ACA Open Enrollment: If You Are Low-Income

October 23rd, 2017
If You Are Low-Income…

You can learn about your options by filling out a single application. It will tell you whether you qualify for coverage through the Medicaid program or for financial assistance to help pay for private insurance offered through your state’s marketplace. You can apply for coverage even if you have been unable to get it in the past.


Under the Affordable Care Act, 31 states and Washington, D.C., expanded Medicaid eligibility to many low-income adults, including adults without dependent children. However, 19 states have chosen not to expand Medicaid under the law. In states that expanded Medicaid, you may qualify for Medicaid if you earn $16,643 a year as a single individual or $28,180 for a family of three, while other family sizes can qualify at higher incomes. In states that did not expand, non-disabled adults who are parents with very low income will qualify (the eligibility levels vary by state). Regardless of your state’s decision on expanding Medicaid, children are eligible for Medicaid or the Children’s Health Insurance Program (CHIP) if their family  income is about $40,000 (for a family of three), or more in some states. If you live in a state that did not expand Medicaid and you cannot find affordable coverage, you could be exempt from paying a penalty for not having coverage.


Whether or not your state expanded Medicaid, you may be eligible for federal assistance when you buy a health plan through your state’s marketplace. This assistance could lower the premiums you pay and reduce how much money you must pay out of your own pocket when you seek medical care. Although premiums for marketplace plans are increasing significantly in many states, if you qualify for premium tax credits, the tax credit should cover most or nearly all of the cost increase.  In general, you may be eligible for tax credits to lower your premium if you are single and your annual 2018 income is between $12,060 to $48,240 or if your household income is between $20,420 to $81,680 for a family of three (the lower income limits are higher in states that expanded Medicaid). The range differs for families of different sizes. If you buy a plan through the marketplace and your income is between $12,060 and $31,050 for a single person ($20,420 to $51,050 for a family of three), you can also qualify for help with cost sharing. Special modified silver plans are available with lower deductibles, copays, and annual out-of-pocket limits on cost sharing.


You can apply for coverage during the open enrollment period that runs from Nov. 1 through Dec. 15 in most states, including those using Coverage through a marketplace plan takes effect on Jan. 1, 2018. After Dec. 15, you may only sign up for a plan under special circumstances.  Open enrollment in states that run their own marketplaces depends on the state. Nine states—California, Colorado, Connecticut, DC, Massachusetts, Minnesota, New York, Rhode Island, and Washington—have extended open enrollment beyond Dec. 15, 2017. Check with your state marketplace for details.

If you qualify for Medicaid, you can enroll at any time, not just during open enrollment. If you have Medicaid today, you continue to have that coverage; You will receive a notice from your state’s Medicaid agency when it is time to renew your coverage.


If you have questions, you can call the federal government’s toll-free 24-hour hotline at 1-800-318-2596. To find in-person help, go to Further information is available at and at

Hospital-owned Nursing Homes See Higher Reimbursement Rates from Medicaid

October 23rd, 2017

Westminster Village North, a nursing home and retirement community in Indianapolis, recently added 25 beds and two kitchens to speed food delivery to residents. It also redesigned patient rooms to ease wheelchair use and added Wi-Fi and flat-screen televisions. This fall, it’s opening a new assisted living unit.

“We have seen amazing changes and created a more home-like environment for our residents,” said Shelley Rauch, executive director of the home.

The nursing home can afford these multimillion-dollar improvements partly because it has, for the past five years, been collecting significantly higher reimbursement rates from Medicaid, the state-federal health insurance program for the poor. About half of its residents are covered by the program.

In 2012, the nursing facility was leased to Hancock Regional Hospital, a county-owned hospital 15 miles away. The lease lets it take advantage of a wrinkle in Medicaid’s complex funding formula that gives Indiana nursing homes owned or leased by city or county governments a funding boost. For Indiana, that translates to 30 percent more federal dollars per Medicaid resident. But that money is sent to the hospitals, which negotiate with the nursing homes on how to divide the funding.

Nearly 90 percent of the state’s 554 nursing homes have been leased or sold to county hospitals, state records show, bringing in hundreds of millions in extra federal payments to the state.

Even though Indiana’s nursing home population has remained steady at about 39,000 people over the past five years, Medicaid spending for the homes has increased by $900 million, in large part because of the extra federal dollars, according to state data. Total spending on Indiana nursing homes was $2.2 billion in 2016.

[Also: Hospitals caught between law and patient well-being in recommending quality nursing homes]

The funding enhancements were pioneered in Indiana, but hospitals in several other states, including Pennsylvania and Michigan, have also used the process. Advocates say it has been a key factor in helping to keep Indiana’s city and county hospitals economically vital at a time when many rural hospitals nationwide are facing serious financial difficulties.

