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Appalachia's health care story

Appalachia Can’t Close the Health Disparity Gap Until it Fixes its Hospitals

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Appalachia is falling behind the rest of the United States in key health metrics. Financial instability in the region’s health care industry, a devastating opioid crisis that still is unfolding, and ongoing socioeconomic challenges mean that the disparity will likely get worse before it gets better.

A study published this week in the journal Health Affairs found that health-outcome gaps between those in Appalachia and the national average have increased since the early 1990s, with infant mortality 16 percent higher in Appalachia from 2009 to 2013, and life expectancy increasing from 0.6 years below the national average from 1990 to 1992 to 2.4 years from 2009 to 2013.

The study blames the usual mix of personal health behaviors— smoking, drug abuse and obesity—but also financial problems in the network of hospitals, clinics and other facilities that deliver healthcare to rural areas. Economic, social and cultural factors are converging to make it more difficult to treat Appalachia’s most vulnerable populations, driving a  growing disparity between this region and the rest of the nation.

Last month, West Virginia’s third-largest private employer announced significant cuts. Two health systems that serve a broad range of patients in Appalachian Kentucky, North Carolina, Tennessee and Virginia are planning to merge in September, prompting concerns that a monopoly may result in higher prices and fewer services.

Those challenges—along with broader ones such as availability of higher education, social services and economic development—mean that the disparity in infant mortality and life expectancy between Appalachia and the rest of the country will likely continue into the future, said Gopal Singh, a senior health equity adviser at the federal Health Resources and Services Administration and a co-author of the study.

“I would not expect patterns or trends to change that much,” Singh said. “For example, drug overdoses played only a 6.3 percent role in terms of contribution to a decrease in life expectancy. That percentage will go up. Drug overdoses will become a bigger factor in driving disparities.”

The factors that can be attributed to unhealthy behavior, such as drug use and obesity, can’t be addressed without a robust healthcare system. Other factors, such as car wrecks and population trends of  younger, healthier people moving out of the region, are also linked to more complex challenges that will take much more to address than a commitment to give up cigarettes or lose weight.

Given the gaps in socioeconomic conditions between Appalachia and other parts of the U.S., the study says solutions would require “a new commitment to investment, at various levels of government, in human and physical capital; infrastructure developments, particularly in higher education; and increased access to high-quality affordable health care.”

A “new commitment to investment” looks unlikely, however, both at the state and federal levels. West Virginia’s budget, for example, cuts higher education, and President Donald Trump’s proposed national budget significantly slashes rural investment. The Affordable Care Act wasn’t implemented until after the study period, but it too may have a muted effect, given that seven out of 13 Appalachian states chose not to expand Medicaid.

While Appalachia is falling behind the rest of the United States in terms of infant mortality and life expectancy, many healthcare providers and facilities that could play a role in erasing that disparity are struggling financially, making treating patients in the region more challenging.

When Charleston Area Medical Center president and CEO Dave Ramsey said the non-profit was on track to lose $40 million and would have to cut programs and 300 positions by the end of the year, he cited West Virginia’s declining economy, rising drug prices, and the nursing shortage for the financial challenges. He said that CAMC sees a high number of people on government insurance like PEIA, Medicare and Medicaid, which reimburse below the cost of treatment. The CAMC program cuts included a pharmacy, pulmonary rehabilitation, a childcare facility and a heart disease unit that emphasized lifestyle changes.

Two large health systems that serve eastern Tennessee and southwest Virginia are planning a merger that would sidestep federal oversight through the use of a loophole in the laws of the two states. Officials from Mountain States Health Alliance and Wellmont Health System, the two parties to the proposed merger, say the plan would cut redundancies and provide better quality of care.

“There is a huge amount of linkage between the proposed merger and health outcomes and health disparities in our corner of Appalachia,” said Teresa Hicks, spokeswoman for Mountain States. “Those health outcomes and health disparities are exactly what we are hoping to be able to redress. If we have to keep directing resources toward duplicative costs dictated by competition, we can’t put those resources into things that are going to make an impact on population health.”

But some medical professionals, as well as officials at the Federal Trade Commission, are wary of what may be a monopolization that could allow price hikes and cuts to service.

