Episode 58. Medicaid Maternal and Infant Health with Joan Alker
Michelle Rathman: Hello one and all and welcome back to a very special bonus episode of The Rural Impact. I'm Michelle Rathman and I mean it when I say thank you for coming back for more conversation that works to connect the dots between policy and rural everything, policy and quality of life.
Okay. I'm coming to you for this back to back episode because I just returned from Atlanta where I attended the National Rural Health Association Annual Meeting which happened to occur at the very same time, the United States House of Representatives voted to advance a bill that has been named by the administration as One Big, Beautiful Bill, but in reality where rural is concerned, it may be big, but it certainly cannot be described as beautiful, not if we're being honest with each other.
Okay. A few examples. Let me just share a few examples with you before I introduce my guest. You know, last week if you had a chance to download and listen. And we hope that you do. And if you haven't, you have a chance to go back and do that. We focused on what we're calling dead zones, and that's because it was on the reporting of KFF Health News correspondent Sarah Jane Tribble, along with InvestigateTV's, Caresse Jackman. And, we also heard from Joshua Seidemann from The Rural Broadband Association.
And during that episode, we explored the intersection between poor health outcomes and access to high-speed internet. And also, in that conversation you might recall that we touched on broadband equity and current policy decisions aimed at eliminating funding designated to close these gaps.
So today it is May 27th in case you're wondering what date I'm recording this, and I want to read you some information that dropped into my inbox on the matter just a short while ago today. And this was an advocacy alert that I received from the Grassroots Community at the National Rural Health Association. Because as we've been saying for many, many years, healthcare outcomes and technology intersect.
And where Telehealth is concerned is just one but example of that. And we know that it requires broadband to make that possible. So, I'm just gonna read you an excerpt from that email. This starts by saying on May 9th, 2025, the National Telecommunications and Information Administration, that is the NTIA sent termination of funding letters to recipients of grants authorized under the Digital Equity Act, which passed in 2021 as a component of the bipartisan infrastructure law.
Enacted under the Infrastructure Investment Act and Jobs Act, excuse me, the Digital Equity Act established and funded three separate grant programs. The DE planning program, that's $60 million formula grant program for states territories, native entities to develop state and tribal digital equity plans, the DE capacity program, a $1.44 billion formula grant program for states, territories, and native entities to implement their state digital equity plans.
And finally, the DE competitive program, which is a $1.25 billion competitive program under which NTIA can issue grants to support digital equity activities consistent with the Digital Equity Act. More than one fifth of Americans do not have broadband internet access at home. According to the Pew Research Center in rural communities, the number jumps to 27%. It's 27% folks.
More than 200, mostly rural counties across the US are dire native healthcare providers and reliable high-speed internet. At least 20 states, including Connecticut, Illinois, Nevada, Alaska, Maine, Vermont, New Jersey, North Carolina, and North Dakota have reportedly lost their funding. West Virginia, Mississippi, Louisiana, Arkansas, and Alabama are all in the top 10 for the highest percentages of populations eligible for the money.
And all of them have already had their applications for funding approved. So, there is a funding by state formula that I'm gonna link on our website, theruralimpact.com. It's a very long name, so I won't put it out here vocally for you, but go to our resource page and you can find the link and in our show notes for all the state funding and how that might be impacting you.
And as I said before, if you have, if your community has benefited from this rural funding for broadband we would like to hear from you to hear how this might impact your ability as a local economy, as a local small town leader, how it might affect you by not receiving these funds to close that digital divide, as we say.
Alright. Also, I wanna just give you one more example, kind of teeing up our guest today. And because the focus of this special episode has to do with Medicaid and honestly you might be tired of hearing about it. I wish we had something else to talk about. But this is really big because today we are specifically talking about the role of Medicaid in covering women of childbearing age, which for small towns and rural areas constitutes the highest share of women and children dependent on this coverage.
So, my guest today is thankfully no stranger to The Rural Impact, and that is none other than Joan Alker, Executive Director of the Center for Children and Families and a research professor at the Georgetown McCourt School of Public Policy.
