PNHP

For its 56th birthday, let’s improve Medicare

For its 56th birthday, let’s improve Medicare

By George Bohmfalk, M.D.
Aspen (Colo.) Daily News, July 31, 2021

On July 30, 1965, President Johnson signed Medicare into law. Less than a year later, the vast majority of Americans over 65 were enrolled. Today Medicare is our most popular and efficient health insurance program.

Medicare has substantially improved older Americans’ health and decreased their rate of poverty, but it has several shortcomings that could be addressed in the huge budget reconciliation bill being formulated in Congress. While a full-on transition to Medicare for All would be the preferred solution, we should incorporate these incremental improvements as soon as possible.

Medicare doesn’t cover vision, hearing or dental care, each of which substantially affects other health issues, like arthritis and heart disease. Many Medicare enrollees who need hearing aids can’t afford them. In a recent year, most who had difficulty eating because their teeth hadn’t seen a dentist, and nearly half with vision problems hadn’t had an eye exam. To improve overall health and quality of life, Medicare should include vision, hearing and dental care.

Traditional Medicare pays only 80% of many charges and has no limit on out-of-pocket expenses. This is a huge economic burden for over half of Medicare enrollees, who live on less than $30,000 a year. With the average enrollee annually spending nearly $6,000 on out-of-pocket costs, medical debt and bankruptcy are ever-constant threats. Congress should place a reasonable cap on annual out-of-pocket costs.

Medicare is now available only to people over 65 and some with disabilities. A recent Stanford University study showed that, of people with cancer, those over 65 did better than patients in their early 60s. One might expect the younger group would fare better, but the factor benefitting the older group was having better access to health care, through Medicare. Lowering the eligibility age to 60 would extend the reliability and better outcomes of Medicare coverage to 23 million more Americans. Given the bipartisan support for doing so, Congress should lower the Medicare eligibility age to 60.

On average, Americans pay over twice as much for medications as do people in other countries. Medicare could save hundreds of billions of dollars by negotiating drug prices, which a previous Congress banned it from doing. As these savings could be used to pay for the other improvements, Congress should allow Medicare to negotiate drug prices.

The above improvements would extend beyond individual beneficiaries. The COVID-19 pandemic has both illuminated and aggravated unconscionable racial and ethnic health care inequities affecting millions of Americans. These improvements to Medicare would not erase any inequities, but they would substantially mitigate many of them. Businesses would also benefit, as they would no longer bear as large a burden of their employees’ health care costs.

Over 150 members of Congress signed a letter to President Biden requesting that the American Families Plan include these improvements to Medicare. If your representative is among them, please thank them. If not, ask them and your senators to support these improvements as a bill is developed.

Happy and healthy 56th birthday, Medicare! Short of expanding Medicare to cover everyone, there is no better way to celebrate it than to enhance the physical, emotional and financial health of older Americans by improving and expanding Medicare coverage.

Dr. Bohmfalk is a retired neurosurgeon in Carbondale and a member of Physicians for a National Health Program.

https://www.aspendailynews.com…

You Want Me to be Blind and Toothless?

Expanding Medicare coverage to hearing, vision and dental would alleviate the suffering of millions including this writer.

By Steven Wishnia
The Indypendent, July 31, 2021

Senator Bernie Sanders has introduced legislation to have Medicare cover dental, vision, and hearing care, along with other additions such as lowering the age of eligibility from 65 to 60. They would be included in a budget reconciliation bill to preclude a filibuster by Senate Republicans, which would be painfully inevitable if it were a standalone measure.

The legislation is “still a work in progress,” cautions Physicians for a National Health Program President Dr. Susan Rogers. But for me, it can’t come a moment too soon. What are three body parts and functions that almost universally deteriorate in older people? Their eyesight, their teeth, and their hearing. What kind of perversity would withhold care for that?

It’s personal. Medicare does not cover the dental work I need after decades of wear and tear on my adult teeth. That has run well into four figures over the last six months, a serious sum on a freelance writer’s income. I’ve been wearing glasses since I was seven-years-old but haven’t been to an eye doctor in almost three years. The last time I went, they tried to charge me almost $700 for a checkup and refused to negotiate. (My hearing is not too bad, especially considering that I’ve been playing amplified music for 50 years.)

What shocked me most when I turned 65 was how much Medicare cost. Basic coverage for doctors and a minimal private prescription-drug policy comes to about $170 a month. Medicare also covers only 80% of doctor and hospital expenses, and private insurance that would cover most — but not all — of the other 20% would bring the bill up to around $500.

The reason Medicare does not cover vision, dental or health is primarily because it was modeled on benefits provided by private insurance when it was enacted in 1965, says Dr. David Himmelstein, a professor of public health at Hunter College and longtime advocate of single-payer health care. Those benefits, largely provided by employers, were aimed at working-age people, he adds. Vision, dental and hearing care were omitted even though the elderly are more likely to need it, notes Rogers.

The 80/20 split was partially a compromise to defuse opposition from insurance companies, says Rogers, and partially, says Himmelstein, because there was a consensus in the health-policy community that “you needed to have some kind of barrier to keep people from seeking care they didn’t need.” But that 20% copayment, they say, was minimal in the 1960s. Since then, health care costs have inflated so much that it’s unaffordable.

Coverage for prescription drugs, also a relatively small expense in 1965, was not added until 2003.

Private Medicare Advantage plans, which began in 1997, often cover vision, dental, and hearing — but the catch is that they also often have a limited network of providers who accept them and people going outside that network will get billed for the full list price.

