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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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The Struggle for Coal Miners’ Health Care and Pension Benefits Continues

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Coal miner Scottie Stinson, left, talks with foreman Scott Tiller outside a mine in Welch, W.Va., on May 12, 2016, as he prepares to enter a mine 40 inches high. Photo: David Goldman/AP Photo

Coal mining continues to be one of the most hazardous professions in our society. Even today, while the number of large-scale mining disasters and the number of deaths have certainly declined, coal miners continue to face a work environment that is inherently toxic and unhealthy. Coal miners who survive the mines walk away from their profession with significant health impairments and shorter life expectancies than most other Americans.

Yet for centuries, miners have braved dangers for the promise of better lives for their families. And since 1946 they have been supported by a compact between miners, owners and the federal government, that made health care and pensions an integral part of the profession in this country.

However, structural changes in the U.S. economy have strained, if not unraveled, this compact. And mine owners have consistently sought to shed their obligations towards miners and their families. Most recently, a judge allowed the bankrupt Westmoreland Coal Company to abandon its promise of paying for the health care of retired union workers as well as its union contracts. The company announced March 4, 2019 that a bankruptcy court has approved the sale of many of its assets to creditors and that business will “continue operating in the normal course.”

Except that it won’t for coal miners, of course, who will lose many of their benefits even as creditors at least get some of the company’s assets. And Westmoreland is hardly the only mining company eagerly reneging on its decades-old promises.

Coal miners have literally provided the fuel for the unprecedented industrialization of this country. Living in West Virginia and having written about the plight of coal workers’ health care as a public policy scholar, I believe the way forward involves the nation honoring its commitment to past and current miners. Yet, it also involves an honest acknowledgment that nation’s energy mix of the future will likely feature a diminished role for coal.

The changing fortunes of the coal industry

Coal miners about to descend into a mine in Maidsville, W.Va. in 1938. Photo: Everett Historical/Shutterstock.com

At the heart of the current situation is an agreement between the federal government and the United Coal Miners of America dating from 1946. Faced with a series of strikes across different industries after World War II, President Truman, in line with a long line of federal interventions in the coal industry, took control over the nation’s coal mines in order to keep them operating. The conflict was ultimately settled by the Krug-Lewis Agreement of 1946 which, among other things, established health care and pension funds for union miners.

For several decades, with a large number of union miners contributing, the health care and pension trust funds were sufficiently funded in general. However, over time both trust funds started to incur structural deficits for a variety of reasons.

For one, employment in the coal industry has been shrinking steadily over the past few decades, from more than 850,000 in the 1920s to just over 50,000 today. Employment reductions have been driven by efficiency gains, mechanization, a shift toward surface mining, and lower demand.

Moreover, of those miners remaining, a vast majority are not union members. As a result, there are only a few thousand union coal miners left to pay into these funds, while roughly 12 times as many are currently drawing health care and pension benefits.

The Great Recession aggravated the situation. Faced with mounting obligation and declining markets, some of the nation’s largest coal companies declared bankruptcy. This allowed them to shed their obligations to their former employees. The situation has shown few signs of abatement under the Trump administration.

As result, both health care and pension benefits are no longer financially sustainable, potentially affecting more than 100,000 retired miners and their families.

Was there or was there not a federal guarantee?

There is a debate about the nature of the original compact from 1946. The issue centers around the question whether the federal government made a permanent commitment to coal miners and their families. This is the position of coal miners and the United Mine Workers of America. Ultimately, this would entail the federal government serving as a payer of last resort should coal companies and unions be unable to sustain their financial commitment.

Others, like the conservative think tank The Heritage Foundation, have argued that the intervention by the federal government was merely temporary. Moreover, they argue that the UMWA has repeatedly violated the agreement and pushed for changes that accelerated the current funding crisis.

Unquestionably, the issue is complex. However, to my eye the evidence seems to favor the former interpretation, as the agreement was repeatedly reaffirmed by the federal government. This occurred most prominently through the legislation in 1996 and 2006.

As the Dole Commission, appointed under President Bush in 1989 to evaluate coal miners’ benefits, put it: “The UMWA Health and Retirement Funds is as much a creature of government as it is of collective bargaining … In a way, the original Krug-Lewis agreement predisposed, if not predetermined, the system that evolved.”

American Miners Act of 2019

The structural imbalances of the UMWA trust funds described above have inevitably led to a number of periodic crises in which pension and health care benefits for miners came under immediate threat of running out. So far, Congress has been able to patch together mostly temporary solutions without comprehensively addressing the problems in their entirety.

