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Casey Britton holds her younger son, Gavin, on the front porch of their home in Linden, Tennessee. Photo by Laura Santhanam/PBS NewsHour

In rural America, tightened access to Medicaid means tough choices

In March, Casey Britton fed her two 13-page Medicaid renewal applications into an ancient fax machine in Linden, Tennessee’s career center before the state’s March 31 deadline. But on April 30, the state sent her a letter, saying it reviewed her paperwork and had decided she didn’t qualify anymore. Their coverage would end May 21, the letter read.

On most days, even with Medicaid, Britton feels like she’s struggling to raise her two sons, ages 2 and 5, and get them the care they need. Without it, even the most basic medical care would become unaffordable.

Thirty-two states and Washington, D.C., have expanded Medicaid access in recent years, and Virginia’s senate this week voted to extend the health care program to 400,000 of its low-income residents. But in April, Tennessee legislators voted to set up work requirements for Medicaid recipients, joining a number of states, including Kentucky, Indiana and Arkansas, that have passed similar laws in recent months. Gov. Bill Haslam signed the bill into law this month. This means adults without physical disabilities or children under age 6 must work, go to school or volunteer part-time or they could lose Medicaid coverage. It is the latest in a series of moves nationwide to tighten access to Medicaid.

Where Britton lives, on the outskirts of Linden, Tennessee, there’s one grocery store. It sells milk for $4 a gallon — an unreasonable price for families on a fixed income like hers, she said. And having health care coverage is one victory, but actually getting care is another story. The county has no pediatrician, so Britton either takes her sons to a nurse practitioner at a local walk-in clinic or drives 60 miles — twice the distance the federal government defines as reasonable access to care — to see a doctor. She forgoes her own health care “unless I feel like I’m dying.”

Casey Britton poses with her husband, Norbie Britton, and her sons, Seth, 5, and Gavin, 2, after an Easter egg hunt in April. Photo courtesy of Casey Britton.

Casey Britton poses with her husband, Norbie Britton, and her sons, Seth, 5, and Gavin, 2, after an Easter egg hunt in April. Photo courtesy of Casey Britton.

In the years after her older son, Seth, was born, he grunted and pointed while Britton and her husband, Norbie, both now 25, guessed what he wanted. No one told her he might need extra help until he started preschool at Linden Elementary School, where he received physical, occupational and speech therapy for the first time, she said. At age 3, he spoke his first words — “mom” and “dad.” Two years later, Seth is still developing his motor skills to hold a pencil properly.

Politicians have promised to improve life for people in Tennessee and across rural America. At his Tuesday campaign rally in Nashville, President Donald Trump told the crowd that “wages are going up, and they’re going up fast. The forgotten men and women of our country are no longer forgotten.”

Britton isn’t as optimistic. Backers of the Medicaid work requirements, an idea supported by the Trump administration, say requiring people to work will help move them out of poverty, and in turn, make them healthier.

“This legislation is about lifting people out of poverty, while still providing the support needed for Tennesseans to be successful and prosperous,” said Beth Harwell, Tennessee’s Republican candidate for governor and state Speaker of the House who introduced the state’s work requirement bill, in a released statement in January when she filed.

Health care advocates say work requirements will deny health care to people already vulnerable to the slightest shift in their economic equation, meaning they are more likely to neglect chronic conditions, end up in emergency rooms more often and ultimately cost the system more money.

Britton doesn’t think the change will help her, either. Right now, she doesn’t work full-time; she raises her sons while her husband works in Nashville. Now that her sons are reaching school age, she has more time for a job outside the home, but there aren’t a lot of opportunities, she said. She has a GED and wants to go to cosmetology school to become a hair stylist, but hasn’t been able to come up with the money for tuition. And the issues she had with her Medicaid application, along with the fact that she has no dental coverage, left her feeling concerned about the future, she said.

“It don’t seem like the Medicaid’s getting any better,” Britton said. “It seems like they’re trying to cut more and more people off that honestly need it and keeping more people on there that don’t need it.”

