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Health Care on the Line

Rural Citizens Vote Against Their Own Medicaid in State and Federal Elections

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About half of the patients at the Lourdes medical clinic on Main Street in Hancock, N.Y., rely on Medicaid for their health care. Photo: Sally Zegers

Most of Betty Rosengrant’s extended family needs Medicaid. They’re also mostly Republicans. Rosengrant says she knows Republicans have proposed cuts to the federal/state health care system, but that “people just vote the way their parents voted, and that’s Republican.” 

Rosengrant, 69, and her family have had their share of medical crises, including her husband’s death from cancer and her own difficult knee replacement. There have been times her family’s needed to rely on Medicaid, which covers costs for those with income below 138% of the official federal poverty level. Some of her children, grandchildren and great-grandchildren have too.

Her family and her town of Hancock, New York (pop. 3,500 if you don’t count summer camp kids or fall hunters), resemble many Republican communities across the U.S. According to the Census Bureau, one in five Americans dwell in rural areas — places where the 2016 voting went heavily for Republican candidates calling for cuts in “entitlements” like Medicaid.

They’re also the communities where Medicaid is key to health care access for one-quarter of the population, according to Families USA. In fact, according to The Washington Post, 51 percent of rural births are covered by Medicaid, compared to just 45 percent nationally and an even lower percentage in urban/suburban areas. In Hancock, many people get their primary care at a storefront clinic on Main Street, where an average of 40 to 50 percent of patients are on Medicaid, according to the clinic director. (The clinic is run by the Lady of Lourdes Hospital, which is 45 miles away in Binghamton.)

There are several reasons more rural people rely on Medicaid. Incomes are lower than in cities. There are also fewer unionized employers or large employers, both of which typically have company-sponsored health plans. As well, with jobs harder to come by, a higher percentage of rural people are self-employed, work part-time or are unemployed. 

Medicaid, established in 1965 as a complement to Medicare for the elderly and disabled, was meant to provide health care access to the poor. Like Medicare, it’s been a target for Republican budget cutters ever since. In October, Senate Majority Leader Mitch McConnell (R-KY) called for cuts in both programs as have GOP House leaders.

Unlike federally administered Medicare though, Medicaid, while funded by the federal government, is administered by the states. This doubles the jeopardy as both Congress and state legislatures continue to attack the program.

One such two-pronged attack was part of the Trump administration’s effort to undo the Affordable Care Act (ACA). In addition to subsidized health insurance plans, the ACA expanded Medicaid access, enabling another 1.7 million low-income people to receive health coverage in states that adopted an option of a higher income eligibility. Most that did had Democratic state governments. Continuing attacks on the ACA threaten that access.

When the Trump administration issued a “guidance” allowing states to impose work requirements on Medicaid applicants, a number of states with Republican-majority governments quickly adopted them, though critics warn the requirement could end up denying people coverage. In three states the new work requirements were approved. Another seven have applications pending.

Pennsylvania has a Democratic governor, but the Republican-controlled legislature is still pushing legislation which, if approved, would require Medicaid recipients to be working or seeking a job, and also would raise their co-pays for care. Most of Pennsylvania’s Republican congressional representatives, primarily from rural districts, also back a Republican tax plan that could severely cut Medicaid in the future by converting it into block grants, which would cap state spending regardless of how many people qualify for coverage.

Ben Waddell, a sociology professor at Ft. Lewis College in Colorado, says he understands why Rosengrant’s extended family and so many other rural Americans vote the way they do.

“Rural people out West descend from people who moved here hoping to make their own way,” he says. “These days, with globalization taking away jobs, what matters to them is having a job and having self-respect, not so much having health care.” He recalls a coal-fired power plant near Norwood, the small Colorado town where he grew up, being ordered closed during the Obama administration and how people there worried about the lost jobs. He says Trump’s 2016 campaign promise to “bring back coal” resonated.