One of the partners in the proposed merger, Mountain States, has been working with a multi-member authority in Lee County, located at the southwest tip of Virginia, to reopen a community hospital that was closed in 2013. Mountain States told the authority it would take $4 million annually to subsidize the hospital. The county can’t afford that, so instead the authority is working with Americore Health on a new plan that would transform the building from a traditional community hospital to a smaller facility subsidized by other health care companies located in the same building. 

The latest version of the plan, said Ronnie Montgomery, vice chairman of the Lee County Hospital Authority, would involve running the facility as a critical-access hospital with up to 25 beds, where patients can stay for up to 96 hours before they go home or are transferred to another facility.

“Lee County starts just a mile or so west of Big Stone Gap and goes for 70 miles down to Cumberland Gap,” Montgomery said. “It’s a big geographical county. Taking patients across the county to Big Stone Gap is putting stress on the emergency vehicles.”

Appalachia’s devastating opioid crisis makes the disparities between health in Appalachia and the rest of the U.S. more glaring. The Health Affairs study showed drug overdoses accounted for 6 percent of the life expectancy gap between 2009 and 2013. The opioid crisis has only become more severe since 2013, so its full impact has yet to be studied. 

“We’re a poor county, one of the poorest in the state,” Montgomery said. “We’ve got a lot of people on Medicaid, a lot on Medicare, and some people don’t have anything. This is the third year we have not had an active coal mine working in Lee County. We used to grow a lot of burley tobacco, and that’s gone. We’ve got a big drug opioid problem.”

Lee County’s problems are a microcosm of Appalachia’s. Singh said that many poorer, more rural areas lack access to family doctors, and improving its health gap will require a multifaceted response. “In terms personal choice, yes, you can reduce inequalities in those areas through reductions in smoking and obesity. Access to care is more of a systemic level factor that drives up some of the differences you see in cost and access disparities.”

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Amid Black Lung Surge, Kentucky Changes Benefits Process for Miners

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William McCool is a 64-year-old former coal miner from Letcher County, Kentucky, with an advanced form of black lung disease. Health experts say the condition is entirely preventable with dust control measures in mines. But today, more miners in Appalachia are being diagnosed with severe black lung than ever before.

“I’ve worked all my life, I’ve seen a lot of coal go down the beltline,” McCool said, pausing to catch his breath between phrases. “Somebody’s made money, but the cheapest thing the company’s got is the worker. Everything else costs them all kinds of money but they can get workers.”

Black lung is a disabling condition caused by the work environment, so miners like McCool are eligible for benefits. The state and federal government both have systems that allow miners to make a claim against their employer for medical expenses and a small stipend. Getting approved can be a long process.

Mackie Branham views a lung X-ray with Dr. James Brandon Crum, who was among the first physicians to note an uptick in black lung diagnoses.
Photo credit Howard Berkes/NPR

“State black lung compensation took about 2 years, then probably 5 or 6 years I got my federal black lung,” he said.

Some miners have waited over a decade for a decision on federal black lung benefits. Many die before they receive them. State benefits have traditionally been quicker. But black lung attorney Evan Smith at the Appalachian Citizens’ Law Center said that’s been changing.

“The idea was that these federal laws were going to be a national baseline, then many states would grant additional protections to treat their workers better than was the minimum required,” Smith said. “What’s ended up happening, especially in recent years, is states have ended up having a race to the bottom.”

Amid a historic surge in black lung cases in Appalachia, the Kentucky legislature this week approved sweeping changes to the state’s workers’ compensation programs, including changes to the process miners must use to qualify for black lung benefits. Miners and advocates warn the changes may shift the balance in favor of coal companies, and make it harder for those with black lung to get benefits.

Ruling Out Radiologists

Phillip Wheeler is an attorney in Pikeville, Kentucky, who represents clients seeking state black lung benefits. Wheeler has been very critical of Kentucky’s workers’ compensation reform bill, known as House Bill 2.

“On its face the amendments in relation to black lung law may seem very benign,” Wheeler said. “But they have a very nefarious purpose.”