The free market simply doesn’t work for health care. The opportunity-cost principle that holds down the price of luxuries and limits most people’s overindulgence in them just doesn’t exist. For example, if I wanted to buy a Fender electric guitar, I’d have choices all along the range from a $220 Indonesian-made budget model to a $3,900 custom-made instrument, and I could save up for it or find a deal on a used one.

But if I break my leg, I can’t wait until Bellevue has a sale on orthopedics. If I get an infection, I’d be unlikely to find legitimate antibiotics on Craigslist.

The current U.S. system has two perverse pricing practices. It forces people to pay the most when they are least able to work to recoup those costs. And list prices are insanely inflated; Medicare and insurance companies negotiate them down dramatically but the person who’s uninsured or under-insured gets stuck owing the full rate.

The market also doesn’t work for selecting health insurance policies. “There’s no transparency in cost because the costs vary so much and you don’t know what you’ll need,” says Rogers. It is far too common that someone schedules a surgery with a hospital and a surgeon that accept their insurance, only to get whacked with a $7,000 bill because the anesthesiologist was out of network.

Insurance companies often argue that high copayments and “narrow networks” are necessary to save costs and discourage unnecessary use. The implication is that people must have “skin in the game” or else they would go to a podiatrist to get their toenails clipped. That hasn’t happened in any country with universal health care, says Rogers, and elderly Americans didn’t “flock to the doctor and overwhelm the system” when Medicare went into effect.

The fundamental choice the market demands is either you pay up or you go without important or essential care. This is both bad for public health and more costly in the long run, because people who go without such care will eventually need it for much more advanced ailments.

The proper metaphor isn’t “skin in the game,” but from The Merchant of Venice: “a pound of flesh.”

“The whole idea that the market can control costs is really erroneous. It hasn’t worked,” says Rogers. Instead, the money is “going to a system that offers profits for not providing health care.”

Medicare for All, in contrast, would have no premiums, no deductibles, and no copayments, says Nancy J. Altman, president of Social Security Works.

Having the Medicare program cover people 65 and older, she explains, was President Lyndon Johnson’s “fallback” to provide health care for the elderly after the national universal health care plan envisioned as the next step after Social Security proved politically impossible. President Harry Truman’s plan was blocked in the late 1940s, when the medical industry denounced it as “socialized medicine” and powerful Southern members of Congress feared it would force the desegregation of hospitals.

Adding vision, dental and hearing coverage, Altman says, “would be an excellent next step toward ensuring that health care is a right and not a privilege.”

It would also be an excellent political move, says Himmelstein: Obviously, the concept of expanding Medicare benefits for people who already have them “has a huge constituency” behind it.

Rogers, however, worries that coverage could be sanded down to inadequacy, such as paying only for routine dental care like cleaning, and not the more complex care older people need, such as partial bridges and crowns.

Medicare, “even though it was a legislative act, it required social movements to make it work. I think we have to remember that,” she says. If Medicare is expanded or Medicare for All enacted, she adds, “we’ll still need to continue social activism to make sure it works.”

And the alternative — as I’d ask anyone opposing adding vision and dental coverage: “You want me to be blind and toothless?”

https://indypendent.org…

Medical Debts Now Surpass All Others, and Likely Shorten Lives

Medical Debt in the US, 2009-2020, JAMA, July 20, 2021, by Raymond Kluender et al.

Data … were obtained from a nationally representative 10% panel of consumer credit reports between January 2009 and June 2020 (reflecting care provided prior to the COVID-19 pandemic)…

An estimated 17.8% of individuals had medical debt (13.0% accrued during the prior year), and the mean amount was $429 ($311 accrued during the prior year). The mean medical debt was highest in the South and lowest in the Northeast ($616 vs $167; difference, $448) and higher in poor than in rich zip codes ($677 vs $126). Between 2013 and 2020, states that expanded Medicaid in 2014 experienced a decline in the mean medical debt that was 34.0 percentage points greater (from $330 to $175) than the states that did not expand Medicaid (from $613 to $550).

Association of Wealth With Longevity in US Adults at Midlife, JAMA Health Forum, July 23, 2021, by Eric D. Finegood et al.

Higher net worth was associated with lower mortality risk (hazard ratio, 0.95). Among siblings and twin pairs specifically, a similar within-family association was observed between higher net worth and lower mortality (HR, 0.94), suggesting that the sibling or twin with more wealth tended to live longer than their co-sibling or co-twin with less wealth.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

In a series of studies dating back 16 years (see: here, here and here), we and our colleagues found that illness and medical bills are a leading cause of bankruptcy. Those findings, based on court records and surveys of debtors, have been derided by scholars funded by the health insurance industry (see our response to them here), and by leading health economists. Those critics have claimed that debtors can’t accurately identify the causes of their financial ruin, and have turned instead to statistical analyses that rest on unwarranted assumptions about who incurs medical debts and when those debts begin to accrue.

Kluender et al document the extraordinary frequency and size of medical debts. Even prior to the COVID-19 pandemic, more than one out of six Americans with a credit record had a medical bill in collection, with medical debts totaling about $140 billion – more than the total amount of all other debts in collection. As the authors acknowledge, that figure surely understates the magnitude of medical debts, e.g. it excludes medical bills charged to credit cards.

Kluender et al find that states that implemented the ACA’s Medicaid expansion reduced medical debts relative to non-expansion states. Yet even in expansion states Medical debts accounted for the majority of all debts in collection.

Finegood et al’s study suggests that debts have health as well as financial consequences. Even among genetically identical twins, lower net worth (assets minus debts) is a predictor of earlier death.