Westminster Village North, a nursing home and retirement community in Indianapolis, recently redesigned patient rooms in the nursing home to ease wheelchair use. (Courtesy of Westminster Village North)

But critics argue that the money flow has not significantly improved nursing home quality and has slowed adoption of community and home health services.

More than two-thirds of Indiana’s Medicaid long-term-care dollars go to nursing homes, compared with the U.S. average of 47 percent.

Joe Moser, who until May was Indiana’s Medicaid director, said while in office that the hospital-nursing home marriages were partly responsible for keeping more people in nursing homes. “It is a factor that has contributed to our imbalance,” he said.

Daniel Hatcher, a law professor at the University of Baltimore and author of last year’s “The Poverty Industry,” said this funding arrangement is a bad deal for the poor and undercuts the purpose of the Medicaid program. “The state is using an illusory practice and taking away money from low-income elderly individuals who are living in poor performing nursing homes,” he said. He noted Indiana is ranked near the bottom of states for nursing home quality by several government and private reports.

But proponents of the practice say that even when hospitals get most of the money, it is well spent.

Marion County Hospital and Health Corp., the large safety-net hospital system in Indianapolis, owns or leases 78 nursing homes across the state, more than any other county hospital.

Sheila Guenin, vice president of long-term care there, said the hospital keeps 75 percent of the additional Medicaid dollars and the nursing homes get the rest. Still, the additional money has improved care. The transfer of the license to the hospital has kept several nursing homes from closing and increased staffing rates at many others, she said.

About 40 percent of the county hospital’s nursing homes have five-star ratings from the federal government, up substantially from 10 years ago, she said. Among the improvements at the nursing homes were the addition of electronic health records as well as high-capacity emergency generators to provide power in case of a natural disaster.

Still, some patient advocates said the extra funding is flowing to hospitals and nursing homes with little public accounting. Ron Flickinger, a regional long-term-care ombudsman in Indiana, said, “A lot of extra money is being spent here, but I’m not sure patients have seen it benefit them.”

A couple reads the paper in one of the common rooms at the Westminster Village North nursing home. (Courtesy of Westminster Village North)

Practice Dates To 2003

Medicaid, which typically covers about two-thirds of nursing home residents, is jointly financed by the federal and state governments. States pay no more than half of the costs, although the federal match varies based on a state’s wealth. In Indiana the federal government covers about two-thirds of Medicaid costs.

The enhanced nursing home payments began in 2003 when a financially strapped Indianapolis hospital owned by the county took advantage of the Medicaid funding provision to bolster its bottom line. In this case, the hospital purchased a nursing home, then provided the money for the state to increase what it spent on the home to the federally allowed maximum.

That increase, in turn, drew down more federal matching funds. Since the federal remittance is larger than the hospital contribution, the hospital got back its initial investment and divided the extra money with the nursing home.

Other county-owned hospitals in Indiana slowly followed suit.

Hatcher said Indiana government leaders embraced the funding arrangement because it let them avoid the politically difficult step of raising taxes to increase state funding to improve care at nursing homes. “It’s a revenue generator for the state and counties,” he said.

All the Medicaid funding for nursing homes should be going to those homes to care for the poor, not shared with hospitals to use as they choose, he added.

The strategy, promoted by consultants advising hospitals and nursing homes in Indiana, is used heavily there because of the plethora of county-owned hospitals. But the federal government is tightening the rules about such payments.

Texas has secured Medicaid approval for a similar strategy starting this month, but federal officials have made the extra funding dependent on nursing homes meeting quality measures, such as reducing falls. Oklahoma is seeking to get federal approval as well.

And in a rule released last year, the federal Centers for Medicare & Medicaid Services announced that it would gradually force states to shift to payment systems that tie such reimbursements to quality of care. Michael Grubbs, an Indiana health consultant, said that rule does not stop the Indiana hospital funding program, but it’s unclear that it will last.

Nursing home operators in Indiana say the financing arrangement has helped them keep up with rising costs and improve care for residents.

Zach Cattell, president of the Indiana Health Care Association, a nursing home trade group, noted the number of nursing homes in the state earning Medicare’s top, five-star rating has increased 9 percentage points since 2011. He said the percentage of high-risk residents with pressure ulcers and those physically restrained also dropped significantly.

An Opportunity Or A Loophole?

In Indiana, the small, county-run rural hospitals generally are not facing the financial threat that has become common elsewhere, in part because of the extra Medicaid funding gained from buying nursing homes, hospital officials say.

