Health insurance has been a special challenge for farmers, most of whom don’t have major corporations paying a large share of their premiums. Some obtain coverage through their farm organizations or their spouse’s employer, but not all.

So you would have thought the Affordable Care Act, which promised to provide coverage to people who were without, would have been appealing to growers. Instead, Obamacare became a whipping boy in rural America.

Republicans used it to defeat any number of candidates, beginning with former Arkansas Sen. Blanche Lincoln, who at the time was chairman of the Senate Committee on Agriculture, Nutrition and Forestry – a position that might have allowed her to write a much more favorable farm bill than the one that emerged in 2014.

The history of Obamacare has been a series of odd developments, as Harwood D. Schaffer and Daryll E. Ray, agricultural economists with the University of Tennessee’s Agricultural Policy Analysis Center, noted in a recent article.

For many farmers, the ACA has afforded them a level of protection that was previously unaffordable, they wrote. “Our concern is the impact that any changes to the law will have upon farmers and other rural residents. We do know that the ACA has reduced the number of the uninsured persons in rural counties across the country.”

Conservative think tank

The philosophical issue is more curious given that the essentials of the design of the ACA were set out by a conservative think tank in the 1990s as an alternative to Clintoncare. It was this plan Mitt Romney used to provide universal health care coverage in Massachusetts when he was governor.

“If many Democrats had their way, universal health care coverage would be centered around a single payer plan like Medicare and Medicaid,” they said. “But to fulfil a vision of universal health care insurance, the Democrats settled on the current design to at least move the ball forward.

“The issue is not really one of the cost to the general public for covering the uninsured because we all will pay for it one way or the other,” they said. Hospitals cannot turn away non-paying patients; they just pass that cost on to the paying customers; i.e, those with insurance, in the form of higher charges.

Alternatively, those unreimbursed health care costs can be covered through taxes to subsidize coverage at a level that each family can afford. (For years one of the most hotly debated items in the Arkansas and Mississippi legislatures was how much those states would reimburse the City of Memphis Hospital for taking care of indigent patients from eastern Arkansas and northern Mississippi.)

“Those who think that they are healthy enough may decide to stay out of the health insurance market—often the young and members of groups like farmers without employer paid coverage—because their expected personal costs for health care are less than the cost of purchasing a policy,” the say. “But in doing so they create a systemic risk for the insurance market because sooner or later it is like playing Russian Roulette; there is a bullet in the chamber in the form of a costly, recurrent illness.”

Late entries to market

Once the expected healthcare costs are greater than the cost of insurance they want to enter the insurance market. Traditionally, insurers have guarded against that type of systemic risk by charging high premiums. Once a farmer or any family member has a skin cancer or an accident, they have a pre-existing condition and coverage suddenly becomes unaffordable just at the moment that they need it.

The ACA tried to get around this problem by requiring everyone to purchase a basic-level policy or pay a penalty on their income tax form. It may seem like coercion but with a mix of customers, insurance companies can cover pre-existing conditions at reasonable rates.

The same issue of systemic risk rears its head in talking about people purchasing just the insurance they need instead of a plan with a minimum level of coverage for most health care needs. Sooner or later they are going to need an additional coverage and when they enter the market they raise the rates for every policy holder.

“At the population level, we know the what—the risk of various diseases—we just don’t know who,” they say. “At the individual level, we can look at family history and narrow our determination of the risk of getting any particular disease, but if we are wrong and come down with the disease the result may be very costly. Universal health insurance coverage allows us to avoid taking that risk.”

Are there problems with the ACA? “Certainly!” the economists write. “One of the biggest problem for rural areas is having only insurance plan in the program. The question is “do we throw the baby out with the bathwater” or do we get about the business of coming up with a workable solution that has broad public support and ensures that no one has to delay a needed medical visit because they can’t afford the cost?