When journalist TR Reid asked policy leaders in other developed nations about the frequency of medical bankruptcy in their country he was generally met by blank stares; medical bankruptcy was virtually unknown. It’s high time that the US join the civilized world and abolish medical debt by implementing universal, first dollar health coverage.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Firefighters’ plight is another example of need for single payer health insurance

Local fight shows need for health care reform

By Jay Brock, M.D.
The (Fredericksburg, Va.) Free Lance-Star, Letters, July 29, 2021

There may be better examples of how dysfunctional our health insurance system is, but the difficulties of 15,000 Fredericksburg-area patients covered by health insurance giant Cigna who are in the unenviable position of having to change providers due to a contract dispute between Cigna and Mary Washington Healthcare [“Firefighters rally to get health care access back,” July 17] is certainly an apt one.

The problem? Our health insurance system is based on our for-profit health insurance industry, which is an exceptionally expensive—and entirely unnecessary—middleman that provides no care to anyone, but whose financial health, given our twisted system, must be protected at all costs. Even at the expense of the health of those 15,000 “covered lives.”

The solution? An entirely new health insurance system, one where the health of the patient, not the financial health of an insurance company, is paramount. American healthcare experts have for decades recommended switching to single payer Medicare for All health insurance to replace the current dysfunctional system that is directly responsible for the healthcare chaos now affecting those 15,000 folks.

But don’t look to our legislators in Congress to change much. Pleas to Representatives Wittman and Spanberger and Senators Kaine and Warner to prevent health insurance dilemmas like this one by supporting such a new system—one that puts patients first—have fallen on deaf ears: these four have so far failed to support any real health insurance reform, preferring instead to perpetuate the current system.

We can and must do better than that.

https://fredericksburg.com…

Medicare Advantage Skips Out on Paying for End-of-Life Care

Medicare Advantage: Beneficiary Disenrollments to Fee-for-Service in Last Year of Life Increase Medicare Spending, U.S. Government Accountability Office (GAO), June 28, 2021

Medicare Advantage (MA) beneficiaries in the last year of life disenrolled to join Medicare fee-for-service (FFS) at more than twice the rate of all other MA beneficiaries, GAO’s analysis found. MA plans are prohibited from limiting coverage based on beneficiary health status, and disproportionate disenrollment by MA beneficiaries in the last year of life may indicate potential issues with their care. Stakeholders told GAO that, among other reasons, beneficiaries in the last year of life may disenroll because of potential limitations accessing specialized care under MA.

Beneficiaries in the last year of life who disenrolled from MA to join FFS increased Medicare costs as they moved from MA’s fixed payment arrangement to FFS, where payments are based on the amount and cost of services provided. GAO’s analysis shows that FFS payments for such beneficiaries who disenrolled in 2016 were $422 million higher than their estimated MA payments had they remained in MA, and were $490 million higher for those that disenrolled in 2017.

Prior GAO and other studies have shown that beneficiaries in poorer health are more likely to disenroll from MA to join FFS, which may indicate that they encountered issues with their care under MA. Beneficiaries in the last year of life are generally in poorer health and often require high-cost care.

Comment:

By Eagan Kemp

This report is a bombshell — even when delivered in GAO’s typically understated style. Having been a senior analyst at GAO for more than a decade before coming to Public Citizen, I can tell you that it takes an overwhelming amount of substantiated evidence to state things as strongly as they do in this report.

The implications couldn’t be more clear and the profit motive more transparent. Medicare Advantage plans — as they also do with other high-cost patients in poor health — are finding ways to avoid paying the high costs of end-of-life care. They often do this through limiting access to specialized care through narrow networks or other unscrupulous means.

These vulture Medicare Advantage companies will stop at nothing to keep their profits high — including forcing beneficiaries and their families to jump through numerous hoops to disenroll from predatory Medicare Advantage plans and enroll back into traditional Medicare at the worst possible time. And all so that traditional Medicare is left to pay the bills instead of Medicare Advantage plans. I am not sure how these people sleep at night.

It should be no surprise that insurers do everything in their power to evade the one thing they are supposed to do: pay for the care their enrollees need. It is exactly why insurers were insanely profitable during the COVID-19 pandemic — by NOT paying for care.

If it wasn’t already clear by now, these findings drive home the point that insurers add nothing but misery and administrative hurdles for patients while raising the overall cost of the health care in America through massive waste, fraud, and abuse.

It is time to end their ability to hurt patients and reap insane profits. It is time for Medicare for All.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Diabetes patients in high-deductible health plans 28% more likely to skip their medications due to cost: Harvard study

As the world celebrates the 100th anniversary of the discovery of insulin for diabetes treatment, researchers find that forgoing medications due to cost resulted in increased emergency department visits for diabetics, especially those taking insulin

FOR IMMEDIATE RELEASE: July 29, 2021

Contact: Vikas Gampa, M.D., vikasgampa@gmail.com
Danny McCormick, M.D., M.P.H., dmccormick@challiance.org
Clare Fauke, communications specialist, Physicians for a National Health Program,  clare@pnhp.org

July 29, 2021—For Americans with diabetes, being enrolled in a high-deductible health plan (HDHP) substantially increases the risk of not taking prescribed medications due to cost, according to a new study conducted by researchers at Harvard Medical School that was published today in the Journal of General Internal Medicine. HDHPs, which now account for half of all commercial health insurance plans, require patients to pay for all care out of pocket until a plan’s deductible is reached. Only after the deductible is reached (typically $1,300 for an individual and $2,600 for a family) does insurance begin to cover medical costs.