Wheeler and other critics say the bill will make it harder for sick miners to get state benefits by restricting the pool of doctors who can determine a miner’s eligibility for state benefits and tilt the process in favor of coal companies.

“I do believe the coal industry is writing this bill to exclude certain doctors that they don’t like,” Wheeler explained. “Essentially it’ll be limited to approximately five doctors in Kentucky.”

Among those excluded is radiologist James Brandon Crum. He’s the doctor who first alerted federal researchers to the spike in cases of severe black lung, which has since been confirmed as the largest cluster of the disease ever documented.

Clinicians who are certified to read chest X-rays for work-related diseases like black lung are known as B-readers. Among B-readers, radiologists like Crum are generally considered to be the most qualified doctors, since the entirety of their training centers on reading X-rays and other diagnostic images. Yet the Kentucky legislation would bar radiologists from providing diagnoses for state benefits claims. Instead, the legislation requires that B-readers also be certified pulmonologists in order to diagnose patients for the state black lung benefits system.

Crum said the move to push radiologists out of the process caught him by surprise.

“Throughout the United States I know of nowhere where radiologists are taken completely out of the evaluation for potential black lung disease,” he said. “That’s what we’re primarily trained in.”

Dr. Kathleen DePonte was also surprised. DePonte is a board-certified diagnostic radiologist and B reader in Norton, Virginia, with more than 20 years of experience in practice.

“It strikes me as odd that radiologists are excluded in part of the process,” she said. “It is curious to me that the legislators feel that the pulmonologist is more qualified to interpret a chest radiograph than a radiologist is. This is very much what radiologists do.”

William McCool said he thinks the change in eligible doctors would have made his claims process much more difficult.

“It’d be pretty much impossible,” McCool said. “I’ve had lung doctors tell me I don’t have black lung.”

Debate in Frankfort

In debate on the bill, Letcher County Democratic Representative Angie Hatton warned the measure could hurt miners.

“When we’re finding increased amounts of this illness it seems to me that this is when they need us the most,” Hatton said. “Why are we making it tougher for them to prove their illness?”

Adam Koenig is a Republican from Kenton County, and the bill’s lead sponsor. He defended the changes as necessary to fix constitutional issues with the state’s existing system stemming from a 2011 state supreme court decision in a case known as Vision Mining. The court ruled the state system at that time was unconstitutional because miners faced tougher requirements than did people who contracted pneumoconiosis apart from mining.

“No one here is trying to deny anyone who does that work from getting their black lung claims,” Koenig said, “But the fact of the matter is the way we’re doing it now is not constitutional, so we’re trying to fix it.”

Phillip Wheeler, the black lung attorney, said he believes that the newly passed bill is itself unconstitutional. He plans to contest the legislation.

“If it’s anything like we expect it will operate, then you betcha we’re gonna file some challenges,” he said.

The bill awaits Governor Matt Bevin’s signature. Its provisions include a period of up to 6 months for implementation. Miners who file for benefits before then may still be able to use the current system.

This article was originally published on Ohio Valley Resource.

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In Rural WV, Sexual Assault Victims Face Unique Hurdles

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Each Thursday in Fayette County, West Virginia, Twanna Warner-Burton stands before a group of people gathered by WorkForce West Virginia, the state agency managing unemployment. But she’s not there to talk about jobs. As a rural advocate for sexual violence victims, Warner-Burton focuses on introducing herself to the group  and handing out brochures detailing the resources available to victims of rape and sexual assault in this rural community.

According to the National Sexual Violence Resource Center, one in five women and one in 71 men will be raped during their lives. In West Virginia, those numbers are one in six women and one in 21 men, according to a 2008 West Virginia Health Statistics Center report. Specific to West Virginia are the roadblocks and fears that can accompany reporting sexual violence in rural communities.

Warner-Burton is part of the state’s Rural Advocate Network, a group specially trained in assisting sexual violence victims in rural areas with everything from undergoing forensic exams to bringing rape cases to court. A large part of her job involves addressing the issues that can stand between a victim and his or her willingness to report the incident.

“As far as what I do, I’m pretty much there for the victim from start to finish,” she said.

