PRESCOTT, Ark. – Rep. Mike Ross, who grew up in this tiny town of 3,600, represents residents like 62-year-old Sandy Barham, a restaurant owner with a heart ailment who can’t afford health insurance for herself or her employees.
"I can’t tell you the stress of living on the edge, just wondering, ‘Am I going to get sick?'" she said in an interview at the Broadway Railroad Café, where fried catfish with hush puppies is a popular feature. "I feel embarrassed, almost, when I go to the doctors and tell them I don’t have insurance."
Many people in and around this economically depressed town can’t afford insurance, even as the battered economy has made it harder for employers to provide coverage for workers. They're looking to Washington for help, and Ross, a conservative Democrat with a strong voice in the debate over health care legislation, says he’s on their side.
Yet Ross stands ready to try to block passage of a House bill that, its supporters say, would provide exactly what Arkansas needs: guaranteed insurance and a wider choice of coverage at competitive prices.
Ross’ position reflects the conundrum confronting many lawmakers, including many he helps lead as head of the fiscally conservative Blue Dog Coalition's health task force. Even if large numbers of constituents might benefit, many of the Blue Dogs generally oppose the $1 trillion bill because they say it’s too costly and doesn’t solve other health care problems in the their mostly rural districts.
"What we’re talking about is containing the cost, slowing the rate of growth of health care down where it can grow at the rate of inflation,” Ross said in an interview, “because if we don’t, it’s going to bankrupt this country.”
Unless changes are made, Ross and six other Blue Dog members of the Energy and Commerce Committee say they’ll vote against the bill this week, bucking party leaders eager for House passage by the end of July. In the hard bargaining taking place, the Blue Dogs are demanding guarantees that the legislation won’t add to the federal budget deficit and would protect small businesses in their districts from employer mandates that would drive up their operating costs.
Yet at the same time, the Blue Dogs also are seeking changes in the way rural hospitals and doctors are reimbursed for their services, which could substantially drive up Medicare and Medicaid expenditures. Competing Pressures
As is often the case in congressional negotiations of this sort, overarching budgetary principles clash with regional or local interests. In pursuing the Blue Dog agenda, Ross may have a hard time reconciling the competing pressures bearing down on him.
An array of politically powerful interests in Arkansas oppose the House bill. Blue Cross Blue Shield, the dominant insurer with 75 percent of the state market, adamantly objects to a proposed government-run plan to compete with private insurers. The Arkansas State Chamber of Commerce, representing nearly 1,200 companies and groups that employ a quarter of the state’s workforce, strongly opposes this so-called public option and another feature requiring employers to provide coverage to workers or pay a penalty equal to 8 percent of their payrolls.
Ross generally agrees with their positions, but has to decide how far he can go in the pursuit of Blue Dog principles without alienating Democratic leaders and many low- and moderate-income constituents who likely would benefit from access to subsidized health insurance and an expansion of Medicaid, the state-federal program for the poor.
Ross "better than anyone knows the makeup of his district” and its health care needs, said Rich Huddleston, executive director of Arkansas Advocates for Children and Families, a nonpartisan social welfare advocacy group. "We believe he supports the overall concern of health care reform…It’s just our hope that whatever he tries to push around cost containment doesn’t get in the way of promoting good health care for kids and their families."
The Nevada County hospital was closed in 1995. (Ann Carrns/KHN)
Ross’ 4th congressional district covers the southern half of the state outside of Little Rock, with a third of it rural and the remainder dotted by towns including Hot Springs, Magnolia, Pine Bluff, Texarkana and Hope, the birthplace of former President Bill Clinton and the nearest town to Prescott with a hospital. Ross’ 660,000 constituents have a median income of $29,675. Republican John McCain swept the district in 2008 with 58 percent of the vote.
Prescott, where Ross and his family live, calls itself “The City of Progress." Its railroad museum, housed in a restored 1912 train depot, is a point of pride. Pink and white crape myrtles enhance the look of the train tracks. Outside of town, horses graze in pastures abutting fields dotted with bulging bales of rolled hay.
