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Health Care in Appalachia

Moving Care Upstream: Appalachian Community Health Workers Take on Diabetes. And Get Results.



Roger Cisco is a fairly new patient in the Williamson Health & Wellness Center’s community health program, which serves some of the clinic’s most high-risk patients for diabetes, cardiovascular disease, and/or chronic obstructive pulmonary disease (COPD). Cisco, 56, was in an on-the-job automobile accident and suffered permanent spinal damage, leaving him paralyzed in his arms and legs. Kelly Browning, Cisco’s community health worker, helps Cisco navigate the many complications he faces, while trying to continue to manage his diabetes. Photo: Anna Patrick/100 Days in Appalachia

Kelly Browning doesn’t wait for Lyle Marcum to come to the door. She knocks and then pushes the glass door open, like she’s been there many times before.

Lyle stays where he is, sitting on a brown love seat, the TV on, and he calls for his dog, Lyla. “Get over here!” She’s running, excited, back and forth, her collar jingling until Kelly finds a leash, connects it to Lyla and slides the rope’s handle over a closet door knob.  

“New plan for you,” Kelly laughs. She’s wearing scrubs, but her outfit only describes a portion of the tasks she regularly has to do. As a community health worker for Williamson Health & Wellness Center in Mingo County, West Virginia, Kelly is assigned to 29 of the primary care center’s sickest patients. Most of her patients have more than one chronic disease, or comorbidity, and almost all of them have diabetes.

For two years now, Kelly has been working with Lyle, a former truck driver who hauled coal and mine equipment for most of his life. Since he was diagnosed in 1996, Lyle has spent the better part of two decades with uncontrolled diabetes. For a long time, he didn’t take the drugs doctors prescribed, and he didn’t eat the way they told him to, but he didn’t see any immediate consequences. So he carried on the same way he always had, working until he retired in 2007.

But Lyle’s luck ran out. “Eventually, stuff starts falling apart,” Kelly said. Lyle lost sight in his right eye. He’s now considered legally blind. And he had to have the top quarter of his right foot amputated, losing his toes. But with Kelly’s encouragement and consistent accountability, Lyle’s checking his blood sugar regularly and he’s taking his medications at least most of them.

“They’re death on diabetes,” Lyle said of Kelly and her team. She’s hoping he’s right.   


Kelly’s a certified nursing assistant, but if you ask her advisor, Jerome Cline, her most important qualification is that’s she’s called the hills and hollers of Mingo County home her entire life. Kelly has known many of her patients for years. She knows how hard it’s been to find work since the coal industry’s decline in the region, she’s been touched by the opioid epidemic just like too many of her neighbors, and she cares about what happens to her patients.

Diabetes is just one of the many battles her patients face. Type 2 diabetes is considered a public health epidemic throughout the United States, but the disease is especially prevalent throughout lower-income communities in central and southern Appalachia, especially in states like West Virginia, Mississippi and Alabama, which currently lead the nation (1 – 3) in rate of occurrence. One in two West Virginians, for example, have abnormal glucose levels.

The community health worker program, the reason Kelly’s knocking on Lyle’s door every week, is one of the ways that the region is trying to fight back. It’s a new version of a well-known, widely used model that employs community members, without requiring a medical background, to support the health of others. The Department of Family and Community Health at the Joan C. Edwards School of Medicine at Marshall University, located in Huntington, West Virginia, is leading the program’s implementation. The program targets high-risk patients that have diabetes, cardiovascular disease, and/or chronic obstructive pulmonary disease (COPD) in rural areas throughout Appalachia. Rather than relying on regular doctor’s visits to treat diseases like diabetes, which are largely impacted by a patient’s daily decisions, the model moves care upstream into the homes of patients to create opportunities for intervention on a weekly basis.    

Community health workers have been working across the world, especially in rural, underserved areas, for decades, said Dr. Richard Crespo, researcher and professor at Marshall’s Department of Family and Community Health. Crespo and his team worked with Duke University to secure grant funding to launch an initial pilot program in 2012 at four health centers, which included Williamson Health & Wellness Center.

The pilot at Williamson focused on 130 high-risk diabetes patients. Within a six-month period, patients reduced their hemoglobin A1C levels by an average of 2.5 percentage points. Rather than using daily glucose readings to track a patient’s sugar management, A1C monitoring offers a much more accurate snapshot by showing average blood sugar level over the previous two to three months.

