Rural hospitals closing at an alarming rate

Rural hospitals in trouble is not a new topic, but the significant increase in closings and risk of such is finally getting some attention. The issue for years has been the large percentage of a rural hospital’s budget that went unpaid due to patient debt and indigent care. In some hospitals, the percentage of these two items is more than 1/2 of the budget.

Per a February, 2019 article in Modern Healthcare called “Nearly a quarter of rural hospitals are on the brink of closing” by Alex Kacik: “Twenty-one percent of rural hospitals are at high risk of closing, according to Navigant’s analysis of CMS data on 2,045 rural hospitals. That equates to 430 hospitals across 43 states that employ about 150,000 people and generate about $21.2 billion in total patient revenue a year.

Hospitals are often the economic drivers of rural communities. Per capita income falls 4% and the unemployment rate rises 1.6 percentage points when a hospital closes, a related study found. Ninety-seven rural hospitals have closed since 2010, according to the University of North Carolina Cecil G. Sheps Center for Health Services Research.

They also broke the impact down by state, revealing that half of Alabama’s rural hospitals are in financial distress, the highest percentage in the country. At least 36% of the hospitals in Alaska, Arkansas, Georgia, Maine and Mississippi are in financial jeopardy.”

Most of the states in trouble chose not to expand Medicaid, but there are some who did or are now doing so. Per several studies by The Commonwealth Fund, RAND Corporation, Economic Policy Institute and George Washington University, expanding Medicaid would help patients, state economies and rural hospitals. Why? It would allow these hospitals to get paid and paid closer to the time of service reducing accounts receivables. Getting paid has an echo effect on employees and consumers.

This issue was brought home by two Republicans pleading with their party to acquiesce in states like North and South Carolina that did not expand Medicaid. GOP Governor John Kasich of Ohio, who ran for President, said Medicaid expansion is a “no brainer” and would add over $13 billion to Ohio over several years. Yet, the most dramatic plea was from Adam O’Neal, a GOP Mayor of a North Carolina town called Belhaven.

After failing to get the GOP majority in Raleigh to help save his town’s Vidant Pungo Hospital that served 20,000 people, he walked 273 miles to Washington, DC over 14 days. “You can’t let rural hospitals close across the country. People die,” O’Neal, told Modern Healthcare in 2014. Unfortunately, Vidant Pungo closed later that year (note a non-ER clinic opened in 2016).

You can add my pleas for help back then (and now). Folks, this stuff is real. I do not care if your tribe is blue, red, purple are chartreuse, hospital closings impact people’s lives and people’s livelihoods. Closings also hurt their community’s economy. My strong advice is for legislators to stop political posturing and do something. I do not care who wins or loses a political game. Stop focusing on keeping your job and do your job. You could start by expanding Medicaid, joining the other 36 states.

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Note to Democrat Senators running for President – stabilize the ACA

The following note was posted on the website for the seven Democrat Senators running for President, with a copy to select others.

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I am an Independent voter and retired, but my career included being an actuary, benefits consultant and benefits manager for a Fortune 500 company. I have shared with Senators and Congress people a few thoughts on stabilizing the ACA, something Democrats campaigned on last fall and won.

Medicare for All deserves debate, but will require a more elongated and data-driven discussion. We need to have Congress take steps to stabilize the ACA now. To do otherwise, is a disservice to Americans.

Here are my thoughts.

– the GOP sabotaged the ACA in two specific steps which increased premiums even more. They defunded 89% of the risk corridors (for initial adverse selection) driving some insurers out of the market. The other is Trump reneged on reimbursing insurers for copays/ deductibles for people making less than 2 1/2 times the poverty level. My suggestion is to pay insurers what we promised in writing and invite those who left back into the exchanges.*

– I suggest the lowering of the eligibility age for Medicare to age 62 (the age when retirees can first draw Social Security). This could be viewed as a pilot for Medicare for All. This action would lower the Medicare premium rate for all and lower the ACA exchange premiums due to the age of those leaving the ACA and joining Medicare. In other words, both the average age of Medicare and the exchanges would be lower, so the actuarial cost per person is less in both.

– Actively encourage the expansion of Medicaid in the remaining states – this will help the economies, healthcare providers and people in those markets. There are now 36 states who have done so. GOP Ohio Governor John Kasich calls Medicaid expansion a “no brainer.”

– Finally, where only one option exists in a rural county, offer a Medicare option, again as a pilot. People should have choices.

There are other changes that would help, but this needs a data-driven analysis and not whatever the GOP did in 2017, which was a horrible approach to legislation that resulted in horrible legislation. Had any of the GOP legislation passed to kill the ACA, the GOP would have lost even more seats and we would be talking about a recession coming our way.

