In the central Idaho community of Arco, where Lost Rivers Medical Center is located, the elk and bear outnumber the human population of a thousand. The view from the hospital is flat grassland surrounded by mountain ranges that make for formidable driving in wintertime.

“We’re actually considered a frontier area, which I didn’t even know was a census designation until I moved there,” says Brad Huerta, CEO of the hospital. “I didn’t think there’s anything more rural than rural.”

There are no stoplights in the area. Nor is there a Costco, a Starbucks or — more critically — a surgeon. With 63 full-time employees, the hospital is the county’s largest employer, serving an area larger than Rhode Island.

Six years ago, the hospital declared bankruptcy and was on the cusp of closing. Like many other rural hospitals, it was beset by challenges, including chronic difficulties recruiting medical staff willing to live and work in remote, sparsely populated communities. A hot job market made that even harder.

But against the odds, Huerta has turned Lost Rivers around. He trimmed budgets, but also invested in new technologies and services. And he focused on recruitment.

Kearny County Hospital CEO Benjamin Anderson, left, and Bradley Huerta, CEO of Lost Rivers Medical Center.

Courtesy of Becky Chappel and Bradley Huerta

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Courtesy of Becky Chappel and Bradley Huerta

He targeted older physicians — semiretired empty nesters willing to work part time. He also lured recruits using the area’s best asset: the great outdoors.

“You like mountain climbing, we’re gonna go mountain climbing,” says Huerta, who also uses his local connections to take recruits and their families on ATV tours or flights on small planes, if they’re interested. “The big joke in health care is you don’t recruit the person you recruit their spouse.”

Huerta’s approach has paid off; Lost Rivers is now fully staffed.

Recruitment is a life or death issue, not just for patients in those areas, but for the hospitals themselves, says Alan Morgan, CEO of the National Rural Health Association. Over the last decade, more than 100 rural hospitals have closed, he says, and over the next decade, another 700 more are at risk.

“Keeping access to health care in rural America is simply a challenge no matter how you look at it, but this shortage of rural health care professionals just is an unfortunate driving issue towards more closures,” Morgan says.

And that’s affecting the health of rural communities. “Most certainly the workforce shortages in rural America are contributing towards the decreased life expectancy that we’re seeing in rural America,” he says.

For some rural hospitals, that dire need is the basis of their recruiting pitch: Come here. Make a difference.

That is the crux of Benjamin Anderson’s approach at Kearny County Hospital in the southwestern Kansas town of Lakin.

With a population of about 2,000, last year The Washington Post ranked Lakin one of the country’s most “middle of nowhere” places.

Anderson says he’s found success targeting people motivated by mission over money: “A person that is driven toward the relief of human suffering and the pursuit of justice and equity.”

It’s not that the hospital ignores practical concerns. Hospital staff often house-hunt for recruits, or manage home renovations for incoming workers. Anderson, who isn’t a doctor, also personally babysits the children of his staff, because Lakin lacks nanny services.

“I mean as a CEO I do a lot of different things, but that’s among the most important, because it communicates we love you,” Anderson says. “We’re gonna live in a remote area but we’re gonna live here and support each other.”

But the cornerstone of the hospital’s recruitment pitch is 10 weeks of paid sabbatical a year, which allows time for doctors to serve on medical missions overseas.

Anderson says he came to appreciate the draw of that after a mentor told him, “Go with them and see what motivates them; see why they would want to go there.” Anderson did. It not only changed his life, he says, “I realized that in rural Kansas we have more in common with rural Zimbabwe than we do with Boston, Mass.”

It’s a compelling enough draw that every couple of weeks, Anderson gets a call from physicians saying they want to work in Lakin, despite its remoteness.

One of those callers was Dr. Daniel Linville. He’d read about Kearny County Hospital and its sabbaticals in a magazine article during medical school. Last fall, Linville joined the hospital, having done mission work since childhood in Ecuador, Kenya and Belize.

He says he and his physician wife were also drawn to the surprisingly diverse population Kearny County Hospital serves, including immigrants from Somalia, Vietnam, Laos and Guatemala. In that sense, says Linville, every day feels like an international medical mission, requiring everything from delivering babies to treating dementia.

But life in Lakin also been an adjustment.

