Will Missouri truly, fully enact the ACA? A key piece, Medicaid expansion, is still up in the air, says Smith. “There are a lot of opponents of ACA in the state legislature. Because it’s a part of ‘Obamacare,’ their first instinct is to resist it.

“When you’re talking rural communities, you’re talking about citizens that are older in age and lower in income. The ACA will be a big help to those folks. There are a lot of folks that would qualify for Medicaid expansion if it is allowed.

“There will also be a lot of folks that would qualify for subsidies on their premiums. So a lot of farmers, who have high premium/high deductible insurance or go without a plan and keep their fingers crossed, would be able to get premium subsidies even if they don’t qualify for Medicaid.

“We would be looking at health insurance plans with much more robust benefits than are being offered today. Plus, if they fall within the right income range – I believe that is 400 percent of the federal poverty level – they’d qualify for premium subsidies. That would make insurance affordable with real merit and value.”

In 2008, a Missouri rancher interviewed for a Farm Press story (see here) on health care said he was considering dropping health insurance and buying a $500,000 life insurance policy. “Then, I’d use that policy as collateral. If I did have a big hospital debt, I’d just sign the policy over to them. When I die, they’d get their money.”

Smith says such considerations continue to this day. “All the time, farmers and other rural citizens must make really tough choices. ‘I can pay for these high premiums and end up with a plan that has a sky-high deductible. And if I meet that deductible and absorb that cost, then I’m looking at a 70/30 split. Thirty percent of a surgery that costs $20,000 means I’m still on the hook for a bunch of money, plus the premium cost.’

That’s led to many farmers taking out life insurance in lieu of health insurance. Some also begin to exercise in earnest in a bid to keep health concerns at bay. “Well, that is fine,” says Smith, “but they’re still in a precarious position (because that approach) doesn’t guard against farm accidents, car wrecks, slipping on the ice, whatever.”

In terms of delivering health care in rural Missouri, hospitals “do a darn good job. But because the state of Missouri – and there are a bunch of other states doing this, as well – doesn’t want to participate in Medicaid expansion, (the problems are building). Right now, we’re not at a point when someone shows up having a heart attack or with a broken leg will be told ‘if you can’t show an insurance card, you’re going to have to fend for yourself.’ Those cases will be treated and stabilized regardless.

“The problem, of course, is if that person doesn’t have insurance and are handed a $10,000 bill. Maybe their farm is making money, maybe not. Maybe they work for a farm equipment store and are making $20,000 or $30,000 a year and are unable to pay the bill. That has an impact on the health care of the whole community because the hospital must absorb it.”

As an example of what rural hospitals are facing, Smith offers the testimony of the CEO of Pemiscot Memorial Hospital in the Missouri Bootheel before the state legislature last year. “He said if we didn’t do Medicaid expansion, when the DiSH cuts come, the very first year the Pemiscot hospital will face a $1 million shortfall. That’s the very first year.

“So, what we’ll see is hospitals cutting back on staff and services. In some cases, they’ll close. And if a hospital like Pemiscot Memorial is routinely $1 million in the red year after year, they can’t keep the doors open forever. Maybe a hospital in a big city can handle that but smaller hospitals can’t.”

That means rural citizens will be forced to bigger city hospitals. There will be many more life flights and ambulances rushing car wreck victims or those having heart attacks to large Missouri cities like Springfield, Columbia, St.Louis and Kansas City.

That won’t just increase the patient load on those hospitals it will also increase their costs.

“Now, when ACA is fully enacted, we’ll have far fewer people that don’t have health insurance. That will be helpful. But if that comes with many more people being flown or trucked into big city hospitals from rural communities it will put all kinds of new pressures on the system.”

In Missouri, the Medicaid expansion debate is still raging. This summer, hearings will take place in the state legislature. Smith says farmers should call their lawmakers and “respectfully encourage them to get Medicaid expansion done and make sure our hospitals are properly funded.”