Medicine in Michigan’s Upper Peninsula looks different and trends show it’s about to change even more.

HOUGHTON, MI—The coronavirus is surging in Michigan’s rural areas, including the Upper Peninsula, which is now seeing spikes as high as the state saw in April before the curve was flattened. 

This has changed everyday life, even for those without a diagnosis. 

Michigan Technological University, for instance, carries a national reputation but sits remotely, to say the least. The Upper Peninsula college is so far in Michigan’s northwest that it can actually be quicker if a student wants to weekend in Chicago to drive through all of Wisconsin rather than journey through Michigan. 

Being remote hasn’t protected them from the coronavirus. 

Most of Houghton County’s nearly 350 confirmed cases have come in the first month of in-person instruction, and though the spread has started to slow, at the end of September the school stopped in-person classes. 

They’ve now transitioned back to online-only instruction for the time being to cope. 

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Houghton isn’t the only community in the Upper Peninsula that has endured an outbreak in the past few weeks. The coronavirus has taken such a firm root north of the Mackinac Bridge that Gov. Gretchen Whitmer rolled back the assessment of how well-mitigated the virus was in the region.

More than ever, Michigan needs rural hospitals for places like Houghton. The problem is, those hospitals are struggling. And if Judge Amy Coney Barrett ensures the end of the Affordable Care Act (ACA) as evidence suggests she will, those struggles could get harder.

The ACA provides for a variety of means of support for rural hospitals and the Michiganders those hospitals serve from making it easier to access health insurance to ensuring that people recovering from the coronavirus will be able to get insurance at all. Nearly a million Michiganders get their health insurance through the ACA, the vast majority of whom are covered by the ACA’s Medicaid expansion. 

Graphic by Desiree Tapia
The ‘Gander heat map of coronavirus cases in Michigan.

Rural Hospitals on Life Support

Hospitals like the one in rural west Michigan where Dr. Rob Davidson works have been clinging to every dime they can over the years. Davidson is a specialist in emergency medicine serving Michiganders. He also is an advocate for science-based public health policy and defending insurance programs, leading the Committee to Protect Medicaid and Medicare. 

And he’s fighting to save the ACA. Almost one in five residents served by Davidson’s hospital received insurance from the Medicaid expansion provided by the ACA.

“To me that’s probably the biggest impact,” he told The ‘Gander. “I think the subsidies and cost-sharing to allow people to buy insurance helps as well, but not nearly as much as the Medicaid expansion.”

There are a lot of reasons why hospitals like Davidson’s struggle. Becker’s highlighted several of the most dire of those reasons. Some include the challenges of recruiting full-time physicians to remote areas or the aging populations in rural areas dealing with chronic conditions. 

But one of those reasons is something Davidson expressed great concerns about: cost pressure.  

“I think you’re going to see rural hospitals close up,” Davidson told The ‘Gander. “Those folks still get sick. They still have to come in from time to time but they can’t pay their bills. So now you have the hospital struggling because they can’t get reimbursed and you have the individual struggling because they have bills piling up.”

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Hospitals treat everyone who comes in the doors. But in areas serving lower-income people, the expenses of the treatments those patients need are harder and harder for hospitals to recoup. The expansion of Medicaid that came with the ACA that Michigan took during the administration of Republican Gov. Rick Snyder has been the essential lifeline of hospitals like Davidson’s. 

It’s more than anecdotes. The vast majority of rural America exists in an area deemed ‘medically underserved’ to such an extent that it can be normal for one doctor to serve thousands of miles. These healthcare deserts provide acute dangers to rural America during a global health emergency.

The Center on Budget and Policy Priorities published a study showing that the ACA’s expansion of Medicaid had dramatically changed the coverage of rural areas in states that took the expansion. By 2015 the uninsured rate in rural areas dropped by a third, the bulk of that gain in coverage came in states with expanded Medicaid.

