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Rural Divide

When a Degree Doesn’t Equal a ‘Good Job.’ Appalachian Youth Rethinking College



Heightened generational and cultural divides are increasingly apparent throughout Appalachia as rural students navigate the path to higher education. College has shifted from presenting a lure of opportunity to one of uncertainty and risk.

To tell community members in a small Appalachian town to pull themselves up by their bootstraps economically in an age when manual labor is becoming less and less crucial is to acknowledge that “good jobs” are disappearing—and often require a college degree. Meanwhile insisting college is the only path to economic opportunity runs the risk of invalidating the experience of generations of families working honest jobs back home.

Families face conflicting choices at the end of high school; Do we encourage our kids to stay, to help out however they can the way we have for generations — or do we send them away to learn new skills, running the risk they might not have a home to return to?

It’s not a matter of will. Rural high school students as a whole actually score better on the National Assessment of Educational Progress than their urban counterparts, and graduate from high school at a higher percentage than the national average, the U.S. Department of Education reports. Nonetheless, many high schools in ARC-designated economically distressed counties go to college at rates between 20 to 40 percent. That’s significantly lower than the 50 percent college-going rates that rural students as a whole hold nationwide, a figure that scores even lower still than the 60 percent rate of students across the U.S. as a whole.

Regardless, when low-income, first-generation college-going families can’t afford to send their kids far away, precarious financial situations can set families back more than they’re prepared to handle. As a result, many families don’t see college as an option. For those that do, college attendance still comes with a slew of social and economic problems.

Some government initiatives have been put in place to help students out of poverty. But what happens when going off to college actually complicates their personal, familial and community lives?

Franklin, a town in Eastern West Virginia with a population under 700, has one stoplight.

Neither of Jared Lathrop’s parents went to college. Of his 11 cousins, only he and his sister took the university route. Of those two, in line with her childhood dreams, his sister got married soon after leaving home, moved back to Franklin and got to work building a family.

Jared is still working on his third degree.

Starting even in middle school, Lathrop said his mother would remind him when he would struggle with homework, “You’ve got to get out of here, you’ve got to go to college, you’ve got to make something of yourself because I want the best for you.”

When he graduated high school in 2007, he immediately enrolled in West Virginia University’s journalism undergraduate program.

“Since I left Franklin almost 10 years ago, there has been a constant fear of failure that I have had for myself,” he said. “Not from anybody putting it on me, but the idea that I would fail at my job, or fail at grad school, and have to go home.”

He said throughout his life, his mother told him that if he didn’t get to college, he wouldn’t get to leave home.

But now, he doesn’t feel like he can come home just yet, even though he wants to.

“My family has told me to come home and reset, but all I could think of was failure,” he said. “Not because I don’t love my hometown, but because the job prospects are so low there that it just felt like rock bottom in a way.”

In 9th grade, Lathrop’s class unofficially divided itself into those who decided they were going to college, and those who were not. A large swath of his class wanted to work on the farms that they grew up on, Lathrop said. Teachers doled out available resources to those “chosen few” amongst the college-ready group: the ones with the grades, family background and financial security to actually follow through on the promise of college.

In 7th grade, he was connected with a program through Shepherd University (then-College) called Gateway, that provided him with the chance to see what a college campus was like. In high school, he was selected to receive aid through the U.S. Department of Education’s Upward Bound, which provides resources to first-generation college students based on financial need.

These kinds of programs aid students like these the most; those who just need an extra push towards their FAFSA application or one more school tour to solidify their future career trajectory.

Two-and-a-half degrees into her own education, Robin Nelson found herself making minimum wage at a hospital in Morgantown, West Virginia.

She too had been told throughout life to go to college as a chance to bring her family out of poverty; but nobody told her what to study, a lack of guidance she regrets to this day.

“You have to college, you have to college,” family and teachers said, “but what they should have said is ‘you have to get a degree in an industry that needs you,’” said Nelson.

“They sort of picked us,” she said about her high school experience. She was selected as a WVU McNair Scholar for her undergraduate studies at WVU, which is federally funded through the Department of Education to serve first-generation and income-eligible students. Nelson received extra attention from her guidance counselor in high school to be connected with the program.

“I was one of the ‘smarter kids,’ so I took more science and math,” she said of her high school preparations for college. “The others took vocational classes. All of those kids are now electricians and plumbers, coal miners. Those people make good money. I wish that’s what I could have done.”

