Sunday, February 26, 2017

Living with a disability in rural america (Part I): children

In this series of blog posts, I will highlight a few of the many challenges faced by individuals with disabilities who live in rural areas. This post will focus on children with disabilities in rural communities.

A Brief History of Disability in Schools
Prior to 1975, children with disabilities were often absent from public school settings. In 1970, schools educated only 1 in 5 children with disabilities and many states had laws preventing children with specific types of disabilities - like deafness, blindness, cognitive, and emotional disabilities - from attending public schools.

In 1975, the Education for All Handicapped Children Act was the first federal statute enacted to ensure that children with disabilities had access to education and due process rights. Today, federal laws like the Individuals with Disabilities Education Act (IDEA) and the Americans with Disabilities Act (ADA) (although not without their own flaws) provide children with disabilities important rights, including the right to receive a free and appropriate education and the opportunity to physically access and participate in a school setting.

But even though the United States has come a long way in providing civil rights for children with disabilities, these children still face many challenges, some of which are unique to rural areas.

Access to Treatment and Intervention
Recently, The Atlantic touched on some of the challenges that families of children with autism face in small towns. In the article, reporter Ann Griswold focuses on a family who lives in rural Madrid, Iowa. The family's daughter, Izzy, was diagnosed with autism at age three and has behavioral difficulties both at school and at home. Because Izzy's family lives in Central Iowa, they have fewer options for things like therapy, school, and pediatricians. For example, applied behavioral analysis (ABA) therapy is often recommended to improve behavior for children with autism. But ABA therapy requires frequent contact between the therapist and child, and these providers may be located hours away, as they are for Izzy's family.

Under the IDEA, schools are responsible for providing the educational services and supports that children with disabilities need. But in reality, this may not be possible if there aren't any service providers (like speech therapists, occupational therapists, or psychologists) available.

Some universities, like the University of Iowa, are researching the effects of telehealth services (interactive video conferencing) to deliver therapy services to children and families with autism. The results are promising, but it is too early to tell whether this will be a truly viable option for rural families over time.

Funding for Medical Services
Even though children with disabilities may be able to access some therapies and medical services through their local schools, these services alone may not be enough or the child may be too young to receive the services through their district. So many families rely on in-home intervention services for their infants and toddlers with disabilities. Some states cover the costs of these treatments through Medicaid but when these programs are cut, like they recently were in Texas, rural families are often left without alternatives.

Places like the North Texas Rehabilitation Center, which serviced 10 north Texas counties for 30 years, are forced to close their early childhood intervention programs because they cannot continue to operate without Medicaid reimbursements. Moreover, if the Affordable Care Act is repealed, the children with disabilities who live in states where home therapies and early interventions are currently covered may also be left without alternatives.

Community and Social Support
Even though children with disabilities are likely to attend their local school district and often have the opportunity to participate in community activities, these families and their children may still feel like outsiders in their own community. As Griswold writes, "[a]lthough getting a diagnosis [of autism] has helped, it does not change one brutal fact of geography: People in the small town have little experience with autism....Izzy's erratic behavior has left the family feeling emotionally disconnected from their community."

A rural child with a disability, like autism, may be the only one in her grade or even in her school. Izzy's mother says that sometimes she thinks about moving to a place where there are more opportunities for her daughter and chances to meet other families in similar situations. But Izzy's father likes the fact that in Madrid, people know who they are and the family feels safe in their surroundings.

And it does not help families like Izzy's when national political leaders like Jeff Sessions publicly attack the federal law that affords children with disabilities these civil rights, or when Besty DeVos reveals that she does not fully understand what the IDEA is. These statements do not set an example of inclusion, tolerance, or understanding for people with disabilities.

This discussion leads me to my next question: given the challenges that rural children with disabilities face, what kinds of opportunities will be available to them when they become adults? My next blog post will examine the historical treatment of adults with disabilities in rural areas and the challenges they face today.

Saturday, February 25, 2017

The FCC's (continued) plan to expand broadband service

Internet access is essential in today's world. If you want to conduct an effective job search, apply to an educational program, find a good doctor, access quality news, or learn anything about the modern world, having access to the internet is imperative. Maybe saying it is essential across the board is too strong, but in today's world, lack of internet access is a high barrier to economic progress.