“If you were a drug company and you dropped hemoglobin A1C by .6 percent, you’d have a multibillion dollar drug,” Dr. Dino Beckett said in a 2018 interview. He’s a physician of osteopathic medicine and the CEO of Williamson Health & Wellness Center.

Dr. Christopher “Dino” Beckett, CEO of Williamson Health and Wellness Center, left, walks with Democratic presidential candidate Hillary Clinton during a tour of the facility in Williamson, W.V., in May 2016. Photo: Paul Sancya/AP Photo

Due to Williamson’s initial success, Crespo has continued working to secure grant funding through public and private sources to expand the program across the region. The program currently includes 29 community health workers across 13 primary-care centers that are helping to treat 650 high-risk patients living in 27 counties across West Virginia, eastern Kentucky and southeastern Ohio. And based on early results, the majority of patients have been able to make significant improvements to their health.

Crespo’s hopeful this model can offer an alternative, effective path forward for a region that is becoming increasingly sick.  


When Craig Robinson started working in Appalachia in the ‘60s and ‘70s to help coal miners with black lung receive medical care, diabetes was around, but it didn’t stand out as a serious public health problem, Robinson said. He’s now the executive director of a primary-care provider in West Virginia.

A lot has changed since then.

Today, more than 30 million Americans, 9.4 percent, have diabetes, according to the American Diabetes Association, with nearly 95 percent experiencing type 2 diabetes, with a disproportionate number living in Appalachia. Diabetes is a slow building disease largely influenced by lifestyle choices over a long period of time — diet, exercise, stress management and so on. Genetic variations also combine with diet and exercise habits to contribute to a person’s overall risk.

If there’s too much glucose in the blood due to a high-glycemic diet — eating large quantities of food with high frequency that cause blood sugar levels to rise like carbohydrates and sugar — the body eventually develops insulin resistance, according to the National Institute of Diabetes and Digestive and Kidney Diseases. And when the body becomes resistant to insulin, it then needs more of it to help glucose enter cells and to keep blood glucose levels down.

“The American diet has become very high in sugar, of course sugary drinks contribute to this,” Robinson said. “We have a very high glycemic diet, which means that our diet tends to make our blood sugar rise and that’s what causes diabetes.”

The Center for Disease Control and Prevention tracks diabetes rates per county throughout the U.S. In 2011, the CDC labeled a 644-county area in the southeast as the “Diabetes Belt.”

To qualify within the belt, counties located in the southeast had to have at least an 11 percent or greater prevalence rate, higher than the national average. Comparing the Diabetes Belt with the map of Appalachia — which spans 420 counties in 13 states from southern New York to northern Mississippi — 232 counties are located within the Diabetes Belt, according to a 2014 report released by the CDC. Every Appalachian county in Mississippi qualified. West Virginia, the only state fully located in Appalachia, had 48 of its 55 counties qualify. It currently leads the nation in rate of occurrence with 15 percent of its population considered diabetic and another 35 percent qualifying as prediabetic.  

Residents living in rural, distressed counties throughout Appalachia are 1.4 times more likely to have diabetes than residents of non-Appalachian counties, according to a 2010 report published by the CDC. To identify “distressed” counties, the Appalachian Regional Commission, a partnering federal organization, examines poverty rate, the rate of unemployment and per capita market income over a three-year period of time.

In rural settings, there are many factors that create barriers to healthcare, ranging from geographic isolation, lack of transportation, and decreased health literacy, according to a 2016 report in the West Virginia Medical Journal.

There’s an association between poor health and low income,” Crespo said. “And for many of the people whose condition is out of control, it’s because of what’s happening in the community.”


When Kelly Browning receives a new patient, before she can start setting health goals, she has to do two things: first, assess her patient’s needs. And second, earn his or her trust.

Cline, the clinical lead for Williamson’s community health worker program, often comes along for the initial home visit. He’s a nurse practitioner and certified diabetes educator, but said there’s no reason to start spouting off how many carbohydrates a diabetic can have with each meal if he enters a patient’s home and sees only a can of stewed tomatoes in the cupboard.