“People don’t always understand all the scaffolding of these programs like Medicare and Medicaid or how globalization really works,” he says, “but they do respond to the simple messages they get from Republicans about how Social Security and Medicare are ‘in trouble.’” He adds, “I think rural voters in Appalachia think the same way.” 

Rosengrant, a lifelong Republican who recently began voting Democratic, is not surprised so many people in her community support politicians who threaten their Medicaid. “Most people around here don’t read newspapers, and just watch Fox TV,” she says. “They don’t even know who the candidates are that they vote for, and even if they don’t just vote party line, they don’t know that the Republicans want to cut Medicaid.”

Dave Lindorff is a veteran award-winning investigative journalist who writes for Salon, the London Review of Books, the Nation and other publications. He is author of “Marketplace Medicine: The Rise of the For-Profit Hospital Chains” (Bantam, 1992) and for five years was a Hong Kong and China correspondent for Business Week magazine. He lives near Philadelphia.

This story first appeared at investigative and solutions journalism website Tarbell.org. 100 Days in Appalachia is co-publishing the story.

Appalachian health

Black Lung Benefits Fund in Deepening Debt as Epidemic Surges

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A new study from the Government Accountability Office finds that the federal fund supporting coal miners with black lung disease could be in financial trouble without Congressional action. As NPR has reported, the GAO found that the fund’s debt could rise dramatically at the same time that black lung disease is surging.

Disabled former miner Bethel Brock fought years to win federal black lung benefits.
Photo by Benny Becker/OVR.

Most federal benefits for coal miners disabled by back lung are paid from the Department of Labor’s Black Lung Disability Trust Fund, which covers the cost for companies that have gone bankrupt.

The trust fund is mainly supported by a tax on coal, but according to the GAO, those taxes have not covered costs, leaving the trust fund over $4 billion in debt. The GAO says that debt could soon climb to more than three times that amount if Congress doesn’t take action.

Other recent federal studies show that black lung disease is surging both in frequency and severity, especially in central Appalachia.

Bethel Brock, a retired paralegal in Wise, Virginia, is a disabled former coal miner who fought for years to win federal black lung benefits. As Brock explained, more cases of severe black lung could raise costs significantly.

“The cost is on giving a miner a health card for his lungs and heart,” he said. “Cases where a miner might have to have a lung transplant can run into the millions of dollars.”

Decades of Debt

In 1981, Congress approved a temporary tax increase on coal in hopes of getting the trust fund out of debt. The increase was extended in 2008, and is set to expire at the end of this year. That would cut the fund’s income by more than half and the GAO predicts the fund’s debt would more than triple by 2050, reaching over $15 billion. Even if the tax cut is extended, the fund’s debt is expected to continue to grow slightly.

Republican Senate Majority leader Mitch McConnell of Kentucky said he’s aware of the issue, but would not say whether he’d support extending the tax.

“It doesn’t expire until the end of the year,” McConnell said, “and so we’ve got plenty of time to take a look at solving that problem.”

The issue puts McConnell in an uncomfortable position. Many of the affected miners are his constituents but he also enjoys support from the mining industry, which opposes extending the tax.

Who Pays?

The National Mining Association told NPR it hopes that some or all of the debt will be forgiven. That’s what happened in 2008, when taxpayer funds absorbed $6.5 billion of the fund’s debt.

United Mine Workers of America president Cecil Roberts argues against forgiving the debt. In a press release, Roberts said reducing the amount companies pay is “not just wrong, it is rewarding bad corporate behavior.”

Evan Smith, a black lung attorney and blogger at the Appalachian Citizens Law Center, said industry opposition to extending the tax raises some big questions.

“I want coal to make sense. I want there to be coal mines, I want there to be coal miners,” he said. “But if you say that you cannot protect your workers at the current price of coal, then does the entire enterprise make sense?”

Because black lung can be prevented by limiting dust exposure, experts for many years thought the disease would soon be a thing of the past. But central Appalachia is now facing the largest epidemic of severe black lung ever documented.

