Anne Dwyer: Hi, all welcome. Today's to today's webinar, and panel session. We are just gonna give folks another minute or 2 to finish signing on and just
Anne Dwyer: start in just a moment.
Anne Dwyer: Yeah, number of folks coming.
Anne Dwyer: All right. We're just gonna give folks one more minute and then we'll get started.
Anne Dwyer: Okay, why don't we go ahead and get started? So Hello! All I'm Ann Dwyer. I'm the Moderator for today's Webinar. I'm an associate research professor at the Georgetown University Mccourt School of Public Policy Center for Children and Families. As some of you may know, the center for Children and families is a nonpartisan research center. And we're celebrating our 20th anniversary this year.
Anne Dwyer: So today we are releasing a new report examining the role of Medicaid in small towns and rural areas. We are also publishing county level maps and looking at how Federal Medicaid cuts being considered by Congress and the new Administration would have an outsized impact on rural America.
Anne Dwyer: So our speakers today are Joan Elker. She is co-founder and executive director of the Georgetown University Center for Children and Families Research professor at the Mccourt School of Public Policy, and the lead author of the report. We also have Aubriana, Osorio. She is Georgetown University, Ccf. Data manager and co-author of the report, Aubriana will be sharing the interactive maps and other data included in our report.
Anne Dwyer: We will also be hearing from 2 special guests today. We have Dr. Katie Bacas, Kazi Manil. She is co-director of the Rural Health Research Center and the Rural Health program at the University of Minnesota. She is also a Professor in the division of Health Policy and management at the University of Minnesota School of Public Health.
Anne Dwyer: Dr. Kazi Manil conducts research to inform health policy that impacts critical times in the life course, including pregnancy and childbirth.
Anne Dwyer: We will also hear from Benjamin Anderson, the president and chief executive officer of Hutchinson, regional healthcare system in rural Kansas.
Anne Dwyer: Prior to moving back to Kansas, Benjamin served as Vice President for Rural health and hospitals at the Colorado Hospital Association, and more information on our speakers with links to their bios can be found in the chat.
Anne Dwyer: So before we get started, a few housekeeping notes, the Q. And a function you'll notice, is not enabled on this webinar. Rather, we will be taking questions from the media representatives via the raise hand function at the end of the presentation today.
Anne Dwyer: And please note, we will only be taking live questions from the media during this webinar. However, other non-media registrants as well as the media, may email any questions to child health at Georgetownedu. And we'll put that email in the chat as well.
Anne Dwyer: I also wanted to remind everyone that this call is being recorded, and will be posted on our website. With that I will now turn it over to Jonah. Elker.
Joan Alker: Thanks, Ann. Good morning, everybody. My name is Joan Alker, and I am the lead author of the report that we're releasing today. Medicaid's role in small towns and rural areas, and I'm joined by such a wonderful panel. Today. I'm really excited about that. And my co-authors, Aubriana, Osorio and Edwin Park and Aubriana will present some additional data resources.
Joan Alker: So before we get to the data, Medicaid is the backbone of many aspects of our healthcare system, including paying for the majority of nursing home residents, covering 40 to 50% of children and births nationwide, depending on where you live.
Joan Alker: covering people with disabilities and many other low-income people. In fact, Medicaid covers almost 80 million people in total, roughly 4 times as many, covered by the Aca marketplaces, and considerably more than the roughly 48 million seniors covered by Medicare.
Joan Alker: This is particularly true in rural areas, as we shall see where a higher share of residents are covered by medicaid
Joan Alker: rural areas face greater challenges in their health. Ecosystems as their residents have higher rates of chronic disease. Hospitals are operating on tighter margins and provider shortages are more acute
Joan Alker: as we share these findings with you today, Congressional leaders are making highly consequential decisions about the future of Medicaid, and in particular, whether or not to impose crippling and Draconian cuts.
Joan Alker: Medicaid's future has quickly become one of the most consequential issues that members of Congress will soon decide upon.
Joan Alker: Documents leaked last week to the press, made clear that Key House Republicans are considering 2.3 trillion
Joan Alker: with a T dollars in Medicaid cuts that equates to almost 1 3rd of Federal Medicaid spending.
Joan Alker: in fact, while some of the math may be a little fuzzy, these discussions make clear medicaid our nation's healthcare insurer for the most vulnerable people in our society is at the top of the list, accounting for almost half of the cuts under consideration to generate revenue that Republicans are looking for, to finance, among other things, extending tax cuts which will disproportionately benefit the wealthy.
Joan Alker: As the report findings, and our ensuing discussion will make clear. Rural communities are at grave risk if substantial Federal cuts are enacted.
Joan Alker: Medicaid is a health insurance program, and I always say this to to remind folks fundamentally Medicaid is protecting families and people from exposure to high medical costs, and Medicaid is very good at that
Joan Alker: cuts to Medicaid, which is already a very lean payer in our healthcare system will result in transferring costs, shifting costs to families and providers, cutting services, and in rural communities, as our guest speakers will discuss healthcare systems are already under enormous pressure and can ill afford any loss of resources.
Joan Alker: So before I get into the data, let me I'm gonna say a few words about the data before we go through some of the specifics.
Joan Alker: The underlying data that we use is from the Census Bureau American Community survey which we and others commonly use, especially when we want to make comparisons across states such as we're doing today.
Joan Alker: But this data does tend to undercount Medicaid. So these estimates are conservative and may be lower than other estimates you encounter in your State that could be based on State administrative enrollment data
Joan Alker: also, with respect to the rural definition that we use in this report, it is the following, we're looking at counties that have no urban areas with a population of greater than 50,000 people.
Joan Alker: Using this definition, new Jersey, Rhode Island, and the District of Columbia have no rural counties, so they are largely excluded from the report's findings.
Joan Alker: Finally, a special note about North Carolina, because the State implemented its Aca medicaid expansion. Relatively recently, this data most definitely undercounts the number of non-elderly adults that are enrolled in Medicaid in North Carolina's rural counties. And if you're interested in North Carolina, the State does have easily accessible administrative data on its website for those counties.
Joan Alker: Okay, now, I'm going to finally turn to the report findings. Here, you see, kind of the key takeaway. And as the slide shows for children and non-elderly adults living in rural areas. They are more likely than those in metro areas to rely on Medicaid for the health insurance
Joan Alker: for seniors. This rate is slightly lower in rural areas, although overall across total populations, it's higher.
Joan Alker: As you can see, almost 41% of children in rural areas are covered by Medicaid as compared to 38% in urban areas. So let's go to the next slide.
Joan Alker: So when we see here and we're going to talk about children. For a couple of slides here.
