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North Carolina’s Most Remote Clinic?

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Ocracoke Health Center is likely North Carolina's most remote clinic. It can take as much as four hours to get to the next nearest health care facility, and that's if the ferries are running or a helicopter can make it to the island. Photo: Rose Hoban

The Ocracoke Health Center is one of those vital institutions that keeps the island going, but that doesn’t always translate into fiscal health.

Despite being a business leader in a busy tourist town, Cheryl Ballance sometimes has had to tell summer guests not to come to Ocracoke.

Cheryl Ballance works in her office at the Ocracoke Health Center. She said the clinic’s payor mix consists of about a third of patients who are uninsured and pay on a sliding scale, including paying next to nothing. The rest of her patients are about 20 percent Medicaid, about 20 percent Medicare and the remaining 30 percent are insured. Photo: Rose Hoban

“Sometimes, we’d get calls from people who said they were nine months pregnant with a high-risk pregnancy, wanting to know if we had resources for them,” Ballance said. “I’d tell them, ‘Oh, you really need to look at the map.’”

Ballance, the longtime head of the Ocracoke Health Center, has seen and heard it all from tourists and from the thousand-or-so year-round residents on the 13-mile long island, which lies south of Hatteras Island on the Outer Banks. The health center is an important place on the island’s map, as it’s the only place to get consistent health services. The center does not turn anyone away, insured or not.

Supplementing the remote island’s health care is Gail Covington, a mobile nurse practitioner, who provides services in homes on Ocracoke and Hatteras islands, and who does not take insurance.

“On a summer holiday weekend, we have this blossom of you know, maybe 10,000 people who show up,” Ballance said. ”I think it’s probably like seven to 8,000 during the week.”

Despite the center’s importance to the life of Ocracoke, the past few years have been challenging financially. Ballance said she’s making a go of it, but it’s difficult to keep providing high-quality care on a shrinking health care dollar in one of the most remote and sparsely populated parts of the state.

Seasonal Work, Yearround Expenses

One issue for Ballance is about a third of her patients are uninsured, even as they work two, three, even four gigs at a time during tourist season, when there’s work to be had.

“The people who support this whole resort are people who are only employed, if they’re lucky, somewhat in April, May, June, July, August, and if we don’t have hurricanes September and October,” she said. “Then by November, everything is closed.”

“They’re making a year’s worth of income during that five to six month period.”

Some workers do leave the island in winter, Ballance said. Maybe “they have a friend that lives out in the mountains, ‘Can you come up here for three weeks, we’re really busy, you can help us at ski lodge?’”

But for many people on the island, funds begin to dwindle in the lean months of the late winter, especially as unemployment checks peter out. It’s something familiar to Erin O’Neal, the clinic’s chief operating officer, who used to work in restaurants when she’d come home from school.

“Anybody who’s waiting tables, and you got a lot of that, or cleaning rooms, aren’t a high hourly rate, their unemployment is gonna be the lowest,” O’Neal said, noting how the law changed to shorten the number of weeks someone can draw an unemployment check. “And if there was a storm, and they drew on their unemployment during that time, they’ve already used part of their weeks before they’ve even gone out with their season. So it’s an even longer extended period of time with no income, it’s really hard for people.”

The flip side is that winters give the clinic’s doctor, Erin Baker, time to dig into problems.

Dr. Erin Baker has been at the Ocracoke Health Center for six years and she’s settled in on the island. She’s the facility’s only physician. Behind her is a telehealth kiosk. Photo: Rose Hoban

“In the summertime, she’s clipping those visits for the residents,“ because the clinic is hopping, Ballance said. “But she spends a lot of time, time you’re never going to get anywhere else … in the winter.”

Getting Away Has a Cost

The isolation that tourists crave also poses challenges for the locals.

When Vince O’Neal was a kid on Ocracoke, his only medical encounters were with the school nurse or his grandmother, a midwife who delivered the island’s babies for decades. That was before the clinic started in 1981.

“We did not have any kind of medical services here until that clinic was built,” said the 59-year-old restaurant owner, and, by his reckoning, eighth-generation Ocracoker.

Otherwise, it was off the island to the doctor, a trip that could take hours, or even a whole day.