In 2009, after an extra year in undergrad, she was awarded a double-bachelor’s’ degree in Criminology and Women’s Studies. Unsatisfied with her options, Nelson said she literally Googled “master’s degree, return on investment” to come to the idea of an MBA, despite the fact that she had never taken a business class in her life. Although she felt like she had to study twice as hard as her peers, she graduated with a 3.9 GPA, at the top of her class at WVU.

Now her minimum wage job comes with $55,000 in debt.

Her parents never helped with her tuition, insisting that the decision to leave was her choice, but they still expect her to move back to their thousand-person town of Marlinton, West Virginia.

At age 32, Nelson works now as a secretary at the university, but is actively seeking a position that uses her business degree. If she doesn’t find something soon, she’s determined to get her Ph.D, which she believes will afford her more selection in her career.

Nelson said that her current employer chose her because she was the most well-educated person to apply; they were surprised she took it.

The first weekend he came home during his freshman year, Lathrop ran into a fellow student from his class for the first time since leaving mere months prior.

“And he said ‘Oh look, it’s that kid who graduated and went off to college, he thinks he’s fancy now,’” Lathrop said. “And nothing had changed between us, and it was said in passing, but the impression was that he thought I was better than him. Income-based, we are the same.”

Away from home, Lathrop said the transition to campus life during his freshman year was one of the most eye-opening experiences.

“Morgantown isn’t the most ginormous city in America, but coming from a town of 700 people where we have one stoplight in the county, to sitting in a lecture hall with 300 students — it was almost a reinvention period of ‘who am I, who do I want to be, am I good enough?’” he said.

He was put on a floor with one person from high school, and 48 other students from places like New Jersey and New York, and heard about their experiences of growing up with 2,000 students.

“Meanwhile I can still name every single one of my classmates who I graduated with,” he said.

It gave him a weird sense of homesickness: rejected at school because of where he was from, but not allowed to return home without something to show for leaving. “Am I good enough for an education, or do I belong back home with everybody else?”

Lathrop didn’t go to his high school reunion this year. But he did go to a diner the last time he was home, the same one he always goes to, with the same waitresses who have worked there since he first ate there in high school. They ask what he’s up to lately, and when he talks about his academics, they say it “sounds like a lot,” and leave it at that.

State-level programs like those that Lathrop and Nelson used to help ease the financial burden put on families and encourage their children to get, and finish, college degrees are threatened under recent proposed budget cuts.

The Appalachian Regional Commission defaults to the findings of a study completed in the 1990’s that found major discrepancies between the Appalachian region of Ohio and the rest of the state in terms of college attendance and achievement. Parents who took part noted that the entire process of selecting a college, applying to the school and for financial assistance, and making the transition from high school to college was too complex to complete without outside assistance–especially for those who lacked the personal experience of this process themselves.

But part of the problem is that of majority cultural sentiment. As a whole, fewer rural white men are convinced than their suburban and urban counterparts that colleges and universities have a role in providing necessary skills, according to the Pew Research Center. And that’s not for nothing. The connection between educational attainment and economic development is becoming less and less relevant as automation puts many manual-labor jobs out of business in Appalachia.

Franklin has always been somewhat of a ghost town, he said, with most businesses closed by 8 p.m., and closed on weekends. Now, the community leaders who were in their 50’s and 60’s when he was there are dying off. There are dwindling resources for his high school classmates who stayed, limited job opportunities, and staple businesses shutting down.

Those who left Appalachia for school, with every intention to come back — Lathrop and Nelson both included — are finding fewer reasons to return.

While there are arguments to be made for increased attention on getting rural students to college, more focus must be placed on following these students through into the workforce. As the urban/rural divide has worsened over the years, the benefit of long-term, systemic aid has been recognized as a more sustainable method of maintaining a local workforce than simple in-school resources.

“In a small town this really isn’t the norm,” Nelson said of her own student debt. “People get married and stay there, and get on welfare…or whatever.”

Lovey Cooper (@loveycooper) is a contributing editor with 100 Days in Appalachia, and reports on the intersection of politics and culture. Her work appears in The Atlantic, Vice, Rewire News and Education Week.

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Rural Divide

New Report Cites Economic Woes, Addiction and Optimism in Appalachia



A view of Main Street in Moorefield, West Virginia. Photo: Famartin/Wikimedia Commons

Siblings Hannah and Hilary Heishman were born and raised in Moorefield, a town of some 2,500 in West Virginia’s eastern panhandle.