Joan Alker: This slide shows you the disparity where the share of children covered in rural areas and small towns is much bigger than the coverage rates in Metro area. You see here that Arizona, Florida, and North Carolina are leading the way
Joan Alker: with an astonishing 21 point difference in Arizona, with 56 of 56% of children covered in rural areas by Medicaid.
Joan Alker: Next slide
Joan Alker: in 6 states, we found that at least half of the children in rural areas and small towns are covered by Medicaid and Chip.
Joan Alker: Those 6 States are listed here, New Mexico, Louisiana, Arizona, Florida, South Carolina, and Arkansas. And remember, as I said up front, that these estimates are probably a little bit low
Joan Alker: next slide
Joan Alker: last slide here on children looking simply at the number of children. So that, of course, is different from looking at percentages and larger states are going to have larger numbers. But what we see here in terms of numbers is that Texas, with 239,000 children living in rural areas covered by Medicaid, leads the way
Joan Alker: with North Carolina closely behind Georgia and Kentucky. Each have about 200,000 children in rural areas covered by Medicaid.
Joan Alker: Okay? Now, we're going to talk a little bit about non-elderly adults with the next slide. Those are adults, age 19 to 64.
Joan Alker: And what our report found is that 15 States have at least one out of 5, if not more, of non-elderly adults in rural areas covered by Medicaid
Joan Alker: as with children. Arizona leads the list with 36% covered.
Joan Alker: and New York comes in, perhaps a surprising second at at 34%.
Joan Alker: okay. So one thing I did want to point out, let's let's move to the next slide.
Joan Alker: This slide is looking at the the share, the differential share, and similar to what we looked at for children. Arizona is yet, again, has the biggest differential with adults. Non-elderly adults covered 36% in rural areas versus about 17% in metro areas.
Joan Alker: New York come second, here. I wanted to flag on this particular list. There are 2 States, Texas and South Carolina, which have not enacted the Aca medicaid expansion, and in a state like that, and Kansas is another one we'll hear from on the panel. Most adults who are receiving coverage through Medicaid are either pregnant women or very low income parents
Joan Alker: who are disproportionately women. So when you see these numbers for States like Texas and South Carolina, that's who you should think about.
Joan Alker: Okay, next slide.
Joan Alker: Now we're going to hear more about this from Dr. Katie Kajimano. But one thing that really popped out in the data was that in counties with a large share of American, Indian and or Alaskan native peoples.
Joan Alker: across all age groups, including seniors and especially seniors we'll talk about in a minute, are more likely to rely on Medicaid for their coverage.
Joan Alker: And let's talk about seniors for a minute. A reminder that Medicaid covers seniors in a couple of different ways nursing home residents we've talked about, but we also have the so-called dual eligibles. These are medicare enrollees who are low income and so Medicaid pays their cost sharing. And that's true nationally for about 20% of seniors.
Joan Alker: And then, of course, there are some seniors who don't qualify for Medicare at all, and may be eligible for Medicaid, due to their income. So that's a quick thumbnail sketch of how seniors are covered in Medicaid.
Joan Alker: and I'm not shown here. But in one of the appendices of the report, and Aubriana is going to show the other resources available to you in a minute. We looked at the top 20 counties in the country, with the highest proportion of seniors, with Medicaid coverage which you can see here, you know, overall. It's ranging between about 16 or 18% in general.
Joan Alker: but absolutely astonishing numbers relating to the counties with the highest number of seniors. 2 thirds of seniors are covered by Medicaid in the counties that include the Pine Ridge Reservation in South Dakota and Apache country
Joan Alker: in Arizona, Apache County. Excuse me in Arizona, which consists primarily of tribal lands, 2 thirds of seniors are covered by Medicaid here, and 7 of the top. 20 counties in South Dakota
Joan Alker: consist of tribal lands, and they have coverage rates for seniors ranging from 39 to 66%. So you can see for these elders, Medicaid is absolutely vital.
Joan Alker: And with that I'm going to hand the virtual mic over to my colleague Aubriana Osorio.
Aubrianna Osorio: Thanks, Joan, in addition to
Aubrianna Osorio: some of the data that Joan just shared.
Aubrianna Osorio: And we have created interactive county maps for each state
Aubrianna Osorio: which you can find by clicking this button at the end of our report here.
Aubrianna Osorio: or alternatively, by clicking on data back at the top of our website
Aubrianna Osorio: and then scrolling down to Medicaid coverage in Metro and small town rural counties.
Aubrianna Osorio: Once you select your state from the list down here.
Aubrianna Osorio: and you can see the map for the total population which shows up first, st
Aubrianna Osorio: and then you can navigate between different populations by using these tabs.
Aubrianna Osorio: We have maps for total children, non elderly adults, and for seniors.
Aubrianna Osorio: Each map also has this little tool tip that pops up as you hover over each county with more information on whether the county is considered metro or rural.
Aubrianna Osorio: the share of people with medicaid coverage, and how that share compares to the State overall.
Aubrianna Osorio: You can also zoom in using these buttons in the bottom.
Aubrianna Osorio: And you can download an image or copy the embed code for web by clicking on these links
Aubrianna Osorio: along with these maps and the top findings that Joan shared. We have 8 appendix tables
Aubrianna Osorio: on the share of children, adults and seniors covered by Medicaid in Metro and rural counties in each State.
Aubrianna Osorio: the top 20 rural counties nationwide, that have the highest shares of children, adults, and seniors covered by Medicaid, and the number of people and the share of the population in each State that live in rural areas.
Aubrianna Osorio: and I will turn it back to Anne.
Anne Dwyer: Thank you, Joan and Aubriana, for that helpful overview of the report. We will now turn it over to hear from Dr. Katie Bacchuskazemanil. So, Katie, please take it away.
Katy B. Kozhimannil: Wonderful. Hello! Good morning!
Katy B. Kozhimannil: thank you to all of you that are covering this in your work. Thank you. To my colleagues at Georgetown that have authored an incredibly important report. Thanks for the opportunity to be here with you today and comment on these important findings and thanks for the prior introduction. I'm Katie Bacchus Kazimanal I use she and her pronouns. I'm a descendant of Anishinaabeg folks from white Earth, nation and also of
Katy B. Kozhimannil: settlers to these lands from Germany, England, and France, and I live and work on Dakota Land on Matoba Day, as Anne mentioned, I'm a professor at the University of Minnesota School of Public Health and also co-director of the University's Rural Health Research Center. It is our mission at the center to conduct policy, relevant research to improve the lives of rural residents and families to advance health equity and to enhance the vitality of rural communities.
