Are US hospitals in trouble?

Many hospitals, especially more rural ones, have been in trouble for some time. More on the rural hospitals later.

“More than 33% of all hospitals are operating on negative margins, according to the American Hospital Association,” per Michael Popke of Benefits Pro in a piece called “America’s hospitals facing ‘massive growth in expenses’.” Here are two select paragraphs from the piece that tell the gist of the story.

“Hospital employment is down approximately 100,000 from pre-pandemic levels, while hospital labor expenses per patient through 2021 were more than 19% higher than pre-pandemic levels. A new report from the American Hospital Association highlights the financial and operational toll the pandemic and inflation has taken on hospitals — concluding that more than one-third are operating on negative margins.

‘Hospitals and health systems have been nimble in responding to surges in COVID-19 cases throughout the pandemic by expanding treatment capacity, hiring staff to meet demand, acquiring and maintaining adequate supplies and personal protective equipment to protect patients and staff, and ensuring that critical services and programs remain available to the patients and communities they serve,’ notes the nine-page report released this month. ‘However, these and other factors have led to billions of dollars in losses over the last two years for hospitals.’”

Per an article called “The South’s health care system is crumbling under Covid-19. Enter Tennessee” by Daniel Payne of Politico, the demise of heath care in more rural areas has been exacerbated by COVID-19.

“Rural hospital closures have been accelerating, with 181 since 2005 — and over half of those happening since 2015, according to data from the University of North Carolina. But that may be just the beginning. Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health care advisory firms.”

The rural hospital concerns predate the advent of the Affordable Care Act. Too many hospitals had high percentages of indigent health care costs, meaning people without insurance. If they were not funded by a county, the hospital was at severe risk of closing. Since fourteen states have still not expanded Medicaid under the ACA, the opportunity for getting paid did not increase and many have closed. And, the patients, employees and communities suffer.

Yet, a major part of this cost dilemma existed before COVID-19. The US has the most expensive health care system in the world, but we rank around 38th in health care quality. That is a pretty poor rate of return on one’s spend. Hospitals spent too much on technologies that need to be used. There exists a correlation between the ownership of a technology and its higher frequency of use. Yet, with COVID-19 and its aftermath, fewer elective procedures and tests were done in hospitals.

These issues need to be evaluated outside of the political lens and with data. Yet, that is not bound to happen. It would at least be helpful to see more people covered with full Medicaid expansion, but that has been politicized for zero-sum game reasons, not to actually help people. It would be helpful to see Medicare expanded, at least down to age 62 from 65. As Medicare works reasonably well, I would like to see it go lower, but whatever we do, it should be evaluated on its results, not a politician’s beliefs.

If people think I am unfairly picking on politicians, it would not be a stretch to say most politicians do not know a whole lot about health care. We saw this with the atrocious “throw stuff against the wall” repeal and replace discussion in 2017 by the thirteen Republicans, which came within one vote from passing the Senate. That would have screwed about 20 million Americans. Senator John McCain gave it a thumbs down vote for its lack of veracity and its poor protocols on evaluation.

And, we saw it with the discussions and passing of the ACA, which Republicans refused to vote for which is strange since it has several Republican ideas in it from Romneycare in Massachusetts, when Mitt Romney was governor there. The ACA is not perfect, but at least we should fully implement it and shore up its deficiencies. It is only people’s lives.

Medical debt impacts 23 million Americans per Kaiser study

In an article called “The burden of medical debt in the United States” by Matthew Rae, Gary Claxton, Emma Wager, Cynthia Clark, Jared Ortaliza, and Krutika Amin, the results of a Kaiser Family Foundation (KFF) are noted. Per the article, a link to which is below, the following conclusion can be drawn:

“We find that 23 million people (nearly 1 in 10 adults) owe significant medical debt. The SIPP survey suggests people in the United States owe at least $195 billion in medical debt. Approximately 16 million people (6% of adults) in the U.S. owe over $1,000 in medical debt and 3 million people (1% of adults) owe medical debt of more than $10,000. Medical debt occurs across demographic groups. But, people with disabilities, those in worse health, and poor or near-poor adults are more likely to owe significant medical debt. We also find that Black Americans, and people living in the South or in Medicaid non-expansion states were more likely to have significant medical debt.”