Hannah and her husband, Kris Jenkins, have built a life for themselves in Moorefield. They’re both veterans and volunteer for all manner of vet-related activities throughout Hardy County – barbecuing at fundraisers, helping out whenever and wherever they can.

Hilary, who now lives in New Jersey, regularly returns home. She was there last week, having dinner with her family, and, she recounts, “The police scanner was on. Because that’s normal, right?”

Hannah and Kris overhear that an ambulance is headed to the local VFW, a place the couple knows well. Hannah is an EMT and all at once, she and her husband jump up from the table, en route to assist.

Hilary tells the story not only for what it confirms about her family, but because, from her perspective, it underscores a truth about rural America at large – one substantiated in a newly released report.

Last week, the Robert Wood Johnson Foundation, National Public Radio and the Harvard T.H. Chan School of Public Health released “Life in Rural America,” reporting the results of a telephone survey of 1,320 adults living in rural communities throughout the country. Hilary Heishman is a senior program officer for the Robert Wood Johnson Foundation who assists with the foundation’s rural grant-making.

Its objective was to gain insight into rural Americans’ views on the economic and health issues challenging their communities. Those surveyed asserted that their most pressing concerns are jobs and the local economy and addiction.

This comes as no surprise to anyone familiar with life today in rural communities – certainly not to Heishman – but neither is she surprised by another significant finding of the report: Throughout rural America, optimism abides.

Rural Americans, the authors of the report write, are largely optimistic about the future, with a majority expressing faith in their community and lauding its virtues – foremost, a shared sense of just that: community.

This finding brought reassurance to Heishman. She was relieved, she said, to hear rural residents express “a lot more optimism and satisfaction with their lives” than is more customarily conveyed through “the stories that people choose to tell about rural America – and about Appalachia in particular.”

Certainly, rural America is, in many respects, reeling. Rural communities are staring down some grim truths.

A majority of those surveyed rate their local economy as only fair or poor. They’re concerned about their job prospects. One in three say they need to receive training or develop new skills in order to keep their job or find a better one. Interestingly, though, those without a college degree are more optimistic about solving major community problems than those with one.

Half of those surveyed say the cost of their family’s health care has caused a major financial problem within the last few years.

Drug misuse is of equal concern.

“In particular,” the authors of “Life in Rural America” write, “opioid addiction/abuse have had major impacts on the lives of rural Americans.” A majority state that opioid addiction is a serious problem in their community; about half say they personally know someone who has struggled with opioid addiction.

In rural Appalachia, drugs are of even greater concern than among rural residents as a whole. Four in 10 in the region consider them the most urgent issue facing their community.

Three out of four say that “the problem of people being addicted to opioids in their local community” is a serious one. Two-thirds say the issue has grown worse in the past five years.

Factor into this the findings of another Robert Wood Johnson study, conducted earlier this year, indicating that Appalachia has higher than average mortality rates in seven of the leading causes of death in the U.S., including addiction and suicide, and Appalachians’ concerns are well founded.

Yet, according to the “Life in Rural America” report, “Most rural adults say their lives have either turned out better than expected or about like they expected…and a majority think their children will be better off financially compared to themselves.”

They like where they live. The authors write that many of those interviewed say they feel attached to their community, identifying its intimacy, the virtues of life in a small town and being around good people as its greatest strengths.

“They’re glad to have the help of neighbors,” Heishman said.

Better public schools, new-skills training and long-term job growth, they acknowledge, is required. Outside help will be essential. Among those who cite the need for that assistance, a majority believe the government will play a primary role.

Another finding that echoes Heishman’s everyday experience, and encourages her, is that more rural residents under the age of 50 than above say they’re active in efforts to solve their community’s problems.

“It’s true,” Heishman said. “In just the last few years, we’ve started to see that trend. More and more people under 50 are stepping in to replace the older adults who had been running and planning everything forever.”

In sum, what Heishman hears in “Life in Rural America” sounds like home.

“I loved hearing this hopefulness and optimism that resonates with my actual experiences,” she said, because that optimism is “how you get through when things aren’t easy.”

“People are not giving up,” she attests. “They’re trying to find local solutions to their problems in lots of different ways. And when you have that, it leads to the kind of hope for the future that we saw in this poll.”

