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.

Debt collections declining in states who expanded Medicaid

Since not every state fully implemented the Affordable Care Act, data now exists that can contrast those who did with those who did not. Thirty-one states and the District of Columbia have expanded Medicaid, with nineteen states still remaining.

For those who do not follow this closely, the ACA uses Medicaid expansion as the vehicle to deliver health care coverage for people beneath 138% of the poverty level. The federal government would front 100% of the cost for three years, eventually declining to 90% thereafter. Yet, the Supreme Court said states could opt out of this feature, which 19 still have done so.

Per the attached article, The Federal Reserve Bank of New York in a study finds a benefit to people in states where Medicaid expansion occurred is debt collections have declined. I have written before that the principal reason for personal bankruptcy is medical debt. The study’s authors note:

“U.S. counties that had a particularly high uninsured rate prior to the implementation of the Affordable Care Act have seen the per capita collection balance fall if their state embraced the Medicaid expansion. If not, the collection balance continued to climb.”

Yet, in states where Medicaid was not expanded, debt collection is noticeably more in comparison. Per The Commonwealth Foundation, Kaiser Family Foundation, RAND Corporation, Economic Policy Institute and a George Washington University study, expanding Medicaid helps those in need, helps a state’s economy and helps hospitals, especially rural ones who have high indigent and uninsured costs. The hospitals in Medicaid expanded states are seeing fewer uninsured patients and seeing better operating margins. Now, evidence shows it keeps more folks out of bankruptcy.

Former Ohio Governor John Kasich, who was the most reasonable GOP presidential candidate in the view of many, said expanding Medicaid was a no brainer. He said it would bring $13 Billion to his state over the next several years when announced. It also helped his constituents. During the campaign he remained a supporter of Medicaid expansion, which swam against the GOP tide. It is hard to be a lone advocate in a sea of political animosity.

It is past time for leaders in the remaining states to stop thinking like party representatives and start thinking like financial stewards. Several states gave serious consideration, such as Oklahoma, Alabama, Idaho and Wyoming, to expanding during the spring, but in spite of strong data showing its benefits to the state, its hospitals and people, Republican animosity toward the ACA defeated the proposals. Medicaid expansion would help many, including those Republican constituents in poverty living In rural areas. It should be noted that these are the same folks who feel their party is not doing more for them.

Make a move legislators and help all your people, but especially your constituents.

http://www.benefitspro.com/2016/06/13/states-that-embraced-health-care-reform-seeing-les?eNL=575f314b140ba09f23187fc4&utm_source=BPro_Daily&utm_medium=EMC-Email_editorial&utm_campaign=06142016

Affordable Care Act – remind folks to sign up by February 15

The Affordable Care Act continues to build its resume, even though there are some who try to ignore this growing success for political reasons. That is unfortunate as many who have not considered the ACA are shortchanging themselves due to available subsidies, which are favored by the majority of Americans per the Kaiser Family Foundation. More on this later.

It troubles me when I see people who are part of fundraising events to raise $150,000 or more to pay for medical bills for an injured or sick child because they lacked healthcare insurance. If these folks had signed up for the ACA, the only money they would need is for the out-of-pocket limit which usually run in the $5,000 to $20,000 range depending on the plan selected. As I have noted before, the number one reason for personal bankruptcy in the US is no or poor healthcare insurance. Yet, it is not too late, as they can still sign up for care since coverage is guaranteed, which previous policies did not offer.

With three weeks to go in the ACA’s current exchange enrollment season, exchange enrollment has hit 9.6 million passing the President’s expectations. The exchange enrollment will likely push toward the Congressional Budget Office (CBO) target of 12 million by the middle of next month.  It should be noted this does not include enrollment under Medicaid in the majority of states who did expand Medicaid, which will only improve with more states considering such expansion.

Further, the non-partisan CBO has for the second time reduced its projections of future medical costs as a result of dampening costs due in part to the Affordable Care Act. As an actuary and former benefits consultant and manager, having more folks covered will help further dampen costs as they seek treatment and get medications before they become eventual train wrecks. Plus, by seeing doctors and nurses in advance, the long term costs are further dampened as they are being served in the more cost-effective place and not in an Emergency Room in a crisis.