“The money has meant a great deal to us,” said Gregg Malot, director of business development at Pulaski Memorial Hospital in northern Indiana. “I don’t see this as a loophole but see it as an opportunity for small rural community hospitals to improve our quality and access to care.”

His hospital is the only one in Pulaski County. The extra Medicaid revenue from acquiring 10 nursing homes statewide — about $2 million a year — has helped finance the hospital’s obstetrics care and the purchase of the hospital’s first MRI, so doctors don’t have to rely on a mobile unit that used to come twice a week, he said. The hospital also spent some of the funding to add a centralized telemetry unit to monitor patients.

Steve Long, CEO of Hancock Regional Hospital in Greenfield, Ind., said his hospital recently built two fitness centers in the county with help from its extra Medicaid dollars. “This would not be possible without the additional funding.”

He rejects the notion that additional Medicaid money reduces the hospital’s incentive to add home- and community-based care in the community. He said new Medicare financing arrangements, such as accountable care organizations, give the hospital motivation to find the most efficient ways to care for patients after they leave the hospital.

But he acknowledged the hospital benefits from seeing more patients go to nursing homes licensed under its name.

“Welcome to health care — it’s a complex and confusing environment where we have all different competing incentives,” Long said.

Why Hospitals Need Better Data Science

October 23rd, 2017

Airlines are arguably more operationally complex, asset-intensive, and regulated than hospitals, yet the best performers are doing a better job by far than most hospitals at keeping costs low and make a decent profit while delivering what their customers expect. Southwest Airlines, for example, has figured out how to do well the two operational things that matter most: Keep more planes in the sky more often, and fill each of them up more, and more often, than anyone else. Similarly, winners in other complex, asset-intensive, service-based industries — Amazon, well-run airports, UPS, and FedEx — have figured out how to over-deliver on their promise while staying streamlined and affordable.

These examples are relevant to health care for two reasons.

First, hospital operations are in many ways like airline and airport operations and transportation services. There are many steps in the service operation (check-in, baggage, the security line, gates), high variability at each step (weather delays, congestion, mechanical issues), multiple connected segments in the user journey — and all these operations involve people, not just machines. In mathematical terms, hospital operations, like airlines and transportation, consist of hundreds of mini-processes, each of which is more stochastic and less deterministic than, say, the steps in assembling a car.

And second, hospitals today face the same cost and revenue pressure that retail, transportation, and airlines have faced for years. As Southwest, Amazon, FedEx, and UPS have demonstrated, to remain viable, industries that are asset-intensive and service-based must streamline operations and do more with less. Health care providers can’t keep spending their way out of trouble by investing in more and more infrastructure; instead, they must optimize their use of the assets currently in place.

To do this, providers need to consistently make excellent operational decisions, as these other industries have. Ultimately, they need to create an operational “air traffic control” for their hospitals — a centralized command-and-control capability that is predictive, learns continually, and uses optimization algorithms and artificial intelligence to deliver prescriptive recommendations throughout the system. Dozens of health care organizations are now streamlining operations by using platforms from providers including LeanTaaS, Intelligent InSites, Qgenda, Optum, and IBM Watson Health. What these solutions have in common is the ability to mine and process large quantities of data to deliver recommendations to administrative and clinical end users.

Improving hospital operational efficiency through data science boils down to applying predictive analytics to improve planning and execution of key care-delivery processes, chief among them resource utilization (including infusion chairs, operating rooms, imaging equipment, and inpatient beds), staff schedules, and patient admittance and discharge. When this is done right, providers see an increase in patient access (accommodation of more patients, sooner) and revenue, lower cost, increased asset utilization, and an improved patient experience. Here are a few examples:

Increasing OR utilization. For a resource that brings in more than 60% of admissions and 65% of revenue at most hospitals, current block-scheduling techniques fall far short in optimizing operating-room time and in improving patient access, surgeon satisfaction, and care quality. Current techniques — phone calls, faxes, and emails — make block-schedule changes cumbersome, error prone, and slow. Using predictive analytics, mobile technologies, and cloud computing, providers are mining utilization patterns to dramatically improve OR scheduling.

For example, mobile apps now allow surgeons and their schedulers to request the block time they need with one click. At UCHealth in Colorado, scheduling apps allow patients to get treated faster (surgeons release their unneeded blocks 10% sooner than with manual techniques), surgeons gain better control and access (the median number of blocks released by surgeon per month has increased by 47%), and overall utilization (and revenue) increases. With these tools, UCHealth increased per-OR revenue by 4%, which translates into an additional $15 million in revenue annually.

