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Hospitals in rural America are adjusting to many new requirements under the Affordable Care Act. For those in states that are not extending their Medicaid roles, that task is even more challenging. Rural lobbies are pushing states for the expansion, saying without it, their hospitals could close.
Susanna Capelouto reports.
SUSANNA CAPELOUTO, BYLINE: Meet Dr. Jameelah Gater. She trained in the big city but settled for a life of working the emergency room in the small town of Eatonton, Georgia, about 80 miles east of Atlanta.
DR. JAMEELAH GATER: You know, it's great to be in the grocery store and you see someone. And they say, oh, you don't remember but you took care of me. I mean that's always rewarding. So yeah, I may not have, you know, to crack a chest open and massage the heart - I don't get to do anything fun like that, but the day-to-day care is great.
CAPELOUTO: But Gater does get her share of trauma; mostly car accidents, house fires and the occasional fall. Her hospital has 25 beds and, on average, 6-to-10 have patients in them. She takes care of anyone who needs her help in this rural farming community of about 21,000 - even those who can't pay.
GATER: We have a young gentleman who's got some significant health problems that I actually admitted last week. And he doesn't have a job or a source of income, but right now doesn't qualify for Medicaid or any other government form of insurance. We still take care of him.
CAPELOUTO: In America, no one gets refused services at an emergency room. And to help rural hospitals cope with taking care of the uninsured, they get what's called Disproportional Share, or DISH payments, from the federal government.
The Affordable Care Act was supposed to reduce that payment under the idea that everyone would have insurance or be on Medicaid. But Georgia is one of 20 or so states that decided to opt out of Medicaid expansion once the Supreme court gave them permission to do so. It's a major worry for the Rural Health Association, which lobbies for the 20 percent of Americans who live in rural areas.
Maggie Elehwany is one of their lobbyists.
MAGGIE ELEHWANY: The poorest areas in this country in the Deep South, in Appalachia, in certain pockets in the west, boy, a lot of those - really a tremendous amount of those - are the states that are opting not to expand Medicaid.
CAPELOUTO: Georgia decided against Medicaid expansion, even though the federal government pays 100 percent of the cost for three years and 90 percent thereafter. Governor Nathan Deal argues that it's foolish to believe the feds will keep paying that 90 percent and worries that states will be left to carry the burden in the long run.
Republican State Senator Dean Burke agrees.
STATE SENATOR DEAN BURKE: Increasing Medicaid doesn't necessarily make things better. You know, we need to increase jobs so that we get more people with regular insurance. And that will be where we can make a difference.
CAPELOUTO: But Burke is also a doctor in rural south Georgia, where he works at a hospital. He's not in the appeal Obamacare camp of the Republican Party. Rather he says the genie is out of the bottle, and he'd like to find a way to make it work for Georgia without stressing future budgets.
Looming large for rural Republicans like him is the potential closure of hospitals, once those federal DISH payments stop coming and the poor are still uninsured. Last month, he and his colleagues got some good news: Congress decided to keep the DISH payments in place for two more years.
BURKE: Decreases the amount of pressure they're under to make a quick decision. And I do think it's given them a little breathing room.
CAPELOUTO: Breathing room that comes in handy during an election year when political ideology trumps any federal dollars left on the table by not expanding Medicaid, says Jonathan Oberlander. He teaches social medicine and political science at the University of North Carolina.
JONATHAN OBERLANDER: It's one thing to be opposed to Obamacare ideologically. But when that opposition means that the state is not extending Medicaid and is threatening the finances of your local hospital, you're going to see the Medicaid expansion in a very different light.
CAPELOUTO: Oberlander expects more states to choose Medicaid expansion once they realize just how much money is at stake.
For NPR News, I'm Susanna Capelouto in Atlanta. Transcript provided by NPR, Copyright NPR.