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* Please feel free to Google these topics: “Marco Rubio and risk corridors” and Donald “Trump and ACA subsidy decision”. The former caused insurance premiums to increase more than they otherwise would have and some insurance companies left the exchanges with the US government owing them money.  The risk corridors were designed to tie insurers over until the initial adverse selection flushed out of the system.

The latter was frustrating because the subsidy helped people in need. Trump untruthfully claimed it will only affect insurer profits, but the carriers committed to the customers to do this under contract. The CBO said this action raised the deficit by $10 billion, since premium subsidies went up to pay for the increased premiums. In my home state of NC, BCBS said before the Trump decision premiums were NOT going to increase. After the decision, the premiums increased 8%.

Saying this in a more succinct way, the GOP screwed American people to win a political argument. Sadly, that is the truth, but very few people know of this. This also is an exemplar of the President’s lying affecting hard-working people. Lying is one thing, but setting policy off lying is another matter altogether.

Note, the ACA is imperfect and complex. But, it still has not been fully implemented in all the states with those who did not expand Medicaid. But, people need to be fully aware of the sabotaging of the ACA undertaken by the GOP, which I find interesting, as the ACA is largely based on a GOP idea. That is politics for you – you did it, so I must be against it.

Hey Dems, focus on these four issues

One of this Independent voter’s frustrations with politics, which is exacerbated by this President, is pressing issues are not getting discussed. And, some are made worse or are sabotaged by the current White House incumbent as we are told to focus our attention on issues he has overstated in importance or sold on fear.

While there are many issues, it is hard to boil the ocean. So, my advice to all politicians, but especially the Democrats who are pushing these ideas, is to narrow the focus to the following four issues.

– Stabilize the healthcare system and have a good debate on Medicare for All, which is a hard sell. The GOP has failed to realize that a reason they lost the House is not listening to most Americans, instead sabotaging the ACA reneging on commitments to insurers and trying to repeal it. As a retired benefits actuary, consultant and manager. I would suggest an idea to stabilize the ACA is to expand Medicare to retirees at age 60 or 62 and measure the impact for its veracity. But, we need to start by paying insurers what we committed to them.

– Climate change is real, is happening and is man-influenced. AOC is dramatizing a little about the end of the world, but the data point she is citing is if we do not make huge strides by 2030 (12 years), our ability to stop the warming trend impact is minimal. She has been ridiculed for he Green New Deal by the GOP, but I would rather discuss her plan than Senator Marco Rubio ignoring the fact the largest city in Florida is the most at risk city on the planet and is seeing a larger number of sunny days flooding from the rising tides. Who is the crazier person, the one speaking to a problem or the one ignoring it altogether?

– Job retraining is key, but we need to understand the major reasons the jobs are going away are technology/ robotics and CEOs chasing cheap labor. It is not immigration or trade, which are down the list. This especially true in those impoverished areas where industry has left them behind moving or closing a plant.

– Finally, the debt and deficit are critical to discuss. The debt just passed $22 trillion and is headed to $34 trillion by the end of 2027. The annual deficit will pass $1 trillion this year, which is nearly 1/3 of our annual revenue. My former party and, in particular, the Freedom Caucus, are as hypocritical as they come. When the Dems had the White House, the Freedom Caucus screamed bloody murder when the debt was $8 trillion, then $13 trillion. But, I give the same caution to Dems I give to the GOP, we must reduce spending and increase revenue. The math will not work otherwise, so says the CBO, Committee for a Responsible Federal Budget, The Concord Coalition and Simpson-Bowles Deficit Reduction Committee.

Of course, there are other critical issues. But, if you focus on the important few, it will resonate. This is especially true for younger folks – climate change, debt, future jobs and healthcare are important. In my view, the GOP has lost its way on issues of import. When I left the party twelve years ago, a key reason was its global warming denying stance. My thesis is if you are denying the greatest threat facing our planet, how can I trust you on resolving other issues?

We are behind the eight ball on too many issues. We are leaving our problems to our children and grandchildren. They will ask us, why did you do that? Why, indeed?

It is time to govern

Now that the elections are over, it is time to put away the rhetoric and focus on governance. This used to be how it was done, until we segmented the news into various markets. The past twenty years or so, we seem to govern off the campaign rhetoric rather than facts and collaboration has become a dirty word.

As an Independent voter, who has been a member of both parties, the governing off rhetoric and lack of collaboration need to stop. Neither side owns all the good ideas and both sides have some bad ones. And, we need to focus on the underlying truths and facts rather than tweets and who wins a public relations battle over an issue. Process matters – when politicians deviate from process, it is for political reasons.