But, back to the Kaiser Family Foundation survey from January. Many may not realize that some strident opponents have brought a lawsuit that questions the ability of the federally run exchanges to offer the subsidy. The federal exchanges had stepped up to cover 37 states, when some states asked them to do so. The US Supreme Court will rule on this later in the year. I do not anticipate that they would rule unfavorably, but stranger things have happened. If they did about 10 million Americans would be screwed, sorry for the use of the most appropriate term. Yet, per Kaiser, what would Americans want in that case:

  • 64 percent say Congress should pass a law making subsidies available in all states;
  • 40 percent of Republicans favor such a law, with a solid majority of Democrats and Independents supporting such legislation;
  • 59 percent of residents in the healthcare.gov states say they would want their state to act to operate its own exchange;
  • By party declaration, 61 percent of Democrats, 63 percent of Independents and 51 percent of Republicans favor a state exchange in those now served by the federal exchange.

Given the fact there is a cost to running an exchange, many of the states asked the federal government to take the lead. In fact, a significant number of state attorney generals have written to the US Supreme Court to not rule against the subsidy.

With all of its complexity and communication challenges, which is partly due to Americans not understanding healthcare insurance, in general, the ACA is building a resume of success. This Congress should heed Americans wishes to improve it where possible, but accept that it is showing success. And, the remaining state legislatures should expand Medicaid as it would help many residents in need, help their economy even further, and keep rural hospitals afloat to serve.

A potpourri of news items

While a few thoughts bounced around as potential themes, I felt it would be best to highlight a few items of note, in a world of many to choose from. In no particular order:

Ukraine troubles continue – One of the things that does not get stated in the downing of the Malaysian airplane is the pro-separatists do not have any planes, so why would the Ukraine military be firing in the air? The evidence points the finger where the missile was launched from and the group that says it had no hand in it is not letting people get to the site to investigate. And, the artillery launcher was moved, presumably back to Russia. Call me crazy, but when your arguments are contradicted by actions, then your credibility lessens. Putin has not learned this yet either. Folks, get to the table and negotiate a settlement to cease innocent people being killed and before your story falls apart. Plus, while I understand economic sanctions in this case as an alternative to military options, in general, I don’t like them, as they tend to punish the wrong people for leaders’ actions.

Israel, Hamas and Gaza – In my simple view, a country has a right to defend itself, but Israel has gone a “bridge too far” and is looking poor for civilian deaths. The UN is correct to assert their position and the violence on civilians and children must end. Hamas should also get poor marks for hiding among the civilians and setting the stage for pawns to be killed, as well as not acknowledging the right for the other to exist. Yet, the conditions are ripe for a group like Hamas to survive. Reasonable leaders (on both sides) need to advocate for a cessation to the violence which is killing its people. Reasonable leaders need to push for finding a way to co-exist. Reasonable leaders need to find ways to stop marginalizing people and look for ways they can thrive, live in peace, raise families and practice their religion. If they do not, then both sides are destined to live in an environment where innocent people are in danger and killed.

Afghanistan election is important – A major step forward for Afghanistan is still in the works. The Presidential vote recount is important to get it right and pass muster. This is the first election post Karzai and it needs to be successful regardless of the winner. The peaceful transition of power is a major element of a sustainable government. This is why the Taliban is in such a dither not to let it happen.

Medicaid expansion push gets a practical conservative voice – Please check out Dana Milbanks’ editorial article on a conservative GOP Mayor in North Carolina marching to Washington to advocate for saving a closed rural hospital in his town. A woman died because of this closing, as she could not make it to the next town in time, which was 75 minutes away. He had reached out to the North Carolina GOP leadership and was told they could not support anything to do with Obamacare. He said it plainly, this is not a political issue, this is an issue about people dying because we don’t have a hospital near by.

Kudos to Senator Bernie Sanders and Representative Jeff Miller for collaborating – I mention their efforts in my previous post, but want to highlight how legislation used to and is supposed to work. Sanders is an Independent, who caucuses with Democrats and Miller is a Republican, yet they said failure to get some action to help our veterans is not acceptable. I hope it catches on as a trend. Again, as you vote this fall, if a candidate advocates strident ideology at the expense of collaboration, a “my way or the highway view,” show them the highway.

Treat others like you want to be treated, especially refugee children – America has had an immigration problem for a while, but legislators would prefer not to act, even though there are votes today in the House to pass the bi-partisan Senate bill passed last year. They also complain about securing the border, yet won’t fund filling open border patrol positions. Irrespective of this, people should not punish children, with some screaming at them, for our own failures. A recent Religion Polling survey noted that 75% of Americans want us to take in these children. We have already made this a political chess game. Let’s stop making it a game and show some stewardship and heart. My friend George Dowdell notes in his blog* about the concept of being a Red Letter Christian, meaning Christians should follow the words that Jesus spoke. So, WWJD?