Slashing infusion center wait times. Infusion scheduling is an extremely complex mathematical problem. Even for a 30-chair center, avoiding the 10 AM to 2 PM “rush hour” in a patient-centric way requires picking one of a googol (10100 ) of possible solutions. Faced with this challenge, NewYork-Presbyterian Hospital applied predictive analytics and machine learning to optimize its schedule templates, resulting in a 50% drop in patient wait times. In addition to improving longer-term patient scheduling, these technologies help schedulers manage an infusion center’s day-to-day uncertainty — last-minute add-ons, late cancellations, and no-shows — as well as optimize nurses’ workloads and the timing of breaks.

Streamlining ED operations. Emergency departments are famous for bottlenecks, whether because patients are waiting for lab results or imaging backed up in queues or because the department is understaffed. Analytics-driven software that can determine the most efficient order of ED activities, dramatically reducing patient wait times. When a new patient needs an X-ray and a blood draw, knowing the most efficient sequence can save patients time and make smarter use of ED resources. Software can now reveal historic holdups (maybe there’s a repeated Wednesday EKG staffing crunch that needs fixing) and show providers in real time each patient’s journey through the department and wait times. This allows providers to eliminate recurring bottlenecks and call for staff or immediately reroute patient traffic to improve efficiency. Emory University Hospital, for example, used predictive analytics to forecast patient demand for each category of lab test by time of day and day of week. In so doing, the provider reduced average patient wait times from one hour to 15 minutes, which reduced ED bottlenecks proportionally.

ED to inpatient-bed transfer. Predictive tools can also allow providers to forecast the likelihood that a patient will need to be admitted, and provide an immediate estimate of which unit or units can accommodate them. With this information, the hospitalist and ED physician can quickly agree on a likely onboarding flow, which can be made visible to everyone across the onboarding chain. This data-driven approach also helps providers prioritize which beds should be cleaned first, which units should accelerate discharge, and which patients should be moved to a discharge lounge. Using a centralized, data-driven patient logistics system, Sharp HealthCare in San Diego reduced its admit order-to-occupy time by more three hours.

Accelerated discharge planning. To optimize discharge planning, case managers and social workers need to be able to foresee and prevent discharge delays. Electronic health records or other internal systems often gather data on “avoidable discharge delays” — patients who in the last month, quarter, or year were delayed because of insurance verification problems or lack of transportation, destination, or post-discharge care. This data is a gold mine for providers; with the proper analytics tools, within an hour of a patient arriving and completing their paperwork, a provider can predict with fairly high accuracy who among its hundreds of patients is most likely to run into trouble during discharge. By using such tools, case managers and social workers can create a shortlist of high-priority patients whose discharge planning they can start as soon as the patient is admitted. Using discharge analytics software, MedStar Georgetown University Hospital in Washington, DC, for example, increased its daily discharge volume by 21%, reduced length of stay by half a day, and increased morning discharges to 24% of all daily discharges.

Making excellent operational decisions consistently, hundreds of times per day, demands sophisticated data science. Used correctly, analytics tools can lower health care costs, reduce wait times, increase patient access, and unlock capacity with the infrastructure that’s already in place.

Short On Staff: Nursing Crisis Strains U.S. Hospitals

October 23rd, 2017

A shortage of nurses at U.S. hospitals hit West Virginia’s Charleston Area Medical Center at the worst possible time.

The non-profit healthcare system is one of the state’s largest employers and sits in the heart of economically depressed coal country. It faces a $40 million deficit this year as it struggles with fewer privately insured patients, cuts in government reimbursement and higher labor costs to attract a shrinking pool of nurses.

To keep its operations intact, Charleston Medical is spending this year $12 million on visiting or “travel” nurses, twice as much as three years ago. It had no need for travel nurses a decade ago.

“I’ve been a nurse 40 years, and the shortage is the worst I’ve ever seen it,” said Ron Moore, who retired in October from his position as vice president and chief nursing officer for the center. Charleston Area Medical’s incentives include tuition reimbursement for nursing students who commit to work at the hospital for two years.

“It’s better to pay a traveler than to shut a bed,” he said.

Hospitals nationwide face tough choices when it comes to filling nursing jobs. They are paying billions of dollars collectively to recruit and retain nurses rather than risk patient safety or closing down departments, according to Reuters interviews with more than 20 hospitals, including some of the largest U.S. chains.

In addition to higher salaries, retention and signing bonuses, they now offer perks such as student loan repayment, free housing and career mentoring, and rely more on foreign or temporary nurses to fill the gaps.