This article was originally published by Ohio Valley Resource.

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Health Care on the Line

As a Key Vote on Repealing Obamacare, Senator Capito Votes to Open Debate on the Bill

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Despite West Virginia Sen. Shelley Moore Capito’s outspoken criticism of the GOP’s proposal to repeal the Affordable Care Act, which would leave millions of people — and hundreds of thousands of Appalachians — with no health insurance, the senator voted with her party today to begin debating how to do so.

Late Tuesday afternoon, the Senate, with the help of Vice President Mike Pence breaking a 50-50 tie, made the vote that was nearly straight down party lines.

Capito immediately released a statement after the vote to debate the repeal, saying she will continue to make decisions in the best interest of West Virginians.

“I remain committed to reforming our health care system while also addressing the concerns I have voiced for months,” she wrote. “I will continue to push for policies that result in affordable health care coverage for West Virginians, including those who are in the Medicaid population and those struggling with drug addiction.”

A week ago, Capito publicly came out against the latest version of the Senate healthcare, saying she had “serious concerns” about the bill, and would not vote to repeal healthcare without a replacement.

Democrats and Affordable Care Act (also called Obamacare) advocates across the state are now slamming her for the decision, which pushes forward a plan that could result in the loss of healthcare coverage for 180,000 West Virginians — one-tenth of the state’s population.

“All of these proposals the Senate has floated sever Medicaid,” said Chantal Centofanti-Fields, executive director of West Virginians for Affordable Healthcare.

Capito’s counterpart in the U.S. Senate from West Virginia, Joe Manchin, also took a shot at her for Tuesday’s vote to proceed on the bill.

“There is no plan for the West Virginians in addiction treatment covered under expanded Medicaid; no plan for the seniors whose health care costs would become unaffordable; and no plan for the miner with black lung who wouldn’t be able to get the care that they need because their rural clinic had to shut down,” Manchin said in a statement released after the vote. “They effectively voted to throw the most vulnerable in West Virginia out into the cold.”

Manchin argued that members of the Senate are still unclear on what exactly they’d be voted to do in reforming health care coverage.

“Forget reading the bill, we haven’t even seen the bill. This is not how we are supposed to do things, and it shuts out the people who elected us,” he added in Tuesday’s statement.

Medicaid expansion has allowed many West Virginians to access healthcare. Medicaid enrollment increased by nearly 62 percent from 2013 to 2016, and three in ten people in the state use Medicaid. It’s also been a success in other Appalachian states like Kentucky, which — despite Senator Mitch McConnell’s claims that it is failing — has seen the most drastic fall in the adult uninsured rate of any state in the U.S., dropping from 20 percent in 2013 to less than 8 percent in 2016. In Eastern Kentucky, more than 60 percent of people are covered by Medicaid.

The decision to debate the bill, though not unexpected, is a far cry from what some GOP lawmakers have been saying for weeks while McConnell has pushed to repeal the ACA without a replacement. Capito was one of several senators who expressed similar concerns and voted to debate the bill anyway. Only two Republicans voted no: Senators Susan Collins of Maine, and Lisa Murkowski of Alaska.

It remains unclear what a replacement might look like because no official legislation has been written, but debate will soon begin in the Senate over whether or not to repeal the Affordable Care Act completely.

In states like West Virginia, some say the looming loss of Medicaid is cause for major concern.

“[GOP senators] made promises not to repeal without a replacement,” Centofanti-Fields said. “It’s worrisome. We’re urging our representatives to work together to come up with expansive coverage. It’s critically important in this state.”

Lyndsey Gilpin (@lyndseygilpin) is a contributing editor of 100 Days in Appalachia based in Louisville, Kentucky. She is also the editor of Southerly, a newsletter covering the American South.

