When the Affordable Care Act (ACA) is fully implemented, it will change America’s healthcare sector. But for the nation’s aging farmers and ranchers daunting problems are still dogging the system.

In early July, the White House announced the delay of the ACA’s employer mandate by one year. The action, said Bob Stallman, American Farm Bureau Federation president, is a good thing as it, “will allow the administration to streamline the process for complying and provide farm employers with the information they need to follow the law.

“Many farmers have been confused from the ‘get go’ about their obligations under the ACA because they employ a workforce that is both seasonal and transitory. The proposed rules regarding what farm employers need to do to comply are complex, raising many questions about responsibility under the law.

“Farmers need access to high-quality, affordable health care for themselves and their workers. Unfortunately, questions about how the ACA will help them attain this have been many, while at the same time definitive answers have been hard to come by. We … look forward to simpler direction so that farm employers will know what they have to do to comply with this law.”

Brian Smith at the Missouri Rural Crisis Center says the delay is unlikely to affect many farms since most have fewer than the mandate-triggering 50 employees. “In some industries, (the delay) may be a good thing. In terms of farmers and agricultural industry, it really won’t have an effect. Most farms have far less than 50 employees and the businesses that support them – farm equipment places, the seed and feed stores – also have less than 50 employees.”

In rural Missouri, the delay of the employer mandate won’t really help or hurt, either. Regardless of when the implementation happens, Smith says the problems with rural health care won’t be solved overnight.

“One thing I’ve been working on quite a bit is Medicaid expansion. That has a great impact on rural communities. What we’re seeing in rural Missouri is that farmers and those who work in the agricultural industry, in general, have much less access to work-based insurance. They usually end up having to go to the private market and that normally results in the highest premium/high deductible type plans.”

In many farmers’ minds, even though they’re paying high premiums with high deductibles, the insurance they have isn’t the most effective. That means, says Smith, “They end up acting as if they don’t have insurance in terms of avoiding doctor visits, putting procedures off and things like that.

“That ends up being a problem economically when … they end up in the emergency room. That is the most expensive way to get care. At that point, you’re likely in worse condition than you would be if you’d been going to the doctor regularly.”

And those who don’t have insurance end up going to the emergency room for everything. Many times, those without insurance are unable to pay the bill and the hospital eats those costs.

That leads to another problem in rural communities: coming DiSH cuts (Disproportionate Share Hospital cuts), which came into being when the ACA passed in 2010. The DiSH cuts are expected to reduce hospital funding $17.1 billion between 2014 and 2020.

“One of the provisions in the ACA involves states expanding Medicaid. Under that expansion, hospitals were going to provide funds to the hospitals swallowing the bills from uninsured patients.

“However, the Supreme Court later ruled that the Medicare expansion is optional. Well, for the states that opted out of that, or opted to wait, the rural hospitals are in a tough spot because those cuts are still coming. Urban hospitals will be able to absorb that quite bit better. Rural hospitals are already having a problem.”

Hospitals are already laying off workers and cutting back on services in anticipation of the cuts, which are set to begin in 2014.

“One example is Liberty Hospital (in Liberty, Missouri) that laid off 129 employees, many of them nurses,” says Smith. “Heartland Health in St. Joseph, Missouri, is planning to end ambulance service in July of 2014. In Columbia, BJC is reducing hours for 35 of their employees and leaving 90 positions unfilled that they were once planning to hire for. Also, BJC in St. Louis is laying off 160 employees.

“So, already the hospitals are beginning to take action. They have no choice because of budgetary realities.”