Several years ago, I cited a study that noted medical debt was the number one reason for bankruptcy by individuals, so the above result is not a surprise. The groups that are most exposed are non-Hispanic Blacks at 16% and people in the age 50 to 64 demographic at 12%. Some of the reasons for this age group being higher is Medicare does not kick in until age 65, people are getting downsized in that group and employer retiree medical benefits have largely gone away.

I posted a piece from Politico the other day about rural health care suffering. An important reason is the fourteen states who have not expanded Medicaid to those below a certain poverty level. This has led to more rural hospitals closing and exposed people who do not have coverage to higher medical debt or forsaking care all together. The debt comes with people waiting until they are a train wreck before going to the ER, a more expensive place to get care.

One of the things I have found in my consulting experience as well as patient and care taking experience, access to health care is critical to a person’s health. The ability to get preventive care before the train wrecks also lowers the cost while improving one’s health. In the US, one of our warts is we are the most obese country in the world per the World Health Organization. We have supersized ourselves to earn that mantel. We must get ourselves on a better path before it becomes too late.

Access to care is key to getting on that better path, but making it a more affordable journey. When people say we have the best health care system in the world, that simply is not borne out by the data – we have the most expensive health care in the world; we rank in the low thirties in health care outcomes. We must use the system more wisely. All of us.

Every community needs a Mama

Since we are at the Ides of March in a month to celebrate women’s history, let me offer a brief glimpse of a woman who almost everyone in a small community in southwest Georgia called “Mama.” Not that they were related, but Mama was a health care giver for the community, a self-appointed nurse who helped many while the regional doctor was away.

When the doctor was in the area for his monthly visits, Mama would accompany him on his visits to hear and see what he had to say, but also to share her thoughts. She had such a good rapport with the doctor, she named one of her twelve children after him. In the interim, Mama would make sure the patients took their medicines, rested and did what the doctor asked. Since this was in the 19th century, many of the cures were home or natural remedies.

I have shared the story before about how her youngest boy loved gymnastic type exercise and would tumble or use any prop for his swings and dismounts. One day, he fell and knocked his two front teeth out of his mouth. He gathered them up and ran in with his bloody mouth. Mama sat him down and boiled some water while she cleaned his mouth. She then dipped the end of a dish towel in the hot water and rinsed it quickly. She told the boy to put the towel in his mouth “as hot as he could stand it.” She cleaned the teeth off and then shoved them back into his now-swelling gums and they held.

I love this example and have heard and told this story many times. Her name was Carrie Jane and she was my great grandmother. Since everyone called her Mama, my grandmother’s children included, they would call their own mom “Mother” in deference to Carrie Jane. I never got the chance to meet Mama, but I do know her children grew up as both characters and with character, my grandmother included.

As an example, she called one of her daughters Carrie Bell, but my grandmother would not call her sister that. Instead, she would call her “Cow Bell” as a means of teasing. And, when Carrie Bell would come to visit, she would ask us kids if we wanted to play “marbles” which was her name for the board game Aggravation.

Growing up in a rural area (using town would be inappropriate), people formed a kinship and helped each other out. These folks could not pay Mama for her services, but would bring the family fresh produce as a means of recompense. If a baby was coming, everyone would go find Mama. I think there are mamas like this in every small community.

These are the kind of women I wish to honor today. People may not have been related to them, but they touched many lives. Thanks Mama and all of the mamas in our history. Tell me about the mamas in your history.

Mental Health is presenting unprecedented challenges

In a recent article in Benefits Pro, a piece on the rising mental health challenges caught my eye. An excerpt from the article follows:

“A new report from consulting firm McKinsey finds ‘unprecedented’ behavioral health challenges among Gen Z Americans. The age group, which ranges from middle-school students to younger members of the workforce, has significantly more issues with behavioral health than other age groups, the study found. Their conclusions are not unique: the U.S. Surgeon General recently issued a public advisory describing a ‘youth mental health crisis,’ which has been exacerbated by the COVID-19 pandemic.