Katy B. Kozhimannil: I also lead our rural maternity care team, and we've been leading research for more than a decade now on access to and quality of care for birthing people in rural communities.
Katy B. Kozhimannil: One of the areas of focus of our work came from a question from 5 grandmothers in rural Alabama, who noticed that the hospitals around them were closing their labor and delivery, their obstetric units, and their daughters couldn't give birth near home, and were traveling long distances for prenatal care, and to give birth to these grannies. Grandbabies.
Katy B. Kozhimannil: and they wondered if this was happening in other rural communities as well, and whether there were effects of these closures on the health of their daughters and grandchildren.
Katy B. Kozhimannil: It turns out they were right on both counts. Hospital-based obstetric care has been steadily declining in rural communities, with effects on maternal and infant health, and as our work has continued.
Katy B. Kozhimannil: You have seeing more and more information about the role that Medicaid plays.
Katy B. Kozhimannil: These data from Georgetown provide clear evidence of the importance of State Medicaid programs for people living in rural communities, remote areas and small towns across the United States. Medicaid policies are super important in rural America, for families, for clinicians for clinics and for hospitals and changes in Medicaid programs that happen either at the State or at Federal levels have disproportionate impacts in rural areas. The statistics reported today. Help us tell why this is the case.
Katy B. Kozhimannil: I'm going to give a little example from from my team's research on the closures of hospital labor and delivery units. That's 1 example of how Medicaid policies can have an impact
Katy B. Kozhimannil: in 2010, 43.1% of rural and almost 30 29.7% of urban hospitals did not offer obstetric care. This was in 2010,
Katy B. Kozhimannil: between 2010, and 2022. There were 537 hospitals that closed obstetrics or closed entirely, but
Katy B. Kozhimannil: hospitals like communities that lost hospital based obstetric care. This was split between rural and urban areas. So 238
Katy B. Kozhimannil: rural hospitals stopped providing obstetrics and 299 urban hospitals stopped providing obstetrics. I also want to say, the denominators are really different here. There are fewer hospitals in rural America than there are in urban areas
Katy B. Kozhimannil: by 2022 52.4% of rural hospitals and 35.7% of urban hospitals did not offer obstetric care. More than half of rural hospitals, and over a 3rd of urban hospitals don't offer obstetrics more than a decade into a maternal health crisis in the United States. Fewer Us. Hospitals provide obstetrics every year with rural hospitals, experiencing the greatest losses.
Katy B. Kozhimannil: The question is always, why
Katy B. Kozhimannil: offering obstetric care is a financial challenge for hospitals, as revenues may not cover the costs of providing that care.
Katy B. Kozhimannil: Medicaid covers nearly half of all births nationally, and plays a substantially larger role in paying for births in rural areas.
Katy B. Kozhimannil: Obstetrics has high fixed costs, and we'll hear from my colleague, Benjamin Anderson soon. Who can speak to this from a hospital administration perspective. But obstetrics requires dedicated space equipment trained staff that are available to support labor and delivery. Whenever a pregnant patient needs care.
Katy B. Kozhimannil: the revenues to cover these high fixed costs are variable, and depend on the volume of births at each hospital, which disadvantages lower volume facilities.
Katy B. Kozhimannil: and the revenues also depend on the reimbursement rate for each birth which disadvantages facilities that serve a high proportion of patients insured by Medicaid, which generally pays less than private health plans for childbirth care.
Katy B. Kozhimannil: What with the while, the influence of Medicaid policy
Katy B. Kozhimannil: on access to, and outcomes of care may begin at birth, or even before the effects of changes in Medicaid are felt across the life course for rural residents, whether it's access to services for children with special health care needs which are often challenging to to access in rural communities, mental health care for adolescents. Again.
Katy B. Kozhimannil: having access to those services and supports and sufficient revenue to support offering those services from healthcare systems, substance use, treatment, access, long-term care for our elders. These are all areas of deep need in our rural communities that are disproportionately financed through Medicaid programs.
Katy B. Kozhimannil: I want to turn back to maternity, care for a brief moment, and I want to ask that we reconsider using the phrase, Maternity care desert. This is a phrase you may have heard you may have even used, but it's not accurate, and it can even be harmful.
Katy B. Kozhimannil: And I want to tie this back to Medicaid policy. So the term maternity care deserts implies that communities without health care, access are akin to a naturally occurring phenomenon like a desert. But they're not. There's nothing natural about whether or not a place has maternity care. It happens because of deliberate policy decisions, including financing decisions that relate to Medicaid policies
Katy B. Kozhimannil: when we use the term desert. And we imply that there's something natural about whether or not a community has maternity care. Additionally, the term yet desert is used to signal emptiness, vacuousness, and deserts are thriving environments, home to indigenous folks and native nations for millennia. When the word desert is used in this way, it contributes to erasure of native peoples who are among those with the least access to maternity. Care.
Katy B. Kozhimannil: please, instead call a place what it is, a place without maternity, care, community without maternity care. We're not saving that many words from maternity care desert. And it's more accurate and can help us point to the policy decisions that can be made to
Katy B. Kozhimannil: affect those access barriers that happen in communities.
Katy B. Kozhimannil: So speaking of native folks, the data from Dr. Elker and her colleagues also emphasize the critical role that Medicaid plays in financing care for American Indian Alaska native folks.
Katy B. Kozhimannil: It's essential to recognize Medicaid as the critically important player that it is
Katy B. Kozhimannil: for native people in the Us. I am sure that many of you are aware, but just to lay the groundwork, the Government's trust responsibility to provide care for American Indian Alaska native people was codified and reified via the Indian Health Care Improvement Act, when it was signed into law as part of the Affordable Care Act.
Katy B. Kozhimannil: The Federal Government currently works with native nations to provide health care services at 3 different types of facilities, the Indian Health Service tribal health centers and urban Indian health facilities.
Katy B. Kozhimannil: These programs are healthcare delivery systems. They are not payers.
Katy B. Kozhimannil: and these systems rely heavily on payments from state Medicaid programs to cover services for enrollees who are native
Katy B. Kozhimannil: importantly, Ihs and other components of the Federal Itu system for native health. They're woefully underfunded
Katy B. Kozhimannil: and Medicaid, and payments from Medicaid are a very important source of revenue. Our recent research showed that approximately 75% of native birthing people did not have access to Indian health service care around the time of childbirth between 2016 and 2020, and the vast majority of American Indian Alaska, native birthing people, with and without access to the Indian Health Service, have Medicaid as a primary payer during pregnancy and childbirth.