The study found that among all patients with diabetes, 20% of those enrolled in a HDHP reported forgoing medications due to cost, compared with 16% of those in a traditional commercial plan—a 28% higher rate of missing medication for those with a high deductible. Among patients specifically taking insulin for diabetes, 25% of HDHP enrollees were unable to afford their medication, compared with 19% of those in a traditional plan—a 31% higher rate of missing medications.

The study used federal survey data on more than 7,000 adult patients with diabetes who were enrolled in a commercial health insurance plan, either with or without a high deductible. The researchers examined how often patients reported not taking prescribed medications because they could not afford it, comparing responses between those in a HDHP and those in a traditional plan without a high deductible.

“Taking prescribed medications is essential for maintaining good health for patients with diabetes,” said Dr. Vikas Gampa, a primary care doctor and instructor in medicine at Harvard Medical School, now at the Massachusetts General Hospital. “Our results show that high-deductible health plans, particularly in this period of escalating prices for diabetes medication, are discouraging patients from getting the medications they need and thus they are placing patients with diabetes at risk.”

The study also found that among the diabetic patients they studied, those that could not take their medication as prescribed because they could not afford it were more likely to have one or more emergency department visits, and potentially more hospitalizations per year, than patients who were not forced to skip their medications. “Putting up financial barriers to care in order to save plans money—as high-deductible plans do—not only takes a medical toll on patients, it is also short-sighted because doing so actually increases other health care costs such as covering emergency department visits,” commented Dr. Gampa.

The study authors believe that the new data are important for patients, doctors, and policy makers. “Patients with diabetes should recognize that a high-deductible plan will put them at risk for missing or delaying their medications, and doctors need to recognize that their patients with these plans may not be able to adhere to treatment plans,” said the study’s senior author, Dr. Danny McCormick, an associate professor of medicine at Harvard Medical School and a primary care physician at the Cambridge Health Alliance. “Ultimately, policy makers need to enact reforms that discourage health plans from implementing financial barriers that block access to needed care, such as high-deductible plans. Our results suggest that policy makers must enact reforms that control rapidly escalating prices for diabetic medications.”

“Association Between High Deductible Health Plans and Cost-Related Non-Adherence to Medications Among Americans with Diabetes: An Observational Study,” Charlotte Rastas, M.D., M.Sc.; Drew Bunker, M.D.; Vikas Gampa, M.D.; John Gaudet, M.D.; Shirin Karimi, M.D.; Ariel Majidi, M.P.; Gaurab Basu, M.D., M.P.H.; Adam Gaffney, M.D., M.P.H.; and Danny McCormick, M.D., M.P.H.; Journal of General Internal Medicine.

Published online first July 29, 2021

The full text of the article is available to media professionals upon request. Please contact Clare Fauke, clare@pnhp.org.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 24,000 members support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

Medicare Reduces Racial and Ethnic Disparities

Changes in Racial and Ethnic Disparities in Access to Care and Health Among US Adults at Age 65 Years, JAMA Internal Medicine, July 26, 2021, by Jacob Wallace, et al.

Question: Is Medicare eligibility associated with reductions in racial and ethnic disparities in access to care and health?

Findings: In this cross-sectional study using a regression discontinuity design, eligibility for Medicare at age 65 years was associated with reductions in racial and ethnic disparities in insurance coverage, access to care, and self-reported health across the US.

Meaning: Expanding eligibility for Medicare may be a viable means to reduce racial and ethnic disparities and advance health equity by closing gaps in insurance coverage.

JAMA Int Med Editorial, by Robert Steinbrook, M.D.

As we have observed before, it is a national disgrace that despite the trillions of dollars spent on health care, the US is alone among developed nations in not providing health care to all its citizens.

The study by Wallace et al provides additional evidence that providing health care for all may reduce disparities in health and improve access and equity in the health care system.

Comment:

By Don McCanne, M.D.

Advocates of single payer Medicare for All certainly understand that such a program would provide health care coverage for everyone in a system that would make it affordable for each of us, simply by funding a universal risk pool with progressive taxes.

What has been a major concern for those of us supporting health care justice for all is that racial and ethnic disparities, with their inherent injustices, currently permeate our health care system. This very important study demonstrates that such disparities would be almost completely eliminated by adopting a universal program based on Medicare.

It is time to bring an end to the ridiculous discussions about there being many ways to expand health care coverage. It is time to enact and implement the program that we know would work well for all of us in America: single payer, improved Medicare for all.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Dr. Paul Song on “Rising Up With Sonali”

PNHP national board member (and PNHP-California president) Dr. Paul Song appeared on “Rising Up With Sonali” on Free Speech TV and Pacifica radio stations on July 28, 2021. Dr. Song discussed a series of nationwide marches for Medicare for All held the previous weekend, the prospects for a state-based single-payer program in California, and the urgent need to get people vaccinated against COVID-19.

Rural Tennessee Is Losing More Hospitals Than Anywhere in the Country, but Covid-19 Isn’t Fully to Blame

Inadequate funding, old and expensive to maintain equipment and dwindling population are all contributing to the crisis. The resulting lack of healthcare access has negative effects across entire communities.

By Taylor Sisk
The Daily Yonder,

This story was originally published by 100 Days in Appalachia.

“I’m hopin’,” Andrea Haas says with conviction.

The Remote Area Medical clinic has come to Jellico, Tennessee, in Campbell County, on the Kentucky border. It’s offering free health care.

Haas’s hope for today is that her teeth will get pulled. She’s suffered all her life from grand mal seizures, and with each episode she bites her tongue. “They said one wrong, good bite and I could lose my tongue,” Haas says. The plan is to extract her teeth and, later, replace them with better-fitting dentures.

It’s 9:30 a.m. Haas, 31, arrived last night. The gates opened at midnight, the clinic doors at 6 a.m. It’s first come, first served.