The report pointed to consumer surveys that found Gen Z members more likely to report behavioral health issues, more likely to be diagnosed with mental health conditions, and more likely to contemplate suicide than other generations.”

Unfortunately, there remains a stigma attached to mental health that prevents too many from getting the needed help. With that said, a possible reason for the uptick is more younger folks are realizing the need than in previous demographic generations. Nonetheless, getting help is something that should be easily enabled. And, it is not just medicine that should be prescribed. Therapy paired with medicine is essential to getting the most productive level of help.

Before I retired as consultant, I used to travel with a behavioral psychologist who helped large companies set up mental health programs for its employees, including depression and obesity management ones. She would tell our clients that 1 in 5 people will have some level of mental health issue in their lifetime. She would add that if she looked at any prescription drug claims report, she would see 10% of the prescriptions be for mental health issues. What she was looking for is who prescribed the Rx, as she would prefer to see a psychiatrist rather a general practitioner.

I have a number of friends and relatives who have had mental health challenges, often multiple diagnoses – anxiety and paranoia are often paired together, eg. Therapy is the key. Having someone to help work through the problems is essential to managing them. The word management is critical as many of these problems don’t go away, so having tools to deal with them on a daily basis is utile.

Rather offer advice that I am not qualified to give, let me just say this simply. If you, a loved one or friend are having mental health issues, get or encourage them to get help from a therapist. Often, the therapy will come from a licensed clinical social worker LCSW. Your health plan or other networks will have several therapists to offer, so go through their bios and typical clients. They will suggest a psychiatrist if medicine is in order. Yet, if you or your relative or friend are having suicidal thoughts, call 911 or a suicide hotline (see below) and don’t wait on a therapist.

Life can be beautiful, but it is also hard. Sometimes it is harder than it needs to be. Just because you need help is nothing, I repeat nothing, to feel bad about whether you are the one in need or if it is your child. Get help. And, manage those challenges.

Hard Truths

Since our pseudo news outlets and social media pot-stirrers capture the imagination with stories that are largely untrue or focus on the wrong things, we seem to be ignoring hard truths. This concerns me as dialogue over factual information is greatly needed. Otherwise, we address the wrong problems.

America no longer is a country of upward mobility. We have fallen in the ranks of people climbing the socio-economic ladder and to whom and where you were born matters more than merit.

America ranked in the twenties in terms of science and math in world educational ranking the last time I checked. It may be worse now. That is not American Exceptionalism.

America has the most expensive health care system in the world but ranks around thirty-eight in quality outcomes. We have one of the hjghest maternal mortality rates in first world countries.

America was put on watch list for democracies around the world. That sentence speaks volumes. When people believe a former president who is known for being untruthful when he says the election was stolen, that gives me concern. The fact he cannot prove any of his wild contentions should be informational. He has won only one out of 65+ court cases and no recounts or audits. It is hard for him to lose any more than this, but he was still at it earlier this week.

That climate change thing is real and it is here. Storms are more severe and impactful. Drought areas are dryer. Wild fires are more intense. And, coastal areas are seeing more sunny day flooding. What is less discussed is the warmer weather pushes further north wreaking havoc on flora and fauna. The Maine lobsters are migrating north and we are seeing more tropical disease carrying insects up this way.

And, there are many other things we are not discussing.

Just a quick word on Jill

Our friend Jill is still having a tough time in her recuperation. She let me know she misses all of us and wishes she could start blogging more. As many of us know, Jill puts a lot of research into her posts, so her opinions are well -grounded. So, to her, blogging is more than just stream of consciousness writing. It is like cooking a well-prepared meal. She takes her time.

She hopefully will be having a treatment which will be beneficial to her. She had a couple of procedures last week to remedy a few related items, but she needs to have this procedure. I am sorry to be so vague, as I did not want to share too much of her personal travails.