Merrian Midgett checks in the prescriptions that came over via courier on the Hatteras morning ferry. There’s no pharmacy on Ocracoke, so if a patient needs medications, they come from Hatteras, that is, if the ferry’s running. Photo: Rose Hoban

Access to emergency care from Ocracoke has gotten better over the years. There are always emergency medical technicians on the island and helicopter service to Vidant Medical Center in Greenville or to the Outer Banks Hospital in Nags Head, but there’s no pharmacy and no lab.

Getting off the island takes hours by ferry to the mainland and then to the nearest hospital or an hourlong ferry ride to Hatteras from the northern end of the island and another 90 minutes from there to Nags Head.

So much depends on the ferry. If the weather turns stormy or foggy, the ferries don’t run. Even when they do, getting to a specialist off the island or to the dentist can mean getting up at 3:30 a.m. to get the 5 a.m. Hatteras ferry run. Prescriptions? They come by courier from Hatteras every afternoon.

But if a tourist gets a stingray barb in their foot or a severe sunburn, the center is where they turn.

“We have people who have been coming here for years,” O’Neal said. “They come every season … they’re already in our system.”

Quality on a Thin Budget

Many of the clinic’s child patients are covered by Medicaid, but Ballance said there’s uncertainty about that payment stream too, as the program gets set to transform from a fee-for-service to managed care payment regimen, where clinics such as OHC get paid a set monthly fee in return for providing all of a patient’s needs.

“We want to sign with every (managed care) provider,” Ballance said. “But I don’t want to sign and then I get, you know, 20 percent less reimbursement. I want to get the same reimbursement, like I get with Blue Cross Blue Shield right now.”

Merrian Midgett greets patients as they come into the Ocracoke Health Center. Photo: Rose Hoban

OHC has achieved the benchmarks required to be a “quality provider” for BCBSNC, which comes with enhanced payment. But achieving the benchmark to become a quality provider has meant extra work.

“We’re almost at that breaking point. I mean, we’re really on the brink, that we have to hire another person,” she said, noting that the cost of living on Ocracoke can make it challenging to recruit year-round workers. “We don’t earn resort income, but we pay resort prices to live here.”

Even the well-paying patients haven’t been as profitable. Traditionally, the clinic has been happy to treat tourists, who do often have jobs – with insurance – that pay enough for them to come to the island for a vacation. But commercial reimbursements haven’t been keeping pace.

“We barely do a margin in our busy season, June, July and August,” Ballance said.

If it weren’t for the funds the center gets for being a “federally qualified” health center, the fundraising and foundation grants, there’d be no way to keep health care going on the island.

“Health care is vitally important for the island, both to meet the needs of the local community and the tourist population,” said Helena Stevens, who heads the Ocracoke Civic and Business Association. She said her organization supports all of Ballance’s fundraising efforts, such as a seafood dinner later this summer.

She wouldn’t even speculate what losing the clinic would mean to the island.

Erin O’Neal (L) and Cheryl Ballance (R) stand in front of the Ocracoke Health Center, which opened in 1981. Photo: Rose Hoban

This article was originally published by the Daily Yonder. It was co-published by North Carolina Health News with the Ocracoke Observer, which has a version in their August print edition. It is reprinted here with permission.

Rural Health Care

Complex Factors Create Lack Of Health-Insurance Competition In Rural Areas

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The small city of Hazard, Kentucky. Photo: AP Photo/David Stephenson

If policymakers use market-based approaches to solve healthcare access problems, they need a better understanding of how rural markets work, says one researcher.

A lack of competition among health insurers in rural areas has reduced the ability of market-based approaches to increase insurance enrollment, a new study says.

The Affordable Care Act of 2010 sought to improve the health-insurance access in part through fostering more competition among insurers. But rural markets have less competition than metropolitan ones, so the impact of market-focused strategies is diminished, according to a study by the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis.

The study looked at insurer participation data across three market-based health insurance programs — the Federal Employees Health Benefits Program (FEHBP), Medicare Advantage (MA) and Health Insurance Marketplaces (HIMs – which were created under the Affordable Care Act). Researchers aimed to see whether the competition within an insurance market affected an individual’s decision to purchase health insurance.

That information is key in determining whether market-based health-insurance helps increase enrollment rates in rural areas where population is less dense.

The study found that, in areas that had been dominated by a smaller number of insurers in the past, the Affordable Care Act’s health-insurance marketplaces for individual policies had lower enrollment.