Earlier this year, Sen. Joe Manchin, a Democrat from West Virginia, introduced the American Miners Act of 2019 to shore up pension and health care benefits. The act as introduced also seeks to preserve the Black Lung Disability Trust Fund, providing medical and pension benefits to miners suffering from pneumoconiosis. This fund is also teetering on financial insolvency if scheduled cuts to the federal excise tax on coal are implemented.

If Congress fails to act, trust funds will ultimately run out of funds, with dire benefits for miners and their families. For one, miners would lose their small pensions, which currently only average US$560 per month. Miners would also need to seek alternative sources of health coverage, or go without. Government would then be on the hook for tens of millions of dollars for those miners qualifying for Medicaid, Medicare or ACA marketplace coverage. Equally crucial, the demise of the historically underfunded Black Lung Disability Trust Fund paying for pensions and medical expenses would be devastating.

Moving forward

Child coal worker Lewis Hine pictured in 1908. Photo: Everett Historical/Shutterstock.com

After the most recent midterm elections, a group of Democratic lawmakers in Washington, D.C., has begun to push energetically for a Green New Deal. While details remain unclear, it is based on a turn away from fossil fuel energy. Unquestionably, we should acknowledge the significant externalities inherent in coal mining and coal-based power production. These affect not only miners but their entire communities and society at large through water and air pollution as well as global climate change.

Given the vast negative effects of coal, it seems prudent to transition to healthier sources of energy production. Yet in this process, we should not forget about coal miners and their families who have brought us to where we are today. The bipartisan support for the American Miners Act of 2019 and similar bills in the past in the often-polarized U.S. Congress is indicative of this recognition. Republican leadership in Congress should end their opposition to a permanent fix.

I believe that any program moving the nation toward greener energy sources must include a lasting solution for coal miners, their families and their communities. This includes both guaranteeing long-term funding for pension, health care and medical programs as well as transitional programs to help them adapt to an economy with a smaller role for coal mining.

Simon F. Haeder, Assistant Professor of Political Science, West Virginia University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Rural People With Disabilities are Still Struggling to Recover from the Recession

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After the devastating losses of the Great Recession, the U.S. has enjoyed one of the longest expansions in its recorded history. For nearly 100 straight months, the U.S. economy has added jobs.

But not all groups have shared equally in the recovery. African-Americans and people in rural communities have been particularly slow to recover, compared to their white and urban peers.

Our team at the University of Montana’s Research and Training Center on Disability in Rural Communities published a new analysis on Jan. 10. Our research shows that people with disabilities, particularly those in rural areas, have also experienced a longer, deeper recession and a much slower recovery.

In December, the U.S. Census released new American Community Survey data, aggregating data from the years 2013 to 2017, for public use. Comparing these new data with summary data from 2008 to 2012 gave us the opportunity to see how employment rates have changed over time for rural people with disabilities in the context of changing economic conditions. We considered people across disability type, including sensory, physical and mental disabilities.

For the U.S. as a whole, rates of employment increased across those two five-year study periods for people with and without disabilities. However, people without disabilities increased by 1.7 percentage points, while those with disabilities increased by just 0.8.

What’s more, people with disabilities are already much less employed than people without disabilities. We found that this difference is widening over time.

When it came to looking at rural and urban areas, the results from our analysis were bleak. We define rural and urban following the Office of Management and Budget’s metropolitan classification. Urban counties are defined as being part of a metropolitan area of 50,000 or more people. Rural counties are defined as micropolitan – where the largest town has 10,000 to 49,999 people – or non-core, if they only have towns of less than 10,000 people.

While urban counties reveal employment gains across the board, rural counties experienced significant declines in employment for people with disabilities. Between each five-year period in metropolitan counties, the most urban areas, employment for people with disabilities increased by 1.01 percentage points. However, rates decreased in rural counties.

Rates varied significantly for different parts of the country. While people without disabilities experienced positive rate changes across nearly all U.S. Census divisions, people with disabilities living in rural counties did not.

In fact, employment decreased for rural people with disabilities in over half of the U.S. divisions, with rates in the most rural counties dropping by more than 2 percentage points in the New England, West South Central, Mountain and Pacific divisions.

These results clearly indicate that people with disabilities in rural areas are being left behind. Rural people with disabilities already experience high poverty rates, less access to health care and specialty services, and other barriers that prevent them from participating in their communities. Depressed employment rates can have dire consequences for this group.

The Conversation

These lower rates lead to less access to health insurance, retirement benefits and other financial resources, which all threaten to further marginalize people with disabilities in rural communities.

Lillie Greiman, Project Director, RTC: Rural, The University of Montana; Andrew Myers, Project Director, RTC: Rural, The University of Montana; Bryce Ward, Research Associate, The University of Montana, and Catherine Ipsen, Principal Investigator, RTC:Rural, The University of Montana

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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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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