The Center’s report explained that it was rural America that benefited most from the Affordable Care Act across the board. And that dramatically improved the financial health of rural hospitals. The rate of uncompensated care in America’s rural hospitals, by 2015, had nearly dropped by half in states that took the expansion.  

Reversing the course on that progress could lead to more healthcare desertification during the heat of a novel virus pandemic. But it isn’t just the people who might get sick that have cause to worry—people who survived the coronavirus are endangered by the loss of the ACA too.

President Donald Trump’s Pre-Existing Condition

It isn’t just the people on expanded Medicaid that have to worry. One of the core tenants of the ACA is the protections for Americans with pre-existing conditions.

Without those protections, people with conditions like asthma, diabetes, heart conditions and, now, the coronavirus could be charged dramatically more than those who have dodged those diagnoses in premiums, or be outright denied coverage altogether.

As The ‘Gander previously reported, not all coronavirus patients recover in a month. Some face lingering health challenges from lung to heart damage from the virus. The ‘Gander previously profiled Maureen Pickelman from Mt. Clemens whose heart was ravaged by the coronavirus. She had irregular heart rhythms, it was weaker than it should’ve been, and it had enlarged. A blood clot prevented her from having the procedure commonly used to correct arrhythmia so she was put on medication to manage the conditions. She was released with eight weeks of home nurse care, and a defibrillator in case of emergencies. 

Pockelman’s long recovery is indicative of the kind of thing that could be considered a pre-existing condition, explains the Kaiser Family Foundation. If Pickelman could get coverage at all without the ACA, that coverage could still entirely exclude any complications that would arise from her battle with the coronavirus. 

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President Donald Trump has often made empty overtures toward protecting people with pre-existing conditions while actively working to undermine those protections as president. That said, his calls for protecting people with pre-existing conditions this time, at least, come after he was personally diagnosed with the coronavirus—the same pre-existing condition as Pickelman. 

Dr. David Best practices medicine in Traverse City, and he’s concerned about the idea of coronavirus as a pre-existing condition if the ACA is repealed by a Trump-aligned Supreme Court.

“Private insurance, they’re in business to make profits and they don’t want to take on high-cost patients if they don’t have to,” Best told The ‘Gander. “That would lead to potential loss of coverage and decreased options and probably more expense if they’re able to get coverage at all.”

Again, though, hospitals will not just turn away Pickelman if her heart problems from the coronavirus threaten her life. But if she can’t pay the bill, it will be a blow to the hospital’s operating budget. A small blow for just Pickelman, but a much larger blow as the over 120,000 Michiganders diagnosed with coronavirus face the same problem. 

Rural Healthcare Desertification During a Global Health Emergency

One of the counties in the Upper Peninsula facing the current explosion of cases, Gogebic County, was also one of the counties to get the greatest expansion of insurance coverage as a result of the ACA. 

Hospital resources are one of the reasons the recent rise in confirmed cases in Michigan hasn’t been met with the same kind of deaths seen in April. Providing hospitals the resources to fight a pandemic is the entire point of flattening the curve, the tactic of slowing the spread of a virus so the systems of public health can build up a response to a novel, unknown disease. 

“The hospital absolutely depends on having folks who have insurance,” said Davidson. “It’s tough to staff, it’s tough to get doctors to these rural areas, and if you take health insurance away from a huge population of people it just makes it that much more difficult.”

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When rural Michiganders lose their insurance, either by losing plans purchased on ACA exchanges, provided through expanded Medicaid, or lost due to pre-existing conditions, that financial burden is shared by the hospitals that serve them. And if those hospitals fail, the fight against the coronavirus gets that much harder for the hospitals that remain. 

Fewer rural hospitals means fewer resources to fight the virus, and the flatter still the curve has to become to keep the death totals low. 

“This is the whole ballgame,” Davidson said. “The concern is that with the death of Justice Ruth Bader Ginsburg and what looks like the confirmation of a very conservative Justice who has already expressed she thinks the ACA is unconstitutional, that it’s very much at risk.”

The Associated Press contributed to this report.