There in Hardy County, West Virginia, Heishman’s optimism is embodied in her sister. Four generations of the Heishman family have owned and operated the local newspaper, the Moorefield Examiner. Hannah – veteran, EMT, community volunteer – is today its associate publisher, maintaining a tradition and helping assure that the voice of a community is heard.

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School-Wide Free Nutrition Program Attracts Fewer Rural Schools



A McKinley Middle School student in West Virginia serves himself watermelon from the fresh fruit and salad bar available for National School Lunch Day. Photo: West Virginia Public Broadcasting

Rural schools are less likely to participate in district-wide free lunch and breakfast programs despite the fact that rural families typically have more economic need for the nutrition program, according to a recent analysis from U.S. Department of Agriculture’s Economic Research Service.

The study of the USDA Community Eligibility Program found that a third of eligible rural schools participated in the program, while 46 percent of eligible schools in urban areas did. The study also found that the Southeast had the highest percentage of eligible schools participating in the program.

USDA Economic Research Service calculations based on data from USDA, Food and Nutrition Service CEP election data

The Community Eligibility Program allows schools to qualify their students for free breakfast and lunch based on community characteristics rather than individual family applications. Schools in high-poverty areas may offer free breakfast and lunch for all enrolled students.

Alternatively, schools with slightly smaller proportion of low-income students may offer free meals to most students without having to process individual applications.

In the 2016-2017 school year, more than 20,000 high-needs schools with an enrollment of nearly 10 million students nationwide had provided free meals for students under the Community Eligibility Program.

The goal of the program is to increase the use of the nutrition program and reduce school administrative costs.

The report titled Characteristics of School Districts Offering Free School Meals to All Students Through the Community Eligibility Provision of the National School Lunch Program explored participation rates by district size and location.

The study authors speculate in some cases switching to CEP might increase demand for school meals in ways that put a strain on the district or a specific cafeteria. Also, districts might not be able to overcome the initial administrative hurdle of qualifying for CEP, even though it would save staff time in the long run.

CEP is a relatively new approach to school nutrition programs that followed the update of school meal standards in 2012.

Once the new standard was implemented, according to ERS, “schools in rural areas were more likely than other schools to report increases in student complaints, decreases in meal participation and higher costs due to lower meal volume.”

Rural schools also reported larger increases in the paid meal price due when the Healthy, Hunger-Free Kids Act was implemented during the Obama Administration. With higher prices for paid meals, fewer students would participate and the cost to deliver meals to free students would increase even further.

Report authors state that “rural districts may stand to benefit from the increase in school meal participation that often accompanies CEP adoption. Or, they may be less likely to participate in the CEP due to a lack of outreach or concerns related to the financial viability of the CEP given their meal costs.”

I think the report reinforces a lot of the important aspects of Community Eligibility, the need for growth, the room for growth. It lays out the opportunities and challenges we’ve seen from the program,” said Crystal Weedall FitzSimons, director of School and Out-of-School Time Programs for the Food Research and Action Center.

FitzSimons said certain categories of low-income students are automatically eligible for free school meals if they meet certain conditions. These include students who are homeless, part of migrant families, in foster care, living in households that participate in the Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance to Needy Families (TANF), or part of the tribal Food Distribution Program.

“That’s a small subset, usually, of kids within a school that would be eligible for free and reduced priced meals,” FitzSimons said.

“Community Eligibility can definitely help support delivery of the school breakfast and lunch in high-need rural districts,” FitzSimons added. “By sharing lessons learned and promoting the benefits of school nutrition programs, we’ll be able to better meet the ultimate goal of making sure that no student has to attend school on an empty stomach. Students just cannot learn when they’re hungry.”

This story was originally published by the Daily Yonder.

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Rural Divide

With Medicaid Expansion, Rural Virginia Clinics Face a Tough Decision



Dr. Teresa Gardner Tyson, right, during a procedure. Tyson is the executive director of the Health Wagon in southwest Virginia. Credit: The Health Wagon

For years, Wendy Gooditis tried to help her older brother Brian access medical care. When he was just 11 years old, he suffered a horrific trauma at the hands of someone outside their family, which resulted in post traumatic stress disorder, or PTSD. Brian’s condition was undiagnosed for much of his life — until about five years ago.

One of the hallmark symptoms of PTSD is terror, particularly at night, something Gooditis said plagued her brother. Early on, Brian found that alcohol brought some relief to his terror-filled, sleepless nights. As an adult, the combination of PTSD, alcoholism and lack of proper care for either condition made his life difficult. In attempting to find adequate healthcare for her brother, Gooditis learned how challenging accessing care in the state of Virginia could be.