Britton and her children are not alone. In 2016, 14.1 million children grew up in poverty nationwide. But that proportion is higher in rural areas, where 24 percent of kids live in poverty, compared to 19 percent of those in urban areas, according to a new report on rural poverty from Save the Children. That gap widened after the Great Recession, according to Census Bureau data, and remains most persistent for single-parent homes, children with disabilities and African-American children. In the latest report, Tennessee ranks 40th nationwide for states where childhood is most under threat. Nearly 1.5 million Tennessee children were enrolled in Medicaid in 2017. In Perry County, there were 2,078 children enrolled. Britton’s two sons were among them.

In January, the Tennessee Justice Center estimated that more than 480,000 Tennesseans could lose Medicaid coverage under the state’s then-proposed work requirement. Bureaucratic red tape — not ineligibility — could pose an obstacle to access. And nationwide, 60 percent of 24.6 million current adult Medicaid recipients work at least part-time, according to the Kaiser Family Foundation.

So far, four states — Arkansas, Indiana, Kentucky and New Hampshire — have received approval from the Centers for Medicare and Medicaid Services to use Medicaid work requirements. And in an agency statement to the NewsHour, CMS said it encourages Medicaid work requirements in response to “strong interest from states to test reforms to help lift individuals out of poverty and improve their health and well-being through work and community engagement.” In other words, plug more people who are considered to be able-bodied and working age into jobs, job training or volunteer work.

A lumber truck drives through downtown Linden, Tennessee. Two sawmills are among Linden's most prominent employers. Photo by Laura Santhanam/PBS NewsHour.

A lumber truck drives through downtown Linden, Tennessee. Two sawmills are among Linden’s most prominent employers. Photo by Laura Santhanam/PBS NewsHour

Residents of Perry County take pride in the Buffalo River that flows past Appalachian foothills, pine forests and rolling pastures where horses and cows graze alongside Tennessee State Route 13 — Perry County’s main roadway. Local leaders say the river could save the county if someone could figure out how to build up rental cabins and the tourism industry.

In 1958, Interstate 40, which runs 2,556 miles from California to North Carolina, passed through the length of Tennessee but missed Perry County by four miles. Longtime county residents say car dealerships and restaurants began to uproot and replant themselves along the interstate, sowing the area’s economic downturn. Two garment factories and an automobile parts plant eventually left.

After the Great Recession hit, Perry County, Tennessee, reported an unemployment rate of 29.8 percent, among the nation’s highest. People left if they were able or found jobs in Nashville or as far as Memphis — more than 140 miles away. Today, the jobless rate is much lower, at 4.2 percent, but 22 percent of the county’s nearly 8,000 residents live in poverty, according to the Census. Britton said the community needs more jobs that pay better so families like hers can thrive.

The new Medicaid mandate in Tennessee is essentially: “We’re going to throw you off unless you go to work.” But recipients have “probably already tried that,” said Timothy McBride, a health economist who has studied rural poverty for 20 years and leads the Center for Health Economics and Poverty at Washington University in St. Louis.

People are surprised when McBride tells them many rural communities resemble central cities — they have similar levels of lower incomes and low educational attainment, he said. But while urban job growth rebounded for the most part after the recession, rural employment has not. Jobs that once offered health insurance coverage are gone, and people who remain in rural communities tend to have less education or fewer job skills than what the job market demands, or are older, McBride said. Chronic illnesses, such as diabetes, heart disease and asthma, go undermanaged or overlooked. Life expectancy in much of Appalachia, where poverty has kept a tight hold for generations, is lower than in Bangladesh or Vietnam, said Carolyn Miles, president and chief executive officer of Save the Children. “That’s a really shocking statistic,” she added.

These trends have played out across rural America for decades, but state and federal policymakers don’t pay enough attention to them, McBride said. And efforts to scale back Medicaid through work requirements could complicate these problems further, he added.