Just keep her in your thoughts and let her know that you are thinking of her. If you would prefer to respond here, I will cut and paste into an email to her. The last time I committed to do this, she responded herself on my blogpost.

Jill;, we miss you and are thinking good thoughts for you.

Our children deserve better – a repeated pre-pandemic clarion call

The following post was written a couple of years ago. Although the pandemic has rightfully gotten our attention, this story bears repeating.

Two time Pulitzer Prize winner Nicholas Kristof wrote an editorial earlier this week in The New York Times called “Our children deserve better.” It is a clarion call to our nation showing the plight of kids in America.

Here are a few quotes to frame the issue:

“UNICEF says America ranks No. 37 among countries in well-being of children, and Save the Children puts the United States at No. 36. European countries dominate the top places.

American infants at last count were 76 percent more likely to die in their first year than children in other advanced countries, according to an article last year in the journal Health Affairs. We would save the lives of 20,000 American children each year if we could just achieve the same child mortality rates as the rest of the rich world.”

“Half a million American kids also suffer lead poisoning each year, and the youth suicide rate is at its highest level on record….The Census Bureau reported this week that the number of uninsured children increased by 425,000 last year.”

These are different views and sources of the threats to US children that note we have a problem. Another source I read a couple of years ago noted America has a much higher maternal mortality rate at child birth than other civilized countries, which further endangers children as well as the mothers.

Yet, these issues are not being discussed in the halls of government. We have a poverty problem in our country with too many living in or just above poverty levels. We have not expanded Medicaid in fifteen states* whose numbers are worse than these national numbers per capita. We have not addressed our national water crisis which has a Flint, MI like exposure to lead in too many cities and a volume of available fresh water issue in other places. We have not invested as we should to diminish crime and provide more opportunities for jobs in disenfranchised areas. There are several pockets of success that can be emulated in more cities.

We also need to address better gun governance, especially with the number one gun death cause by far being suicide and a non-inconsequential accidental gun death rate. And, we have not dealt with the continuing and rising exposure to technology and artificial intelligence which have taken and will take even more jobs in the future. Finally, there is that climate change thing we need to deal with.

These are real problems. And, they will get worse. Data driven analysis of causes and solutions are needed. They are both multi-faceted. Investing more now, will save huge amounts later. This is not just an urban issue, it is rural one as well. The opioid crisis is rampant in these impoverished rural areas, for example.

None of the solutions will fit on a bumper sticker. And, political attempts to oversimplify issues should be questioned. Here is an easy contradiction to spot – if people believe gun deaths are a mental health issue, then why the effort to eliminate or not expand mental health benefits?

Please make your legislators aware of these issues and ask pointed questions. These questions deserve answers, not bumper sticker slogans. These concerns deserve to be talked about, studied and acted upon.

*Note: The number of states who have not expanded Medicaid is now twelve. Here is a link to a tracking of the states who have and have not. What puzzles me is this change would help people in rural areas, which tend to vote more conservatively. So, not expanding Medicaid hurts health access, but also rural hospitals and economies, with the federal government funding 90% of the cost. As former Republican governor of Ohio and presidential candidate John Kasich said, Medicaid expansion is a “no brainer.”

Shore up the ACA – letter to the editor

My local newspaper ran my following letter to the editor Sunday. I have been preaching the message of improving the Affordable Care Act for seven years offering suggestions. I will link to one of those posts below. What I have never cared for is the naysaying, sabotaging and attempts to repeal it that have been a substitute for debate in the Republican party.

The legislation Republicans almost rammed through in 2017 was ill-conceived, poorly developed and punitive to multiple millions of Americans. These were the key reasons Senator John McCain saved the GOP from itself and voted it down before he died.

“Three times now the U.S. Supreme Court has upheld the Affordable Care Act in the face of Republican attempts to rule it unconstitutional.