In this spirit, here are the issues that this voter thinks we should focus on. Many voters have voiced agreement on some of these, but some issues just don’t get due attention.

– we should stabilize and shore up the ACA which most Americans favor: funding commitments to insurers will stabilize premiums, as will expanding Medicaid and considering the expansion of Medicare down to age 55, 60 or 62.

– we should ditch the harmful tariffs and work with our allies and the WTO to pressure China to stop the intellectual capital theft. Tariffs hurt consumers and producers, especially our farmers.

– we should address infrastructure needs which are many, doing so as we have done in the past with a blend of business, venture capital and federal, state and local government funding.

– we should recognize that the two biggest threats to our planet per the World Economic Forum are our water crisis and climate change, which exacerbates the first issue: strides have been made, but we need to reassume our global leadership role on climate change and focus on measures to address both.

– we should add more governance around gun control issues: Gun-owners and non-gun owners have voiced agreement on measures that would help. It should be noted most gun-owners do not belong to the NRA, so the NRA’s political activism against reasonable change should be noted, but not over-emphasized.

– The deficit and debt are building to a point of huge reckoning. It has been eight years since the Simpson-Bowles Deficit Resuction Committee report was shelved. It was shelved because it recommended $2 in expense cuts to every $1 in revenue increases. It was shelved because neither party had the political courage to roll up their sleeves and make tough decisions – we cannot get there with only expense cuts or revenue increases, needing both.

– We should stop the lack of civil discourse and beating up on the media. The media’s role is vital to our democracy. Pay attention to where your news comes from. Be wary of opinion disguised as news. Tweets are not long enough to show context or subtlety and are an easy way to misinform, as a result. To this end, it is vital for our democracy to return to appropriate Congressional oversight. We are not a kingdom.

If anything, we must have our politicians work together. The crime bill the President is pushing and that passed the House is not perfect, but is a bipartisan effort. It makes steps forward. Let’s make needed improvements and get something done. And, that is what Americans want most from our politicians – stop the grandstanding and get stuff done.

 

 

What are we voting for?

So, much of the focus has rightfully been on countering the most divisive US President this Independent voter has witnessed. He has bullied, denigrated, lied and made himself the center of attention on far too many issues.

Yet, let’s look at this record he touts as his reason to give him free rein. His followers say he has done what he promised. To me, therein lie the problems.

While the economy is going well, the economic growth has lasted 9 1/2 years, the second longest in US history. We have also had over 8 years of job growth. The tax law and deregulation have helped make it a little better, but we are doing so on borrowed time with increasing debt and less governance.

We have announced the pull out of the Paris Cilmate Change accord and are an outlier in the world. The President lied to people about climate change being a hoax and has added insult by damaging our environment through enabling industrial polluters. He is borrowing time the world does not have.

The ill-conceived tariffs are bad enough, but bullying and lying to our allies far exceed the damage tariffs will do. We are harming our relationships, which are a key strength of America. We are also less trustworthy. As Trump’s former economic advisor said after telling him he lied to the Australian PM, Trump is a “professional liar.”

We have focused on immigration as a major problem, but it has been sold on fear and is not as big a problem as advertised. We have made immigrants the bogeymen and have lost sight of the impact of domestic terrorists already here. Yes, we should fix immigration, but three promising bills before this President were waylaid for political reasons.

We have allowed a President to build off Republican leadership efforts to sabatoge the Affordable Care Act making premiums higher than they otherwise would be. His party has screwed Americans to win a political argument. And, now the GOP has the unmitigated gall to say they want to protect pre-existing conditions.

We have put in place two very conservative justices, but the President forced the Senate to move away from a super majority to a simple majority. This has made it easier to get a less moderate Justice on the court. I want well-tempered jurisprudence, not partisanship. The most recent Justice lied to the Senate.

We have allowed a President to make money off the Presidency, which he has been sued over. The trial is permitted to move ahead. We have not criticized a President enough for denigrating rhe media. Trump is on record  as lying more than any other politician. Our democracy is at stake because of these two issues. He is President, not King.

Finally, civil rights are under attack with this President. His hate speech and bullying have greased the skids for white supremacists. The President is a racist and misogynist.

This is his record. And, I have not even discussed the Russian issue. I would give him kudos on discussions with North Korea and some deregulation. The tax cut helped some, but went too far and is hurting our debt. And, we have done little to better govern guns or invest in our infrastructure.

That is what I think as an Independent voter, who left the GOP over ten years ago. We need to better govern this President. He certainly is not up to the task.