Understanding the problem

At home, when Seth gets frustrated, he bites and throws his cup and toys — including, once, a plastic tricycle, Britton said. Earlier this month, the pediatrician in Columbia referred Seth, who has demonstrated signs of autism, to a nearby specialist. But the added costs of regular appointments 60 miles away made Britton nervous: “That’s a lot of gas to go back and forth to Columbia.”

To reach Britton’s double-wide trailer, you drive past two sawmills — among Linden’s leading employers — where lumber trucks haul 60-foot-long pine logs to cut down into support beams for homes and businesses outside Perry County.

Down a dirt driveway and through the open screen door, the first thing you see is a Confederate battle flag on the living room wall, hanging over a chocolate brown corduroy couch.

Reliable public transportation doesn’t exist — a common problem in rural America — so people often rely on their family, friends and churches. This complicates everything from buying groceries to getting to a doctor’s appointment. You can hire a van from a private company to get where you need to go, but it charges per passenger and calculates its fare based on distance. That quickly prices a lot of people out of a ride.

Lack of transportation is a common access problem for health care across rural America, said Joan Alker, who directs Georgetown University’s Center for Children and Families, which in 2017 released a report about Medicaid coverage for rural children. Other access issues include higher poverty rates, higher unemployment rates and difficulty keeping enough health care providers in rural facilities, she said.

As a result, Britton and her husband drive — a lot. Each day, Norbie leaves at 6:30 a.m. and drives 90 miles east to Nashville, where he demolishes the city’s mansions. Each night, he drives back, reaching home as late as 10 p.m. They earn less than $20,000 a year. Together, they spend $200 on gas each week and $500 monthly on the mortgage. Each month, they pay an average of $200 in utilities and receive $430 in food stamp benefits, Britton said.

It takes an hour by school bus to get to Linden Elementary. So Britton makes the 20-minute drive in her Nissan Altima, which has no AC and is missing the right rear passenger door handle. Britton tugs a twisted metal wire to open the door to load Seth into his booster seat.

Casey Britton loads her older son, Seth, into his seat. On an 84-degree day in May, their car had no air-conditioning. Weeks later, she said her car began to rattle and she didn't feel safe taking Seth to a behavioral therapy nearly 60 miles away. She had to cancel the appointment. Photo by Laura Santhanam/PBS NewsHour

Casey Britton loads her older son, Seth, into his seat. On an 84-degree day in May, their car had no air-conditioning. Weeks later, she said her car began to rattle and she didn’t feel safe taking Seth to a behavioral therapy nearly 60 miles away. She had to cancel the appointment. Photo by Laura Santhanam/PBS NewsHour

On May 24, the Tennessee Department of Health Care Finance and Administration mailed Britton a letter, saying the state had received paperwork for her and Gavin and that their Medicaid coverage was reinstated. This was after she appealed the decision and submitted pay stubs to prove they qualified for Medicaid. But since she received the letter in April saying her coverage was cut off, the car has started rattling so much that Britton doesn’t feel safe driving it further than to town and back. She said she must reschedule Seth’s appointment with the behavior specialist until she can afford repairs.

McBride said policymakers need to look more closely at these kinds of realities; sometimes the incentives laid out by programs like Medicaid work requirements don’t match up with people’s day-to-day lives. Since President Lyndon B. Johnson waged his War on Poverty in the 1960s, the United States has tweaked Medicaid and Medicare to remedy rural needs, such as creating payment incentives to recruit health care providers to rural areas, but McBride said those policies don’t go far enough to deliver a lasting solution.

“Will it be fixed in the future?” he said. “I’m not sure it’ll be fixed until we recognize this problem exists and we understand what it is.”

In the meantime, Britton will be waiting. She gets angry when Trump talks about building a wall, like he did in Nashville this week, saying that money could help people instead. And she has her own health needs. She wishes she could buy new eyeglasses — which have been held together for five years by super glue and tape — or have a dentist look at her teeth. But that likely won’t happen anytime soon. “I go without before they go without.”

This report was produced through the Save the Children U.S. Press Fellowship.

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