“This finding suggests that an underlying level of competition, based upon historic and/or institutional factors, plays a role in [the Affordable Care Act health-insurance marketplace’s] success or lack thereof in rural places,” the study said.

The study also indicates that a lack of population density doesn’t lower health-insurance enrollment. Rather, the region’s previous lack of competition predicted the lower enrollment rates.

The study used data from the three health insurance programs, as well as the “Herfindahl Index,” which measures market concentration.

Data showed that insurer participation began to decrease in 2017, across the country, but most especially in rural counties and in states that did not expand Medicaid.

Focusing on counties with population densities below 100 people per square mile, the study found that counties that continued to attract insurers tended to have lower prior-year Herfindahl indexes, meaning the counties previously had market competition.

“Over the first four years of [health-insurance marketplace] operation, 2014-17, there was significant entry and exit of insurers in both urban and rural counties,” the study found. “In 2017, data began to show signs of weakening insurer participation, especially in rural counties and in states that did not implement Medicaid expansion.”

The study concluded that a complex set of factors, not just population density, made rural areas less competitive.

“Years of evidence across three market-based health insurance programs clearly indicate that rural places are less competitive,” the study found. “Our findings suggest that while this is due in part to the limitations of small populations, low population density, and fewer available providers, other factors are also at work.”

Those other factors can include things like “the presence and type of hospital systems, the policy environment at the state level, the entrenchment of certain insurers who were early entrants to the private market, the payer mix and even the specific geography in terms of terrain and infrastructure.”

Abby Barker, with RUPRI, said in an email to the Daily Yonder that the study points to the need for a re-evaluation of how rural areas are different than urban areas.

“I think you could say that population density, and some of those other population-related measures… are expected to be significant. But what we added is this measure of competition that shows that another explanatory factor is how concentrated the market is and has been over time. The methods don’t really identify which is MORE important, but the contribution of this work is to say that prior market concentration matters. In my view, it suggests that policies that rely on competition to achieve certain access/affordability goals, really have to be intentional about overcoming this sort of inertia that tends to exist. Once certain insurance issuers are established in a particular geographic region, it’s a little harder for new ones to come in.”

Policies should address the specific needs of rural areas in the future, she said.

“This brief didn’t really examine the urban county data, but I think implicitly our message is that rural places DO have the potential to be different in terms of how much we can rely upon the market model to work well, at least in certain rural places, at least without recognition that rural places may require something explicit in a market-based policy to mitigate these types of issues,” she said.

This article was originally published by the Daily Yonder.

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Rural Health Care

Federal Efforts to Help Rural Hospitals Could Hurt Urban Ones, Opponents Say

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In this Thursday, July 30, 2015, photo, a sign stating "Save Our Hospital" sits outside of Wedowee Hospital in Wedowee, Ala. Eight rural hospitals have closed in Alabama over the last 15 years and more closures are possible as rural hospitals struggle to stay open. Voters in Randolph County will go to the polls Tuesday on a proposed one percent sales tax to try to keep the doors of the hospital open. (AP Photo/Brynn Anderson)

A Trump administration proposal calls for increasing Medicare reimbursements for some rural hospitals by taking money from hospitals in major urban areas. Both opponents and proponents of the measure say the entire Medicare reimbursement system needs an overhaul.

While proposed changes to Medicare reimbursements to hospitals may keep some rural hospitals from closing, industry executives say the entire system of reimbursement needs to be reformulated.

A proposal by the Trump administration would raise reimbursement rates for some rural hospitals by taking the money from reimbursements to the richest hospitals. Advocates for rural hospitals say it is a way to save those hospitals from closing. But hospital advocates in urban areas say their hospitals shouldn’t be penalized to help those in poorer communities. Still, others say the way reimbursements are determined is flawed.

For some rural hospitals, the proposal could be a game-changer. But about half of all rural hospitals won’t be affected by the changes.

Currently, Medicare reimbursement for hospitals is determined by the U.S. Center for Medicare and Medicaid Services (CMS) using the “area wage index,” which adjusts a hospital’s reimbursement rate based on how much the hospital pays its staff. Hospitals report their wages to the CMS, where they are compared to wages in their respective labor markets. The index is intended to create an annually updated measure that shows how hospital wages compare across regions.

Under this method, hospitals located where wages are lower than the national average receive lower reimbursement rates than those in areas where wages are higher than the national average. Research from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill found that the median wage index for urban hospitals is substantially higher than the median wage index for rural hospitals, regardless of the hospital’s size.