Katy B. Kozhimannil: So, just to conclude, the footprint of Medicaid in Indian country and across rural lands is substantial and important consideration of this important of this importance is relevant for the nation's maternal health crisis and for health care, access, and outcomes generally.
Katy B. Kozhimannil: Thanks so much for the opportunity to speak with you today.
Anne Dwyer: Thank you, Dr. Arkazi.
Anne Dwyer: Now I will turn it over to Benjamin Anderson. Ben, please take it away.
Benjamin Anderson: Yeah, thank you all for for having me. And and I always appreciate hearing from Dr. Cosimano. One of the one of the nation's leaders in in maternal health, equity, and and specifically in rural and underserved areas. So insightful. I was taking notes as well. I'll begin just briefly with a story that happened actually, 2 days ago at our health system.
Benjamin Anderson: There's a baby that was born here last week with no prenatal care, and came in with significant issues, and I won't get into the details of that for for hipaa reasons. But I'll tell you that this baby is going to spend months in the ice, in the, in the, in the Nicu there was not access to
Benjamin Anderson: to prenatal care, and the the expenses related to this child will likely exceed a million dollars by by the time she goes home
Benjamin Anderson: much of that would have been preventable with adequate prenatal care. That was not the story here, but I will tell you that the story of Hutchinson, Kansas, where I live is the story of rural America we've got.
Benjamin Anderson: We're a city of about 50,000. We've got agriculture, tourism, manufacturing. Of course, we have a health system. We have school systems at college. We've got a golf course. We've got a prison. We've got wealthy and poor folks, and we very much represent the middle of Middle America. We are known for an internationally renowned golf course called Prairie Dunes Country Club, and we're also known for crippling rates of substance use disorder and health disparities. Here we have both extremes in this community.
Benjamin Anderson: Our health system cares for about 100,000 people in an immediate service area, but really cares for patients all the way out to western Kansas, where I used to live in one of the most remote, geographically disparate and remote areas of the United States, including Southwest Kansas, which is also one of the most racially diverse areas of the United States because of the presence of the world's largest beef packing plants. So we care from folks from that whole region.
Benjamin Anderson: and our health system which cares for that region is sustained largely or in part by Medicaid.
Benjamin Anderson: Medicaid supports moms.
Benjamin Anderson: kids, and older adults, especially, not exclusively, but especially, and we would say in western Kansas the years we lived there in Spanish, which means the mothers hold the keys to the kingdom, and and moms really guide the health of communities. And
Benjamin Anderson: and it's why it's so important that we focus on maternal child health. But older adults, too, are also cared for by moms. And they are also particularly vulnerable, as the data suggested earlier. So cuts to Medicaid mean fewer providers, and just speaking very plainly, fewer providers are able to sustain receiving patients that have Medicaid.
Benjamin Anderson: Fewer. Poor people will be able to access, care.
Benjamin Anderson: A health system like ours that takes all payers and those who can't pay is currently operating at break, even literally, in a 15 million dollar budget. This month we had a $24,000 profit.
Benjamin Anderson: Barely we made it through, and that's caring for every one of those who can't pay
Benjamin Anderson: people lacking access to care due to Medicaid cuts, access care through the emergency department. The most expensive and inefficient way, and those losses that we sustain for them doing so, and not being able to pay for it.
Benjamin Anderson: close hospitals and close nursing homes, and we saw it
Benjamin Anderson: very plainly during Covid, as we saw many, many nursing homes closing down, and hospitals as well as they were facing that additional pressure. We have 2 major public health issues. And I think Katie focused really intently and articulate on one of those. And that's the maternal child health issue or maternal child disparities and specifically maternal health deserts and the closing of those units.
Benjamin Anderson: The other one is seniors in what some researchers would call the 2030 problem, which is when the last of the baby boomers turn 65, and enter and even overwhelm our skilled nursing and our broader healthcare delivery systems
Benjamin Anderson: with needs as they're entering retirement without enough
Benjamin Anderson: money, without enough friendships and without enough, you know, resources to really sustain through the end. They end up in nursing homes. They're vulnerable.
Benjamin Anderson: and we have to be prepared for that. And Medicaid is a really crucial safety net for sustaining those healthcare delivery systems. Now I live in. We live in a pretty conservative culture in the middle of America that deeply values hard work and human dignity, and anything that disincentivizes. Hard work is bad for the individual, bad for communities. That's very much part of the culture of middle America. Working people
Benjamin Anderson: who get sick, whose kids get sick and who can't access healthcare can't work no work, no taxes.
Benjamin Anderson: We. We become a less productive and a more vulnerable community that way.
Benjamin Anderson: and when they access care, not being able to work, they're going through our emergency department in in the least efficient and most expensive way.
Benjamin Anderson: The American health system, and we are an example of that. It was. It was often said during Covid, that you know the health systems in the Icu, like we've never seen strain on it like we've seen right now, and we're not. We're not completely out of the proverbial icu. We're still recovering.
Benjamin Anderson: We're still trying to figure out how to recover the lost access in maternity care, and what to do with seniors who really aren't safe at home anymore. But really,
Benjamin Anderson: are are. We don't have access to the skilled nursing beds that we need to be able to care for them there. How do we? How do we develop the infrastructure around home health and care coordination case management. Those types of things. Medicaid is a crucial backstop for that to happen. And it's so important that we that we sustain it, that we prop it up.
Benjamin Anderson: we have an opportunity to rebuild a system right now, and and there are many in this country that are doing that, following the pandemic and and significant cuts as are identified in this report would cripple those efforts to recover. So with that, I'll turn it back over to you all.
Anne Dwyer: Thank you to Ben and Dr. Covimanil, for your really important and powerful remarks. We will now open up to questions from the media
Anne Dwyer: through the raised hand function. And just as a reminder, the Q&A function is not enabled. So please again use that hand, raise feature and again remind, we'll be taking live questions from media representatives. At this time, however, other registrants can email any questions to child health at Georgetownedu, and my colleagues can put that email in the chat as well.
Anne Dwyer: And again, Media is welcome to use that email as well. So with that we will go to our 1st question. So I see.
Anne Dwyer: Let's see here. Mike Moran, go ahead and talk
Anne Dwyer: or ask a question. Thank you.
Mike Moen: Can you hear me? Okay.
Anne Dwyer: Yes, we can hear you.
Mike Moen: Okay, Mike Moen, here from public news service. Thanks for your time. Everyone today.
Mike Moen: I have a few questions first, st Joan, you know, with the threats
Mike Moen: coming from Congress, especially from a Gop lawmakers to cut funding for Medicaid.
