$5,000 to check out a stomach ache? Rural families ask for health insurance help

WASHINGTON — When Kyle and Tiffany Lechtenberg’s son came down with severe stomach pains last summer, they worried it could be appendicitis. Fortunately it wasn’t, but with their insurance plan’s high deductible, they had to cover out of pocket the entire $5,000 it cost to check it out. “It’s been insanely expensive for our young family,” Tiffany Lechtenberg said of their insurance situation. Many Americans are feeling the pinch of health care costs these days, and that’s certainly true for those in farm country like the Lechtenbergs. They own NorthView Family Farms in Spencer, Nebraska, where they raise cattle and grow commercial alfalfa along with other crops. “This is a big deal in agriculture because it does impact the lion’s share of farmers and ranchers,” said Rob Robertson, the Nebraska Farm Bureau’s chief administrator. “It is definitely one of the top two or three issues out in farm country right now.” Republicans’ effort to repeal and replace the Affordable Care Act foundered last year and bipartisan negotiations have gone nowhere fast since then. So farm state lawmakers seeking to address rural health care are turning to a familiar piece of legislation — the farm bill. Years ago the Lechtenberg family had insurance through Tiffany’s employer when she was working full time as a registered nurse. Once they had newborn twins and a toddler, however, the stress and lack of day care options prompted her to stay at home. (The family now has four children.) They started buying insurance through Nebraska’s Affordable Care Act marketplace and they’ve had four different insurers, seeing their deductibles rise to nearly $13,000. A simple ear infection can put them out $200. Their premiums fluctuate because of the income-based tax credits available in the marketplace. While those tax credits may be predictable for employees cashing basically the same paycheck every two weeks, farm revenues can vary widely from one year to the next based on everything from weather to crop prices. What they pay is based on an estimate of how well the year goes, meaning in down years they tend to get a substantial credit at tax time but other years they face a big liability. The farm bill is typically focused on crop subsidies and food stamps, forestry management and conservation programs. This year, Sen. Joni Ernst and Rep. David Young, both Iowa Republicans, are pushing legislation aimed at providing more mental health resources for farmers and ranchers, for example, and those proposals are likely to be included in the farm bill. And Rep. Jeff Fortenberry, R-Neb., has his own proposal that’s in the committee-approved House version of the farm bill that would help underwrite some startup costs for association plans that could be offered by organizations such as the farm bureaus. It’s an idea that dovetails with the Trump administration’s move to loosen restrictions on such association plans and treat them more like large employers. The farm bill is “an unusual place to park this, admittedly, but it’s my attempt to be creative here, to try to revive the whole health care legislative initiative because we have to,” Fortenberry said. The Lincoln lawmaker often cites letters from constituents on the issue, including one from a farmer who simply listed the figures of his health insurance costs and tax liabilities alongside the relatively low price of beans and corn and the simple conclusion: “This doesn’t work.” Fortenberry said high insurance rates mean people are dropping out or sending a family member off the farm to take a job just for the health benefits, creating economic distortions. He said he’s looking for a multi-pronged solution that includes trying to make more affordable insurance products available and establishing “invisible risk sharing.” Such pools blunt the impact of customers with particularly expensive health care needs without segregating them with other high-cost individuals. But the first, admittedly small, step is focused on getting rural health associations off the ground with some seed money in the form of loans and grants. His proposal authorizes up to $65 million — not a big sum in the framework of the overall health care landscape. “But it’s a start and I think it’s a very innovative start,” Fortenberry said. The hope is that associations will have access to the kinds of large-group policies that tend to cost less than plans on the individual market. The Iowa Farm Bureau is already moving forward to partner with Blue Cross affiliate Wellmark on new health benefit plans allowed by a state law signed earlier this year by Iowa Gov. Kim Reynolds. Those plans are not subject to required benefits and costs of the Affordable Care Act. The Nebraska Farm Bureau is also looking at offering its members health plans, and is generally supportive of the Trump administration’s move to loosen rules for such plans. Robertson cautioned, however, that the bureau doesn’t want the door opened so far that it encourages the proliferation of fly-by-night operations. It’s not clear how soon the Nebraska Farm Bureau could start offering the plans. “From our members’ standpoint, anything is better than what they have now so the sooner the better,” Robertson said. “But, again, there’s a lot of hurdles to clear.” Karen Pollitz, senior fellow at the Kaiser Family Foundation, said the Trump administration’s proposal to loosen the rules surrounding association plans comes with clear trade-offs. By not covering prescription drugs, mental health services or other areas, those association plans would likely be cheaper, but they could create a dynamic where people switch back and forth between those plans and those offered on the exchanges depending on their needs. “This is a way to make cheaper coverage available but really only to people who can get by on cheaper coverage,” Pollitz said. “It doesn’t really give any new options to the people who need all of the coverage that is provided now, and not only that, it makes that comprehensive coverage more expensive for people when they need that.” Before the ACA there were more options because insurers were allowed to cherry-pick their customers, she said. Once they were required to take everyone, however, it was a different story. It’s just hard in low-density areas to get a big enough risk pool to cover the high-cost cases, Pollitz said. Many rural counties are down to a single insurer, although she said that’s most common in areas that, like Nebraska, didn’t expand Medicaid coverage. There are millions of Americans buying their own insurance on the marketplace who are not eligible for subsidies, she said. “They are looking for cheaper options, but if the cheaper option is an association health plan that won’t cover mental health or drugs or maternity care — that will work while you don’t need those things,” Pollitz said. “But as soon as you need those things, the coverage that includes those benefits will cost even more than it does today.” Brian Depew of the Center for Rural Affairs said Fortenberry’s proposal is interesting. Innovative strategies to improve coverage are needed, he said, but the details are important. Depew said the ACA was a major step in the right direction for providing an avenue in which people can get insurance, but the system is stressed right now and needs improvements. “That can’t be the last thing we ever do about health care for rural people and rural places,” Depew said of the ACA. Fortenberry says he’s been working on bipartisan initiatives to get health care legislation going again but that those seem stuck for the time being. “I am a firm believer that we have to lean back into this health care debate quickly,” Fortenberry said. “Current vehicles are stuck or nonexistent. This is a new one. It’s imaginative, it’s creative. It’s not the fullness of an answer, but it points us in that direction.” Association plans offered through the farm bureau sound good to the Lechtenberg family. If nothing else, they would have the predictability of knowing how much they have to pay from one year to the next. “I feel like about anything would be an improvement from what we have right now,” Tiffany Lechtenberg said.