance coverage alone does not guarantee affordable medical treatment.
Although approximately 92% of rural residents have health insurance, many remain exposed to substantial medical expenses. Over the past two decades, average individual deductibles for employer-sponsored insurance have risen from approximately $500 to nearly $2,000, with family deductibles often twice that amount.
A household may therefore pay hundreds of dollars each month for insurance and still face thousands in additional expenses following an emergency.
Mahoney described growing interest in policies that would limit out-of-pocket medical costs, including monthly caps and stronger protections for Medicare beneficiaries. Such proposals are intended to reduce medical debt and prevent an illness or injury from creating long-term financial instability.
He also discussed proposals for a public insurance option or broader Medicare eligibility, which could provide an alternative to private insurance plans and reduce the connection between employment and healthcare coverage.
That issue is especially important in rural communities, where residents may have only one or two insurers to choose from. Limited competition can give insurance companies considerable influence over premiums and coverage terms.
Mahoney said private equity investment in healthcare has also raised concerns. Investment firms sometimes acquire physician practices, diagnostic facilities and other medical businesses in markets where patients have few alternatives. He cited research and investigative reporting describing cases in which acquisitions were followed by pressure on medical staff, aggressive debt collection and efforts to increase revenue without corresponding improvements in care.
The briefing also included an account from John Zippert, co-publisher of the Greene County Democrat in Alabama's Black Belt region and a board member of a local hospital, nursing home and clinic.
Zippert said approximately 85% of his county's population is Black and about half live below the poverty line. His healthcare organization applied for assistance through the Rural Health Transformation Program but did not receive funding. According to Zippert, the state instead prioritized telecommunications and other projects while leaving immediate hospital needs unmet.
His account illustrated a central concern raised throughout the briefing: money designated for rural healthcare transformation may support new infrastructure without providing sufficient direct assistance to hospitals already struggling to remain open.
Mahoney also described three overlapping financial pressures confronting American households. The expiration of enhanced marketplace subsidies has sharply increased premiums for people buying their own insurance. Employer-sponsored insurance premiums are projected to rise approximately 9% to 10%, which he described as the largest increase in more than two decades. Additional Medicaid administrative requirements are expected to cause further coverage losses.
The effects could reinforce one another. As healthier individuals leave insurance marketplaces because premiums become unaffordable, the remaining insured population may require more expensive care. Insurers can respond by raising premiums further, placing additional pressure on households that remain enrolled.
Mahoney said he did not believe the marketplaces had entered an irreversible collapse, but warned that rising costs could make coverage increasingly difficult to sustain.
The speakers differed in their areas of expertise, but their accounts described a common problem. Rural healthcare depends on a financial structure that is becoming increasingly difficult to maintain, particularly in communities with aging populations, limited employment opportunities and high rates of chronic illness.
For patients, the consequences are already visible in longer drives to medical appointments, delayed preventive care, reduced maternity services and growing medical debt. For hospitals, the pressures come from declining reimbursement, uncompensated treatment, staffing shortages and the expense of maintaining essential services for relatively small populations.
Bono questioned whether a healthcare system organized around financial returns could adequately serve communities where medical needs are substantial but revenue opportunities are limited.
“When we treat health care as a business, the dollar will always be at the center of every healthcare decision, not the patient,” she said.
The unresolved question for rural America is whether federal and state policymakers can establish a financing system that allows hospitals to remain operational while making medical care affordable for the people who depend on them.