Mike Moen: We're seeing roughly some numbers being floated 2 and a half trillion dollars. So talk to us again about the maybe you brought this up at the beginning, and I'm sorry
Mike Moen: about the the real concern that organizations like yours have about the Medicaid funding landscape. Given the political mood in Washington right now to to cut that funding and and
Mike Moen: how it impacts. So the data you're sharing today.
Joan Alker: Sure. Thanks, Mike, and welcome my colleagues to jump in as well. But as I mentioned, up top we we now know in this
Joan Alker: wasn't a surprise, but the level of cuts being considered to Medicaid is horrifying.
Joan Alker: Just last week there were documents leaked from Key House Republicans that they're considering cuts as high as 2.3 trillion dollars. That's almost 1 3rd of all Medicaid funding
Joan Alker: and Medicaid is a very lean program. Lord knows we have some challenges with high costs in our healthcare system, but Medicaid is already the lowest payer in the system. So why are all the cuts being directed, and Medicaid is in this list of cuts that was leaked the number one source
Joan Alker: of revenues that Republicans have put on the table.
Joan Alker: and as we've heard, Medicaid serves the most vulnerable people in our society.
Joan Alker: So
Joan Alker: the Medicaid issue was not discussed at all. During the Presidential campaign. There was complete silence about it, despite the fact that it is the largest source of public coverage by far in the United States. It's also a very popular program with the voters of all political stripes.
Joan Alker: It is serving children. It is serving seniors in nursing home people disabilities. And I really don't think the public wants to see these large cuts.
Joan Alker: And what our data here shows today, which I think is less well known about Medicaid
Joan Alker: is how, as vital as Medicaid is, for everywhere. It is even more vital for rural communities which face greater challenges already to maintain a thriving health system.
Joan Alker: And that's what our data show that these communities which already face additional challenges will be devastated by significant Federal cuts to Medicaid. So let me see if Katie or Ben want to jump in there.
Benjamin Anderson: We're living, we're we're. We're a living testament of that. We need that safety net to maintain the system.
Benjamin Anderson: We are working on, on, you know, optimizing our operations to be as efficient, as efficient as possible, and every month a little bit better we. We certainly went through a very difficult time as a health system.
Benjamin Anderson: Post covid. Where we were losing even 10% of of our operating margin was, it was negative, and we recovered from a lot of that. But we're still break even. And so it's really, really crucial that this safety net remains in place, or or we see health outcomes drop, but but we also see access close. And it's not just for us. It's in western Kansas as well where I was previously. 40% of our payer mix inpatient payer mix was Medicaid.
Benjamin Anderson: I mean, and if we were to see significant cuts to those payments, that's it, there's not an amount that we can tax our local communities from properties tax standpoint to to offset those Federal cuts, it would result in loss of access, and I, and I don't know if there's an awareness and appreciation of Federal level at the devastation that this would cause to the middle of America.
Katy B. Kozhimannil: That's so. Well, said Benjamin, and such an important question. Thank you for that, Mike. Just to add a little bit of data to this briefly, from the perspective of maternity, care access, which is where my team has has done quite a bit of work. One of the things that well, I'm going to say 2 things. One is the data that I cited earlier about the declines in maternity care access between 2010 and 2022
Katy B. Kozhimannil: that didn't capture the end of the of the Covid Public Health Emergency, which Ca. Which had with it a number of financial measures that would that supported the healthcare delivery systems being able to
Katy B. Kozhimannil: financially continue to to move forward. And so anecdotally, we've been hearing and seeing more closures since then, and we're hoping to study that moving forward. But when we look at that dynamic, we have a study that we did a couple of years ago, where we interviewed rural hospital administrators about their decisions to provide
Katy B. Kozhimannil: maternity services and to keep that service line available. And they told us there are 3 major considerations that they have one is workforce. Do you have enough clinicians? Do you have enough nurses? Do you have enough folks to provide anesthesia, or there for doing
Katy B. Kozhimannil: doing a C-section if needed. The second thing was clinical skills.
Katy B. Kozhimannil: Do those clinicians that are available have this the skills that they need to safely take care of the patient population at that institution, and the 3rd one, which is a determinant of the other 2, was financial viability.
Katy B. Kozhimannil: Are there resources coming in that? Allow you to offer what you need to to hire folks, and to train and support them in doing their work and doing it well, and feeling good about that we also, in that same survey? Asked rural hospital administrators. You know what was their sort of break, even point in terms of number of births that they could
Katy B. Kozhimannil: that they needed in order to be financially viable and safe to provide births, and that number varied across different hospitals and contexts and different state environments. But on 1 3, rd fully 1 3rd of those that we interviewed were operating obstetric units below that number
Katy B. Kozhimannil: they were operating below what they felt was their minimum for financial viability and safety. And when we asked them why they said, community need
Katy B. Kozhimannil: they? Said, the people here are poor. They do not have cars. They are going to come here to have babies, and this is really important for us to try to do, even below thresholds that
Katy B. Kozhimannil: could keep us going, and those thresholds are entirely based on policy and heavily influenced by Medicaid policies. So I offer that as a specific example of what we've heard from rural communities about the tight line. They are walking every day to provide care in their communities.
Anne Dwyer: Thank you so much. I see. Next. Adrian, you wanna go ahead. You should be able
Anne Dwyer: to speak now.
Adrienne Hoar McGibbon: Hi, yes, Adrienne Hormogiven from Virginia public media we're based in Richmond. Virginia has its own state-run marketplace
Adrienne Hoar McGibbon: for healthcare insurance. Have you taken a look to see if there's a difference in a Medicaid. Care for States that still rely on the Federal marketplace versus State run marketplaces, and if there has been more protection for people in rural communities, in states that do have State run marketplaces. Thank you.
Joan Alker: Thanks, Adrian, for that question, and my colleague, Edwin Park, can jump into on this answer. I think the short answer is, no, because they're kind of 2 separate systems of public coverage. Obviously, they interact. But a person cannot be eligible for Medicaid
Joan Alker: and the marketplace right? They can only be eligible for one or the other. And certainly there's an issue on the table for Congress to consider, which is whether currently the subsidies for tax credits in the marketplace have been enhanced the last few years, and that's really contributed to the growth in the marketplace, overall.
Joan Alker: irrespective of whether it's federally administered or state administered, and those subsidies are expiring this year. So that is a question for that population. But what we're talking about here is that Medicaid which serves about 4 times as many people as the marketplaces
Joan Alker: is slated for these huge cuts. In fact, the number one source, it appears, of of revenues that are being sought for other priorities. So I hope that answers your question, and we can go to the next question.