“When Trump was inaugurated in 2016, I thought, ‘This administration is not going to do anything to help people like my brother,’” Gooditis said, “and I decided then that I had to do something to fix this situation.”

She announced her candidacy at the end of February 2016 for a seat in the Virginia General Assembly. Two weeks later, she found her brother dead. He was 57 years old and Gooditis is haunted by the question of what his life might have been like if he’d had appropriate medical care.

“I had $500 and…just me, as far as my candidacy,” she said. “It would have been so easy to quit. But, at this point, I’d met so many people like my brother. I made it my mission to help.”

Wendy Gooditis, left, gestures as she speaks with voters at a restaurant in Berryville, Va., Wednesday, Oct. 25, 2017. At the time, Gooditis was running for the 10th district seat. Photo: Steve Helber/AP Photo

Gooditis was elected to the House in 2017 and when she got there, she wasn’t the only person who wanted to change healthcare in the state.

In late May of 2018, Virginia’s General Assembly passed a budget that included Medicaid expansion, a provision of the federal Affordable Care Act, or ACA, that allowed states to choose whether to allow people at a slightly higher income to be eligible for the program. Governor Ralph Northam signed the bill on June 7 last year and on January 1, 2019, some 400,000 residents of the state will be eligible to enroll in Medicaid.

Healthcare facilities across Virginia are beginning to prepare for the new population that is eligible for coverage under the federal program. At the same, though, the current presidential administration is working to dismantle the ACA, the law that made expansion possible. In many ways, the situation in Virginia reflects the national turmoil over the access and affordability of healthcare.

For Virginia’s Free Clinics, Medicaid Expansion Is a Double-Edged Sword

On its face, Medicaid expansion seems like good news for clinics whose mission is to provide care for those who may not otherwise be able to afford it. Although qualifications vary from state to state, in Virginia the expansion population will include people who make up to 138 percent of the federal poverty level. For a family of four, that’s $42,435 per year in 2018.  

Many of those Virginians are using the services currently available at free clinics. That means, upon their enrollment, Medicaid could be a new source of income for these healthcare providers that typically rely on grants and donations to serve their client population. But these clinics will face significant challenges as they prepare to serve patients who are newly covered by Medicaid.

The Virginia Association of Free and Charitable Clinics, VAFCC, provides a range of services for free clinics, such as technical assistance, training, advocacy and resource development. There are about 70 free and charitable clinics in Virginia; 63 are members of the VAFCC. Only about 10 of those members will accept Medicaid initially. The rest are evaluating their infrastructure, patient population and community needs before reaching a decision.

CEO of VAFCC Linda Wilkinson said whether a health clinic will begin accepting Medicaid depends on multiple factors. One is whether they have the appropriate infrastructure internally to bill the federal program for the services they provide newly enrolled Medicaid patients. Another is whether these patients will have an alternative provider in their community to turn to should the clinics choose not to accept Medicaid.

For some clinics, creating a billing infrastructure will take significant investments in the hardware to complete the process, like computer software and electronic records systems, but also could mean adding additional staff trained in the process, which can be expensive.

When it comes to access, roughly half the state is classified as being medically underserved by the Virginia Healthcare Association. That means there are too few primary care providers, a high infant mortality rate, or a large population of elderly people, according to the Health Resources and Services Administration. In addition, many areas of Virginia are considered health professional shortage areas, where there aren’t enough providers to serve the population.

Whether there are enough providers in any given community can be a politically-charged issue, but so can the eligibility requirements. Wilkinson said about 100,000 Virginians who earn between 139 percent and 200 percent of the federal poverty level will remain uninsured. Some clinics will continue to provide free or charitable care and serve that segment of the population.

The Sinclair Health Clinic says its Decision is Made

The Sinclair Health Clinic in Winchester, Virginia, is one of the 10 VAFCC member clinics that intends to begin accepting Medicaid in January. Since approximately 80 percent of the clinic’s patients will be eligible for the program under expansion, the decision was a foregone conclusion for Executive Director Brandon Jennings for a couple of reasons. For one thing, there aren’t enough providers in the area to absorb that many new patients.

The Sinclair Health Clinic. Credit: Provided

“We would basically kick 1,600 patients out of our clinic because they’d no longer meet our eligibility criteria,” Jennings said of the patients who would be Medicaid eligible, “and there’s no one in town to pick them up.”