According to the CMS, the system perpetuates an already existing inequity.

“High wage index hospitals, by virtue of higher Medicare payments, can afford to pay their staff more, allowing the hospitals to continue operating as high wage index hospitals,” CMS said in a statement. “Conversely, low wage index hospitals often cannot afford to pay wages that would allow them to climb to a higher wage index. Over time, this creates a downward spiral that increases the disparity in payments between high wage index hospitals and low wage index hospitals, and payment for rural hospitals and other low wage index hospitals declines.”

Source: National Rural Health Association ruralhealthweb.org | @NRHA_Advocacy

Proposed Changes

To address this, in April CMS Director Seema Verma proposed changing the system to increase reimbursements for hospitals near the bottom of the area wage index and to reduce reimbursements for those near the top of the wage index. (Under the proposal, hospitals in the bottom 25 percent of the wage index would increase by half the difference between their wage index value and the national 25th percentile wage index value. Hospitals in the top 25 percent of the wage index would receive lower reimbursements, which would keep the changes from raising the overall cost of the program.)

Verma called the policy a rethinking of rural healthcare.

“One in five Americans are living in rural areas and the hospitals that serve them are the backbone of our nation’s healthcare system,” Verma said. “Rural Americans face many obstacles as the result of our fragmented healthcare system, including living in communities with disproportionately higher poverty rates, more chronic conditions and more uninsured or underinsured individuals.”

The difference could mean thousands of dollars per patient for rural hospitals.

For example, under the current reimbursement system, a hospital in a rural community might receive a payment of $4,000 for treating a patient for pneumonia, according to CMS. But at a hospital in an urban community with a higher wage index, the same treatment might be reimbursed at a rate of $6,000.

Still, those payments are well below what hospitals must spend to treat patients. According to a study by the AHA in 2015, Medicare and Medicare reimbursements to hospitals were $57.8 billion less than what it costs the hospitals to provide services.

The study found that Medicare reimbursements amounted to an estimated 88 cents for every dollar spent by the hospitals.

“Payment rates for Medicare and Medicaid, with the exception of managed care plans, are set by law rather than through a negotiation process, as with private insurers,” the study found. “These payment rates are currently set below the costs of providing care, resulting in underpayment.”

Something Is Better Than Nothing for Many

For some hospitals, the money they get from Medicare may be pennies on the dollar but may still generate substantial revenue for the healthcare organization. And the consequences of not having that federal funding can be dire.

The Pineville Community Hospital Association (PCHA) in Pineville, Kentucky, filed for bankruptcy in November 2018. As part of that filing, Jon Gay, with Lexington-based law firm Walther, Gay & Mack, an attorney for the bankruptcy trustee, said an estimated 90 percent of the hospital’s patients were Medicare or Medicaid recipients. In June 2019, according to bankruptcy records, a deal was reached to have personal property, certificates of needs and other licenses transferred to a non-profit organization, Pineville Community Health Center (PCHC), which took over hospital operations.

The city of Pineville stepped in to help the hospital, loaning PCHC $300,000 to ensure the hospital stays open. For residents in the Pineville area, the closure would mean traveling to the next nearest hospital more than 15 miles away.

Prior to that June agreement, however, CMS had terminated its agreements with PCHA after an investigation found several lapses in patient care, meaning no payments would be made for any future Medicare or Medicaid patients to the hospital. While PCHC is working with CMS to obtain a new provider agreement, the loss of federal revenue to the hospital forced the facility to lay off half of its staff — an estimated 60 people.

“Without Medicare (and) Medicaid, we can’t operate because 75 percent of our revenue is generated through Medicare and Medicaid,” Pineville Mayor Scott Madon told WYMT TV in a June 3 interview.

Pineville, the county seat of Bell County, had a population of 1,732 in the 2010 census. Bell County’s unemployment rate has remained relatively stable, sitting at 5.8 percent as of February 2019. But, according to numbers from the Kentucky Center for Statistics within the Kentucky Department of Education and Workforce, the county’s total workforce in February was 8,448 people. A difference of just 60 unemployed residents would raise the county’s unemployment rate to 6.5 percent. As one of the largest employers in the county, if the hospital were to close, creating the loss of another 60 jobs, the county’s unemployment rate would jump to 7.2 percent, one of the top 10 highest unemployment rates in the state.