All manner of health care services are in limited supply in this part of central Appalachia. In March, Jellico Medical Center, a 54-bed acute-care hospital, officially shut down after not having admitted a patient since November.

It’s an increasingly, depressingly common story. Communities across Appalachia, as across the whole of rural America, are struggling to maintain hospital care. Rural hospitals are closing at an alarming rate – 138 since 2010, according to research from the University of North Carolina, with a record high of 19 in 2020.

There are a number of reasons why: Rural hospitals operate under perilously tight margins; many are in the red. Buildings and equipment are commonly old and costly to maintain. Rural hospitals serve declining populations – young people leave in search of opportunities – populations that are, on average, less healthy and of lower income, with a higher percentage who are under- or uninsured.

Campbell County ranks 93rd worst in health outcomes of Tennessee’s 95 counties and has a poverty rate approximately double that of the nation.

“I’m hopin’,” Haas repeats, this time in reference to the hospital reopening. She worries about those who now must drive almost an hour to Knoxville or across the border to Kentucky to see a doctor, and even more about those with no means to make the trip.

There is some encouraging news. An Indiana-based health care system, Boa Vida Healthcare, has reached an agreement with Jellico’s city council to reopen the hospital, reportedly within the next six months. Still, local residents have been conditioned not to get overly optimistic. The previous owner was around for just two years.

Covid-19 took an incalculable toll on rural communities. In the first months of the pandemic, says Jacy Warrell, executive director of the Rural Health Association of Tennessee, “a lot of rural communities thought it was a bigger-city issue and that they didn’t have to worry about it because they were more isolated.”

But when it did hit, it spread quickly. By September, the death rate in rural America had surpassed that of urban centers.

Tennessee’s hospitals, like those across the nation, experienced a dramatic drop in revenue throughout the pandemic and continue to lose money. A recent American Hospital Association report estimates the pandemic could cause hospitals to lose as much as $122 billion this year.

Tennessee has experienced more rural hospital closures per capita than any state. In 2018, the state legislature passed the Tennessee Rural Hospital Transformation Act to support rural hospitals “in assessing viability and identifying new delivery models, strategic partnerships, and operational changes” to support health care services in rural communities.

Consultants were sent out to meet with rural hospital administrators and other community leaders. Essentially, what they told them, says Randall Rice, board president of the Tennessee Health Care Campaign, was that they needed more money. “That was not a revelation,” he says.

More money is certainly required. So, too, is a more strategic, integrated approach to rural health care. Andrea Haas knows she and her neighbors deserve better.

Reverberating Consequences

The recently departed owner of Jellico Medical Center was Florida-based Rennova Health. Rennova also previously operated Jamestown Regional Medical Center, an hour and a half to the west along Tennessee’s Cumberland Plateau, but shuttered it in June 2019.

A third hospital, Cumberland River, in the Clay County town of Celina, 45 miles northwest of Jamestown, closed in March 2019, temporarily reopened, then closed again last August. (It was not owned by Rennova.)

Rennova Health still operates Big South Fork Medical Center in the Scott County town of Oneida, about halfway between Jellico and Jamestown. The hospital has closed twice in the past decade and is now a shell of what it once was. There’s no longer intensive care, surgery, obstetrics, or geropsychiatric care. For a time, there were no inpatient beds; six have only recently been made available.

Today, the hospital’s only doctor, Deepak Reddy, lives in the facility to be immediately available around the clock.

Big South Fork Medical Center employees recently reported – not for the first time – that the company was behind in issuing paychecks, and that a number of them wouldn’t be returning to work until paid. This follows a pattern from Jellico Medical Center, where in February employees reported being unpaid and quit their jobs, creating a staffing crisis. Ambulances were diverted from the emergency room to neighboring hospitals, 45 minutes to an hour away.

The consequences of a closed or minimally operational hospital reverberate throughout the community. Some of those consequences are immediate.

Scott County generally has two ambulances in service at a given time. Paramedic Alison Jeffers says that if either has to transfer a patient out of the county, “You’re looking at two and a half hours minimum – and that’s if everything cooperates, there’s beds at the facility, traffic’s good – two and a half hours minimum before we get back into town.”

Moreover, that travel time can be the difference between life and death. For patients in trauma, the first hour is known as the “Golden Hour,” after which the risk of death increases dramatically.

Other consequences have longer-term effects. Pam Thompson is a behavioral-health counselor with Mountain Peoples Health Councils, a nonprofit community health center in Scott County. When she moved back to the county, she considered starting a private practice, but the hospital had shut down. Without emergency services for clients in crisis, she elected not to open her own practice.

Thompson says there are no private-practice therapists in the county.

Challenging Times for Independent Operators

Luke Collins was the first person in his family born in a hospital. He served eight years as mayor of Clay County and last month was elected mayor of the town of Celina. He ran on a platform that advocated the reopening of Cumberland River Hospital.

Collins, like government officials across rural America, knows the economic consequences of a closed hospital. “The ripple effect is huge, and I don’t know how you would even measure it.”

Clay County advertises itself as the “Gateway to Dale Hollow Lake,” an attractive location for a retirement home. The absence of a hospital is a deterrent.

“I love this community and love this hospital,” Collins says. “It’s very, very important that we find a way to get this hospital back open.”

His ally in this effort is Johnny Presley. Presley is determined to reopen the hospital in Celina, and then those in Jamestown, Jellico and beyond.

Presley grew up in Crossville, an hour south of Celina. His passion for health care was sparked in his youth, riding in his dad’s tow truck responding to traffic accidents. He became a volunteer fireman, an EMT, then a physician assistant and health care administrator. He’s now on a mission to restore hospital care to the region. Some consider it a quixotic quest. Presley believes he can succeed.

