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These Sheriffs Release Sick Inmates to Avoid Paying Their Hospital Bills



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

Inmates suffering heart attacks, on the verge of diabetic comas and brutalized in jail beatings have been released so sheriffs wouldn’t have to pay for their medical care. Some were rearrested once they had recovered.

Michael Tidwell’s blood sugar reading was at least 15 times his normal level when sheriff’s deputies took him to the hospital. But before they loaded the inmate into the back of a car, deputies propped up his slumping body and handed him a pen so he could sign a release from the Washington County Jail.

“I could barely stand up or keep my eyes open,” he recalled.

Tidwell said that he didn’t know what he was signing at the time, and that he lost consciousness a short time later. The consequences of his signature only became clear in the weeks that followed the 2013 medical emergency.

By signing the document, which freed him on bond from the small jail in south Alabama, Tidwell had, in essence, agreed that the Washington County Sheriff’s Office would not be responsible for his medical costs, which included the two days he spent in a diabetic coma in intensive care at Springhill Medical Center in Mobile.

It’s unclear whether Tidwell, who was uninsured at the time and in poor health afterward, was billed for his care or if the medical providers wrote it off. Neither Tidwell’s attorneys nor the hospital was able to say, and Tidwell was unable to get answers when he and a reporter called the hospital’s billing department.

What is clear is that the sheriff’s office avoided paying Tidwell’s hospital bills.

Tidwell had been on the receiving end of a practice referred to by many in law enforcement as a “medical bond.” Sheriffs across Alabama are increasingly deploying the tactic to avoid having to pay when inmates face medical emergencies or require expensive procedures — even ones that are necessary only because an inmate received inadequate care while incarcerated.

What’s more, once they recover, some inmates are quickly rearrested and booked back into the jail from which they were released.

Local jails across the country have long been faulted for providing substandard medical care. In Alabama, for instance, a mentally ill man died from flesh-eating bacteria 15 days after being booked into the Mobile County Metro Jail in 2000. And in 2013, a 19-year-old man died of gangrene less than a month after he was booked into the Madison County Jail. In both cases, officials denied wrongdoing and surviving relatives settled lawsuits alleging that poor jail health care contributed to their loved ones’ deaths.

But the use of medical bonds isn’t about inferior care. It’s about who pays for care.

While medical bonds have been a last resort in many states for more than 20 years, experts say they are employed in Alabama more often than elsewhere. Their use in some counties but not in others illustrates the vast power and latitude that sheriffs have in Alabama, which is the subject of a yearlong examination by and ProPublica.

Several Alabama sheriffs, including Washington County Sheriff Richard Stringer, said in interviews that they often find ways to release inmates with sudden health problems to avoid responsibility for their medical costs. Stringer denied any wrongdoing in his office’s handling of Tidwell’s emergency.

“We had a guy a couple of weeks ago with congestive heart failure. … The judge let him make bond so the county didn’t get stuck with that bill,” Lamar County Sheriff Hal Allred said in a March telephone interview. “We don’t have any medical staff in the jail. I wish we did, that would be great, but the way the county finances are, I won’t live long enough to see it.”

Typically the process works like this: When an inmate awaiting trial is in a medical crisis, a sheriff or jail staffer requests that a judge allow him or her to be released on bond just before, or shortly after, the inmate is taken to a hospital. If the request is granted, the inmate typically signs the document granting the release.

Michael Jackson, district attorney for Alabama’s 4th Judicial Circuit, said he is aware of multiple recent cases in which sheriffs released inmates on bond without first obtaining a judge’s approval. Jackson said he also worries about the risk of inmates reoffending after they receive medical treatment.

“I’m not saying there should be no situation where an inmate can get released early, but it shouldn’t be about money,” Jackson said in a phone interview this month. “No one’s watching them when they get out, and people might get robbed or their houses might get broken into.”

While judges usually sign off on bonds, lawyers who represent inmates and other experts say sheriffs are often the key decision-makers and can be held legally responsible for what happens after they release inmates via such methods.

If an inmate is already sick or injured when he or she is released, sheriffs are “not going to be able to avoid the liability just by opening the trap door and letting them go,” said Henry Brewster, one of Tidwell’s attorneys.

“They Have to Do Something”

Shortly after Tidwell was locked up for a probation violation in 2013, his sister Michelle Alford, a nurse at a Mobile hospital, said she brought his diabetes medications to the Washington County Jail and gave them to the guard on duty.