It’s a classic rural scene, but the government seat of Nevada County is barely hanging on. Vacant storefronts dot the streetscape. Last year, Potlach Corp., a forest products business, closed its mill, eliminating about 180 jobs.
The economy is taking a toll on health care on Prescott. Two in 10 residents have no health care insurance, and those who do have coverage have seen their premiums skyrocket by 80 percent since 2000, according to data compiled by Ross’ office.
Locally owned J.D. and Billy Hines Trucking Inc. has had to raise the deductible on its family policy to $2,000 to keep premiums, now $336 a month for employees, from rising faster. At her restaurant, Barham sometimes hears patrons talking about how they’re going to afford prescriptions. "They’ll say, ‘I’m going to get half my medication," she said.
Barham frets about the well-being of her own uninsured employees, and has on occasion paid for them to see a doctor. But she has her own problems to worry about: poorly functioning heart valves that may eventually need surgery. Her hope is to remain healthy until she qualifies for Medicare, the federal program for the elderly and disabled, in three years.
The Prescott area’s has health problems that go beyond access to insurance. Its hospital, which was the only one in Nevada County, closed in 1995, with local doctors saying low federal reimbursement rates were partly to blame. Doctors themselves are in short supply: only three practice in Prescott, and two are nearing retirement age.
These issues worry Ross, 47, a five-term House member who is a former pharmacy owner and the grandson of a nurse. He said they’re not fully addressed in the House legislation, with its focus on providing insurance for millions of Americans. In response, the Blue Dogs have demanded “rural health equity” in the bill, including reimbursement rates for hospitals and doctors well above Medicare and Medicaid levels.
“You know, it’s easy to provide everybody a shiny new insurance card,” he said. “But what’s important here is they actually have access to a doctor once they get the insurance card.”
Across the state, over 500,000 people, including those with and without insurance, lack ready access to a health care or medical facility, according to the Community Health Centers of Arkansas, a primary care association representing 12 federally qualified health centers and providing services through 62 facilities to 129,000 patients.
"The issue for us in this area is that we've got to be sure health care is affordable and accessible and it's not just about coverage," said Sip B. Mouden, chief executive officer of the health centers. "We do need health care coverage, but we also need the availability and accessiblility of providers in the local area."
Consider the situation of Dr. Charles Vermont, a quintessential rural doctor. He typically sees 40 patients a day in his office, and visits others in the hospital in Hope and in local nursing homes.
Cell Phones and Poems
He is free with his cell phone number, and often fields calls from patients at home during the evening and on weekends. His offices are equipped to take X-rays and do blood tests and other lab work, and to stabilize emergency cases. In addition to notices about co-pays, the wall of his waiting room features a poem by a patient, an ode to Vermont’s compassion.
Now 63, he’s suffering from sciatica, but can’t plan retirement in part because he worries about who will take care of his patients. If the lack of movie theaters and sophisticated restaurants doesn’t scare young doctors away, the often overwhelming stress of being on one’s own and caring for an aging, poor population usually does. "Prescott is not a lifestyle destination," he said drily. "How do you recruit and retain new physicians?"
Vermont would like health care legislation to include more equitable reimbursements for rural and primary care physicians in particular; greater regulation of insurance companies, and more financial incentives for deployment of physician assistants to help rural doctors. Insuring more people also would help: Many of his patients lack coverage, one reason his office is owed more than $100,000.
At the Arkansas Hospital Association, president and CEO Phil Matthews is seeking adjustments to Medicare and Medicaid payment rates, which he says have been so low they have contributed to the closings of 20 hospitals since 1985. Randy Zook, president of the Chamber of Commerce, is wary of piling on more costs to businesses. “And we’re real suspicious,” he said, “that a government-run plan is a Trojan horse that would lead to a single-payer, government run insurance program.”
So far, Ross and the Blue Dogs aren’t saying precisely what it would take to win their support, and they have planned to submit amendments.
“We are very committed to health care reform and making health insurance affordable and accessible,” Ross said. “But we just think the Democratic leadership has gone about this the wrong way.”