Anne Dwyer: Great. Thank you so much, Joan. Next Andrew, d'amelio. If you would like to
Anne Dwyer: talk, you should be allowed to talk now.
Andrew DeMillo: Yeah, Hi, this is Andrew Demillo. With the Associated Press. I actually had 2 questions. One wanted to see if there had been any kind of breakdown or look at the impact. Or I guess the difference between expansion states and non-expansion states when it comes to rural hospitals closing their obstetrics programs or closing entirely. And the second question is kind of more broadly
Andrew DeMillo: with legislative sessions. Starting right now, are you seeing much in terms of governors proposing their their own changes or their own restrictions that they want to make to Medicaid? Or are they kind of in a holding pattern to see what happens with the trump administration.
Anne Dwyer: I don't know, Katie, if you have thoughts on the expansion, non-expansion, and hospital closures for obstetric care.
Katy B. Kozhimannil: Yes, I do. And I'm rushing to get. I'm putting a link in the in the chat for the host and panelists that hopefully can be shared my, my colleague, Caitlin Carroll, led research specifically on this question of
Katy B. Kozhimannil: Medicaid expansion. The association between medicaid expansion and closure of hospital-based obstetric services. So we saw good research showing that medicaid expansion was associated with greater support and longevity of rural hospitals generally. But what we did was, look specifically at access to obstetric care. Given the financial situation for that service line specifically being
Katy B. Kozhimannil: unique in the fixed costs. That it has, and also in the
Katy B. Kozhimannil: payer. Mix that is, paying for birth services. So
Katy B. Kozhimannil: what we found is that we used a large national hospital data.
Katy B. Kozhimannil: set of data, and we found that expansion led to a large reduction in hospital closures. But this effect was concentrated among hospitals that did not have obstetric units. We found, when we looked at closure of obstetric units, we found that rural obstetric units were less likely to close immediately after expansion, but this effect faded after 2 years, so it may have prolonged in the immediate term the ability to continue to operate an obstetric unit. But
Katy B. Kozhimannil: the closures it didn't have a
Katy B. Kozhimannil: long term effect on reducing closures in hospital-based obstetric care and of obstetric units. So I hope that's helpful.
Benjamin Anderson: I could add to that as well. The Stroudwater Associates out of Maine, recently, earlier, actually early last year, did a really comprehensive look at the impact of Medicaid payment on Texas
Benjamin Anderson: maternity units. And it's obviously a large swath or large sample size. But I would encourage you to reach out to Stroudwater to get access to that. I think they would publicly share it, but they used it in the Texas Legislature to have these conversations. So yeah, they may have a relevant study for you, too.
Joan Alker: And Andrew, I would just jump in and say that your question highlights one of the proposals that's actively being considered by Congressional leaders
Joan Alker: is to cut the enhanced match for Medicaid expansion. Currently, all States receive 90 cents on the dollar, and it's misleadingly often referred to as a proposal to equalize match
Joan Alker: by which they mean cut match from 90 cents on the dollar to the regular F map that the State is receiving for children and people disabilities, and so
Joan Alker: be aware of that terminology there about equalizing matches, actually cutting the match rate for the Expansion group, which would cause millions of people to immediately lose coverage, because another number of States have so-called trigger laws, where their expansion will go away, and also would pull out hundreds of billions of dollars from the system that money that States really couldn't make up so. And we can go to the next question.
Anne Dwyer: Great Danae, you should now be able to ask your question.
Dené Dryden: Hi, thank you. Danae. Dryden, Rochester, Post Bulletin in Rochester, Minnesota. My question is more for Dr. Cozumanel and or Benjamin. I wonder if you could speak more to the relationship between Medicaid as a payer and rural hospital finances as sometimes reimbursements to the hospital. Sometimes those don't cover the cost of delivering that care to the patient.
Benjamin Anderson: I'll I'll lead off, because I know Kitty has a lot to add to this.
Benjamin Anderson: medicaid is a is a pretty good payer in a rural health clinic.
Benjamin Anderson: So it it does. It doesn't often cover the cost of delivery. But you have to look at maternity care holistically
Benjamin Anderson: and look at it as a whole ecosystem, and when you look at the Medicaid encounter rates, you get in a rural health clinic. It can sustain a maternity care program if you look at the at the whole picture. And so also those follow up appointments for kids. Those are Medicaid payments, and often what we found in rural health clinics is Medicaid would be our
Benjamin Anderson: our more favorable payer it certainly would be, would it was incentivizing preventive care and getting people in early and often. And so in certain areas of the health system, they may be the lowest payer, but in other areas they pay very favorably. And also when you consider federally qualified health centers. Medicaid's a very, very favorable payer, and so
Benjamin Anderson: and and it, it allows for those systems to cover wraparound services and other essential services. So dr. Cosmano feel free to to expand on that.
Katy B. Kozhimannil: Great points, and I agree entirely.
Katy B. Kozhimannil: as a service line care related to obstetrics, to labor and delivery is.
Katy B. Kozhimannil: there are folks that have discussed that this is under resourced for both public and private payers generally as a service line, and part of that is what I mentioned earlier of the tension between the fixed costs that are specific to this service line. You have to have a lot of
Katy B. Kozhimannil: professionals with very specific training, and you have to have specific beds and specific equipment for infants, and so the the cost of having birth in your facility is is high and is specialized, and then? And so
Katy B. Kozhimannil: I think that Benjamin
Katy B. Kozhimannil: mentioned, considering that in the context of the entire ecosystem of a hospital, and what having an obstetric service line can do for your bottom line in terms of bringing in regular payments from Medicaid and other payers, but especially from Medicaid. So this is a problem, a financing problem for maternity care.
Katy B. Kozhimannil: that is, for which Medicaid is a primary payer in many rural areas. And so is an important component of it's an essential component of of keeping a unit open in rural communities and frankly, also in many urban communities. And so I don't.
Katy B. Kozhimannil: There are urban communities that are losing maternity, care services, and those also tend to be in predominantly Medicaid paid hospitals. The other thing that I want to say about the importance of Medicaid for service lines other than maternity care, and for maternity care as well, is that folks are often able to access services without out of pocket payments or copayments which can incentivize preventive care services and coming in for the visits. And again, that helps the hospitals from a financial perspective
Katy B. Kozhimannil: that folks are actually coming in for their visits when they have Medicaid coverage, as opposed to going without care, and again winding up in an emergency department, or just having poor health and going without access to services that may be necessary to support them in health and quality of life.
Benjamin Anderson: Yes.
Anne Dwyer: Thank you.
Anne Dwyer: All right, Tom, please feel free to ask your question.