“Now that we’ve been out here practicing for a little bit, we realize exactly how rural we are,” Linville says. It’s not just that same-day shipping takes four days; transferring a patient to the next biggest hospital in Wichita means the ambulance and staff are gone for an 8-hour round-trip ride.

And, in an incredibly tight-knit community where he is a newcomer, he’s often reminded that patients see him as another doctor just passing through.

“We’re seen a little bit as outsiders,” Linville says. “We get asked frequently: ‘How long are you here for?’ “

I don’t know, he tells them. But for now, I’m happy.

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The politics of health care are changing. And one of the most controversial parts of the Affordable Care Act — the so-called “Cadillac tax” — may be about to change with it.

The Cadillac tax is a 40% tax on the most generous employer-provided health insurance plans — those that cost more than $11,200 per year for an individual policy or $30,150 for family coverage. It was a tax on employers, and was supposed to take effect in 2018 — but Congress has delayed implementation twice.

And the House, now controlled by Democrats, recently voted overwhelmingly — 419 to 6 — to repeal that part of the ACA entirely. A Senate companion bill is bipartisan and now has a total of 61 cosponsors — more than enough to ensure passage.

The tax was always an unpopular and controversial part of the 2010 health law, because the expectation was that employers would cut benefits to avoid the tax. Still, ACA backers initially said the tax was necessary to help pay for the law’s nearly $1 trillion cost and help stem the use of what was seen as potentially unnecessary care.

In the ensuing years, however, public opinion has shifted decisively, as premiums and out-of-pocket costs for patients have soared. Now the biggest health issue is not how much the nation is spending on health care, but how much individuals are.

“Voters deeply care about health care, still,” says Heather Meade, a spokeswoman for the Alliance to Fight the 40, a coalition of business, labor and patient advocacy groups urging repeal of the Cadillac tax. “But it is about their own personal cost and their ability to afford health care.”

Stan Dorn, a senior fellow at Families USA, recently wrote in the journal Health Affairs that the backers of the ACA thought the tax was necessary to sell the law to people concerned about its price tag, and to cut back on overly generous benefits that could drive up health costs. But transitions in health care, such the increasing use of high-deductible plans in the workplace, make that argument less compelling, he said.

“Nowadays, few observers would argue that [employer-sponsored insurance] gives most workers and their families excessive coverage,” he wrote.

The possibility that the tax might be implemented has been “casting a statutory shadow over 180 million Americans’ health plans, which we know, from HR administrators and employee reps in real life, has added pressure to shift coverage into higher-deductible plans,” says Rep. Joe Courtney, D-Conn. And that, he adds, “falls on the backs of working Americans.

Support or opposition to the Cadillac tax has never broken down cleanly along party lines. For example, economists from across the ideological spectrum supported its inclusion in the ACA, and many continue to endorse it.

“If people have insurance that pays for too much, they don’t have enough skin in the game. They may be too quick to seek professional medical care. They may too easily accede when physicians recommend superfluous tests and treatments,” wrote N. Gregory Mankiw, an economics adviser in the George W. Bush administration, and Lawrence Summers, an economic aide to President Barack Obama, in a 2015 column in the New York Times. “Such behavior can drive national health spending beyond what is necessary and desirable.”

At the same time, however, the tax has been bitterly opposed by organized labor, a key constituency for Democrats. “Many unions have been unable to bargain for higher wages, but they have been taking more generous health benefits, instead, for years,” says Robert Blendon, a professor at the Harvard School of Public Health who studies health and public opinion.

Now, unions say, those benefits are disappearing, with premiums, deductibles and other cost-sharing moves are rising as employers scramble to stay under the threshold for the impending tax.

“Employers are using the tax as justification to shift more costs to employees, raising costs for workers and their families,” said a letter to members of Congress from the Service Employees International Union in July.

Deductibles in health insurance plans have been rising for a number of reasons, the possibility of the tax among them. According to a 2018 survey by the federal government’s National Center for Health Statistics, nearly half of Americans under age 65 (47%) had high-deductible health plans. Those are plans that have deductibles of at least $1,350 for individual coverage or $2,700 for family coverage.

It’s not yet clear if the Senate will take up the House-passed bill, or one like it.

The senators leading the charge in that chamber — Mike Rounds, R-S.D., and Martin Heinrich, D-N.M., — have already written to Senate Majority Leader Mitch McConnell to urge him to bring the bill to the floor following the House’s overwhelming vote.