“Having 1,600 patients on day one needing to find a provider would be downright impossible for a town of our size, and I would argue [that would be true] for a lot of towns in Virginia,” Jennings said. The clinic was already having trouble placing clients with specialists before Medicaid expansion became an option, he added.

Even though the clinic will accept Medicaid, Jennings said patients will ultimately have more control over what doctor they can see. Without expansion, most of them can’t afford to see another provider.

“There’s no reason they have to stay with us,” Jennings said. “They can move down the street if they can get in to see another provider, and some may very well do that.”

Dr. Brandon Jennings, executive director of the Sinclair Health Clinic in Winchester, Va. Credit: Provided

But, the decision to begin accepting Medicaid means the clinic will need to make some fairly drastic changes to how it operates. Care is currently provided free of cost to all patients so there is no billing department at the Sinclair Health Clinic. As a facility that accepts Medicaid, however, they will need to bill Medicaid, but that’s not necessarily a simple task. Healthcare is a heavily regulated industry and the Centers for Medicare and Medicaid Services has strict regulations that all practices who bill them for services must abide by.

“There are usually, depending on the practice size, anywhere from one to five people sitting in the back,” Jennings explained of a typical physician’s office, “and the only thing they’re doing is billing and discussing with insurance companies about ways to get claims paid. We don’t have any of that built in.”

But the Sinclair Health Clinic has at least one advantage as they shift to accepting Medicaid: two of their staff members previously worked in practices that billed, although not specifically Medicaid. Still, there will be challenges in building an infrastructure to handle billing. The clinic has been working with Athena, the company that supplies their electronic medical records system, which has a billing component.

Medicaid will Work for Sinclair, But Not for Everyone

The challenges the Sinclair Health Clinic is facing in the wake of Medicaid expansion is similar to that of other free clinics across Virginia, including the Health Wagon in the Appalachian Mountains of southwest Virginia.

The Health Wagon’s Executive Director Dr. Teresa Gardner Tyson, right, and Clinical Director Dr. Paula Hill-Collins,l left, in their mobile clinic. Credit: The Health Wagon

Clients of the Health Wagon usually don’t have health insurance, often live in chronic poverty and many have low educational attainment. Preliminary estimates at the Health Wagon show that about 50 percent of their clients served by their one mobile and two brick-and-mortar clinics will become eligible for Medicaid under expansion. Executive Director Dr. Teresa Gardner Tyson stresses that those are very early estimates and said she expects that number to grow.

The organization partners with Remote Area Medical (RAM) each year for the Remote Area Medical – Wise Health Expedition, the largest medical outreach of its kind in the country. The program provides free health, vision and dental care at what’s usually a one day event. People arrive sometimes days in advance to wait in line to get care they otherwise would be unable to access.

Tyson contends that the free event, held every July, was instrumental in the political shift in the state that led to Medicaid expansion.

“We’ve spearheaded that [event] for the last 19 years,” she said. “For the last five years, the Health Wagon has invited all legislators, Democrat and Republican both, to come and look at what we face here in Appalachia. We’ve invited these politicians to come and see people lining up when we open the gate. We give out about 1,700 numbers on that Friday by 5 a.m.”

People who come after that, Tyson said, are turned away.

“I think it’s been very eye-opening for them,” Tyson said. She wants politicians to understand that in the United States, in 2018, people sometimes arrive a week in advance to get healthcare.

“This is happening in central Appalachia, where we need more focus to help us turn around healthcare disparities here in the mountains,” she said.

Dr. Teresa Gardner Tyson in the mobile clinic. Credit: The Health Wagon

Although Tyson said her organization is in the preliminary stages of determining if they will accept Medicaid, the Health Wagon faces the same challenges as the Sinclair Health Clinic. Medicaid billing would also be a new practice for the nonprofit, but Tyson said the Health Wagon is considering an alternative approach. Rather than changing the way the two existing clinics operate, the Health Wagon may add a third physical location to solely serve the newly expanded Medicaid population.

“It’s a very real possibility that we’ll open up a rural health clinic and get those patients into care there,” said Tyson.

There is perhaps an additional obstacle for the Health Wagon, though– the culture of their clients.

In addition to billing CMS for services, practices that accept Medicaid must also send a copy of that bill to the patient. Patients aren’t required to pay anything, but Tyson is worried that some of the population she serves might not understand that. After all, they currently receive their healthcare free of cost and never have to look at a paper bill.