The thing we have to do when we find it, is address it,” Cline said of food insecurity issues that patients may be experiencing “Because if we don’t address the food shortages, it’s not going to matter.”

This Thursday, Nov. 29, 2018 photo shows Williamson, W.Va., seen across the border from Kentucky. Photo: Tyler Evert/AP Photo

In Mingo County, where the coal industry once supported a booming economy, a quarter of residents live in poverty, and the life expectancy rate is one of worst in the nation, according to the Institute for Health Metrics and Evaluation.

Because Kelly is a longtime member of the community, she knows the nearby churches and food pantries to call to get her patients connected to more reliable food sources. She also works with a rural bus service to ensure they have transportation to and from their doctor’s appointments. And because she knows that healthier options are often more expensive, rather than asking patients to overhaul their entire diet, Kelly often works with them on portion control to decrease their carbohydrate and sugar intake.

Across the 13 healthcare providers currently active in the program, community health workers have done everything from helping a patient who was sleeping on the floor obtain a bed to organizing the construction of a wheelchair ramp to help another patient easily enter and leave his home.

“When it comes to somebody’s well being, what is too much?” Kelly said.

To ensure comprehensive care, Kelly and her fellow community health worker, Aletta Hatfield,  meet with Cline and the program’s overseeing RN, Melissa Justice, once a week to discuss patient care. It’s one of the aspects that makes this community health worker model unique, Crespo said. By placing community health workers on a care coordination team, they don’t have to be experts in medicine to be able to offer comprehensive care. And even on days that they don’t meet, Kelly can call Cline or Justice to ask small questions she doesn’t know the answer to.

“What the community health worker needs to know in our model,” Crespo said, “is what the patient needs to know. So if a patient needs to know how to do their own glucose monitoring, then the community health worker needs to know that.”

Out of the 650 high-risk patients currently enrolled in a community health worker program throughout central Appalachia, 323 of those patients have diabetes. And so far, Crespo said, 54 percent of diabetic patients have been able to lower their A1C levels by an average of two percentage points, which is very significant in clinical terms.

But it’s going to take more than lowering A1C levels to ensure that this kind of work can continue and grow.


Currently, grant funding is the make or break between having or not having community health workers, Crespo said. Some health centers, after seeing initial results, have made their own investment to expand their number of community health workers beyond their grant’s support.

Since 2017, Crespo and his team at Marshall have led quarterly meetings with insurance providers to share results of the programs. Three payers have signed on with select health centers, including Williamson Health & Wellness Center, to develop a model for payment during a temporary test period.

“All payers will say ‘Yeah, primary prevention saves us money, but what they look at is their bottom line at 5 o’clock. And it’s the [reduction in] ED [emergency department] and hospital visits that bring the cost down,” Crespo said.

The American Diabetes Association released research in 2018 reporting the total cost for treating diagnosed diabetes patients rose from $245 billion in 2012 to $327 billion in 2017.  

During Williamson’s pilot program, emergency room visits decreased for diabetes patients by 44 percent and overall hospital stays were reduced by more than 30 percent, according to Crespo. They haven’t averaged, yet, how much money community health workers are already saving payers by reducing hospital visits, but Crespo is hopeful that if these trends continue, and if more payers sign on to the model, community health workers like Kelly Browning won’t ever have to worry about job security.


Kelly Browning checks Lyle Marcum’s blood pressure during her weekly visit to his apartment in Matewan, West Virginia on May 14, 2019. Because Browning checks Marcum’s vitals during every visit, she was able to respond immediately when she found his blood pressure to be higher than normal. Photo: Anna Patrick/100 Days in Appalachia

Shortly after Lyle Marcum became one of Kelly’s patients, he peeled a piece of tape off of the bottom of his left foot. Except it wasn’t tape. It was skin.

For months, Kelly treated the wound. But it kept spreading and growing, until eventually he was forced to have the leg amputated slightly below his left knee. Because her patient load requires her to travel throughout Mingo County, Logan County and even crossing the border into Kentucky, Kelly couldn’t make it to Matewan every day to check on Lyle, who lives alone, during his recovery process.

To help with the days she couldn’t visit, Kelly walked into the Matewan Sheriff’s department to ask that someone check on Lyle regularly. She made friends with a young woman that works at the town’s water department to get her to bring food to him. She had the senior center, just a few hundred yards away from his apartment, provide him meals. She even had her own mother stopping by to bring food and offer company.