In fact, he did temporarily reopen Cumberland River Hospital, in April 2020, just as the pandemic hit. There were issues. Presley cites the denial of Covid-19-related financial support from the state, delay in payment from insurance companies and the local EMS opting to transport patients to other hospitals. The hospital closed again in August.

These are challenging times for independent hospital operators. Alan Morgan, CEO of the National Rural Health Association, says federal requirements to “modernize health care and move toward electronic medical records created tremendous cost pressures” on small hospitals. “And those systems have to be updated yearly.”

Larger hospital systems are better positioned financially to access advanced technology. They also have greater purchasing power and the advantages of consolidated administration.

The Affordable Care Act put additional strains on rural hospitals – especially in states that haven’t yet expanded Medicaid – by limiting their ability to write off bad debt. Then came the pandemic, further diminishing at-risk margins.

“The pandemic made it much more difficult to be an independent rural hospital,” Morgan says, “and I think that’s going to be the case going forward.”

Reassessing Needs and Repurposing Appropriately

Twelve states have not yet adopted Medicaid expansion as allowed for under the Affordable Care Act. None of the eight states with the most rural hospital closures has implemented expansion. (Voters in two of those states, Missouri and Oklahoma, last year approved ballot measures to expand.) A 2018 study from the Colorado School of Public Health found that hospitals in non-expansion states are six times more likely to close than those in expansion states.

Six of those non-expansion states are in the Appalachian region, Tennessee among them.

A 2020 analysis of rural hospital financial and operational data by the Chartis Center for Rural Health found that more than half of Tennessee’s rural hospitals are performing at a level similar to that of rural hospitals that have closed since 2010.

“I don’t understand how we can continue to pass up those dollars,” the Rural Health Association of Tennessee’s Jacy Warrell says.

But, of course, Medicaid expansion isn’t a cure-all. Among the other primary issues that must be addressed is a workforce shortage. The average age of clinicians in rural communities is higher than nationally; attracting new providers is difficult. And Morgan says he’s hearing from rural hospital administrators that increasingly more nurses are leaving for higher-paying traveling-nurse positions.

The pandemic worsened the workforce shortage, with older practitioners, at greater risk of contracting the virus, choosing to retire.

In a report titled “The Ambulance Is Our Emergency Room,” the nonprofit Tennessee Health Care Campaign offers several recommendations for bolstering the state’s rural health care workforce. These include providing more state-funded loan-repayment opportunities for recent graduates as incentives to work in rural communities; incentivizing colleges and universities to reserve spots in their programs for rural residents; and expanding the reach of case managers, community health workers and in-home providers.

The THCC report was the outcome of listening sessions with community members throughout the state. Among its other recommendations is helping facilitate free-standing emergency rooms. In Tennessee, freestanding ERs must be hospital owned. The THCC suggests changing that policy, creating more opportunities for ERs to open in areas where hospitals have closed or aren’t financially viable.

And it urges the state to provide grant and investment opportunities to bolster primary, preventive, behavioral and oral care services in communities. Mountain People’s Health Councils, in Scott County, is a model of community-based services. It’s community owned, operating six clinics, including a new facility with pediatric care, behavioral health and dentistry.

The THCC report offers sound recommendations, but addressing the rural health crisis requires much more. It requires, first, says Richard Henighan, an east-Tennessee nurse practitioner and THCC board member, reassessing needs and repurposing appropriately.

“Some of these rural counties don’t need an old-fashioned rural hospital,” Henighan says.

The National Rural Health Association’s Morgan agrees: “I think in many communities, the need for inpatient beds is going to be minimal.” More services are now provided on an outpatient basis.

The focus, he says, should be on a 24/7 emergency room, primary care, general surgery and “a high reliance on telehealth,” then determining what else the community most needs – what services they would otherwise have to travel the farthest to receive.

Henighan says an important lesson he learned in conversations held while helping compile the THCC report was that reopening a hospital in a rural community “doesn’t necessarily mean the problem was fixed.” A broader issue, he says, is a failure to integrate services to meet the sum of a community’s health care needs.

A lasting solution requires addressing the social determinants of health, bringing together the hospital, clinics, local government agencies, business leaders, churches, civic clubs – the full resources of a community.

Morgan stresses that a successful rural hospital’s strategy must embrace preventive health and chronic-care management and “empowering the community to take control of their own health.”

‘The Answers Are There’

The federal CARES Act, passed by Congress to financially respond to the pandemic, provided an infusion of money to rural hospitals. Far more assistance is needed.

The THCC’s report asserts that “the state offers no assistance to rural community leaders to discourage hospital owners from closing the facility, finding a replacement administrative structure, or addressing the health needs after the loss.”

For Henighan, “the big disconnect” is that those being most harmed by the current state of health care continue to elect people who are ignoring them.

“Health care has become a political game with the leaders in our state,” says Michele Johnson, co-founder and executive director of the Tennessee Justice Center, referencing the refusal to expand Medicaid. “And the people who’ve paid the price for that are our rural communities.”

More fundamentally, Johnson believes “health care as a commodity violates who we are as a nation.” In her work, she sees firsthand “how that destroys lives and destroys families and communities.”

Robin Feierabend, a retired family physician in Kingsport, Tennessee, is a member of a group called Physicians for a National Health Program. “Our whole health care system is currently so fragmented and so dysfunctional that I don’t think there are any simple solutions,” he says.

“But with a national health care plan, there’s the opportunity for much more coordination and oversight, and for matching of health care needs with populations, as opposed to our current competitive approach to providing services.”