The cost nationwide for travel nurses alone nearly doubled over three years to $4.8 billion in 2017, according to Staffing Industry Analysts, a global advisor on workforce issues.

The burden falls disproportionately on hospitals serving rural communities, many of them already straining under heavy debt like the Charleston Area Medical Center.

These hospitals must offer more money and benefits to compete with facilities in larger metropolitan areas, many of them linked to well-funded universities, interviews with hospital officials and health experts show.

Along West Virginia’s border with Pennsylvania, university-affiliated J.W. Ruby Memorial Hospital in Morgantown is spending $10.4 million in 2017 compared with $3.6 million a year earlier to hire and retain nurses.

But these costs are part of the facility’s expansion this year, including adding more than 100 beds as it grows programs and takes over healthcare services from smaller rural providers that have scaled back or closed.

J.W. Ruby, the flagship hospital for WVU Medicine, offers higher pay for certain shifts, tuition reimbursement, $10,000 signing bonuses and free housing for staff who live at least 60 miles away.

Next year, the hospital is considering paying college tuition for the family members of long-time nurses to keep them in West Virginia.

“We’ll do whatever we need to do,” said Doug Mitchell, vice president and chief nursing officer of WVU Medicine-WVU Hospitals.


Nursing shortages have occurred in the past, but the current crisis is far worse. The Bureau of Labor Statistics estimates there will be more than a million registered nurse openings by 2024, twice the rate seen in previous shortages.

A major driver is the aging of the baby boomer generation, with a greater number of patients seeking care, including many more complex cases, and a new wave of retirements among trained nurses.

Industry experts, from hospital associations to Wall Street analysts, say the crisis is harder to address than in the past. A faculty shortage and too few nursing school slots has contributed to the problem.

Hospitals seek to meet a goal calling for 80 percent of nursing staff to have a four-year degree by 2020, up from 50 percent in 2010. They also face more competition with clinics and insurance companies that may offer more flexible hours.

Healthcare experts warn that the shortfall presents risks to patients and providers. Research published in August in the International Journal of Nursing Studies found that having inadequate numbers of registered nurses on staff made it more likely that a patient would die after common surgeries.

UAB Hospital in Birmingham, Alabama, has invested millions to attract nurses, but still has 300 jobs to fill. At times, nursing vacancy rates in some of its departments has hit 20 percent or higher.

“We’ve rarely canceled a surgery or closed a bed because of lack of staffing,” said Terri Poe, chief of nursing at the hospital, the state’s largest, which serves many low income and uninsured residents.

Last year, the medical center covered nearly $200 million in unreimbursed medical costs for patients. It spent $4.5 million for visiting nurses during fiscal 2016, including $3 million for post-surgery services, compared with $858,000 in 2012.

Healthcare labor costs typically account for at least half of a facility’s expenses. They jumped by 7.6 percent nationally last year, after climbing at a rate closer to 5 percent annually in recent years, said Beth Wexler, vice president non-profit healthcare at Moody‘s. The spending has proven a boon for medical staffing companies like AMN Healthcare and Aya Healthcare.

Missouri’s nursing shortage reached a record high in 2017, with almost 16 percent – or 5,700 – of positions vacant, up from 8 percent last year. Thirty-four percent of Missouri registered nurses are 55 or older.

“Our biggest challenge is getting the pipeline of experienced nurses,” said Peter Callan, director of talent acquisition and development at the University of Missouri Health Care in Columbia, which is expanding. “There are fewer and fewer as people retire.”

Last year, the academic medical center hired talent scouts to identify candidates, Callan said. It spends $750,000 a year on extras to attract and keep nurses, including annual $2,000 bonuses to registered nurses who remain in hard-to-fill units and up to five years of student loan repayment assistance. It offers employee referral bonuses and a chance to win a trip to Hawaii.

Smaller hospitals find it much harder to compete in this climate. More than 40 percent of rural hospitals had negative operating margins in 2015, according to The Chartis Center for Rural Health.

In rural Missouri, 25-bed Ste. Genevieve County Memorial Hospital had to offer signing bonuses, tuition reimbursement and pay differentials when staffing is “critically low” in units such as obstetrics.

They haven’t closed beds, but have hired less experienced nurses, raised salaries and turned away at least one patient who would have been in its long term care program.

“We’ve had to try whatever it takes to get nurses here,” said Rita Brumfield, head of nursing at the hospital. “It’s a struggle every day to get qualified staff.”