“You just become whatever they need from you,” Kelly said. For Lyle, that often looks like gentle and sometimes not so gentle encouragement to keep going.

“Me and him have been in some knock down drag outs,” Kelly said.

“I won’t let him give up.”

This story was co-published with Spotlight for Poverty and Opportunity, a nonprofit, nonpartisan site featuring commentaries and original journalism about poverty and mobility. Follow us on Twitter @povertynews. Read the story on their site here.

Anna Patrick is a journalist based in Thomas, West Virginia. A former reporter for the Charleston Gazette-Mail, her work has appeared in the New York Times and CNN’s Parts Unknown. Raised in Appalachia, her work explores the lives of folks who call these mountains home. 

Health Care in Appalachia

Eula Hall’s Mud Creek Clinic: Kentucky’s ‘People that Help People’



At 91, Eula Hall still goes to the Mud Creek Clinic, now the Eula Hall Health Center, each day to help care for patients in her rural Kentucky community. Photo: Taylor Sisk/100 Days in Appalachia

Six of Eula Hall’s 10 full siblings lived into adulthood. Her family was among the more fortunate.

Growing up in rural Appalachian Kentucky, Eula has witnessed poverty; she lived it. She remembers regularly seeing children with staph infections that would peel their skin away.

Her mother knew to use disinfectant, Eula recalls today, seated at the command post of the health care clinic she founded in the little town of Grethel on the banks of Mud Creek.

The Eula Hall Health Center in Grethel, Kentucky. Photo: Taylor Sisk/100 Days in Appalachia

But most didn’t. Most had no names for the preventable conditions that befell their families, let alone effective cures. There were no health care professionals to minister to them in their rural Kentucky communities. Home remedies – turpentine or kerosene, for example, administered both externally and internally – only worsened these afflictions.

Eula could never abide such misery; from childhood, she was driven to alleviate it. So in 1973, with a $1,400 donation and two local doctors as volunteers, she opened the Mud Creek Clinic here in this Floyd County community of 1,500. Today, it’s part of a network of clinics providing quality, accessible health care.

‘It’s Not Living’

Eula Hall was born on Oct. 29, 1927, in nearby Pike County. It was coal mining country then as now – though not nearly so now as then.

Eula’s dad, L.D. Riley, farmed, felled trees and fathered 20 children, 11 with Eula’s mom, Nanny Elizabeth Riley, his third wife. She’s the last of those 20 still living.

When Eula was a girl, her mother would take her to sit with a sick neighbor, just to be there, to help out, “and I would see things that would keep you awake.”

“Tuberculosis was rampant. Pneumonia – you didn’t know what it was because you didn’t have a doctor. You’d get a toothache and your jaw would swell up and get infected. You’d see people die.”

“You’d wonder, ‘Who’s next? Who’s next?’”

Eula watched her mother nearly bleed to death in childbirth.

“You ain’t got no life,” Eula says. “If you’re living like that, and every day you’re scared, every day of your life you live in fear that this will be my little brother, my little sister – it’s not living.”

Then, of course, there was the slow death of the mines. In her chilling ballad “Black Lung,” Hazel Dickens laments: “Cold as that water hole down in that dark cave/Where I spent my life’s blood diggin’ my own grave.”

For Eula, the memory of black lung is a rattle in the night.

Her father never owned a car, so the kids walked wherever they went. “We would go to the neighbor’s house and play with the children or help the mother break up beans or whatever needed to be done,” she recalls.

Returning home in the dark, they’d pass people sitting on their porches. “You’d hear them cough and you might see the glow of their cigarette. You’d hear them wheezing, trying to get their breath. And it would be coal mining. They had black lung. They couldn’t sleep. They had no electricity, no air conditioning, no fan – they were sitting outside trying to breathe.”

“Both of my husbands were coal miners,” Eula says. “My brothers were coal miners. My brother-in-law got killed in the mines. My brother got his back broke in the mines. My sons – I had three sons that were coal miners. Scary.”

In the late 1960s and early 1970s, she served as president of the Kentucky Black Lung Association. She’d trained previously as a VISTA volunteer.