In the meantime, Jacy Warrell remains optimistic. “I think what needs to happen is for policymakers and administrators to really listen to the needs of the community and become partners in solving these issues. I think the answers are there.”

Those who began queuing up before midnight in Jellico for the Remote Area Medical clinic’s offer of free health care would like some hard evidence of those answers. They’d like assurance of sustained hospital care. They’d like to know they haven’t been forgotten.

“Everything gets shut down,” says Charity, 23, of nearby LaFollette, who prefers not to give her last name. She’s the mother of three; she worries about her community’s future. “Nobody wants to come here.” Her concerns are well founded. Without such essential infrastructure as health care, many rural communities will cease to exist.

Andrea Haas is hoping Jellico Medical Center will soon be reopened, that people will no longer have to drive out of county for care, that her aunt can return to her job in the emergency room. “I’m hopin’ and prayin’,” she says.

https://dailyyonder.com…

Specialists Shun People of Color

Racial and Ethnic Disparities in Outpatient Visit Rates Across 29 Specialties, JAMA Internal Medicine Online First, July 19, 2021, by Christopher Cai, et al.

[Using nationally representative data from the Medical Expenditure Panel Survey] We tabulated office and outpatient department visits to each physician specialty and calculated adjusted rate ratios (ARRs) for each racial/ethnic minority group (compared with the White population).

Black individuals had low visit rates (vs White individuals) to most specialties (23 of 29 [79.3%]. Among specialties with many visits, Black:White disparities were particularly marked for dermatology (ARR 0.27; 95% CI, 0.21-0.34), otolaryngology (0.38; 95% CI, 0.32-0.46), plastic surgery (0.41; 95% CI, 0.23-0.75), general surgery (0.55; 95% CI, 0.44-0.69), orthopedics (0.59; 95% CI, 0.51-0.69), urology (0.62; 95% CI, 0.50-0.78), and pulmonology (0.63; 95% CI, 0.48-0.81). Black individuals had higher visit rates to nephrologists (2.78; 95% CI, 1.37-5.62) and hematologists (1.65; 95% CI, 1.0-2.70) and similar visit rates to internists, geriatricians, and oncologists.

For Hispanic and Asian/Pacific Islander individuals, visit ratios (compared with White individuals) were … significantly lower for 20 of 29 (69.0%) and 21 of 27 specialties (74.1%), respectively. Similar patterns were present for Native American individuals, although the 95% CIs were wide.

The study findings demonstrate a consistent pattern of racial and ethnic disparities in outpatient care, implicating systemic defects that are best characterized as structural racism.

Figure:

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

This study (disclosure: we’re co-authors) provides yet more evidence of the pervasive effects of white supremacy in medical care.  Black, Hispanic, Asian and Native American people get far less care from virtually every medical and surgical specialty than non-Hispanic White individuals.

The inferior insurance coverage (and hence reimbursement to physicians) of Black, Hispanic and Native Americans probably drives much of the disparities for those groups, but people of color had somewhat lower visit rates even after controlling for insurance coverage.

Fixing these inequities in care will require erasing financial distinctions among patients by assuring that everyone’s insurance pays the same fees, and that co-payments and deductibles are banned.  Only a comprehensive single payer reform can achieve that.  But additional measures will also be needed: e.g. greatly increasing the ranks of minority physicians; offering grants to practices to locate in minority neighborhoods; and changing the racist culture that permeates many medical institutions.

http://healthjusticemonitor.org…

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Patients of Color Less Likely to Get Specialist Care Than White Patients

By Amy Norton
HealthDay, July 26, 2021

People of color are consistently less likely to see medical specialists than white patients are, a new U.S. study finds, highlighting yet another disparity in the nation’s health care system.

Researchers found that compared with their white counterparts, Black Americans, Hispanic Americans and Asian Americans had significantly fewer visits to doctors of various specialties — ranging from dermatology to orthopedics to general surgery.

They were not falling behind, however, in visits to primary care doctors, suggesting that specialist care is the issue.

While the study cannot pinpoint the reasons, there’s a likely a culprit, according to Dr. Steffie Woolhandler, one of the researchers.

“We think disparities in the ability to pay are the main driver here,” said Woolhandler, a professor at City University of New York at Hunter College.

It can be difficult, she said, to find a specialist who accepts uninsured patients or those on Medicaid (the federal insurance program for low-income Americans). And to a disproportionate degree, those patients are people of color.

Other times, Woolhandler said, people have insurance, but their plan requires out-of-pocket costs — such as deductibles and copays — that they cannot afford.

“You could define the system as structurally racist,” Woolhandler said.

She pointed to one finding that supports the importance of insurance coverage in access to specialty care: Black patients were about three times more likely to be seeing a nephrologist (kidney specialist) than white patients were.

That, Woolhandler said, may partly reflect the fact that Medicare — the federal program for older Americans — pays for the treatment of advanced kidney disease, regardless of patients’ age.

That suggests universal health care coverage could go a long way toward erasing racial disparities in specialist care, Woolhandler said.

The study — published July 19 in JAMA Internal Medicine — used data from an ongoing federal survey looking at Americans’ health care use.

Researchers focused on more than 132,000 U.S. adults who responded to the survey between 2015 and 2018.

Compared with their white counterparts, Black respondents had lower visit rates to most of the 29 medical specialties covered in the survey. Some of the biggest gaps were in dermatology, otolaryngology (ear/nose/throat), orthopedics, urology and general surgery — where Black Americans were anywhere from 38% to 73% less likely to have had a visit. That was with factors such as self-reported health, income and insurance taken into account.

