Livingston County has lots of dentist offices. They just don’t do much good for the county’s most vulnerable residents.
The last dental clinic that accepted Medicaid patients closed suddenly last fall. Bringing more dentists into the community hasn’t filled those gaps.
“You can have dentists, but if they don’t take Medicaid, then you can’t help folks who have low socioeconomic status,” Livingston County Public Health Director Jennifer Rodriguez said. “That’s certainly been a barrier for us.”
But not the only one. Many of the county’s OB-GYNs have moved to higher-population areas, forcing patients to travel more than a half-hour to Rochester.
Livingston County’s health care challenges aren’t unique. In fact, the county may be better off than most rural parts of New York state.
A state report released last month studied 16 of New York’s rural counties and found “low rates of health care providers, and an alarming lack of access to basic care in many counties.” Federal budget cuts and other changes codified in the so-called "Big Beautiful Bill" could make expanding coverage even more difficult, according to the report.
“We probably found or confirmed what many people in rural communities already know, which is that there’s some real challenges in terms of access to care,” State Comptroller Tom DiNapoli, whose office created the report, told the New York Public News Network’s Pat Bradley. “And in the context of what’s happening because of actions of the federal government coming out of Washington, what is already a challenging situation is only going to become more challenging.”
One of the counties that the Comptroller’s Office studied was Yates, which is situated squarely between Canandaigua, Seneca and Keuka lakes.
Out of a population of about 25,000, Yates County has four physician assistants and no OB-GYNs or pediatricians.
Other counties studied in the report were located outside the Finger Lakes region. Rural roundtables hosted by the Comptroller’s Office in 2023 found that the Finger Lakes suffered from “primary care staffing shortages and a severe shortage of dentists that accept Medicaid.”
The Yates County Public Health Department didn’t respond to requests for comment.
Diane Delvin, the director of public health for Wayne County, declined an interview, but wrote in an email that “Wayne County is fortunately better off than most of the counties listed in the report.”
Rodriguez said the Livingston County Health Department is trying to do what it can.
The department operates a sexual health clinic that works with SUNY Geneseo students, and it oversees a mental health clinic that sees anyone, regardless of their ability to pay. The mental health clinic sees many patients from neighboring counties, especially Steuben, which has a much smaller county health department.
“While the provider ratio is still 640 to 1 in Livingston County versus the New York State average of 260 to 1, we’re still able to help folks through our clinic and open access hours, meaning that they can really come at any time,” Rodriguez said.
Other regional health care providers are trying to bridge the gaps in rural areas. For example, Rochester Regional Health tries to overcome patients’ transportation issues by providing telehealth appointments and transportation services. They also operate a Mobile Mammography Clinic that stops in multiple counties throughout the region.
The organization tries to fill provider shortages mostly by hiring primary care doctors and nurse practitioners, according to Ingrid Watkins, who oversees three counties as medical director of primary care for the eastern part of Rochester Regional’s coverage area. A large staff of generalists keeps patients out of the emergency room, she said, and helps fill gaps in pediatrics, gynecology and other areas.
“Our goal is to make sure that everybody has a primary care provider and that they get robust care at primary care offices. And then basically we, as primary care doctors, help coordinate care with specialists,” Watkins said. “A lot of patients who don’t have a primary care doctor end up going to the emergency room, where the emergency room doctors are ending up doing some of the primary care work.”
That is unlikely to improve, as millions of Americans are projected to be kicked off Medicaid under provisions of the Big Beautiful Bill.
According to the state Department of Health, 27% of rural New Yorkers are enrolled in Medicaid, including 20% to 25% of residents in most Finger Lakes counties.
Asked about Medicaid cuts, Watkins said Rochester Regional Health is figuring out next steps.
“Our goal is to take care of patients, and we just do that in any environment that comes up, so we just have to work with the impacts of (the) legislation,” Watkins said. “We have whole teams that are working on what that means for us.”
New York state has six rural hospitals that receive a larger portion of their income from Medicaid patients than at least 90% of hospitals nationwide. That includes Newark Wayne Community Hospital, according to data from the University of North Carolina at Chapel Hill’s Sheps Center published by a group of U.S. senators. An additional five have experienced three consecutive years of financial losses, including Geneva General Hospital.
“These Medicaid cuts that are coming down are going to be a challenge, particularly for our rural hospitals, some of which already are at a very tight margin,” DiNapoli said.
The Big Beautiful Bill included $50 billion for rural hospitals over five years, but that will only offset a little over a third of the estimated cuts to federal Medicaid spending in rural areas, according to KFF, a nonpartisan organization that conducts research on health policy. Half of that funding will be distributed “equally among all states with an approved application,” and Centers for Medicare and Medicaid Services will have some discretion to distribute the other half, according to KFF.
“There’s no clear information about how that money is going to be distributed,” DiNapoli said of the rural hospital fund.
In Livingston County, Rodriguez said Noyes Hospital in Dansville will survive because of its affiliation to UR Medicine and the University of Rochester. But hospitals in neighboring counties are at greater risk, and Livingston County could still face tough choices about which services to fund and which to cut, according to Rodriguez.
“Every time the government cuts Medicaid funding or does any takebacks, then obviously we have to pay more of a local share, so that falls back on our taxpayers and our municipality members,” Rodriguez said.
There are other blows in the bill, according to DiNapoli’s report.
One provision caps the amount of federal loans a medical student can take out at $200,000 — far below the more than $286,000 price tag for the average medical degree. DiNapoli’s report predicts that limit will deter some would-be doctors from pursuing medical school. Those who still do become doctors will likely take out more private loans — and those aren’t eligible for forgiveness under federal programs that help health care professionals pay off their loans if they agree to work in rural areas.
Watkins said loan forgiveness and assistance can be a powerful recruitment tool in incentivizing doctors to work at rural facilities, like the Rochester Regional Health clinic in Lyons.
“People come out of medical school, dental school, nurse practitioner school, PA school with a lot of debt,” Watkins said. “And for the government to continue loan repayment to help enhance recruitment to rural areas is huge.”