“I said, ‘If there’s going to be a war on poverty, there’s plenty of things to fight about, and there’s plenty of people to fight for if you can organize.’ I wanted to make known everything people was suffering from.”

She was a member of the Eastern Kentucky Welfare Rights Organization. Jesse Jackson came to Mud Creek. She drove Ted Kennedy around in her SUV. Mitch McConnell. Bill Bradley. Alongside Bishop Desmond Tutu, she was presented with an honorary doctorate from Berea College.

Through it all, her number-one priority was health care: access to services, attention to black lung, clean drinking water (she launched the Mud Creek Water District). Education was next.

“All the way down the line,” Eula says, “there were major, major problems that needed to be dealt with.”

An Ambition Fulfilled

Eula remembers how in the rural community of her youth, people built their homes without the benefit of  heavy equipment to level the land. The houses were constructed on slopes, the front porches on stilts.

She recalls the day a neighbor woman was climbing to her porch when a step broke, a 16-penny nail piercing her ankle. “She took tetanus and died. She died and left six little children.”

“I can remember them coming back – they lived close to where we lived; you could see their house from ours – and I can remember the day of her funeral. The little children come back and they laid down on the porch, and they cried.”

Eula Hall. Photo: Taylor SIsk/100 Days in Appalachia

“One shot probably would have saved her,” Eula says. “She didn’t go to the doctor; didn’t have money; no car. And it always stayed in my mind. We’re supposed to be living in the land of plenty – and people suffer like that?”

That experience, and countless others, drove her to effect change.

The first iteration of Mud Creek Clinic was in a rented home on Tinker Fork, but Eula soon recognized the need for more space. So she moved her husband and five children into a two-bedroom mobile home and converted their three-bedroom house into a six-examination-room medical facility.

In 1977, Mud Creek Clinic joined with Big Sandy Health Care, a nonprofit that operated a clinic in nearby Magoffin County. Big Sandy is today based in Prestonsburg, the Floyd County seat, and serves five southeastern Kentucky counties spanning the Appalachian foothills: Floyd, Johnson, Magoffin, Martin and Pike. The partnership provided Mud Creek with access to federal funds and a wider network of health care professionals.

In 1982, the clinic burned to the ground, a suspected act of arson. Eula set about to rebuild it.

The Appalachian Regional Commission put up $320,000; a radiothon, raffles and soup-bean suppers were held; Eula stood in the middle of the road with a gallon collection bucket; and donations arrived, she says, from half the states in the nation and the United Mine Workers Union.

The morning after the fire, Eula set up office on a picnic table under a willow tree. Staff and patients arrived; health care was provided. Among the missing essentials was telephone service to call prescriptions into the pharmacy. So Eula contacted the telephone company, explained the situation and requested that they come out and install a phone.

Where would it be installed? Install it on this tree here beside me, she instructed. The phone company folks paused to ponder. You put telephones on poles at mine sites, she reasoned, you can put one on a tree at a health care site. The telephone was installed.

“It was that kind of determination that nothing, nothing, stops us from seeing the patients,” says Big Sandy CEO Ancil Lewis.

“I tell that story when we have a little bit of snow and some of the staff wonder if we should close,” he says. “Or if we have a power outage at a clinic or something. ‘Should we close?’ I remind them of Eula’s determination to continue to see patients.”

‘Finance or Finagle’

In most respects, things are better today in this region than when Eula was a child. But well-paying jobs – jobs that might buy you a little security, maybe allow you to afford to see a doctor – are still few and far between. The needs were, and remain, considerable.

Floyd County ranks 114th of Kentucky’s 120 counties in health outcomes; the other four counties Big Sandy serves are in the bottom 20 percent. Four of the five counties have family poverty rates above 30 percent, compared with Kentucky’s 21.5 percent and 16.7 percent nationally.

Big Sandy Health Care is a federally designated community health center, the mandate of which is to provide health care services to low-income, uninsured people on a sliding-fee scale.

For this rural community, like most in the country, transportation is a major barrier to access. It’s therefore critical to provide as many services as possible under one roof. Eula has always embraced that imperative. Big Sandy’s resources have allowed her to advance it.

Now called the Eula Hall Health Center, the clinic in Grethel provides primary care, behavioral health care, dental and optometry. There’s a pharmacy, a food pantry and a free-clothing center. Telemedicine is also being introduced to access psychiatric care at the University of Kentucky.