To see the entire graphic on the U.S. nursing shortage, click

Gone To Texas: Migration

October 23rd, 2017

By Kevin McPherson and Bruce Wright

If you live in a Texas city, you’ve probably seen endless highway projects and a skyline dotted with cranes. People are drawn to Texas for jobs, a low cost of living and a high quality of life. Our natural resources and central location in the country, adjacent to the sea and on a national border, have helped create and sustain competitive advantages in transportation, energy, wholesale and retail trade and more.

Of course, there’s nothing new about this. People have been flocking to the Lone Star State since its inception.

But who’s coming, and where do they end up?

A deeper understanding of Texas migration patterns can help us understand current trends — and plan accordingly.

A heritage of fast growth

Texas has been a fast-growing state for more than a century, growing more than twice as fast as the U.S. as a whole (Exhibit 1).

The elements of migration

The population of any region is determined by its births, deaths and migration to and from the area.

Of Texas’ total population growth between 2010 and 2016, migration accounted for almost exactly half (Exhibit 2). Net domestic migration — arrivals to and from other U.S. states — represented about 32 percent of the total increase, with net international immigration accounting for 19 percent. “Natural increase,” the population change due to in-state births less in-state deaths, represented 49 percent of the state’s net growth.

This pattern isn’t universal, however. In the same period, for instance, net migration accounted for just 22 percent of California’s population increase, and all those gains represented international immigration; the state’s domestic migration turned negative, with a net loss of more than 383,000 residents to other states.

A 2016 report by the Texas Demographic Center analyzed the state’s migration patterns for the 2009-2013 period in detail. On average, only about 16 percent of moves in this period represented net migration to the state (Exhibit 3). The remainder moved within Texas, with nearly 61 percent staying within the same county. While such moves don’t change the state’s total population, they can have significant demographic and economic effects on the areas involved.

But the pattern varies with location. According to the Texas Demographic Center, smaller counties (those with populations of 65,000 or less) received the majority of their new residents from other parts of Texas. Larger counties received most new residents from other states, while border counties, unsurprisingly, received a majority of new residents from international immigration.

Where from? Where to?

Americans traditionally are a mobile breed, constantly on the move for new opportunities. In 2015, California and Florida ranked first and second, respectively, both as the most common last residence of new Texans and the most common destination for those leaving Texas (Exhibit 4). In both cases, the balance of inflow and outflow favored Texas.

In the 2010-2016 period, Texas led all states in net domestic migration, with nearly 867,000 new residents (Exhibit 5).

Patterns within Texas

The vast majority of Texas’ population growth occurs in its metropolitan areas, due to the jobs and economic opportunities they offer. Texas has three of the nation’s 10 most populous cities (Houston at fourth, San Antonio, seventh and Dallas, ninth) and two of its 10 largest metropolitan areas (Dallas-Fort Worth-Arlington, fourth, and Houston-The Woodlands-Sugar Land, fifth).

In 2016, Texas was home to five of the nation’s 10 fastest-growing cities of 50,000 or more, including the top three (Exhibit 6).

The Census Bureau’s county-level statistics indicate that migration among states is largely a metropolitan affair. Exhibit 7 shows the five U.S. counties contributing the most net domestic migration to each of Texas’ five most populous counties from 2011 through 2015. Of the 25 possible positions, 19 are counties within the nation’s 20 largest metropolitan statistical areas.

The data offer some support for the popular notion that Texas is providing a haven for Californians escaping the state’s cost of living and sky-high real estate prices; nine of the 25 slots are occupied by California counties. Ironically, though, while Austin is often considered the epicenter of this phenomenon, the exhibit also indicates that Travis County draws new residents from a remarkably diverse set of locations.

Exhibit 8 examines more recent Census immigration data for the five most populous Texas counties. Note that, despite in-migration from dozens of other states, both Dallas and Harris counties experienced negative domestic migration between July 1, 2015, and July 1, 2016. In both cases, however, net international immigration more than made up the difference.

Austin’s a booming high-tech hub, and to many locals, growth spells one thing: Californians. Yet according to the Census Bureau, those crowded roads may be carrying more ex-Floridians than former residents of the Golden State.

Of the top 10 states accounting for Travis County’s net domestic migration, California placed only third between 2011 and 2015 (Exhibit 9).

And still they come

Despite the fluctuations of the state and national economies, businesses and their employees continue coming to the Lone Star State, attracted by its high quality of life and business-friendly tax and regulatory structure.

According to the Tax Foundation, Texas has the nation’s fifth-lowest state and local tax burden, and recently Chief Executive Magazine named Texas the “Best State for Business” for the 13th year in a row.  In the year ending in August 2017, Texas added more jobs (nearly 299,000) than any other state. Recent arrivals include the North American headquarters of Toyota and Kubota Tractor, both formerly based in California. In 2017, Site Selection magazine awarded Texas its Governor’s Cup, citing 642 projects expanding or creating new corporate facilities in the state.