Same-sex marriage train continues down the track – 19 states now allow same-sex marriage and fifteen more have ruled in favor, but are awaiting the appeals process. The Fourth Circuit US Court of Appeals has ruled in favor of same-sex marriage over the Virginia case, but their jurisdiction includes South and North Carolina. The Attorney General in NC said after the ruling this week, that he will no longer fight the current court cases, since the appellate court has spoken. I said a few posts ago, this train has left the station and eventually all states will allow same-sex marriage, as to do otherwise is discriminatory and unconstitutional. So, I repeat the question I asked then, if you are against same-sex marriage, where do you want to spend your time?

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There are many other topics worth talking about. I would love to hear your thoughts on these and other topics. Thanks, in advance, for your comments. Note, you can check out George Dowdell’s terrific post on Red Letter Christians with this link: http://georgedowdell.org/2014/07/28/take-seriously-what-jesus-said/#more-3033

 

Tuesday’s gone with the wind – a few odds and ends for this Tuesday

As a tribute to the great southern rock band, Lynyrd Skynyrd, I will use a chorus line of one of my favorite songs of theirs, to highlight a few odds and ends this Tuesday – “Tuesday’s Gone.” If you don’t know the song, give it a listen. You may also like “Call Me the Breeze” and “Simple Man” as well by the band. But, before Tuesday’s gone with the wind, here you go.

Economic recovery continues, but the recovery is continually challenged by people not spending. Wal-Mart announced a 5th consecutive quarter of negative same store results, year over year. They cite dampened wages as the culprit. When you have a heavy sales economy, people need to make a decent wage rate or they do what every else does, spend less. In this ongoing debate about minimum wage increase, this is a key outcome by not getting more money into people’s hands. By the way, you can trace the desperate nature of the retailer, car dealer or college, etc  in direct proportion to their eagerness to sell you something. I have had “final offers” made to me over and over again – but you said it was final three times ago.

Moral Monday’s in North Carolina have started up again, but the issues remain the same. They did help get more notice on the poor teacher pay plight which came to a head last year by limits and changes made by our conservative General Assembly. They have promised to do something this session and they need to or opportunity will be lost. The other issues remain – expand Medicaid to those in need, repeal the voter restrictive Voter ID Law which has been ruled unconstitutional in four other states and is on trial right now here, eliminate the severity of the unemployment benefit cuts which are highly punitive, and avoid fracking in our state. I attended my second Moral Monday yesterday and witnessed a diverse group of a couple of thousands people including doctors, teachers, professors, ministers and students. Their voice needs to be heard and heeded.

Failing to remember history, even recent history, can blind your reasoning, especially when people are adamantly against something they were for a few years ago. Former Senator Jim DeMint is adamantly against Obamacare, which is strange because it was patterned after Romneycare which he strongly advocated in writing, TV appearances and campaign speeches for Romney, as something we should do for the whole country. He particularly liked the mandate, as it shows personal responsibility, which he hates today. Newt Gingrich went on TV with Nancy Pelosi to show a united front that global warming was real and man-influenced and we need to do something about it. Newt noted he was wrong before to say it was a hoax. This change was in 2006. Then he ran for President in 2012 and he said he was wrong to say he was wrong. In this cases, two wrongs do not make a right. The make a wrong a wrong.

Finally, our friend Karl Rove won’t stop making a scandal out of nothing. This time Hillary Clinton is the target. Instead, why don’t we talk about a real scandal and ask Rove why his subordinate Scooter Libby went to jail. The greater question is why did not Rove who admitted later that he knew the same information that Libby did. Libby outed a CIA operative (Valerie Plame) in the press to discredit her husband who was a former Middle East ambassador that took issue with the Bush White House misusing his information inappropriately as evidence of Weapons of Mass Destruction as a reason to invade Iraq. The ambassador’s report said for the trail he looked into, there was no evidence, yet the White House said he did find something. Please feel free to Google various combinations of Karl Rove, Scooter Libby and Valerie Plame. My problem with this, is over 4,000 US soldiers (and countless civilians) died because of making up the WMD reason on false or unverified intelligence. That is a scandal.

Speaking of trails, happy trails to you on this Tuesday. Have a great week. I would love to hear your feedback.

 

Obamacare – a few reminders and successful anecdote

As I mentioned in earlier posts, Obamacare, while imperfect, complex and rolled out poorly, moves the ball forward in a major way to address our uninsured problem in the US. The website difficulties are being fixed, but it is important to remember a few things. Early implemented parts of the law have already extended coverage to 3 million young adults, eliminated the denial of coverage for pre-existing conditions on children (adults will get this on January 1,2014), eliminated lifetime maximum benefit limits, improved prescription drug benefits for seniors, restricted the profit margin on insurance premiums leading to policyholder rebates the last two summers to name a few key changes thus far. 