Tom Corwin: Hi! Can you hear me?
Anne Dwyer: Yes, we.
Tom Corwin: Whoa? Okay? Yeah. It.
Anne Dwyer: Go ahead!
Tom Corwin: Thank you. South Carolina's governor has already announced that he is going to seek a waiver to impose work requirements for Medicaid adults, the considered able-bodied adults, and I know this is outside the scope of your report. But
Tom Corwin: on top of the cuts you have a sense of what that kind of imposition.
Tom Corwin: What kind of impact that would have on the Medicaid population.
Joan Alker: I can speak to that. And Hi, Tom, you know, in the context of South Carolina, South Carolina is not an an Aca expansion state.
Joan Alker: So the adults in your program are primarily parents, very low income, disproportionately women. And so, while I think we all have an interest in supporting work.
Joan Alker: This policy is a mistake. It's misguided, and it's especially misguided in a state that does not have the Medicaid expansion when you're talking about just parents who are caregivers
Joan Alker: and are are very low income. So there's sort of 2 separate issues on the table about work requirements. Congress is considering them as a way to cut Medicaid, and then, of course, the Administration may consider waivers on this point as we saw last time, but I think
Joan Alker: the waivers take a little bit of time. So right now all eyes should be on Congress to see what they're going to do, not only in work requirements which we hear a lot of discussion about. But frankly, that's small potatoes compared to some of these really big cuts they're considering like getting rid of the expansion match like even capping and block. Granting the program.
Tom Corwin: Thank you.
Anne Dwyer: Thank you, Joan, and I know. Thank you, Tom. I know Dr. Casimonel has to pop off, so thank you so much for joining us today we'll stay on to the end of the hour. We have just a few more questions, Mike. I see you have another question. Why don't you go ahead.
Mike Moen: Actually I I know that some people have to get going, and I appreciate you. Taking up the follow-up questions. Dr. Cosman, I have 2 questions.
Mike Moen: Could you briefly talk about
Mike Moen: the rural landscape for Medicaid, rural Medicaid landscape for Minnesota and the Dakotas? I'm just at brief observations, and then for Joan Elker the importance of Medicaid for preventative care just to touch on that, if possible. Thank you.
Katy B. Kozhimannil: I I can briefly say so I will say our our research center and the work that I do tends to be national in scope. But obviously I'm from this this place. I grew up in Minnesota and North Dakota, so I know both
Katy B. Kozhimannil: firsthand as a as a family member and as a community member, the importance of Medicaid in our rural communities it is absolutely essential to providing access to health care services in greater Minnesota and in most parts of the Dakotas, the
Katy B. Kozhimannil: There are just a handful of cities of big cities, and we have vast vast areas where people have to travel, great distances to access basic care and
Katy B. Kozhimannil: Medicaid is an absolutely essential source of revenue for those hospitals to keep operating and to provide different types of services and additional training and support for clinicians and for administrative and other staff in those areas, quality, improvement, measurement. Sometimes what we think of as ancillary, that not direct.
Katy B. Kozhimannil: Clinical services also require
Katy B. Kozhimannil: the revenue that's generated by Medicaid to be able to be operating in communities, and not only are they places for folks to access care. But they're sources of jobs and support for communities. They are an economic engine for our rural communities across Greater Minnesota and the Dakotas. So thank you for that question, and for the opportunity to emphasize that importance. Perhaps others would have
Katy B. Kozhimannil: additional information, and I do have to hop off. I apologize so much. Thank you all. Thank you for this opportunity.
Joan Alker: Yeah, I'll quickly address a preventive care question, you know, if we see cuts to Medicaid, which is such a critical source of financing for coverage for children, and preventive care is critical for everybody. It's critical for prenatal care as well as Ben talked about.
Joan Alker: But we see provider rates get cut. We see benefits being trimmed, and that doesn't make sense, because people wind up sicker. And then they're in the emergency room, and children can't get their asthma inhalers, and they wind up in the emergency room and they miss school. So there are a whole cascade of consequences. Once we start.
Joan Alker: if the country makes a decision to start trimming care, and these are very short sighted, particularly when you're talking about children, particularly when you're talking about prenatal care in the long term. It's a much better investment of taxpayer dollars, because it'll pay dividends in the long run to make sure that these families are getting the care they need.
Mike Moen: Thank you again.
Anne Dwyer: Thank you.
Anne Dwyer: Thanks, Mike. We'll move to hope next hope. Please ask your question.
Hope Kirwan: Thank you. Hope Kerman, with Wisconsin public radio. My question is for Joan. I'm curious. If this report looked at how these numbers differ. You know, numbers of rural participation kind of differ in states that have not adopted Medicaid expansion. I'm just curious if this report kind of says anything about how rural participation in Medicaid is affected by expansion or a lack of expansion.
Joan Alker: So we we have looked at that in the past, but we did not look at that per se. In this report we can share with you in the past. Yes, Medicaid expansion is very consequential for the enrollment rates of non elderly adults, and you can see this in North Carolina. I can maybe share that with you. Offline. They have some administrative data that really makes that point.
Anne Dwyer: Great and we'll move on to Phil. Go with, please feel free to ask your question.
Phil Galewitz: Hey? There! Good to see you. Thanks for taking my question. My question is more about the politics of this
Phil Galewitz: is the idea that rural America strongly went for
Phil Galewitz: for trump in the election. Is it thinking there that people, either one didn't see the connection between Trump and his policies could affect them on Medicaid, or how do you? How does sort of your research?
Phil Galewitz: Obviously, there's going to be a big lobbying push in the next 6 months in Congress. But how do you get people in rural America to realize that the trump policies could negatively affect them? And is the thinking, now that they voted for trump.
Phil Galewitz: Either they didn't know this could happen that these proposals would be made, or they.
Phil Galewitz: It wasn't a priority for them.
Phil Galewitz: Curious how you answer that.
Joan Alker: Yeah. So I want to let Ben answer this. I'll just say, as I said, up front. There was no discussion of Medicaid during their Presidential campaign frankly, by either candidate.
Joan Alker: The Harris campaign did. It put out some reports relating to Medicaid cuts, but there was no discussion of Medicaid. The voters didn't hear about Medicaid, and they heard from President Trump that he would protect Medicare and social security in the Aca. And so there was a lot about protecting health care, and that's part of the irony here. But Medicaid was not mentioned.
Joan Alker: So so that's that's where we are. But, Ben, I'm going to hand it to you.