“At a time when health care expenses continue to go up, and Congress remains divided on many issues, the repeal of the Cadillac Tax is something that has true bipartisan support,” their letter said.

Still, there is opposition to repealing the tax. A letter to the Senate July 29 from health care economists and others argued that implementing it, instead, would “help curtail the growth of private health insurance premiums by encouraging employers to limit the costs of plans to the tax-free amount.” That letter also pointed out that repealing the tax “would add directly to the federal budget deficit, an estimated $197 billion over the next decade, according to the Joint Committee on Taxation.”

If McConnell does bring the bill up, there is little doubt it will pass, despite support for the tax from economists and budget watchdogs.

“When employers and employees agree in lockstep that they hate it, there are not enough economists out there to outvote them,” says former Senate GOP aide Rodney Whitlock, now a health care consultant.

Harvard professor Blendon agrees. “Voters are saying, ‘We want you to lower our health costs,'” he says. The Cadillac tax, at least for those affected by it, would do the opposite.

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation, and is not affiliated with Kaiser Permanente.

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Lead contamination in the drinking water in Newark, N.J., is not a new problem, but the city’s fleeting solution has become newly problematic.

Officials in Newark, the state’s largest city, which supplies water to some 280,000 people, began to hand out bottled water Monday.

That’s because the U.S. Environmental Protection Agency has concerns about water filters that the city distributed to residents.

Last fall, Newark gave out more than 40,000 water filters, even going door to door to reach families with lead service lines. The toxin is believed to have leached into drinking water through the old pipes between water treatment plants and people’s homes. Free filters and cartridges would remove 99% of lead, the city of Newark said.

But recent test results introduced an element of doubt about that claim. A regional administrator at the EPA sent a letter Friday to city officials, saying tests on two homes suggested the filters “may not be reliably effective.” Samples showed the filtered drinking water had lead levels exceeding 15 parts per billion, which is the federal and state standard, EPA regional administrator Peter Lopez said.

City leaders acknowledged the problem in the days that followed.

Gov. Phil Murphy and Mayor Ras Baraka, both Democrats, said in a joint statement that they were prepared to do “everything the City needs,” including doling out free water bottles.

They added that the city and state will need assistance from the federal government to provide and distribute the bottles.

In January, Baraka urged President Trump to help protect Newark’s fraught water infrastructure systems instead of funding a wall at the U.S. Southern border to deter migrants. “It will cost an estimated $70 million to replace the lead service lines in Newark,” Baraka said in a letter.

A spokesperson for Sen. Cory Booker, a former mayor of Newark and presidential candidate, told NPR that the senator had made efforts to address New Jersey’s water problem. “We’ll be sending a letter to the [EPA]” later on Tuesday with other federal lawmakers in New Jersey, “urging the EPA to help the city and state with distributing bottled water to its residents,” spokesperson Kristin Lynch said.

Booker also introduced the Water Infrastructure Funding Transfer Bill in May. He said the measure would give states flexibility to fund infrastructure projects. That bill’s passage was blocked in Congress, Lynch said.

Newark resident Emmett Coleman told USA Today that he spent an hour on Monday waiting for two cases of bottled water. “In the senior building, it’s bad,” he said. “All of us are sick or have problems, and we can’t drink the water. And the filters aren’t working.”

The distribution scene would have looked familiar to residents in Flint, Mich., who suffered from years of contaminated drinking water and subsisted on bottled water. And like Flint, Newark has a high poverty rate — about 28%, compared with the national rate of 12.3% in 2017, according to the Census Bureau.

About 15,000 homes in Newark had lead service lines that brought contaminated water to their residences, the city said in a statement. It advised residents to take precautions, including getting children’s blood tested for lead exposure.

The city will continue to test both the filters and filtered water.

The Natural Resources Defense Council and Newark Education Workers Caucus sued Newark and New Jersey state officials last year, accusing them of violating the federal Safe Drinking Water Act. “If it takes filing a lawsuit to end violations of federal drinking water law, we’ll do it,” Claire Woods, an attorney with NRDC, said at the time. That lawsuit is pending.

Authorities say there is no safe level of lead exposure. Pregnant women and children are the most vulnerable groups, with dangers that include fertility problems, damage to organs and cognitive dysfunction.

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