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Rural hospitals may struggle under House GOP’s proposed healthcare overhaul

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Over the last two years, the number of coal mining jobs in Boone County, West Virginia has halved. Drive through the county now, and signs of depression are becoming evident in shuttered storefronts and homes in increasing need of repair.

Given that context, it’s somewhat startling to stumble across the brand new Boone Memorial Hospital on the edge of Madison.

Boone Memorial is a small, rural, hospital in southern West Virginia. The next closest facility is in Charleston about 45 minutes away. Before the Affordable Care Act, Boone had to absorb almost $6 million of uncompensated care costs a year.

In 2015, after the ACA became law, uncompensated care costs for Boone Memorial dropped to a little more than a million dollars. Uncompensated care is when hospitals are not reimbursed for services – usually when patients are unable or unwilling to pay. One reason for that 4 million dollar shift may be because West Virginia expanded Medicaid through the ACA.

“A change in the cash flow from Medicaid, would impact us pretty significantly,” said Boone Memorial CEO Virgil Underwood. “And if we were not in a position where we were watching our cash flow as closely as we are, it certainly could be problematic for us.”

Empty pre-op beds at the new Boone Memorial Hospital. (Photo: Kara Lofton / West Virginia Public Broadcasting)

Not an isolated issue

Boone Memorial is not the only hospital in Appalachia for which a shift in cash flow could be problematic.

However, it’s hard to make sweeping statements about trends in rural hospitals because there are so many factors that impact how well a rural hospital is doing. But, we did take a look at the data.

“Medicaid expansion states have rural hospitals with a median operating margin that is positive and it is statistically higher than those states that did not expand Medicaid,” said Michael Topchik, national leader for the Chartis Center for Rural Health.

West Virginia is one of 32 states, including Washington, D.C., that expanded Medicaid.

After the ACA, uncompensated care costs in West Virginia’s rural hospitals went down almost across the board. In fact, uncompensated care costs halved from almost 85 million in 2013 to about 43 million dollars in 2015.

“So we saw that those patients that didn’t have insurance, had insurance and so that was a really good thing for us and for a lot of the rural hospitals or any of the hospitals in West Virginia,” said Skip Gjolberg, CEO of St. Joseph’s hospital in Upshur County.

CBO report consistent with other analyses

The Congressional Budget Office released a report this month analyzing the impact of the U.S. House of Representatives health care proposal to replace the ACA. Critics of this report say the CBO is unreliable and does not make accurate predictions. But the information in it is consistent with other analyses from agencies like the Kaiser Family Foundation and Michael Topchik’s Chartis Foundation and is the best tool to project potential impact.

Topchik said the CBO report predicts that overall, the federal government will make fewer payments to states under the ACA replacement plan.

CEO Virgil Underwood does physical therapy exercises at the new Boone Memorial Hospital. (Photo: Kara Lofton / West Virginia Public Broadcasting)

Potential for Diminished Capacity of Care

“So inherently, there will be a scaling back of coverage of the amount of people covered and the ability of people to then receive care in rural hospitals will be diminished,” he said.

The CBO report projects that by 2026, 24 million people will lose health coverage – partially through changes in the way that Medicaid is funded. For one thing, all those Medicaid expansion patients who gained coverage under the ACA, may now lose it.

“That’s not going to help rural hospitals and very well could push some of the most marginalized hospitals over the edge,” Topchik said.

Rural hospitals generally disproportionately care for the elderly and Medicaid population. For hospitals like Boone Memorial and St. Jo’s, changing in the way funding is reimbursed for those populations could make things really tough.

“West Virginia hospitals, and we’re no exception, are on a pretty tight margin. And anything that will either decrease our volume or reduce the reimbursement we get will negatively impact this hospital,” said Gjolberg.

If the expansion money goes away, Gjolberg said their margin of profit would likely disappear as well.

And if hospitals like St. Jo’s and Boone Memorial have to scale back services or disappear altogether, it would mean fewer health care services in rural areas that need them the most.

This story was originally produced by West Virginia Public Broadcasting.
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