Benjamin Anderson: Yeah, I think the outcome of the election. I sort of live in this. Yeah, in the nucleus of what you're talking about. The outcome of the election was a result of a of a segment of America feeling forgotten. Again
Benjamin Anderson: again history was repeated, and so I don't think there was an understanding really of how the impact of this policy of this, this Administration's policies would negatively affect the most vulnerable folks in in Middle America or in in rural places. But Medicaid wasn't the forefront of their minds, and I don't know that there's enough of a
Benjamin Anderson: health. Literacy doesn't sound like the right word. But there's not not enough of a general understanding of the healthcare delivery system to realize what was at stake specifically related to Medicaid cuts.
Anne Dwyer: Thank you. Okay. I think we'll do 2 more.
Benjamin Anderson: To answer your question, how how do you educate them? People? I would say, people in rural America value relationships, even over logic.
Benjamin Anderson: even over data.
Benjamin Anderson: they have to trust their source. And so I think there's an opportunity for local community leaders that have trust with people to be able to educate at a grassroots level.
Benjamin Anderson: That's not easy work. It's heavy lift.
Phil Galewitz: Thank you.
Anne Dwyer: Thank you. Tess, please feel free to ask your question.
Tess Vrbin: Hi, I'll try.
Tess Vrbin: Can you guys hear me? Okay.
Anne Dwyer: Yes, please. Go ahead, Tess.
Tess Vrbin: Okay. So I'm a reporter in Arkansas. A State that had 1 million of its 3 million people on Medicaid before the great post Covid, unwinding of 2023, which here in Arkansas lasted 6 months, while in most places it lasted a full year. It's been criticized for being too rushed about like
Tess Vrbin: more than 184,000 people lost their medicaid coverage during that time because they didn't provide necessary eligibility, information. There were criticisms of like due diligence from the State, and I was wondering, since that was something that happened nationwide
Tess Vrbin: whether the report touched on it or not. Is that something that
Tess Vrbin: that you all have an understanding of? How it might have impacted rural folks? Because Arkansas is a very rural State and one of the
Tess Vrbin: poorer States as well. And there's also a big shortage of maternity care here. But I think that there's still a lot of work to do in reporting on the the impact of the unwinding. But is there anything that y'all can provide some perspective on in terms of
Tess Vrbin: how that might have affected rural people.
Joan Alker: Yeah, that's a great question, Tess. And this data is from 2023. So it just starts to show the impact of unwinding. But it's not going to show the full impact of unwinding. And one of the questions I had in my mind
Joan Alker: when we ran this data, since we knew we'd see a little bit of unwinding is, can we tell yet how it affected rural areas as compared to Metro areas? Because it's you know, one of the things we were worried about. And yes, Arkansas was a state that was extremely aggressive, and had a lot of
Joan Alker: people, particularly children, who were removed for paperwork reasons, not because they weren't eligible. Did that affect rural counties more?
Joan Alker: Possibly so. We don't know the answer to that question yet, but it's a good question, I think, what this data show, particularly for Arkansas, is that Medicaid is going to continue to be an absolutely vital coverage source, even post unwinding for families in rural Arkansas. And per your question, there's probably some families there
Joan Alker: who are eligible, but they're not currently enrolled. So great question. The data is just a little too early to tell. But again, I think what's clear is that, particularly in a state like Arkansas
Joan Alker: rural communities, Medicaid is absolutely vital. So, Ben, and if you want to add anything to that.
Benjamin Anderson: I go what you're saying. And and I think, it's important that we connect
Benjamin Anderson: we connect local people and we connect stories with the vitality of that program, because stories sell.
Anne Dwyer: All right. We'll go ahead and go to our last live question from Ariel Hart. Please feel free to ask your.
Ariel Hart: Hey? Can you hear me?
Ariel Hart: Can you hear me?
Ariel Hart: Great? Thank you. So
Ariel Hart: question about Chip. We always, when we're talking about Medicaid kind of assume that Chip is in. There is chip in the on the chopping block along with Medicaid. Do we have any? Is there any reason to believe it wouldn't be, or that it would be. And then I don't know if you can answer this question specifically, but I'm very interested in who are the caretakers of small children who are on Medicaid? Or, if you have an expansion state, do you know.
Ariel Hart: is there an association there between the income level of people who are the caretakers of small, of of any children, I guess on Medicaid, if they're always parents, or if there are other people instead who tend to need to be on Medicaid if they are, if they are caretakers of children. Thank you.
Joan Alker: 2 quick things, and then, Ben, you might want to jump in on the the adult question in Kansas, since you're a non-expansion state, but we haven't, Ariel. To your question about Chip. We have not seen any discussions yet so far about whether Chip is or is not on the chopping block
Joan Alker: again it falls into the category of nothing was said about it during the campaign. We haven't heard anything about it. There are cuts contemplated in non mandatory spending is a focus of cuts, and Chip is kind of a weird hybrid. But so we just don't know, is the answer. Something we're going to have to stay tuned.
Joan Alker: and in terms of the parent and caretaker relative category in Medicaid, particularly for States that are non-expansion states like Georgia and Kansas. You know these tend to be parents, but of course they could also be grandparents, or you know, other family members who are their caretaker relatives. I don't think I haven't seen good data on exactly how that breakout is. But, Ben, maybe you've encountered that issue in Kansas.
Benjamin Anderson: No, I I mean I am a
Benjamin Anderson: ironically, a father of a child with a disability, and I'm somewhat familiar with resources that exist. For helping with funding for family members as caretakers. But
Benjamin Anderson: but I wouldn't consider myself an expert in that area. I do know that there is limited funding that it's difficult to access. And in the case of the Idd waiver, for example, disability waiver is a 10 year. Wait in Kansas, and somebody has to die or leave the State for somebody else to be able to access that. And with that then comes funding for caregivers to care for a loved one.
Benjamin Anderson: But I wouldn't know enough about the State level policy to be able to comment more on it.
Anne Dwyer: Okay, thank you. With that we'll end our Q&A portion of the webinar and we'll just kick it over to to Ben, do you have any last remarks you'd like to make.
Benjamin Anderson: Just thank the group for the interest in this. It's important that the story is told in a way that honors rural America. That that that
Benjamin Anderson: really speaks on behalf of the most vulnerable folks in our country. And so you have. You have an opportunity to help carry this story, and thankful that, Thankful that you're leading in to do so.
Anne Dwyer: All right. Well, thank you to our panelists and special guests for the remarks, and thank you to all of you for your interest in the report and the critical role Medicaid plays in providing health coverage to people living in small towns and communities
Anne Dwyer: as a reminder, this webinar is also recorded. So that recording will be made available online.
Anne Dwyer: With that I hope everyone has a great day.
Anne Dwyer: Thank you.