The Affordable Care Act has led to an increase the number of insured people. However, providers still provide uncompensated care, especially in states which have not expanded Medicaid eligibility. Rural hospitals feel the largest financial strain. Since the beginning of 2010, 57 rural hospitals have closed, according to data from the North Carolina Rural Health Research Program.
Of these 57 rural hospitals, 41 of them (72%) were located in states that choose not to expand Medicaid. A recentHealth Affairs[1] article compared rural hospitals in Medicaid expansion and non-expansion states in terms of the amount of uncompensated care they provided and their profitability and market characteristics in 2013. They found that compared to hospitals in expansion states, those in non-expansion states provided greater amounts of uncompensated care as a percentage of revenues and appeared to be more financially vulnerable.
ACA calls for reductions in disproportionate- share hospital (DSH) payments to fund the increased health care costs associated with Medicaid expansion. These payments are supplemental payments to hospitals that serve disproportionate numbers of Medicaid and uninsured patients; they are intended to help subsidize the cost of uncompensated care.
In the face of increasing closure of rural and critical area hospitals one has to wonder about the shortage of timely acute and emergency services, specifically surgical and obstetrical services. Using public, self-reported data from Virginia physicians, the state of my medical institution, I was able to take a more in depth look. Using Geographic Information System (GIS), I plotted a point for each general surgeon as well as Obstetrician. I used the self-reported address for which the provider identified as his/her practice. I was then able to use 2010 census data to create density map of provider per 100,000 by county (See figures below).
What I found was that there are well over 40 counties that lack either a general surgeon, an obstetrician, or both. Some counties are in close proximity to more densely populated counties; however, there are areas on the map which are likely “surgical deserts.”
Thus far, only one rural hospital has closed in Virginia. Not surprisingly it was in Lee County in the southwestern corner of the state already greatly affected by physician shortage. If the current trends continue, one has to wonder what consequences may begin to surface in those areas lacking timely surgical and obstetrical care.
Adrian Diaz is an MPH candidate (Harvard TH Chan School of Public Health 2016) and is a medical student at Virginia Commonwealth University School of Medicine.