Now Joan was gracious enough to join me while I was on the road in Atlanta recording from my hotel room, and we discussed a recently released research focused on maternal and infant health in rural communities and its connection to Medicaid and policy. And this is policy that we are keeping a very close eye on because you know by now that the Senate has the ball in their court to decide the fate of access to healthcare coverage for millions of rural women, children and families.
So, but before we bring in Joan, I just wanna mention to you that one other thing I did a, I wanna do a special shout out to our partners at the American Heart Association. Again, I was just in Atlanta and I had some time, privilege really, of spending some time with a few of AHA's outstanding rural champions last week.
And I wanna remind you that if you are a rural health provider, a rural health leader, there is still time for you to enroll in the American Heart Association's Rural Healthcare Outcomes Accelerator before June 30th, 2025. So, there are 45 program grants remaining available. Get started with contract today simply by submitting a form that we're also gonna put the link on our website.
It's to the Rural Accelerator expedited enrollment form. Again, you'll find that on theruralimpact.com. And keep in mind, there is absolutely no obligation to enroll with a submission of this form, but by doing so, you are one step closer to joining hundreds of other rural hospitals in bringing this incredible program and all that it offers to your community.
Okay, friends, with that said, I invite you to now tune out that background noise. Put yourself in that podcast frame listening of mind, and hear my important conversation with Joan Alker. I know you're ready. I sure am. So let's go.
Michelle Rathman: Joan Alker, we have met before and I am so grateful that you have joined us again because you have yet another really timely, as you always do, research paper that focuses on Medicaid, plays a key role for maternal infant health in rural communities. And Joan, I just wanna send my appreciation for you joining us here today on The Rural Impact because what you have to share is very important to say the least.
Joan Alker: Oh, thanks Michelle for your ongoing dedication to highlighting these issues.
Michelle Rathman: Well, unfortunately I wish I was highlighting other issues, but here we are. So, what I'd like to do for our listeners who have not yet read the paper, and hopefully this conversation will inspire, if you will, folks to read, understand, as we say always on this podcast, connect the dots between policy and rural quality of life.
And this is a biggie. So. This report has several really critically important key findings. And I thought maybe Joan, we could just go through them, and as I kind of rattle them off, if you could kind of get into the details. So, the first key finding of this report, obviously we know Medicaid is a vital source of health coverage for women of childbearing age across the us, but it is even more important to those living in small towns and rural communities than metro areas.
Talk a little bit about some of those numbers.
Joan Alker: Sure. So, we took a look in our ongoing series. As you know, we've been doing this work for many years now. Looks at rural communities in small towns with urban cores of less than 50,000 people. And we took a look at women each 19 through 44. And of course Medicaid is important to women across the country, but as we found for children and non-elderly adults more broadly, Medicaid is more important as a sort of a, a point in time. And that this is one thing I really wanna emphasize is, is these numbers are actually an underestimate for a variety of reasons.
But you can get the feeling with, with the ratio. So for women of childbearing age in metro areas, it's about one in five who are according to the state of source, covered by Medicaid really at a point in time. But in rural areas it's, it's over 23%. So it's getting closer to one in four.
And when you look at other data that looks at, births covered by Medicaid, which nationally is about 40%, but for rural areas is 47%. So, you can see how absolutely, yes, almost half. So absolutely critical, critical for rural communities to grow and thrive, to have strong Medicaid program.
Michelle Rathman: You know, you one of the key findings, not surprising to me during this work, 20 counties nationwide, 20 counties nationwide, have approximately half of women of childbearing age covered by Medicaid, as you say. And those are in, let's go down the list. Where might these be?
Joan Alker: Yes, it's really interesting. When you look at the, the states with the highest share of women overall covered by Medicaid, New Mexico and Louisiana are tied at the top. And of the top 20 counties nationwide, six are in Louisiana, five are in New Mexico, three are in Montana. We've got two in Colorado and Kentucky and one each in Arkansas and Idaho.
So, one thing you'll notice about all of those states is that they have all taken up the Affordable Care Act, Medicaid expansion for adults. And of course that is the piece of the program that is especially targeted for cuts right now on Capitol Hill.
Now there are cuts galore in, in the bill moving through the house, so all states will be impacted, but certainly states that have taken up the Affordable Care Act Medicaid expansion will be even more harshly impacted. And so, I think you can see just by looking at that list, how critical the Affordable Care Medicaid expansion has been for rural areas.