This law, which is largely a GOP idea, has been fought every step of the way with some GOP led states like my own in North Carolina not expanding Medicaid and offering state exchanges, both of which have led to increased premiums in the North Carolina version of the federal exchange markets and the former harming our impoverished citizens and state economy. For those who lost coverage like me (this is not news), if you make less than $111,000 as a family of five, e.g. (it varies by family size), you will also benefit from a subsidy on the exchange which will decrease your net premium. Note, a key reason for higher premiums for some is the elimination of the pre-existing limitation on coverage.

Enough about that, let’s use a real example, as this will be where the rubber hits the road. As noted above, my family is losing coverage under the individual market, but this is not a surprise, because my new insurance company told me this would happen when I signed up in May. I should add one of my adult children is losing coverage as well because we had to get a high risk pool policy, as he was denied by the insurance company because of a pre-existing condition. This denial will not happen under the new law, as noted above, which is a huge selling point.

So, I knew that our coverages would cease on December 31 and was waiting for the federal exchange options to be offered. With the new pricing structure to recognize the better benefits, the elimination of the pre-existing condition limitation, health care inflation and the impact of my state not expanding Medicaid which increased the cost in NC, because of my age I was one of the people looking at a premium increase for a slightly worse coverage plan without the subsidy. So, I shopped on the exchanges and here is what I can do, without a subsidy:

Keep slightly worse coverage levels with my current provider and $200 per month higher cost than both plans we have now for my son and everyone else;

-Obtain a similar plan through another insurance company with $55 per month less cost than we pay now;

– Obtain better coverage through another insurance company for about $160 per month more than my current plan, but less than the one offered by them above.

All of our doctors are in both networks, so that is not an issue, but this is very important in people’s decision-making. We will actually be doing the third option due to the better family coverage, although the second choice was tempting.

Now, again this is without the subsidy. So, with the subsidies shoppers will be seeing even lesser premiums than what is indicated above.  So, a few takeaways. If your coverage is ceased, don’t panic and look at the options that are available. If your family income is beneath 4 x the poverty limit ($111,000 for a family of five, $94,000 for a family of four, e.g.) then you will get an additional price break.

But, also note the following. If your state did not expand Medicaid, the cost of plans under the exchanges will be higher. If your state did not push a state based exchange, the competition is likely to be among fewer insurance companies, so the exchange cost options will tend to be higher. Obama deserves all the criticism he is getting on the poor rollout of the website and not being painstakingly thorough on what was going to happen. Yet, the GOP machinations are driving costs up as well with these two issues and not working to make this complex law better since election last fall, choosing to not support the education efforts and voting to repeal it over 40 times. I have been a broken record on this issue even before the election – make it better, not stand in its way.

People need to give the new law a chance and look at the options available. States that did not expand Medicaid need to strongly rethink this, as they are harming people and their state economies, so say the Rand Corporation and Kaiser Foundation. What was less noticed with the numbers announcement on exchange enrolments this week, was that 390,000 people have signed up for the Medicaid expansion in October.

But, all of this will be compromised if Obama’s team does not keep improving the website.

A Pretty Sad Group of People

Through the lens of this fiscally conservative, socially progressive Independent voter, as low as the Republican led US Congress has been ranked, there is a legislative body that dwarfs them in terms of poor legislative activity. While the US Congress has been favored less than a “colonoscopy” per Senator John McCain, the Republican led General Assembly of the State of North Carolina truly takes the cake. The key difference is both chambers of the General Assembly plus the Governor are all Republican, so my fellow citizens get to witness up close what happens when you have an unfettered body passing legislation that is not only contrary economically to what is needed, but stomps on opportunity and rights of others who are disenfranchised.

As a 54 year-old former Republican, I have never been so embarrassed and disappointed by a governing body of people. But, don’t take my word for it. They have been ranked low in formal polls with approval ratings beneath 40%. In an informal poll by the online Business Journal magazine, which tends to be a more conservative cross-section of people, the General Assembly has been given a D or F grade 55% of the time. Also, the Moral Monday crowds which have been protesting every Monday since the first of May, have grown in number and the arrests have increased to close to a 1,000 people. There would have likely been more, but the authorities are weary from arresting ministers, professors, teachers, doctors of all races and ethnicities. The national attention that the Moral Monday protestors have been given at the expense of this legislature is appropriate.

