(By David Hancock, ’76 Contributor) How has Obamacare, the Affordable Care Act of 2010, impacted your personal health care choices? When you ask that complex question, you’ll get a very complex answer depending on who you speak with.  If it’s someone in a rural area, don’t expect happy talk.

While Obamacare enrolled over seven million people in insurance coverage in 2014; the costs of insuring all people regardless of their health condition is seeing its impact. On July 3, 2015, the New York Times reported “Health insurance companies around the country are seeking rate increases of 20 percent to 40 percent or more. The insurers report their new customers under the Affordable Care Act turned out to be sicker than expected.”

This makes sense. When you add more people to health insurance rolls and accept people who have pre-existing conditions, you will have higher costs and resulting higher premiums. And the results are in the numbers. National Health Expenditures (NHE) grew 3.6% to $2.9 trillion in 2013, and accounted for 17.4% of Gross Domestic Product (GDP).

And we’re seeing the costs rise. The per capita cost of health care expenditures is over $8,900 per person, according to the Centers for Medicare & Medicaid Services. Per capita costs were $8,170 in 2009, $8,411 in 2010 and $8,658 in 2011. Simply, it’s rising year after year. According to the Kaiser Family Foundation, the average monthly health insurance premium per person in the private market was $235.27 in 2013.

This is an increase from $215.65 in 2010. In Colorado where I live, the monthly per person rate has increased from $183.65 per person in 2010 to $226.34 in 2013. There’s no denying it, we are spending more on health care. And yet, we continue to get the message from the Obama Administration and Democrats in Congress that health care costs were going to decrease and relief was in sight.

The health care issues are not just confined to private insurance. The largest shares of total health spending were sponsored by households (28 percent) and the federal government (26 percent). Since October 2013, 12.8 million more people in the U.S. were enrolled in Medicaid. In total, in 2015, over 72 million people are enrolled in Medicaid. This is in large part due to the expansion of Medicaid coverage to people in states that agreed to the expansion under Obamacare.

One of the key aspects of Obamacare was to open up government health insurance (Medicaid) for low-income adults with incomes up to 138% of the poverty line. To be eligible, an individual must earn no more than $15,900 or $32,500 for a family of four. Half of states went ahead and expanded, but the other half chose not to. Enrollment in Medicaid, in states that have expanded has jumped 8.3% compared to 1.6% in the remaining half of states.

The Democrats in Congress have argued this 8.3% increase in Medicaid enrollment shows that Obamacare is working because more people are covered by health insurance. This premise would be accurate if the cost of health care was decreasing. However, health care costs continue to increase. This means big losses to the consumer in higher prices and higher monthly premiums. In addition, health care professionals are seeing that same impact on their wallet.

We are seeing large hospitals and hospital systems thrive and grow and seeing smaller health care providers and rural hospitals continuing to get smaller and become less profitable. In some cases, they are even closing their doors. Since 2010, 47 rural hospitals have closed across the country, according to the North Carolina Rural Health Research Program. This is an increase from 3 closures in 2010 to 13 in 2013 and 16 in 2014. Why is this happening?

There are several reasons. One is economic. Many rural communities rely on one or two large industries or employers who help to maintain the economy. If that employer goes away, so does the economy. For example, in the southeast U.S., where textiles were a big industry, unemployment has risen significantly due to the outsourcing of production facility jobs to countries like Mexico where the products can be produced at a cheaper price.

Second, when the economy goes soft, the ability of a hospital to stay open decreases. When unemployment increases, the number of people enrolled in Medicare and Medicaid increases. With decreased reimbursement payments per patient for Medicare and Medicaid, hospitals in rural communities just can’t stay open.

Third, the number of people going to hospitals in rural areas has decreased as well. The way doctors, patients and insurance companies use hospitals is changing. In the past, a hospital was a place for a person to be cared for while they got well. The options are now changing and many people are now using hospitals for a specific procedure or surgery and then getting their rehabilitation at another facility.

This can be particularly problematic for rural areas where families have to travel 40 miles or more to go to their closest specialty hospital. This creates significant problems for rural families who have to take time off work or school in order to visit and care for their loved one; away from home, away from their support system and away from their primary care physician.

Lastly, communities are dependent on having a hospital in their community. Imagine if you are a business and you want to build a factory or an office in a community, one of the first things you want to know is if the community has basic services. Those basic services include hospitals to care for employees.

University of North Carolina professor Mark Holmes studied the economic impact of 140 rural hospital closures nationwide. He found that three years after the closure, losing a hospital costs a community “about 1.6 percentage points in unemployment, about $700 in per capita income, and that was in

[year] 2000 dollars so that would be probably about $1,000 currently.”

Two senators are working on solutions to the problem of rural hospital closures. Senator Chuck Grassley (R-Iowa) and Senator Cory Gardner (R-Colo.) have introduced Senate Bill 1648, “The Rural Emergency Acute Care Hospital Act.” The act would reduce hospitals’ financial reliance on vanishing inpatients. The Act, if approved, will let rural hospitals with fewer than 50 beds, including critical access hospitals, be re-designated as “rural emergency hospitals.”

Those hospitals could maintain an emergency room and ambulance and telemedicine services, as well as other traditional hospital functions, including convalescent skilled nursing care. But they could stop providing acute inpatient care; which is not financially lucrative for those facilities.

Although this is just one fix to the myriad of problems in the U.S. health care system and Obamacare, this is one way to start.

As we approach the end of 2015, and look toward the 2016 election, we are seeing candidates for both the Republican Party and the Democratic Party who are outside of the mainstream political system who are gaining a lot of attention. Is this just temporary? Or is this a sign of American temperament with the status quo?

We will need bold leadership, and we need to look toward adaptive solutions that encourage private investment, changing regulations for hospital reimbursement with private and public government insurance, low taxes and incentives to invest in small rural communities. Our futures demand it.

David Hancock is a Colorado businessman and a doctoral candidate in public health leadership at the University of Illinois-Chicago.