Similarly, Hispanic patients and Asian patients had lower visit rates than white patients for the majority of specialties. Several of those gaps persisted once the researchers weighed people’s health ratings, income and other factors.

Frederick Isasi is executive director of Families USA, a nonpartisan consumer health care advocacy group. He agreed that health insurance is probably an important reason for the findings, but only part of the story.

“We know there are implicit biases in health care,” said Isasi, who was not involved in the study. “When people of color walk through the door [of a health care facility], they have a different experience than white people do.”

In this study, respondents of all races were similarly likely to see primary care doctors, who are the providers giving patients referrals to a specialist when needed. What’s not clear is whether referrals might have differed based on patients’ race.

In addition, Isasi said, people of color are more likely to distrust the health care system, based on personal and historical experiences. That, coupled with the dearth of Black providers and Hispanic providers in particular, may make some patients hesitant to see a specialist.

Woolhandler agreed that those factors are likely at work.

There are also practical obstacles, she and Isasi said, such as taking time off work, or needing to travel to a specialist because there are none in the local area.

“And the lower your income, the harder that is,” Isasi pointed out.

The bottom line, he said, is that insurance is a necessary part of the solution, “but not sufficient on its own.”

Even the finding on nephrology care can be seen, in part, as a reflection of how the system fails people of color, Isasi said. Black Americans need that care, because they progress to advanced kidney disease at a disproportionately high rate.

“The best health care system,” Woolhandler said, “is one that coordinates good primary care with specialist care when needed. In the U.S., we’re not providing that on an equal basis.”

https://consumer.healthday.com…

On its 56th anniversary, America’s most popular and effective health care program needs an upgrade

By Jessica Schorr Saxe, M.D. and George Bohmfalk, M.D.
NC Policy Watch, July 26, 2021

On July 30, 1965, President Lyndon Johnson signed Medicare, his “number one priority,” into law. On July 1, 1966, using primitive communication techniques such as post cards and door-to-door canvassing, the vast majority of Americans over 65 were enrolled. Today Medicare is our most popular and cost-effective health insurance program.

Medicare has improved health and reduced poverty for tens of millions of older adults, but despite its many strengths, it needs improvements that should be addressed in the budget reconciliation bill being formulated in Congress. While a full-on transition to “Medicare for All” would be the preferred solution, we should make every effort to achieve these improvements as soon as possible. These improvements are particularly critical to Black Americans who have poorer health, more chronic conditions, and more cost-related barriers to care than whites.

Four needed changes stand out:

More forms of healthcare should be covered – Medicare doesn’t cover vision, hearing and dental care, each of which can have a major impact on overall health. According to a 2018 Commonwealth Fund analysis, most people on Medicare who needed a hearing aid didn’t have one, most who had difficulty eating because of their teeth hadn’t seen a dentist in the last year, and almost half of those with vision problems hadn’t had an eye exam in over a year. Medicare should include vision, hearing and dental care.

Out-of-pocket are too high and should be capped – Traditional Medicare pays only 80% of its approved charge for most medical services and has no limit on out-of-pocket expenses. These costs are daunting for many. More than half of people covered by Medicare live on less than $30,000 a year, and many can’t meet their basic needs. The median income for African-Americans covered by the program is only $23,000. At the same time, the average beneficiary spends almost $6000 annually on medical care. It doesn’t take a math genius to figure out that those numbers don’t compute, so it’s no surprise that over half of recipients fear an illness would lead to bankruptcy or debt. Congress should place an affordable cap on out-of-pocket costs.

The age of eligibility should be lowered – Medicare is only available to people over 65 and some with disabilities. Getting adequate healthcare sometimes resembles a game of craps—roll the dice and see if you can wait until you are over 65 to get a serious illness. A recent Stanford University study showed that people over 65 had better cancer outcomes than patients in their early 60’s. One might expect the younger group to do better, but the older group had the advantage of better access to healthcare through Medicare. Lowering the eligibility age to 60 would give 23 million more people the security and better outcomes of Medicare coverage.

Drug prices should be lowered through negotiation – On average, Americans pay more than twice as much for medications than do people in other wealthy countries. Allowing Medicare to negotiate drug prices would save hundreds of billions of dollars. These savings could be used to pay for the other improvements.

These proposals are popular. A large majority of seniors want to see coverage of dental, vision and hearing care. Support for lowering the Medicare age is bipartisan, as is support for drug negotiation.

These improvements would also extend beyond individuals. The COVID-19 pandemic has both illuminated and aggravated unconscionable racial and ethnic healthcare inequities, such as a disproportionate death rate which actually widened the gap in life expectancy between Blacks and whites, wiping out years of progress. Improvements to Medicare would not erase all inequities, but they would substantially mitigate many. Businesses would also benefit, as they would no longer bear as large a burden of their employees’ healthcare costs.

More than 150 members of Congress have signed a letter to President Biden requesting that the American Families Plan include an out-of-pocket cap, improved benefits, a lowered eligibility age and prescription drug negotiation for Medicare. If your representative is among them; thank them. If not, ask them to support it. Ask your Senators to support these improvements.

Happy and healthy 56th birthday, Medicare! Short of expanding Medicare to cover everyone, there is no better way to celebrate this milestone than to enhance the physical, emotional, and financial health of seniors by improving and expanding Medicare benefits.

Dr. Jessica Schorr Saxe is a retired family physician and chair of Health Care Justice – NC. Dr. George Bohmfalk is a retired neurosurgeon and chair-elect of Health Care Justice – NC. Contact them at hcjusticenc@gmail.com.

http://ncpolicywatch.com…