The legislature is following the GOP playbook that is being used by many GOP led states. Our Governor, who initially said the Moral Monday protestors were predominantly from out-of-state (a random survey said 97% were from in state), has had no qualms about having Grover Norquist, the de facto leader of the GOP, fly in to NC on numerous occasions. Note, he was not boarding a plane from a NC city to fly here. Yet, the citizens in this state apparently do not matter in this lobbyist-fueled legislature, which is prima facie evidence of what can happen with unfettered access to decision-making. Well, what have some of those decisions been?

– Significant reduction to unemployment benefits – NC is the only state to reduce long term unemployment benefits so much that they lost Federal long term unemployment benefit funding. This was done in addition to cutting regular benefits by 1/3. Cuts were needed, but this was well beyond the call of duty and will harm people, as well as the economy with $780 million flowing out of the economy the rest of this year alone.

– Not expanding Medicaid benefits under Obamacare – I have written several posts on this failure to act. This will harm 500,000 people and forego bringing billions of dollar to the state that would help the healthcare economy where rural hospitals are suffering as they chase dollars to pay for services. The Rand institute is the latest group to say expanding Medicaid should be a no brainer for a state.

– Reducing funding for education – Teacher pay in NC ranks 46th in the country. So, the solution was to provide very little for raises, cut teacher assistants, cut tenure, cut extra pay for Masters’ degrees and install a voucher program for going to private schools. NC is attractive to industry because of its innovation and education. We have just fallen from 4th most attractive in 2012 to 12th best in 2013. By my math, that is not progress.

– Reducing taxes that benefit the wealthiest – Estate tax is gone, plus the upper end will enjoy the largest of tax cuts. This is called a job creating law, yet trickle down economics has been shown by numerous studies to fail in creating jobs, the most recent of which was by the Congressional Research Office last fall that was buried by Senator McConnell before the election. A recent informal poll by the Business Journal shows its more conservative readers judge this tax change as a positive by only 44% to a negative view of 43%, the rest undecided. Note, this is a tax cut, mind you these readers are not supporting overwhelmingly.

– Funding for environmental protection continues to get cut and oversight committees either disbanded or replaced by business friendly members. The NC Biofuels group that I touted only a few weeks ago for creating a new source of ethanol with reed grasses, will have to shut its doors. We are investigating ways to allow fracking and it took a lot of effort that showed even conservative legislators to not derail an admired law put in place in 2007 to require utilities to provide 15% of their power by alternative energy (or be responsible for the perpetuation if in another state) by 2021. This repeal effort was fortunately defeated by some saner heads.

– The General Assembly has just passed a restrictive abortion rights bill that copy cats other states’ laws like that which was signed in Texas after the famous filibuster. They are about to pass concealed gun laws which will allow guns in restaurants and bars with a permit and alow them on college campuses, if locked in a car. Plus, some of the licensing is being changed over the objection of law enforcement, which is a group you would not typically want to ignore on crime issues. And, they are about to pass a Voter ID law which will reduce early voting, making it harder for college students to vote, eliminate same day registration and require photo IDs. As I have noted, the problem in our country is not enough people voting, not voter fraud, yet this law’s unstated purpose is to make it harder for people to vote and impact typically non-Republican voters more.

– If that were not enough, the state legislature initiated a spitting contest with the City of Charlotte over a city run airport that has been well run by the state’s own admission. Back in February, the legislature proposed a bill to yank control from the City and place it with a regional authority. This was without previous discussion with the City. Whether this is a good idea or not, it was extremely poor form to pose this without detailed conversation with stakeholders before unleashing the news. As of this writing the City of Charlotte has an injunction against the state to cease and desist. Note, this is after the state started down the path of yanking the control over water and sewage resources from the City of Asheville. I believe this is being decided in the courts as well.

My friend Amaya who blogs on www.thebrabblerabble,wordpress.com from another part of our state has written several similar posts. We both are pulling our hair out over this sad group of people. The litany of changes that will harm people, harm the economy, harm the environment, increase gun deaths and make it easier to win elections just boggles the mind. The last point about the airport and water fights with two of its cities show lack of good faith negotiation. These may be the right courses of action to take, but the process to get there showed that the General Assembly has not been very trustworthy. Maybe that is the best way to leave this. They have breached our trust on almost every front. They have been more concerned with the business interests of wealthy donors than its own citizens. The unfortunate part is with the gerrymandered districts from last year, we are likely stuck with this untrustworthy lot. And, that leaves the NC citizens with being sad for this body’s actions.