Texans know what keeps us here, and the rest of the country is catching on.

But growth brings its own challenges. Texas’ population is expected to reach nearly 60 million by 2050, bringing with it skyrocketing demand for water, housing, transportation, schools and jobs.

Housing in Texas’ urban areas is increasingly expensive, due in part to high demand from new residents. According to the Texas Association of Realtors, home sales and home prices hit record highs in both 2015 and 2016. Inevitably, some are being priced out of the hottest markets. Texas’ homeownership rate was 61.5 percent in 2016, eighth-lowest among the 50 states, and it’s been falling since 2008, due at least in part to rising housing costs.

Transportation needs will change dramatically. In some areas, highways such as I-35 and I-10 can’t keep up with current traffic. Of course, teleworking, ridesharing and mass transit may change the picture in the future, but in the near term Texas cities can expect worsening traffic and deteriorating road conditions.

And of course, not all areas of Texas are growing. Rural counties losing residents to metropolitan areas face their own challenges, such as access to health care, teacher shortages and inadequate local government revenues.

No matter what the future holds, though, some people will always be drawn to Texas. Texans have faced many challenges over the years, and they’re up for this one as well.

West Texas’ Rural Values ‘Under Assault’ Lawmaker Says

October 23rd, 2017

With the regular and special legislative sessions behind them, area legislators are embarking on the next season — campaign season.

Filing for the March 6 Republican and Democratic primaries begins in less than a month, on Nov. 11, just days after the Nov. 7 election to vote on constitutional amendments proposed by legislators earlier this year.

Though state lawmakers in the conservative Big Country are seemingly safe in their primaries, and in the 2018 general election for that matter, several attending a West Texas Republican meet-and-greet here last week said this time of year is an opportunity to hold town hall meetings and measure the pulse of constituents in their districts.

Abilene’s Stan Lambert, whose District 71 is made up of Jones, Nolan and Taylor counties, told the Stamford attendees that legislators were going to “continue to stay connected, to find out what is important and listen to you.”

West Texas and its rural values is “under assault,” said San Angelo’s Drew Darby, whose nine-county District 72 includes Coke, Howard and Runnels counties in the Big Country.

“West Texas is growing but not as fast as the urban centers,” he said. “There are 19 of us — 19 Stan Lamberts, 19 Drew Darbys, 19 Dustin Burrows — that represent two-thirds of the land mass of Texas, the land west of Interstate 35.”

Flood-ravaged Harris County has 25 state representatives, Darby said.

The Texas House has 150 members.

“In January of ’19, guess who’s going to be wanting your education dollars, guess who’s going to be wanting your water dollars so they can build infrastructures on the coast,” Darby asked. “Guess who’s going to be wanting your transportation dollars — there are over 500 state highways under water, literally under water, in the last disaster.

“Where do you think they are going to get the money? They are going to get it from rural Texas.”

West Texas has to form relationships in the Legislature, he said, and find common ground.

“The last time I checked, they do not raise beef cattle in the back of H-E-B. They do not have a cotton farm in the back of the Men’s Wearhouse. They don’t have producing oil and gas wells in downtown Dallas. The hide, the hair, the food, the fiber, the energy that moves this state comes from rural Texas.”

Darby said he believes West Texas will lose one, maybe two, state representatives with redistricting following the 2020 Census.

State Sen. Charles Perry of Lubbock, who represents 50 counties and a slim slice of Taylor County, said the good news is that Texas is growing, but he pointed out the newcomers “are not bringing roads and bridges and schools with them.”

In setting the state budget, legislators face the same problem as every school and city in the state — “deferred maintenance,” he said.

“We’ve kicked the can down the road because we have Medicaid and a health care entitlement system that is squeezing every dollar out of our budget,” Perry said.

District 83 State Rep. Dustin Burrows of Lubbock said that going back 20 to 30 years, education was the biggest slice of the budget pie, and health and human services was only a small part.

“The cost of health care has gone up significantly more than everything else,” he said. “Since 1980, medical inflation has been two to three times the Consumer Price Index. That means less money available for public education, higher education, roadways and for property tax relief.”

Burrows said in talking to folks from his seven-county district, which includes Mitchell and Scurry counties, most people say their largest expense is health insurance. A family of four spends an average of $17,000 a year on health insurance. By 2019, that figure is expected to be between $22,000 and $30,000, he said, adding people simply can’t afford it.