The Federal Communications Commission (FCC) began a plan to expand broadband access across the country in 2010. (This is not the first time that such a plan has come down from the White House.) Now, their Connect America Fund (CAF), created in 2011, is in "Phase II." The FCC uses the fund to subsidize the costs of expanding broadband coverage to areas that are underserved. Service providers must accept the monetary support in order to receive the subsidy during the six-year implementation of the program. "The FCC has focused on areas that are clearly unserved or underserved by unsubsidized service providers." This means rural America. (In the past, the FCC has also expressed heightened awareness of Native American's need for broadband access.) Service providers in some areas have not accepted the funding and thus are not required to provide broadband in their locale, at least not at FCC standards. Here's a map of "Accepted Areas," where CAF funds are being put to use as of September, 2015.

The broadband service provided under the fund has certain minimum requirements to ensure that access to internet means something about quality and price too. There are requirements for speed, latency, usage allowance, and even pricing. The pricing requirement reads, "Service providers must offer service at rates reasonably comparable to rates in urban areas." This seems like a high bar; it is much more expensive for a provider to bring coverage to sparsely populated areas than to urban centers.

The FCC boldly claims that "Consumers everywhere – both urban and rural – will benefit." I read that as a goal, not a reflection of reality.

On their "Progress Portal" for the CAF, the FCC website links to data reflecting the progress of their five main goals. The goals:
  • Preserve and advance voice service
  • Ensure universal availability of voice and broadband to homes, businesses, and community anchor institutions
  • Ensure universal availability of mobile voice and broadband where Americans live, work, or travel
  • Ensure reasonably comparable rates for broadband and voice services
  • Minimize universal service contribution burden on consumers and businesses.
This spreadsheet shows "High-Speed Internet Penetration by State" between 2014 and 2015. New Mexico was the only state to actually decrease on their metric. Alaska showed the next worse progress, an increase of only .3%, where the margin of error is about 1%. Arkansas, Iowa, and New Jersey also showed less than a 1% increase. World Atlas reports Alaska and New Mexico among the top six least densely populated states. Internet access is improving, but the improvements may be slow and disproportionate. That is not surprising.

As far as ensuring "reasonably comparable rates," the Progress Portal says that only 120 service areas are not in compliance. Meaning there are 120 areas where service providers are charging rates incomparable with rates in urban areas.

The Daily Gazette, based out of Schenectady, New York, recently reported that the fund is providing $170 million to support broadband access in Upstate NY. Democratic Senators Schumer and Gillibrand praised the move, expressing hope that it would address a widespread problem of lack of broadband access in rural areas. The article cites that as of December of 2015, 239,000 households did not have access to the benchmark internet speeds set by the FCC. Time will tell how big of an impact this funding will have in rural areas.

In 2020, Phase II will reach its six year mark and the FCC plans to do an evaluation of the program. They plan for a "competitive bidding process" in areas that are still "unserved." Some areas receive coverage from what they call "rate-of-return" carriers, which are not eligible for the Phase II funds, but are subsidized nonetheless.

See this blog post on broadband access in India.

Friday, February 24, 2017

Repealing Obamacare (ACA) may exacerbate the opioid epidemic in rural America

The opioid epidemic is a serious public health issue in the U.S. Opioid overdose deaths have more than quadrupled since 1999. In 2015, there were over 22,000 overdose deaths involving prescription opioids, equivalent to 62 overdoses a day. Since 2014, overdose deaths have increased by approximately 3,000 deaths a year. Nearly 13,000 people died from heroin overdoses in 2015, a 20.6% increase since 2014. Heroin overdose deaths have quadrupled since 2010. Although all states have experienced increases in nonmedical prescription opioid overdoses, states with large rural populations, like Kentucky, West Virginia, Alaska, and Oklahoma, have experienced disproportionately high increases. The widely acknowledged opioid epidemic in rural areas has been discussed in previous blog posts here, here, and here. However, the government has made strides in tackling this epidemic in recent years by passing new healthcare laws.