While sexual assault survivors across the country face reporting challenges, including victim blaming and sometimes skeptical law enforcement questioning their claims, Nancy Hoffman of the West Virginia Foundation for Rape Information and Services, or WV FRIS, said victims in rural areas have an additional set of roadblocks to contend with.

In West Virginia, 38 percent of the population lives in rural communities, countryside areas dotted with small towns where everybody knows one another. Victims know not just the perpetrator of sexual violence, but their family and friends, too. And the rest of the community likely knows them both — law enforcement included.

“If they know you as the victim, chances are good that they know the perpetrator,” said Hoffman. “That becomes a factor in making the decision, ‘Do I want to report or get help here?’”

Victims wanting to keep the assault private face difficulty in finding a police department or hospital nearby in which they are unknown. This lack of anonymity deters victims from seeking both legal and medical help.

“You’re going to know somebody at the hospital if you go to get a rape kit,” said Warner-Burton. “If you’re going to get a protective order, you’re probably going to know the magistrate. The magistrate is going to know the (accused).”

Even the simple act of visiting the police station to report sexual violence can open the victim to scrutiny. In a small community, residents driving by might recognize the car parked outside the station. And when everyone knows everyone, residents can have difficulty wrapping their heads around the idea of their neighbors committing sexual crimes.

“There’s very much a resistance to wanting to acknowledge that sexual violence occurs in the community, because that means people that you know, that you love, that you see every single day are committing sexual violence,” said Johnanna Ganz, the Rural Projects Coordinator at the Sexual Violence Justice Institute in Minnesota, which conducts trainings in West Virginia.

While small, close-knit communities can offer a lot of good, they can make victims think twice before taking action.

Additionally, since both parties’ family and friends are familiar to one another, victims in rural areas often fear retaliation for speaking up about sexual assault.

Hoffman said victims question what kind of position making a report will put them and their families in, especially if the perpetrator is powerful or has prominent friends and family in town.

“The retaliation can be direct threats to the family,” Hoffman said. “Itf could impact [(the victim)] getting a job in the community, particularly if the offender is someone who’s well-known or well-liked.”

Outside of these fears, victims are often unsure of where they can find a specialized sexual assault nurse examiner, or SANE, for a forensic exam, especially if their community doesn’t have a hospital. Distance to athe nearest hospital, minimal cellular service and bad weather impedingstymieing travel on country roads can all compound this problem.

Hoffman said even if survivors overcome these challenges, they face a criminal justice system that is often unresponsive to sexual violence cases, leaving them to wonder whether it is in their best interest to report the crimes against them at all.

However, women like Hoffman and Warner-Burton focus on the solutions, of which they are many in West Virginia.

“Some of the most creative work I’ve seen … comes out of rural communities,” said Ganz.

For example, the Rural Advocate Network Warner-Burton is a part of began in 2007, serving seven rural counties throughout the state. The advocates meet quarterly, but Warner-Burton said they have 24/7 access to WV FRIS resources. They act as advocates and educators in the community, not just helping victims once sexual violence has occurred, but leading prevention programs, as well. An advocate might partner with a police officer onfor a high school assembly discussing sexual assault and rape before prom. 

The advocates create relationships with everyone from police officers, to judges, to nurses, to guidance counselors, to Head Start program leaders. Warner-Burton said based on theose relationships she has cultivated over the years, first responders and medical personnel in the community know to call her when they encounter a rape victim.

These advocates formare part of a broader sexual assault response team (SART) in the community, made up of law enforcement, nurses, detectives, and other stakeholders victims interact with during the reporting and investigating process.

Warner-Burton’s SART team encompasses 10 individuals.

“My team, we are very close,” she said. “Your whole main goal is to keep this team strong.”

FRIS invests significant effort in training these teams and other first responders through in-person trainings and online trainings.

“We are spending a heck of a lot of time training first responders and encouraging collaboration,” Hoffman said. “So they develop and share that victim-centered approach.”

Recognizing the difficulty nurses face in taking time off for the required 40-hour SANE training — especially in a rural hospital with a small staff — FRIS created a 24-hour online training course. Once nurses complete this course, they spend two days in a classroom to reach 40 hours.

“Everything in this line of work is baby steps.”