“It’s certainly part of Eula’s mission to bring health care to where it’s needed and to provide health care to anyone irrespective of their ability to pay,” Lewis says. “That’s something that Eula’s always been a strong advocate for. And she’s been, I would say, a master at finding ways to get care for people, finding ways to either finance or finagle.”

Eula has a memory from childhood of a doctor’s office with a little red sign in the window that read, “All outpatient services strictly cash.”

“Well, “ she says, “people didn’t have cash. My parents didn’t have money.”

“I was always imagining having something like what we’ve got now, like Big Sandy Health Care, where people can go in, and nobody kicks you out because you’ve got no money.”

Committed to Community

Eula Hall has been fighting this war for a lifetime. Trust that she’s fighting it still.

“At my age,” 91, “people might think, what can she do?” she says. “But you don’t know what I do,” and it’s plenty.

She no longer drives, but her four-wheel-drive is still on the road, transporting patients to and from the clinic and elsewhere as needed. Each morning, she convenes with staff member Linda Adams to assess the day’s challenges. Who’s going to need a ride into the clinic? Who may not have their co-pay? Who’s hungry? This is holistic health care.

And that telephone remains by her side. Eula knows who to call when a neighbor’s having trouble collecting their benefits or a fundamental need proves elusive.

The memories are still vivid, of the constant fear of death in these faraway hollers. Many on staff at the clinic were raised in this region. They know the area well and have committed to serving it.

Robin Holbrook is a long-time employee of the Eula Hall Health Center. Photo: Taylor Sisk/100 Days in Appalachia

“This clinic has been more of a community center than anything,” says Magoffin County native Robin Holbrook, a physician’s assistant who’s worked at the clinic for nearly 30 years.

Holbrook emphasizes the importance of understanding the culture, and of then helping convey a healthy-living agenda throughout the community: “Diabetic education and proper nutrition, immunizations – preventative medicine has always been the key component of rural health.”

“It takes a real unique person to work here,” Eula says. “Just anybody wouldn’t want to work here. It’s hard work, long hours and you’re on your own. But we’ve been blessed. We’ve really been blessed.”

Regarding her own health, she says: “I’m glad to be alive. I feel good. I’ve got some medical problems. I’m a diabetic. But I don’t have major problems to be my age. I tell you what I’ve got that I thank God every day for: I’ve still got my mind. I know what I’m doing, and I know how to do it.”

Eula arrives at the clinic at 8 o’clock. She says it’s the encounters with patients who need her help that push her to get up each morning. “That’s what gets me here every day.”

“We’re here,” Eula attests. “We’re going to take care of these patients. We’re going to take care of them the best way we can, however we can.”

“We’re just people that help people.”

Editor’s Note: This story originally identified the worker’s rights organization Hall volunteered with as the East Kentucky Worker’s Rights Organization, but has been updated to reflect the name of the organization at its incorporation, the Eastern Kentucky Welfare Rights Organization.

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Health Care in Appalachia

New Report Outlines Sound Strategies for Healthier Communities in Appalachia



Early Childhood Coordinator Jacki Wimmer reads to pre-K students on Tuesday, May 7, 2013, at Iaeger Elementary School in Iaeger, W.Va. Wimmer works in a program that provides a bag of books to families to encourage reading at home. Wimmer says some students never see a book until kindergarten. The school is located in McDowell County, an area overwhelmed with poverty, unemployment, drug abuse, and teacher shortages. McDowell County on Wednesday was expected to win approval to expand its role to include social services in a county that faces deep economic challenges. The project, called Reconnecting McDowell, brings together medical professionals, telecommunications firms and a teachers' union. Photo: AP Photo/Randy Snyder

As state administrators throughout Appalachia grapple with mounting health care costs, a new resource is offering assistance to policymakers by taking lessons from success stories outside of the health sector.

A healthy community is born of sound policies. That’s the premise of a just-released report from the Washington, D.C.-based nonprofit Trust for America’s Health titled “Promoting Health and Cost Control: How States Can Improve Community Health and Well-being through Policy Change.”

The study examines successful policies outside the health care sector that states, including those in the Appalachian region, have adopted to improve their communities’ health and well-being outcomes while reducing health care costs. Among those included are universal pre-kindergarten, rapid rehousing legislation and housing rehabilitation loans and grants, syringe-exchange programs and tobacco and alcohol taxes.