The Affordable Care Act (ACA) or Obamacare combined with the 2008 Mental Health Parity and Addition Equity Act (MHPAEA) made major advances in improving and ensuring treatment for people with substance use disorders (SUDs). The ACA increased access to health insurance by expanding Medicaid eligibility, allowing children to stay on their parent’s health plans until age 26, and provided financial subsidies to help people afford health insurance. The Medicaid expansion has had an especially large effect on people with SUDs. In states that expanded Medicaid, the percentage of people with SUDs or mental health disorders who were hospitalized fell from 20% in 2013 to 5% in mid-2015. This expansion has been particularly helpful in states, like West Virginia, that have been hit hardest by the opioid epidemic. In West Virginia, which had the highest drug overdose rate in 2015, the rate of uninsured people who were hospitalized with SUDs or mental health disorders fell from 23% in 2013 to 5% in 2014.

The ACA and MHPAEA also closed gaps in health insurance coverage. These laws eliminated annual and lifetime insurance benefits limit on behavioral health services and ending discrimination based on pre-existing conditions. Moreover, before these laws health plans often didn’t include substance abuse treatment or had very strict limits on what they covered and for how long, so the benefits were rarely used. Roughly a third of individually sold private health insurance plans didn’t cover SUDs treatment before the ACA. The ACA required all health insurance plans in the individual and small-group markets to provide essential healthbenefits (EHBs) and included SUD services as EHBs. The ACA also required individual and small group plans to comply with the MHPAEA. The MHPAEA required the majority of health insurance plans to cover mental and behavior health conditions at the same level they cover physical health conditions. However, this law will be “useless” if the ACA is repealed and there is no insurance coverage for low-income people.

States with large opioid epidemics have benefitted substantially from the ACA and MHPAEA. In Kentucky, 1,500 people received addiction treatment through Medicaid in early 2014 but by mid-2016 that number rose to around 11,000 people. In New Hampshire, over 10,000 people have received addiction treatment after the ACA expanded Medicaid in that state. In Pennsylvania, 124,000 people have received addiction treatment after the ACA expanded Medicaid. The ACA has also provided $5.5 billion in spending on addiction and mental health treatment.

If the ACA were repealed not only would the policies promoting SUDs treatment disappear, 2.8 million people with SUDs may lose the coverage they obtained under the ACA. 220,000 of those people have opioid use disorders. Furthermore, the repeal of the ACA will affect rural Americans more than urban Americans. As discussed in a previous blog post, rural America experienced the highest rates of health insurance coverage gains through Obamacare. The Urban Institute's Health Reform Monitoring Survey found that coverage for rural individuals between June 2013 and March 2015 increased by 7.2%.

The ACA also provided grants to many community health centers in rural areas to begin or expand mental health and medication-assisted treatment. As mentioned in a previous blog post, Congress passed the 21st Century Cures Act in December 2016, which sets aside $1 billion in grants to help states expand drug treatment programs over the next two years. However, if the ACA is repealed and many people with SUDS lose their health insurance, they will likely lose access to the new treatment options provided by the 21st Century Cures Act.

The GOP’s current ACA replacement proposals fall short and could undo many of the gains made in treatment for people with SUDs mentioned above. The plan proposed in January 2017 imposes deep cuts to federal Medicaid funding for states which would eliminate or reduce access to insurance for millions of low-income people. The plan also replaces ACA tax credits with fixed amounts, which would make health insurance less affordable for lower and moderate income families who are the most likely to be uninsured. These changes could make insurance less affordable for millions of Americans who may lose their insurance. But even before the ACA is repealed and replaced, the Department of Health and Human Services (HHS) could weaken SUD services coverage. They could do so by not enforcing the ACA’s EHB requirements, which require insurance plans to cover SUDs services. The future of EHB requirements looks bleak since Tom Price, the newly confirmed head of HHS, has criticized them in the past.

Any "replacement" plan for the ACA must contain provisions that protect SUDs treatment. The U.S. cannot afford to ignore the opioid epidemic that is plaguing many states in America, especially rural America. If the new health care plan ignores this crisis, thousands of Americans may die a year from opioid overdoses because they will no longer have any access to treatment programs through their health insurance.