She says she explained to the staff that her brother is a “brittle” diabetic, meaning he needs frequent monitoring. She provided the jail with a two-page document that explained how often his blood sugar needed to be checked, what symptoms to watch for and the purpose of each medication.

The jail’s employees, none of whom had any formal medical training, did not follow those instructions, according to Tidwell’s jailhouse medical records, a copy of which Alford provided to and ProPublica.

On his fourth day in the aging jailhouse, Tidwell became ill and vomited off and on for the ensuing 48 hours. He was unconscious for most of his final two days there, according to court and medical records.

Before he was taken to Washington County Hospital, Tidwell’s blood sugar reading was 1,500 mg/dl; a normal reading for him is 80 to 100 mg/dl. Over the less than seven full days he was incarcerated, he had lost at least 17 pounds, records show.

Tidwell’s release form bears his signature scrawled incomprehensibly outside the signature box, overlapping the typed prompt for “Signature of Defendant.” It does not match other examples of his signature on court documents reviewed by and ProPublica.

“If you’re in there and you get sick, they have to do something and get some medical attention,” he said. “But if you’re in so bad of shape that they’re trying to hold you up and get you to sign something, that’s wrong.”

Tidwell, who was 42 at the time, was assessed at the local hospital and taken to Springhill, a larger and better-equipped hospital, where he lay in a coma in the intensive care unit. He was suffering from renal failure and other complications related to his diabetes, according to the records.

During a conversation in his office in downtown Chatom, Stringer, the Washington County sheriff, said that he and his jail staffers are not medically trained. Instead, they “listen to what [inmates are] complaining about and examine them to determine if they need medical bond, because people will do anything to get out of jail.”

If they decide an inmate has a serious and potentially costly medical issue — and doesn’t pose a threat to the public — Stringer said he or the jail’s administrator will call a judge and request that the inmate be released.

Asked last week whether he believes Tidwell was legally able to provide consent to being bonded out, Stringer said: “They’ve got to be physically able to sign the bond. I’m sure he was [conscious] or he wouldn’t have been able to be bonded out. … It’s been so long ago it’s hard to remember all these things. I’m sure we did what needed to be done.”

But in an earlier interview, the sheriff provided an alternate explanation for Tidwell’s hospitalization.

“When someone comes in and says he’s a diabetic, we try to prepare a meal that will accommodate his diabetes,” Stringer said. “But now on commissary, they’re on their own there. I mean, you know you’re diabetic. Don’t order — he actually ordered 12 honey buns.”

Tidwell, who denies eating a dozen honey buns in the jail, recovered and was sent home from the hospital.

He filed a lawsuit against Stringer and several sheriff’s office employees in 2014; it was settled the following year. Stringer said he believes he and his employees would have been exonerated had the suit gone to trial, but because he said the settlement was for “something like $20,000 … it’s not worth fighting it.”

But Tidwell’s problems didn’t end there. Exactly three months after Tidwell was released on bond, a judge issued a bench warrant for his arrest on another probation violation.

“They’ll Lower the Bond” and ProPublica have reviewed the cases or media reports of inmates in 15 of Alabama’s 67 counties who were issued last-minute bonds or released on their own recognizance just before they were hospitalized for emergencies.

In September 2018, for instance, a 38-year-old inmate at the Lauderdale County Jail was taken to a nearby hospital after he suffered a stroke that left him partially paralyzed and unable to communicate verbally, stand or perform daily tasks, state court records show. The inmate, Scottie Davis, was released from sheriff’s office custody on bond the following day, though he couldn’t sign the release document. Someone instead wrote the words “Unable to sign due to medical cond.” in the space for the inmate’s signature. Davis was responsible for the medical costs after he was bonded out.

Lauderdale County Sheriff Rick Singleton said when inmates are too ill to sign their names, sheriff’s officials notify a judge who decides whether to allow them to be released on bond.

And earlier last year, in Randolph County, an inmate was released on a medical bond before going to the hospital for surgery, according to The Randolph Leader, a local newspaper. When he wasn’t able to immediately get the procedure, he was rearrested on a new misdemeanor charge and booked back into the Randolph County Jail.

The county ended up on the hook for over $10,000 the procedure was expected to cost. Some county officials view the turn of events as an unfortunate financial setback.

Randolph County Commissioner Lathonia Wright said in a phone interview this month that paying inmates’ hospital bills is “really rough” on the county’s budget, but it sometimes can’t be avoided.