Per this retired actuary, benefits consultant and benefits manager, the ACA is not perfect and could use some improvements. But it is helping Americans, including provisions required in employer sponsored plans, which people tend to forget.

What has puzzled me for 10 years is that the law is somewhat based on Republican ideas, the latest being Romneycare in Massachusetts, which at least one Tea Party leader, S.C.. Sen. Jim DeMint, once supported.   

My strong advice to my former party, stop trying to screw Americans by killing the ACA and let’s find ways to shore up its deficiencies.”

Please stabilize the Affordable Care Act NOW to help Americans | musingsofanoldfart (wordpress.com)

A Tuesday tale

I met with an old friend last week for lunch. He was visiting his daughter and we decided to get together, masked appropriately. He shared a wonderful story that I hope will warm your heart, as it did mine and my wife’s when I told her.

He said his daughter is a specialized nurse. He and his wife had adopted both of their children in their first week. For medical history reasons, his daughter wanted to find out about her birth parents. He gave a nice piece of advice to be prepared for the consequences which may not turn out like you want.

He went on to say she was adopted when they lived in Ohio, who changed their laws to allow for open records, provided the birth parents did not specifically say no during the transition form sealed records.

After much legwork given a common name, they found the birth mother and father. It turns out the birth mother was also a nurse and her father was the doctor her mother worked for. It was the mother who turned down the doctor’s proposal to be married, so they put the child up for adoption.

So, if that does not give you enough tingles that people she never met were also in the medical field, the next item might. We live in North Carolina, not Ohio. And, the daughter does not live in her home town having moved within the state. It turns out the birth mother lives nine miles away from the daughter.

The rest of the story remains to be told. I will add the mother who raised her is in medical research, so her daughter’s interest is most likely due to her influence and example, but DNA to help others might have also been a factor.

The story is not intended to judge anyone’s motives or reasons for placing a child in adoption. We do not know the circumstances or history of those involved. I would only surmise decisions like this must be difficult.

Franklin was on the side of the Angels and got chastised

I have written before when Franklin Graham has used his pulpit to denigrate groups of people who do not worship, love or gender present like he does. I have added it detracts from the many good things his Samaritan’s Purse organization does, when he demonizes groups. Yet, this time he is getting flak from his own followers for suggesting that people get the COVID vaccine.

Here are excerpts from an article called “Franklin Graham believes Jesus would take COVID vaccine. He’s still catching grief”.by Joe Marusak of The Charlotte Observer. A link to the article is below.

“Evangelist Franklin Graham is still catching grief from some of his Facebook followers weeks after saying Jesus would have supported getting a COVID-19 vaccine.

Based on the parable of the Good Samaritan, Graham said he concluded that Jesus would have supported getting all types of vaccines.

He said nobody should have to endure what some of his staff and their family did after contracting the coronavirus…

‘My wife and I have both had the vaccine; and at 68 years old, I want to get as many more miles out of these old bones as possible!’

Some of his followers, however, are still fuming about his COVID vaccine recommendation.

‘You my friend Franklin Graham are leading your sheep to slaughter,’ a woman posted Friday.

‘Satanic sell out,’ another woman posted.

‘STOP,’ said another last week. ‘It is NOT your job as a pastor to try and talk people into taking a vaccine that is considered experimental.’

Other comments were along these same lines. Just in the selection of these three, only one-half of one them raised an actual issue that gave him or her pause referencing “experimental.” The vaccines were rushed, but we have had the benefit of seeing the results of such along with the stops and starts. The J&J vaccine has some issues they are looking into, but for the vast most part the vaccines have been safe.

What amuses and concerns me is the vitriol used to share their opinions with the reverend, who is just trying to offer encouragement. He did exactly what I did after getting my vaccine and that is to share a positive experience. “Satanic” is a little harsh as a retort and offers no counter argument.

That is a bigger problem where people are replacing arguments with bullying and name calling. The latter does not improve anyone’s argument, even when they are a current or former politician. Being smug does not make one right, it just makes one smug.

Franklin Graham says Jesus would get COVID shot | Charlotte Observer