Michelle Rathman: Yeah, I do wanna one point of clarification. We are recording this on Monday, the 19th of May. And overnight on Sunday, the 18th of May, we're seeing the bill move through rather quickly, and there is a goal in mind with a finish line being Memorial Day. I have no crystal ball. I didn't think things would happen in the middle of the night last night, but hence they did. And let's talk about the fact that rural communities, as we know they've been suffering, it's been in the headlines. I think you would have to be literally, literally living under a rock if you did not understand that we have rural hospital closures. And now not just rural hospital closures. The list is growing other, unfortunately, already underserved areas, and there's kind of a creep of that happening. So, when we put that together with, you know, the loss of obstetric services and then the loss of coverage, you know, what kind of, for lack of a better word, what kind of disaster do you see coming our way?
Joan Alker: Yeah, boy, the data is really sobering, Michelle. As you know from other research, the majority of rural hospitals now do not have obstetric care, which is really frightening. And already we know that women in rural areas the farther you are from care, the worst outcomes you're gonna have for both mom and baby.
So, it's very scary. I mean, I know you know this as a mom who, who gave birth a couple times like this, this one is, I can rattle off the numbers, but like it just gives me a pit in my stomach. To think of you know, going to labor or having, having problems while you're pregnant or after you're pregnant.
I mean, this is such a precarious time for women and just the thought of them being further and further away from care they need. I mean, you know, more women of childbearing age live in metro areas now, relatively speaking, and, and I, and I really fear that rural communities simply cannot grow and thrive unless the situation gets turned around.
Michelle Rathman: I, it would be hard pressed. Actually, I will just share with you on my way. I'm recording this clearly folks can see I'm not in the studio. I'm recording this at the National Rural Health Association Annual Meeting, and I happen to be a, in a shared ride with somebody who was coming here for a different conference, and she's due in September and she lives in rural Ohio. She said, we're very fortunate because our hospital is affiliated with a particular larger system. And we have a really good program. And as we were talking about it, she said, I couldn't do this living, you know, in the middle of nowhere without having that care. And it just makes me, to your point, it makes it more and more and more dangerous and you lay over other policies that's making it more and more dangerous.
But that's a different conversation for a different time. So, let's just talk about what you foresee. I mean, one of the things that, you know, I've always, I always ask is. The data that you have, the research you have is so it's there. It's not, it's not true or false. It is. It, it just is that the, these numbers don't lie.
What in your mind are the things that we're missing to convey to our lawmakers as they make these incredibly irreversible almost decisions about how we're gonna cover women of childbearing age in this country, in rural in particular? What are we missing? What are they missing? You're talking to a lot of folks.
I'm just curious what you're hearing about why the message that we're all talking about isn't seeming to stick.
Joan Alker: You know, one thing that's really jumped out at me and, we had this report planned for many, many months. So, in that respect, the timing is coincidental, but, we've really seen a shift in the discourse by Capitol Hill leaders who are pushing these cuts, you know. Months ago, we heard a lot about waste, fraud, and abuse, and we're not even hearing so much about that.
We're now, we're really hearing about these are undeserving people who don't deserve healthcare. And in particular they keep talking about this 29-year-old man who's on his grandmother's couch playing video games. And so I, you know, it's mythical. There's no evidence here about this.
And, and really the reality is that we need to talk about women more. I mean, this has really struck me of late, you know, how important Medicaid is for women throughout their lifespan you know, before they get pregnant. So, they're in optimal health, while they're having, kids. And then of course, you know, women are caregivers, right?
So, they're caregivers for children and they often are caregivers for aging parents. And of course, Medicaid is so important for long-term care with the majority of seniors in nursing homes being covered by Medicaid. So, this program is vital to women's lives and we're not, we're just not hearing enough about that, about how critical.
You know, there's a lot of rhetoric about, well, we're protecting children and families. Well, no, no, that's not correct. I mean, as we've just talked about, Medicaid is absolutely vital for women of childbearing age. And so, cuts that are gonna take, you know, hundreds of billions dollars out of the program are gonna be very, very harmful.
