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State poor will pay for anti-Obama GOP 

President Obama was re-elected handily and the hated Obamacare enjoys the certainty of being the law of the land next year and beyond, but Republicans in a few states, including Arkansas, still have one last card to play.

They can thwart one of his big campaign promises from way back in 2008, which was to improve the quality and volume of health care in rural America and the well-being of rural and small-town dwellers. All they have to do is block Obamacare's expansion of Medicaid, which in Arkansas would deny health insurance to some 250,000 people, three-fourths of whom are low-income working families and most of whom live in small towns and on country roads.

Obama promised in his 2008 campaign to address the age-old shortage of doctors, nurse practitioners and hospitals in rural areas — a huge problem in the South, where the countryside and towns are the locus of so much of the region's poverty, and to a lesser extent the rest of the country.

It is not just a matter of sickness or health for people in rural Arkansas, although the state ranks in the bottom three states on almost every measure of health and health delivery, mostly owing to the state of medicine away from the urban centers. As the chambers of commerce in every county seat know, the lack of speedy access to doctors and hospitals deters industry, educators and other professionals, retirees and natives who contemplate returning home.

Rural medicine was Dale Bumpers's big issue when he ran for governor from tiny Charleston in 1970. He started area health education centers to train doctors in regional hospitals in the hope that they would practice in rural areas, began scholarships for medical graduates who would start small-town practices and changed the law to allow osteopaths to practice medicine in Arkansas after he saw that across the border in Oklahoma osteopaths furnished much of the rural primary care.

It all helped, but there were still big obstacles. Country doctors had no backup and no access to technical support, and too many people were uninsured and too poor to pay their bills in a timely way.

Then came Barack Obama of Chicago promising that he would raise the quality and affordability of health care outside the cities. No one paid much attention in these parts; rural Arkansas delivered mammoth majorities against him in 2008 and 2012. But it is one promise that he kept.

From his stimulus package in 2009, he sent Arkansas $102 million — more than for all but one state — to develop a high-speed broadband network to connect 474 community hospitals, clinics, regional health centers, universities and other sites so that small-town doctors and clinics would have the same fast access to laboratories, specialists and medical educators as those in big cities and a digital medical records system that will make doctors' work easier and treatment safer. Rural doctors where the links are completed can send images of, say, a fetal abnormality from radiology machines to Little Rock and get the results in seconds.

Under the same stimulus act, Arkansas received $14.4 million for community mental health centers scattered around the state, half for expanding their facilities, and another $300,000 to train health professionals like nurse practitioners.

Already, under the Patient Protection and Affordable Care Act — "Obamacare" — Arkansas is getting money for 30 more medical residency slots at the six area health education centers (we have to have more country doctors to meet the new demand), the state medical center is getting more than $300,000 over four years to provide scholarships and loans for primary care doctors to serve in rural and underserved areas, and two universities received sums for nurse training.

All these steps don't reach the big problem, which is that most people in rural Arkansas cannot afford much care. When sickness becomes dicey, they travel to the nearest town with an emergency room. If the baby's sickness gets scary, they go to the doctor's house in the middle of the night. Many docs don't stay long after they've served their scholarship dues.

Expanding Medicaid to cover the remaining poor who are not covered — in Arkansas, those are childless adults from 19 to 64 — was half the solution under Obamacare. The other half was to require people above the Medicaid threshold (roughly 135 percent of the poverty line) to obtain private insurance individually or through their employer, with the government helping with the monthly premiums until a family's income exceeds 400 percent of poverty.

A slim majority of the U.S. Supreme Court gave Republicans bent on abolishing health reform one opening. It said the states could take expanded Medicaid or leave it. The states with the biggest gaps in coverage — Arkansas, Alabama, Louisiana, Oklahoma and the like — are leaving it. Governor Beebe wants to take it, but Republicans by and large have said they would vote not to cover the poor, although it will bring more money into the state treasury than it will ever take out.

The single rational objection to the expansion — that it might in a few years place huge demands on the state budget that would force a tax increase — vanished when the computations showed that over the next dozen years Medicaid expansion will relieve the state budget of more than $700 million rather than add to it because the federal government will take over some state Medicaid obligations and the flood of federal spending on health care in the state will bring a tide of new tax revenue.

But one justification — it will thwart Barack Obama — still trumps everything. Last year, that was a proven winner. This year, maybe not. A few Republicans this month said they might take a second look.

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