Craig Becker, president and CEO of the Tennessee Hospital Association, said the changes to the Medicare reimbursement rates could reshape his state’s healthcare system.

The proposed changes would allow Tennessee hospitals, especially those in East and rural Tennessee, to keep healthcare professionals on staff, as well as help hospitals continue to provide services to their communities, he said.

“Because of the broken Medicare formula, hospitals in Tennessee have lost more than $300 million in Medicare reimbursement in the last 10 years. That money could have been applied to technology, higher wages, recruitment efforts, purchasing of medical equipment and updating many of our aging facilities,” he said in an editorial in the Tennessean.

The issue is particularly important for those in rural Tennessee, he said, where 10 rural hospitals have closed in recent years. Becker said one reason for their closures, among the many, was the area wage index and declining reimbursements.

A Flawed System

Nationally, however, many feel that taking from urban hospitals to give to rural hospitals isn’t an answer to the funding crisis. American Hospital Association Executive Vice President Tom Nickels said another solution needs to be found.

“The area wage index is intended to recognize differences in resource use across types and location of hospitals. Hospitals, Congress and Medicare officials have repeatedly expressed concern that the wage index is flawed in many respects,” Nickels said in an emailed statement. “The AHA appreciates CMS’s recognition of the wage index’s shortcomings. At the same time, improving wage index values for some hospitals – while much needed – by cutting payments to other hospitals, particularly when Medicare already pays far less than the cost of care, is problematic. CMS has the ability to provide needed relief to low-wage areas without penalizing high-wage areas.”

In fact, a study by the U.S. Office of Inspector General entitled “Significant Vulnerabilities Exist in the Hospital Wage Index System for Medicare Payments” found that the Medicare reimbursement system is flawed. CMS lacks the ability to penalize hospitals that submit inaccurate or incomplete wage data and has little oversight to ensure hospitals submit accurate data, the report said.

The Inspector General’s report found that these vulnerabilities might prevent the CMS from accurately determining local wages, which would, in turn, affect Medicare payments to hospitals.

But that doesn’t begin to cover how flawed the system is, said Alan Morgan, CEO for the National Rural Hospital Association in Washington, D. C.

The proposed changes won’t address the needs of nearly half the rural hospitals in the country, those considered critical access hospitals, he said. Critical access hospitals, generally speaking, are those with fewer than 25 inpatient beds in rural areas. For those 1,300 rural hospitals, which are not dependent upon the wage index, the administration’s proposal would have no effect.

“Is this (proposal) a good thing? Yes,” Morgan said. “Is this going to address some payment inequities? Yes. Is this going to solve all the problems faced by rural hospitals? No. It’s a good provision. It’s a targeted provision. But it won’t help almost half of the rural hospitals in our country.”

This article was originally published by the Daily Yonder.

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Rural Health Care

N.C. Attorney General Approves Sale of Rural Hospital System, But with Added Protections

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North Carolina Attorney General Josh Stein in Asheville last Wednesday posing with members of the Health Equity Coalition after announcing his approval of the sale of Mission Health to HCA. Photo: Deborah Miles

Citizens were concerned. They voiced those concerns. And it appears their voices were heard.

When it was announced in August that Nashville-based HCA Healthcare had reached a deal to purchase Mission Health, many residents of Western North Carolina – most particularly those in the region’s rural communities – had trepidations about ceding control of their health care future to an outside operation.

Mission Health is based in Asheville, a city of 90,000 and the economic hub of otherwise largely rural Western North Carolina. It’s a not-for-profit health care system – the only one managed in the region – covering 18 counties. In addition to its flagship medical center, Mission Hospital in Asheville, Mission owns five smaller hospitals in the surrounding rural counties. 

HCA is a for-profit system that owns 178 hospitals in 20 states. The asset purchase agreement stipulated that a newly formed foundation called the Dogwood Health Trust would manage the proceeds of the sale, with an objective to use social determinants of health to improve the health and well-being of the communities Mission Health now serves.

The $1.5 billion deal was contingent on the approval of North Carolina Attorney General Josh Stein. Stein deliberated for some five months, and last week announced that he was granting that approval, but with the addition of significant provisions to preserve the delivery of health care services throughout the whole of the region – provisions that were agreed to by HCA and Mission Health.