Along with developing more convenient training for nurses, West Virginia is making SANE services more accessible for victims. The state now requires that each county have a written plan dictating where services are available within the county and how victims can access those services. In May of 2017, the commission finished reviewing the plans and is currently sending feedback.

“We have many counties in our state that don’t have hospitals,” Hoffman said. “If a victim called a law enforcement officer and wanted an exam, there should be a very specific protocol of where that victim’s going to go, how they’re going to get there, how they’re going to get home after the exam, and that it’s done in a confidential manner.”

Through these programs and others like them, West Virginia is working to create an environment where rural residents feel comfortable and confident in reporting rape and sexual assault. These efforts involve the coordination of various moving pieces that all must come together just right. But, when the pieces fall into place and victims feel supported, it makes a difference.

“We have an increase in victims that come into our office,” Warner-Burton said. Still, she cautioned against mistaking progress for an absolute solution. “Everything in this line of work is baby steps.”

Miriam Finder Annenberg is a freelance journalist. She grew up in southwestern Pennsylvania and now lives in Chicago.

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This Annual Free Clinic has Become ‘Ground Zero’ for Parachute Journalists Writing about Healthcare in Appalachia

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Each summer a pop-up clinic in Wise County, Virginia providing free medical, dental and vision care attracts thousands of people from a multi-state region — along with journalists eager to write about the healthcare needs of poor people in Appalachia.

British philanthropist Stan Brock founded Remote Area Medical (RAM) in 1985 and has since enlisted more than 100,000 volunteers to deliver more than $112 million worth of free health care services to 700,000 individuals and 67,000 animals at mobile clinics around the country.

About 2,500 people were treated at this year’s clinic at the Wise County Fairgrounds. Brock said he was asked to bring the clinic there two decades ago, and it’s been held annually since.

The Wise County clinic is not the only one set in Appalachia, but it receives outsized attention for its location in the heart of Southwest Virginia coal country and its illumination of the challenges facing rural healthcare systems across the United States. Patients in need of care flock to the clinic from communities in Virginia, Kentucky, West Virginia and Tennessee.

Health systems in that region have been hard-pressed by declining revenue and over the last few years have pursued a merger that will could affect services for decades to come — but the potential merger probably likely be settled until September.

In the meantime, people start lining up the night before for a chance to get long-running medical issues resolved at the Wise RAM clinic.

“The thing about the Wise, Virginia phenomenon is that it’s outdoors on a fairground, which gives it a unique atmosphere,” said Brock. “When you read the coverage of all of these things — in every case, I think they talk about why should people in the world’s richest country be having their care in a chicken coop and horse barn? It’s the fact it’s out there in the middle of a field, and these people have to undergo the hardship of waiting outdoors — not even in the shade, often in the rain — that all adds to the drama.”

Those images, painted in prose and photographs, are beamed out to audiences around the world.

Journalists often focus on the people waiting in the parking lot. The New York Times story on the 2017 clinic started there, as did coverage from an Australian outlet. Others, such as Bristol’s WCYB, the Washington Post and the UK Daily Mail opened with scenes of patients describing their ailments to doctors and nurses. The Bristol Herald Courier and Roanoke Times both led with people receiving dental care — a popular scene that’s been used in years past by journalists as well.

The sheer size of the RAM clinic and the scope of suffering by those attending provides much of the lure for journalists wanting to put a face on the challenges facing the country’s healthcare system. The pain is real, and the clinic has grown over the course of multiple presidential administrations. In 2009, the first year of President Barack Obama’s administration, NPR and the Huffington Post were among the outlets covering the RAM clinic in Wise County. In 2013, filmmakers produced a documentary when the RAM clinic set up at Bristol Motor Speedway.  

This year, the political hook was two-fold: A new president, whom Brock said should have been visiting the Wise clinic, and a Virginia governor’s race with a doctor as candidate, who did visit.

The years of coverage of the Wise County RAM clinic feel like an overwhelming accumulation of untreated illness and proof of the gaps in the nation’s healthcare system. With Congress in session and the Senate majority pushing for a vote on repeal of the Affordable Care Act, neither the clinic nor the stories that accompany it will likely be going away anytime soon.

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