And so, I think really understanding and thinking about it in the context of people's lives and communities. And, and I do think we have talked more about women. There's more and more data coming out about how women will really, really be harmed by these cuts.
Michelle Rathman: Well, truth be told, you know, being, being honest, it's funny because we are, you know, they, they are talking about women wanting to have, you know, raise the birth rate in the United States. They are talking about it and at the same time, removing you know, basically talking very seriously about eliminating those supports and lest we forget how many children, how many infants are covered, and the programs that Medicaid offers for children.
And, and Joan, the other thing I wanna mention to you, because we we just dropping a series. We're talking with KFF Sarah Jane Tribble and Karesse Jackman from InvestigateTV, and they're talking about dead zones. And so what I'm hearing is I talk about people, it's like, yeah, we should have an uptick in telehealth and telehealth is the answer. You know, telehealth is better than no care for obstetrics. And I'm sitting there going, as a woman who's had two children, two emergency C-sections of her own who had prenatal care, you know? That's not going to fill the gap, especially if you don't have coverage for it and literally have the coverage for it, i.e., broadband. So, I don't see that as a solution saving anyone anytime soon.
Joan Alker: Absolutely not. I think there's obviously a role for telehealth, you know, particularly behavioral health, other crises that we face. But when we're talking about women of childbearing age, having access to the care they need, giving birth, nope. Telehealth is not gonna cut it. And I just you know, the majority, the vast, vast majority of births are in hospitals.
We're still up at, I think about 96% as the country. And going to the hospital to, to have a baby is still, you know, that's the number one reason folks go to the hospital. I mean, that's just the reality here. So, that's just not gonna cut the mustard and there's no substitute for having facilities, you know, within a reasonable distance that can address women's needs.
Michelle Rathman: And we don't need more women delivering in ERs and we don't need more women delivering in the back of an ambulance. I mean, this is all like this really, the writing is on the wall, Joan,
Joan Alker: Yeah.
Michelle Rathman: is, it's beyond a wake up call. So I wonder, you're watching very, very, very closely. I will turn back to you and your colleagues 'cause I really do wanna understand and share to the best of our ability should this bill pass. I don't think it's gonna pass the way that it is. However, I do think that we can anticipate some significant cuts, and I know you'll be watching and reporting to the best of your ability, what the impact of that is for rural women, communities, hospitals, economies, because this is all connected, right?
Joan Alker: Absolutely. And as you know, oftentimes the rural hospital is the largest employer in any community. So, there are huge economic impacts that we're gonna see rolling out. But, you're absolutely right in terms of the timing. You know, the house is, is barreling forward. And, by the way, you know, everybody's gotta be a night owl if they wanna keep track of what Congress is doing because they're doing it all literally in the dead of the night.
And I'm not kidding.
Michelle Rathman: No. We don't even know what's the context.
Joan Alker: That's right. You know what was really shocking to me when the committee acted last week, so they released the bill Sunday night on Mother's Day, 10:30 PM. They did the markup Tuesday for 26 hours straight. They didn't even get to, I stayed up till 1:00 AM. I watched from 2:00 PM to 1:00 AM and they hadn't started Medicaid yet.
Hadn't started Medicaid yet, so they really got to it in the, in the middle of the night. And that continues this week. They're going to the rules committee. They say 1:00 AM Wednesday morning. I mean, I have never heard of this, and we don't even have the bill. And, when the committee acted and voted last week for these historic Medicaid cuts, the Congressional Budget Office, which is the nonpartisan scorekeeper, had not even had time to score and estimate the impact of 10 of the 26 Medicaid provisions.
There were 26 Medicaid provisions in spill and a couple of them are fine, very small ones. You know, they're minor. But they hadn't had time to even score. They didn't even know what they were voting on. They had no score. And you know, we still haven't seen all of that information yet.
Yet they're gonna, they're cranked through another version, which is gonna have even deeper Medicaid cuts this week because some of the Freedom Caucus members said they wanted more Medicaid cuts. So, more are coming clearly, but we don't even know what they are. I mean, it's truly shocking to me.
Just look, Congress, you know, often does crazy stuff, but I have never seen anything like the cavalierness with which this, these Medicaid cuts, which are vital. I mean, there's literally a life and death matter for people that they're running these through in the middle of the night and we don't even know what they are.