“It really feels like we all pulled together to do some good things for the people of Western North Carolina,” said Risa Larsen, one of many of the region’s residents who advocated for more protections. “We’re overwhelmed with the fact that what’s in the new agreement way exceeded our expectations.”

Heightened Oversight

In the original draft of the agreement between HCA and Mission, HCA committed to providing services at the smaller regional hospitals for five years. That commitment has now been extended to 10 years.

The revision also provides more explicit language on exactly what services must be provided.

Further, HCA is prohibited from closing any facilities or discontinuing services unless agreed upon by both a hospital’s local advisory board and an independent monitor. That monitor will also regularly review whether HCA is maintaining its overall commitments.

Jay Nixon, the former governor and attorney general of Missouri who was brought in by citizen advocates as an advocacy consultant while the attorney general deliberated over the proposed sale, said the addition of this independent oversight is a significant development. Advocates feared that a local advisory board would alone be insufficient protection, given that half of its members would be appointed by HCA, the other half by Mission.

Nixon, who, as Missouri’s attorney general, challenged HCA in the courts, is also encouraged by the enforcement powers the agreement vests in the attorney general’s office, and in measures added to maintain transparency.

According to the agreement letter, Dogwood Trust will hold public meetings “to discuss the needs of the region and to obtain input on the priorities for addressing the social determinants of health” in Western North Carolina.

Dogwood will hold an open meeting with the public each year and will provide an annual report detailing how it’s using its funds

“General Stein and his staff stepped up to the challenge,” Nixon said, “and I believe the citizens of the region were a very positive, direct force in assisting him and his team in dramatically improving this agreement and raising the clear opportunities that the region will have for decades to come.”

Committing to Diversity

Equally important to advocates was regional, ethnic and gender diversity on the proposed 15-member Dogwood Health Trust board.

Dogwood has committed to having no more than five members from any one county by Jan. 1 of next year and no more than four members from any county by 2021. This is good news for those who feared the board would be Asheville-centric, removed from the concerns of its rural neighbors. The Dogwood board must include at least one member from each of the five regions with a hospital by Jan. 1 of next year.

And in a commitment letter to Stein’s office, Dogwood chair Janice Brumit wrote that the foundation would take into consideration ethnic and gender diversity as part of the its “commitment to be fully and fairly representative of western North Carolina.”

The revised agreement gives the local foundations that oversee the individual hospitals more flexibility in pursuing their own health care initiatives. And the local foundations and Dogwood Health Trust will have the right to bid on hospitals if they’re put on the market or closed.

The deal also stipulates that Dogwood will commit $25 million over five years to addressing opioid use disorder.

“Access to healthcare is truly a life or death issue,” Stein said in a press release announcing the agreement. “I am satisfied that this new agreement protects healthcare in western North Carolina, ensures that the full value of Mission’s assets will continue to be used for public purposes, and requires that the Dogwood Health Trust will be independent and representative.”

Due Diligence

Risa Larsen said the wait for Stein’s decision had been anxiety-inducing; the outcome, sweet.

“We really appreciate the hard work that the attorney general, his office, Mission, HCA and Dogwood Health Trust have done,” Larsen said. “I mean, good night, they’ve been working hard. The 10-year commitment on the rural hospitals, the more explicit language about the services, the independent monitoring – I never would have thought that would happen.”

“I’m delighted,” said Highlands Mayor Pat Taylor, who’s been at the forefront of the effort to secure more protections.

Asked if he saw any holes in the agreement, Taylor said, “Not anything that can’t be addressed and worked out. This is a complicated process, so I know there are going to be some problems and some holes. But I think we have a good foundation now to all work together to provide good health care for this region.”

“It’s important to take a deep breath,” Nixon said, and assess the task ahead. Western North Carolina will now have “a $1.5 billion foundation specifically to address health outcomes in the region while not taking away any of the hospitals or institutions.”

“But the public is going to have to stay involved,” he cautioned. “You saw in this situation, I believe, that an involved public – an informed citizenry that respectfully, in essence, petitioned their government – was a positive force for goodness here.”

“This is how it’s supposed to work. This is what democracy is supposed to look like,” Nixon avowed, praising Stein’s office for its openness and availability to all parties involved. “But I do think that folks are going to have to continue to stay vigilant.”

“Everybody played a part in moving this to a better place,” he concluded, “but everybody needs to continue to play a part in making sure it delivers the maximum of its capacity.”

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