According to John Auerbach, president and CEO of Trust for America’s Health, the study kept its focus on the state level “because at this juncture, there’s less policy that’s being developed at the federal level.”

The researchers examined 1,600 policies, then honed the list to 13 that met their criteria of addressing pressing issues and proving themselves effective, while being deemed widely feasible.

“We were pleased to see, in terms of looking at these 13, that every state has done at least one of them,” Auerbach said. “We didn’t want to have a list of policies that were aspirational but hadn’t actually been tested in a range of different states.”

Syringe exchange is one such widely replicable policy that has already show positive outcomes in health costs down the road. Appalachian states have been among the hardest hit by the opioid epidemic. The crisis has presented a heightened risk of infectious diseases—including hepatitis C, hepatitis B and HIV—from shared and unclean syringes.

From 2006 to 2012, during the rise of the epidemic in the region, Kentucky, Tennessee, Virginia and West Virginia experienced a 364 percent rise in hepatitis C infections.

These risks translate to real costs for states where abuse is the worst. In North Carolina, the state Department of Health and Human Services reported that between 2011 and 2016 Medicaid charges for hep C treatment spiraled from $3.8 million to $85 million.

Led by the North Carolina Harm Reduction Coalition, which provides support and services to help reduce the harmful consequences associated with drug use, advocates took action. They helped educate law-enforcement and emergency-response agencies on the efficacy of syringe exchange and enlisted law enforcement’s help in crafting legislation that was widely supported. In July 2016, North Carolina passed House Bill 972, legalizing syringe-exchange programs.

In the first year after legalization in North Carolina, nearly 4,000 people were served by a syringe-exchange program. More than 2,500 HIV tests were administered. Program participants also distributed 5,682 kits of naloxone, a treatment that almost immediately reverses opioid overdose. In that first year, syringe-exchange programs were responsible for more than 2,000 reversals.

According to the report, between 1990, when syringe-exchange programs were legalized in New York City, and 2002, HIV prevalence among studied intravenous drug users decreased from 50 percent to 17 percent. The programs delivered one-year savings to the government of $1,300 to $3,000 per client and reduced HIV treatment costs by $325,000 per HIV case averted.

“While establishing programs to increase access to clean syringes can be a politically contentious issue,” the “Promoting Health and Cost Control” authors write, “the evidence supporting the effectiveness of these programs is overwhelming.”

States have taken different approaches to syringe-exchange legalization. According to Auerbach, “The states that have allowed greater flexibility in terms of the development of those syringe-access programs—for instance, where they’re located, under what circumstances they’re located—have had a greater benefit to health and economics.”

As of last year, there are 320 syringe-exchange programs in 40 states, D.C. and Puerto Rico.

The study also found that universal pre-kindergarten—publicly funded preschool available to all 4-year-olds regardless of family income, the child’s abilities or any other eligibility factor—is another initiative that has produced far-reaching effects.

The authors report that investments in high-quality early-childhood education can reduce the risk of chronic illnesses, obesity and eating disorders, behavioral health problems such as depression and anxiety and more. As a 2017 report titled “Creating a Culture of Health in Appalachia” details, the Appalachian region trails the rest of the country in many of these health outcomes.

The authors site a study conducted in Los Angeles that found that approximately half the cost of a pre-K program can be recouped through reduced public spending on Medicaid and other social programs.

In 2002, West Virginia passed legislation requiring that pre-K be made available to all 4-year-olds in the state by the 2012-13 school year. The West Virginia Universal Pre-K program is now available in every county in the state and is one of three state-funded programs that meet all of the National Institute for Early Education Research’s quality benchmarks.

Between 2003 and 2011, the state’s pre-K participation rate more than doubled, and in the 2016-17 school year nearly two-thirds of all 4-year-olds were enrolled in the program. A 2015 assessment found that third-graders who had attended a pre-K program scored four percentage points higher on average in English Language Arts than those who hadn’t.

Auerbach points out that 20 new governors took office in the last election. His ambition is for the “Promoting Health and Cost Control” report to be a resource as they map their health care strategies. The organization plans to monitor policy changes in respect to the report’s findings through regional meetings with state health officials.