We don't have scores. It's, it truly is really shocking.
Michelle Rathman: I find myself just, just gobsmacked is the word I can, I think of so more often than not. And you know, one thing I wanted to mention to you is because they were talking about, you know, work requirements and I've read some really interesting different ways to put that. I mean, jumping through fire hoops, you know, to, to have benefits that you are deserving to have, they did exclude pregnant people from that the last I heard, but I don't know where that stands in because we haven't seen it.
We don't know where it stands. Right.
Joan Alker: Yeah. Look, there's, there's a lot of exemptions, but there's, first of all, there's many ways that adults on expansion, which includes a lot of women of childbearing age, we want them to be covered before, during, and after they're pregnant, right? That's what's optimal for maternal infant health. So, there's more frequent eligibility checks that will affect everybody, all adults on Medicaid.
That kind of red tape we know will lead to coverage loss. There are cuts to a variety of funding mechanism, provider taxes and other things that have been important for the financing. That'll affect everybody. And, the issue with the work requirements is that these exemptions don't work very well in practice.
We've seen that.
Michelle Rathman: Data tells us. Yeah,
Joan Alker: Yes, we've seen that from the states that have done them and they're saving $300 billion there. That's just purely from coverage loss. Purely from coverage loss. I mean, the estimates from the parts they did score in Congressional budget office had time to score for the first round was over 7 million more uninsured people.
So, and that's, you know, that number is gonna grow, and it's not even counting Affordable Care Act marketplace effects. But, you know, I would say this, Michelle, to your listeners, a lot of lip service has been paid to rural communities by the proponents of these cuts. And we hear a lot about how they wanna protect rural hospitals and rural communities, but that's not in the bill.
So I would say, you know, listeners rise up and speak about this because there's a lot of lip service being paid to this. But nothing, there's nothing in there that I see that is going to cause anything but harm for rural communities.
Michelle Rathman: Yeah, I echo that. I thank you for saying that. I, and I just wanna tell people you know, you can, I'm teaching a class tomorrow about the, you know, the media and health literacy together. We've been bombarded with information falsehoods, not, you know, this, this process has not been transparent. To your point, there are so many proposals on the table that really, really harm rural America, and I don't wanna hear from people who say, well, people voted so, but I don't wanna hear that. Because at the end of the day, mothers, children, families, our schools, our hospitals, we'll sort that out later. Right now we are staring right at a catastrophe coming our way.
A tsunami of change that's going to put a lot of people out of access to healthcare, but not not needing healthcare. So, all those uninsured population are still gonna need healthcare down the road. And what happens then? I hate to say I speculate, but I think that we know if we do what we say we do, which is to connect the dots between our quality of life and the policy that we all have to live by as a result.
So, oh my gosh, Joan, you actually bring me, I had, I'm breaking out in hives 'cause I'm so stressed out about this particular issue. You bring me calm with your data. I certainly do appreciate it. I mean that.
Joan Alker: Well, Michelle, you know, thank you for your ongoing work. You're, you're such a hard worker out there constantly doing this work. Every time I see you, you're out there. And, and this is what has to happen. Communities just need to have the conversation. So that's, that's the bottom line here. And, and I, you know, this is not a foregone conclusion.
They're not done yet. There's a lot of division within the Republican party about this, so, so communities just need to get engaged, talk to their community elected officials, their leaders, and, and make it clear that these communities have a lot at stake.
Michelle Rathman: Yes, and I'll just say to our listeners, I want I really mean this. Convene a group of stakeholders in your community. You know, if you're a hospital leader, if you are a city manager or a county commissioner, or what have you. Come together and have some business leaders have some conversations, connect the dots to how it's gonna impact the quality of your own community's economic vitality. All of these have implications and you know, we want healthier people. We want healthier babies. We want people to thrive, and that cannot be done with bad policy. Let's just say it. So.
Alright, Joan, we'll be watching. I'm always on the radar screen looking for your research. We appreciate it and to everyone, this has been a very special, brief, Rural Impact.
We are gonna see you the next time on a brand new episode. We'll see you soon.