“I don’t think anything D.C. is going to do is going to fix the underlying culprit, which is medical inflation,” Burrows said. “They’re reshuffling the deck chairs on the Titanic — that’s what I really see in this.”

Businesses are not growing and not hiring, he said, because they are having to buy health insurance for their employees.

Burrows said reform is needed at the state level on making health care more competitive in price.

In response to a question from the audience, Lambert said the biggest challenge facing area lawmakers is the growth along and east of the I-35 corridor, and to “effectively communicate to urban legislators what the needs are of rural Texas.”

Perry said a “one size fits all” approach won’t work when it comes to education and other issues facing the state. Lueders-Avoca ,with 41 students in high school, has different challenges than a 600-student elementary in Lubbock or an urban district in Houston.

Rural Texas chalked up some wins in the last legislative session, the group noted.

Lambert said prior to the start of the meeting that one of the key pieces of legislation requires an agency to study the impact of rules and regulations on communities under 25,000 before implementation.

For example, Lambert said, if the Texas Parks & Wildlife Department passes a rule prohibiting gassing of rattlesnake dens, then it would have to come up with another plan for harvesting snakes to offset the $4.5 million impact that would be lost with the Sweetwater Rattlesnake Roundup.

“I thought it was a good session,” Lambert said. “One thing I learned was you don’t always get everything done in one session. There are multiple issues that will take multiple sessions.”

Happy National Rural Health Day from TORCH!

November 19th, 2015

Texas is one of the most urban and most rural states in the country. Rural Texas, for that matter is comprised of over 3.2 million residents spread over a geographic area the size of France! Our organization has been blessed for the last 27 years to be the principal voice and advocate for the rural and community hospitals all across our great state. Along with our partners at the Texas Association of Rural Health Clinics and the Northwest Texas Hospital Association, we want to wish all of the many rural healthcare leaders, providers and stakeholders an enjoyable #NationalRuralHealthDay 2017. This is the one day a year that we callout the contributions that are made every day to improve the health of rural Americans by these dedicated professionals.  Join us on November 16 as we celebrate #powerofrural.

In a time of great change, we often look to those on the cutting edge for direction. However, when it comes to rural areas, we often lead from the bottom up; drawing from what it is that we do best: caring for our fellow man, holding firm to our values and traditions and routinely employing a genuine ‘can do’ spirit. While the healthcare marketplace is shifting, we feel rural hospitals and providers are poised to lead the way and to succeed in the future delivery system. TORCH is channeling that energy into new programs around population health. We hope that rural providers will want to learn more about these opportunities and to get in on the ground floor of this evolutionary effort to strengthen rural healthcare in Texas for the long term.

U.S. Census data show that the 2,000 or so rural and nonurban hospitals that serve the rural population treat a patient base that is generally older, sicker, and less affluent than their urban counterparts. By focusing on the health of the population in the years ahead, we feel we can preserve what’s best about rural healthcare facilities, while at the same time bringing improved quality of life to rural people and communities. Not only that, but with the recent spate of hospital closures, preserving healthcare in rural communities means preserving jobs and economic stability in these areas as well. The food, fuel and fiber that Americans depend on comes largely from rural areas. In order to meet the needs of our growing country, we must have a healthy and dependable rural workforce.

So what’s the big takeaway from all this talk about the future of access to care and rural economic viability? Well, please take a moment today to remember and thank those people you know who make it their life’s pursuit to provide life-saving healthcare services to our family and friends in rural areas. Then on the other 364 days of the year, be sure to do whatever you can to shop local for your own healthcare needs, to promote the creation of sound healthcare policy that recognizes the unique needs and issues of rural healthcare providers and to urge your elected officials to support legislation that will help save rural hospitals and support rural communities. If you’ll do that, we promise that you will have helped to move rural healthcare forward in the year ahead.

For those of you with a penchant for social media, let’s all do our part to get #NationalRuralHealthDay ‘trending’ this year. Use this hashtag or #powerofrural as a rallying cry on November 16th and be sure to share with all of your connections, friends and followers why you feel rural healthcare is such an important part of the fabric of life for all Americans. Many other resources can be found here.

Lastly, please be sure and send us pictures and stories from your own rural healthcare celebrations. We are currently working on a piece for our year end edition of Rural Matters and would like to highlight our facilities and clinics that celebrate NRHD.  Please send us any pictures from your festivities along with a brief write up to Carrie Ruiz. You will find us on both Facebook and Twitter by searching for ‘torchnet’, so please join us and we hope that you have a fantastic #NationalRuralHealthDay, everyone. Go Rural!