“From a cultural perspective, if they receive that [Medicaid statement], it might be a barrier for them to returning for care if they thought they owed a bill and they weren’t able to pay it,” she said.

Enrollment Challenges

Before either the Sinclair Health Clinic or the Health Wagon can begin seeing Medicaid patients or billing for services, eligible patients have to apply to actually receive Medicaid benefits. And the application is complex.

Jennings, with the Sinclair Health Clinic, said their staff has been completing mock applications so they can understand what their clients will be facing, and so far, even the healthcare professionals on his staff have been confused. That can potentially mean problems for this population, Jennings said, some of whom struggle with literacy.

“We’re not being resourced to help with that at all, and so it’s a problem,” Jennings said. “Yet, we need to [help people apply] as part of the community because our patients need to enroll for the full benefit.”

Just being eligible for coverage under Medicaid expansion isn’t enough, Jennings said. Patients must be enrolled in the program to receive coverage.

The Health Wagon has applied for a grant to fund two eligibility coordinators to help clients apply for Medicaid.

“We want to get our patients into the system so that they have access to the care we have long championed for,” Tyson said.

The VAFCC has some resources available to help clinics handle this aspect of expansion, according to Wilkinson. She also said the Department of Medical Assistance Services, the Virginia State Department of Social Services and are doing excellent, and necessary, work to make residents aware of their potential eligibility, as well as help them apply.

“Some patients may have health insurance for the first time in their life,” she said, but issues with the application and technology may pose a problem, just as they did in the early days of the ACA.

When the online marketplace to purchase insurance through the ACA was initially rolled out under the Obama administration, results were disastrous. Headlines in early October 2013 included: “Tech Problems Plague First Day of Health Exchange Rollout” from NPR and “How Long To Fix Obamacare Tech Problems? Long” from CNBC, among many others.

Technical glitches in the Healthcare Exchange have continued over the years, but now, the Trump administration is committing fewer resources to helping enrollees work through those problems. Even so, approximately 11.8 million people signed up for coverage under the ACA in 2018 and around 27 percent of them were new to the program.

The Bigger Picture

The fact that Virginia, once a reliably red state, is now decidedly purple may be due in large part to the issue of healthcare. It spurred Gooditis to run for office, and several Republican lawmakers joined Democrats in the vote earlier this year to expand Medicaid in the state.

“I came to the conclusion, for me and my district, that ‘no’ just wasn’t the answer any longer,” Republican State Senator Ben Chafin told the New York Times in May. Chafin represents the area served by the Health Wagon in southwestern Virginia.

“Doing nothing about the medical conditions, the state of health care in my district, just wasn’t the answer,” Chafin added.

Chafin is not alone in his stance. Other Republicans are also changing how they talk about healthcare.

The Washington Post reports that in 2014, 84 percent of ads about healthcare from Republicans or from organizations affiliated with the Republican party, attacked the ACA. In current midterm campaigns, Republicans seem to be avoiding the issue of healthcare altogether.

“Yeah, we probably can’t talk credibly about repeal and replace anymore,” Republican Congressman Tom MacArthur of New Jersey told the Post.

Notably, there’s nothing about the issue of healthcare on Virginia Congresswoman Barbara Comstock’s website. Comstock represents the 10th district, which includes Winchester, where the Sinclair Health Clinic is located. In 2014, her campaign platform included repealing and replacing Obamacare. Comstock’s office did not respond to a request for an interview for this article.

In four states, Montana, Nebraska, Idaho and Utah, Medicaid expansion will be on the ballot in November. The Fairness Project, a grassroots organization that supports economic fairness, is working with groups in those states to give voters a voice in the debate.

“Ballot initiatives are powerful because they strip away the political theater and partisanship, cut out the lawyers and lobbyists and give voters a clear, direct way to help their families and their neighbors,” said Jonathan Schleifer, executive director of the Fairness Project, via email.

Despite the problems that Medicaid expansion will create for free and charitable clinics in the state of Virginia, many administrators and advocates are enthusiastic about more people being able to access healthcare, including Sinclair Health Clinic’s Jennings and the Health Wagon’s Tyson.

The two will continue to consider how changes to their billing and operational systems will impact their patients and clinics over the next few months, and will handle events outside of their control as they happen.

“This is the boat we’re in,”Jennings said. “We’ve got to figure out how to make it float.”

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