“We think these work,” Auerbach said of the policies highlighted in the report, and “they have the added benefit of being effective before someone becomes ill.”

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Health Care in Appalachia

Why Fewer Appalachians Signed Up for Affordable Care Act Coverage in 2019



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

Fewer residents of Appalachia will have health insurance under the Affordable Care Act in 2019 than the year before. Enrollment numbers are down throughout the region, as they are nationwide, and some advocates say they aren’t surprised.

In 11 of the 13 Appalachian states that enroll residents through the federal website (Maryland and New York administer their own ACA marketplaces), only Mississippi saw a rise in enrollment numbers. West Virginia and Virginia saw the largest declines.

In West Virginia, some 22,600 residents signed up for or renewed health care policies under the ACA, as compared with about 27,400 for 2018, a 17.5 percent drop.

In 2017, 34,045 West Virginians were enrolled.

Of the 39 states that use for enrollment, the only that experienced a steeper decline was Virginia – but that was expected. As allowed for under the Affordable Care Act, Virginia expanded its Medicaid program in 2018, reducing the number of people in need of ACA coverage.

Credit: Kristen Uppercue/100 Days in Appalachia

So if Virginia’s decline was anticipated due to changing health care policies in the state, what happened in West Virginia?

Kat Stoll said the primary factors are a reduction in spending for advertising and assistance, general confusion about the current and future state of the program and a stronger economy. Stoll is the policy director for West Virginians for Affordable Health Care, an advocacy group that works at the state and federal levels on health care issues that affect low-income consumers.  

The advertising budget for the ACA under the Obama administration was more than $100 million a year nationally. The Trump administration slashed that budget by 90 percent.

Stoll believes this has a negative effect.

“People need that reminder,” she said, adding that “with media coverage of the ongoing repeal and replacement debate at the federal level,” the dissemination of information about the program helps clear up confusion.

“I was surprised by how many people thought the [ACA] was gone,” Stoll said.  

She also pointed to the decline in spending for the state’s navigator assistance program, which provides in-person help in determining eligibility and financial assistance for health care coverage.

In 2017 in West Virginia, navigator programs administered by the West Virginia University Research Corporation and First Choice Health Systems received federal grants totaling $600,000. In 2018, those budgets were reduced to $100,000, an 83 percent cut. The Trump administration also cut budgets for navigator programs throughout the country.

Stoll cited a stronger economy as another potential source of the drop in enrollment numbers. The number of West Virginians eligible for Medicaid also declined. Both point to the assumption that more people are working, and may be receiving health care coverage through their employers.

“We were surprised to see the Medicaid enrollment drop,” she said. “We don’t think that was the result of any particular policies at the state level that presented barriers to eligibility for Medicaid. It might actually indicate some uptick in our economy, and that was reflected in some of the revenue estimates from the governor’s office.”

Stoll does not believe the Trump administration’s decision to remove the individual mandate, or the penalty for not having health insurance, was a big factor in the decline in numbers.

“I think people go to the marketplace to get the premium subsidy,” she said. “It’s more of a reward than a penalty system.”

Stoll said about 80 percent of West Virginians in the ACA marketplace receive a premium subsidy.

“I think the key to the marketplace’s success is getting the word out that there are premium subsidies available.”

Stoll cites one final curtailing factor in ACA enrollment: cost.

Cost is a factor for those at the higher-income levels of eligibility who don’t receive a subsidy, she said. And for those of lower-income, “even with generous subsidies, there are still out-of-pocket costs; there are still some premium costs. And when you’re dealing with a family right at that 150 percent of the poverty [level], having to spend perhaps a hundred bucks a month on insurance premiums and knowing you’re going to have copays – that’s a concern.”

“That’s a hard thing to squeeze into your family budget,” she added.

“Affordability has certainly been helped by the Affordable Care Act,” Stoll allowed, “but it’s not solved.”

Nationally, 8.4 million people enrolled or were automatically re-enrolled in an ACA health insurance plan during the 2019 open enrollment period; in 2018, that number was 8.7 million. But the drop wasn’t as precipitous as had been feared after a sluggish start to the six-week open-enrollment period. Enrollment picked up considerably in the final days.

Final enrollment data for 2019 to be released next month will include the results for those states that operate their own marketplace.

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