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State Sen. Fred Mills, R-Parks, right, chairs a Senate committee hearing Wednesday, May 15, 2019.

Overall the expansion of Medicaid insurance coverage since 2016 has been a success, giving almost 500,000 people who make very little money access to primary care and life-saving treatment in many cases.

Grace Notes: John Bel Edwards signed Jeff Landry-backed health bill reluctantly. Someone should tell this outside group that supports him.

While there are problems with every large-scale insurance program that has an eligibility requirement, the fundamentals of expanding health care access remain a strong positive for the state.

That issue has an economic dimension as well, including one that Gov. John Bel Edwards has touted: In Louisiana since Medicaid expanded on his initiative, no rural hospitals have closed in the state.

That might not seem news, but in fact the failure of smaller, rural hospitals is a big story across the nation.

Governing magazine reported that at least 95 rural hospitals have closed since 2010, according to the University of North Carolina’s Sheps Center for Health Services Research.

Many have been in the southeastern states — largely Republican-led — that like Louisiana shied away from the expansion authorized by “Obamacare,” the 2010 U.S. Affordable Care Act. But of the three states in the region that did expand Medicaid through 2017, Arkansas, Kentucky and Louisiana, only Kentucky has experienced any rural hospital closures, with three facilities shuttered after Medicaid expansion, according to UNC’s research.

That’s an important gain, because smaller hospitals in more rural areas typically have a lot of potential patients in low-wage jobs.

Still, small hospitals feel threatened, and the Legislature responded this year: A new law, signed by Edwards, prohibits the creation of most new freestanding emergency rooms.

State Sen. Fred Mills, a St. Martin Parish Republican, says stand-alone emergency departments drain profitable services from rural hospitals that operate on narrow margins.

The bill was heavily amended, allowing it to be approved almost unanimously, with a 33-1 Senate vote and 92-0 House vote.

Thus, larger metropolitan hospitals are also protected in this game of divvying up the market: Mills' proposal will prohibit creation of freestanding emergency departments in Louisiana that are not licensed as part of a hospital's main campus or as a hospital's off-site campus. Still, no hospitals will be able to create an off-site ER within the primary service area of a rural hospital.

Freestanding emergency rooms permitted by April 1 won't be affected.

Is this protectionism? Yes, in an election year, as well — hardly a coincidence.

Mills’ protectionist bill might give small hospitals a temporary advantage, but ultimately, their future will still probably be determined by the realities of the marketplace.

Medicaid expansion made Louisiana an outlier in national trend of stalling insurance coverage

As Governing pointed out, there are multiple reasons for rural hospitals to close, from less population in their towns to a growing demand for complex treatment and operations that are never going to be economical except in larger hospitals.

Of the two initiatives, it is Edwards’ Medicaid expansion that does the most for rural providers of health care.