 

Thursday thumbnails redux

Since I am kicking around several topics, let me throw a few together for your reading and reaction. Your thoughts are welcomed and appreciated.

  • It would be terribly unfair to say Republicans are racist, but it seems there are more than a few racists running for important offices in various states under the GOP banner. In Virginia, Illinois  and Florida, for example, a few candidates have a history of racist comments and associations. To their credit, the GOP leadership is not backing all of these candidates, but they should not back any and should condemn their words and actions in no uncertain terms. It is disappointing that the US President has done neither and has greased the skids for white supremacist hate groups who now feel empowered. Trump had a truly a low bar to step over to condemn white supremacists last summer and he tripped.
  • Sexual assault is a heinous crime, yet the accuser does not often come forward given the backlash they get. So, for it to take years to come forward is not uncommon. The fact they do so when the accused is being considered for high office, should reveal a greater sense of character. Professor Blasey Ford deserves due consideration and time for her accusations of Supreme Court nominee Brett Kavanaugh. Call me crazy, but we should take the time to get this right as this is one of the nine most important people in our courts. Because we did not take time back in 1991, we may have a man guilty of sexual misconduct on the bench already.
  • I have written before that Democrats are lousy marketers. Even when they have a better story to tell, they often let Republicans define the talking points. The Democrats have many fine candidates running for office. Some are running uphill battles in gerrymandered districts, but they are running well. What should be shouted from the rooftops is they will help improve and stabilize the ACA as it continues to be sabotaged by the GOP making premiums even higher, they will protect our environment against the further roll back of regulations enabling polluting and stay committed to the Paris Climate Change accord, they will make sure we do not devalue our allied relationships and retrench further from our global leadership role, and they will advocate for rights of all citizens, especially those in poverty. And, to be frank, since the GOP has ceded its leadership toward addressing the debt and deficit, the Democrats can be seen as better financial stewards.

Truth be told, the President touts what he has done with the economy, but what he fails to tell people is we are in the 113 consecutive month of economic growth, the bull stock market traces back to March, 2009 and unemployment was low when he took the reins. What has been done, is he is borrowing from our future to make a good economy a little better, but the cost is doing nothing but add fire to our burning debt.

Presidents get too much credit and too much blame for the economy. They do provide headwinds and tailwinds, though, and this President has done both. The headwinds will show up later as noted by most economists, while the tailwinds add today.

Media – focus more on the problems needing solving and less on who wins

The main stream media is doing a better job on focusing on the issues, but they still have a bias toward conflict. Who wins and loses based on the airing of an issue or problem is covered way too much for my taste. The end result is problems and their many causes do not get addressed or are oversimplified, so they go unsolved.

The dilemma is we citizens lose. The focus must be on the issues rather than who benefits from whatever hits a news cycle. Substance matters more than image. Here are a few examples to digest.

We have a poverty problem in the US. It is not just a declining middle class. Too many are living beneath paycheck to paycheck or are one paycheck away from being in trouble. The United Nations just released a report that confirms the US has a poverty problem citing numerous examples and numbers. Instead of asking lawmakers what are we doing about it, the media focused on the Trump administration admonishing the UN for the report. The problem exists whether or not it makes Trump look bad, as it took decades to decline to this point. Addressing poverty is more important.

We have a significant and growing debt problem that has been made worse by the Tax law passed in December. The economy was already doing pretty good with a long growth period. Yet, rather than address our debt, we borrowed more from our future. This malfeasance must be highlighted. Yet, most of the focus is on the economy doing well and its impact on the midterm election. Note the economy would have done well without the tax change, but we have a day of reckoning coming that will require more revenue and less spending. What are we going to do about it now, especially with a good economy?

The Affordable Care Act has needed improvements and stabilization for some time. The American public favors this as do lawmakers from both parties. Yet, the media focuses too much on the political  impact of an ACA that could be doing better. Not only has the party in power not helped the ACA, they have sabotaged it making premiums go up even more. As I see it, the President and GOP own the ACA. Letting premiums go up hurts Americans. If the ACA fails, our poverty problem will get even worse and the economy will suffer.

Issues like immigration, climate change, water shortages, tariffs, exiting international agreements, eg, all need to be focused on. We need to drill down on what makes sense in a data driven and reasonable manner. Attempting to resolve issues based on optics of winning or losing won’t solve anything. And, that is what our President and legislators seem to be more interested in.

So, media please start asking our leaders what they plan on doing about these problems and asking them to explain why certain measures don’t seem to be helpful.  And, leaders stop worrying about keeping your job and start doing your job.