Amy Goldstein of The Washington Post has a great look at a “bare county” in rural Nevada – a county that has benefited from the Affordable Care Act but now has no insurer willing to offer coverage there next year, no matter what ultimately happens to repeal in Congress.
She visited Lyon County, which includes “a stretch of highway that Life magazine once called the loneliest road in America.” In the town of Silver Springs, a doctor visits just once a week. But under the ACA, people got insured, including 3,500 who got Medicaid once Brian Sandoval became the first Republican governor to adopt expansion. Another 1,400 got covered on the exchange, most with subsidies.
Telemedicine now supplements the sole itinerant doctor and, as Goldstein writes, “the new coverage has paid for back surgeries and brain surgeries for people who otherwise would have been left broke or unhealed.” Nevada’s uninsurance rate dropped from 23 percent pre-ACA, to 12 percent once it went into effect.
You’ve read about people like these newly covered Nevadans before:
- Robert Garcia, who was living in a horse trailer and showering in the dark using friends’ garden hoses, got Medicaid coverage which let him get surgery for three crushed discs in his back.
- Tom Lovelace, who has a landscaping business and a distrust of government, had a life-threatening aneurism in his brain in his 30s. Medicaid paid the $99,000 bill –retroactively.
- Jenny Claypool, who has both bipolar disorder and borderline personality disorder, gets a subsidized plan that pays for mental health care.
But with the turmoil surrounding the Affordable Care Act and the problems that have festered because of political gridlock … all of that is in jeopardy. Republicans want to roll back Medicaid. And exchanges, subsidies and insurance plans would look different under any version of Republican repeal and/or replace legislation.
Only one insurer, Anthem, was expected to offer exchange plans in 14 rural Nevada counties, including Lyon. It changed its mind, and now 8,000 people face the prospect of no exchange options next year – which means no access to federal subsidies. It’s the largest “bare patch” in the country.
Some states like Tennessee have been able to address the threat of bare counties, or new insurers have come in. Officials in Nevada are trying. Sandoval has asked the four insurers active in the state’s ACA marketplace that are part of Medicaid managed care in urban areas to come up with a solution. “The reduced footprint of carriers on the exchange,” he wrote, “is a national embarrassment for a state that has made great strides in reducing our uninsured population.”
In Nevada, state officials are talking to the Trump administration about ways to bend rules, such as letting people in rural areas sign up for health plans in urban areas like Las Vegas, or merging the state’s four ACA regions into one, so carriers in urban markets would also have to sell in rural ones. Nevada is also exploring a more unusual strategy – letting people buy into Medicaid. Sandoval vetoed that, pending more study. It would be an unprecedented and modified variant of single payer, but instead of Medicare for all, it would be Medicaid for all.
But so far, there’s no solution for Lyon County – or the people who have come to count on coverage.