“I hate that we have to pay for it out of taxpayer money, but the law demands that we take care of people that are incarcerated in the jail,” he said. “If we get a bill, we pay for our medical bills. They come straight from the hospital.”

In urban counties with larger populations, the majority of inmates’ medical problems are dealt with in the jails, usually by private companies that provide infirmaries, round-the-clock nurses and doctors who make regular visits.

But in some rural counties, sheriffs do not have any staff members with medical training or the budget to absorb significant hospital costs.

Jim Underwood, who was sheriff of Walker County from 2015 until January, said the county budgeted about $350,000 per year for jail health care while he was in office. The sheriff’s office did everything it could to keep costs down, Underwood said, adding that before he was sheriff, one inmate’s medical care cost about $300,000.

“I think that a lot of it does depend on what they’re charged with … but there are people released because of medical bills,” he said. “You have to go through the judge; they’ll lower the bond.”

Underwood said he believes the practice “happens everywhere” in Alabama, though it takes different forms in different counties. One sheriff’s office has paid for inmates to wear ankle monitors while out on bond for unexpected medical care; another waited for an inmate’s relatives to secure a private bond before allowing him to be taken to a hospital, records show.

Sheriff’s officials in Washington County, where Tidwell was in custody, have faced other lawsuits alleging improper use of medical bonds, including in the case of a woman who died of a stroke one day after being released from the county’s jail in 2016. In that case, which was settled this year, an audio recording captured a top sheriff’s office official asking jail staff to ensure the woman was released on a medical furlough, a method of release similar to a medical bond, before taking her to the hospital.

Nora Demleitner, a law professor at Washington and Lee University in Virginia who specializes in criminal sentencing, said medical bonds may violate inmates’ rights and the way some sheriffs use them is “totally flawed.”

“It’s a stunning problem,” she said. “When [inmates] file lawsuits, and rightly so, they should get civil compensation.”

Demleitner added via email that the phenomenon is prevalent in a number of counties and entirely absent in others. and ProPublica have reviewed media reports of sheriffs pursuing medical bonds for inmates with medical crises in 25 states.

Alan Lasseter, a Birmingham-based attorney who has filed lawsuits over alleged police misconduct and jail health care issues, said sheriffs’ reliance on medical bonds appears to be on the rise.

“It’s only something I’ve been hearing about for about two years, maybe longer, but it’s becoming more common and it’s really starting to resonate with me that it’s been happening more and more in Alabama,” Lasseter said.

“They Are Responsible”

Marcus Echols said his daughter was 9 years old when he first learned that she was his child. Until then, the girl’s mother had been collecting child support from another man who was eventually determined not to be her father, according to court records and Echols.

In 1998, a judge in Morgan County ordered Echols to pay more than $9,000 worth of back child support and interest in monthly payments of $500.

Over the ensuing years, Echols, who pays support on other children and has had trouble keeping a job, repeatedly failed to make the required payments. By November 2015, when he was arrested for contempt of court for failure to make child support payments, his debt totaled more than $50,000. He was booked into the Morgan County Jail in Decatur, a city in north Alabama.

Two months later, on Jan. 16, 2016, Echols suffered a heart attack inside his painted cinder-block cell.

For over half an hour, guards argued over whether he needed to be taken to the hospital, Echols, now 49, said.

They eventually took him to Huntsville Hospital. Several hours later, Echols said, he awoke from a procedure and was told by a doctor that he had needed three stents inserted because his heart had suffered extensive damage over the extended period of time between when he went into cardiac arrest and his arrival at the hospital. Medical records reviewed by and ProPublica confirm Echols’ account of his condition and treatment.

The doctor also informed him that he had been officially released from Morgan County Sheriff’s Office custody, Echols said.

Echols said he was glad to find out that he would be allowed to go home instead of back to jail, but when he received a bill less than two weeks later from Huntsville Hospital for the costs of his medical care, he learned that he was personally responsible for more than $80,000.

“I didn’t get the bill until about a week after I got out of the hospital,” Echols said. “It just showed up in the mail.”

Echols said he never learned what mechanism the sheriff’s office had used to release him from its custody, and none of the court records associated with his lawsuit provide any clarity.

“I didn’t sign nothing. … When I woke up,” he said, “the doctor told me that the sheriff’s office had told him to tell me that I had been released from jail.”

A local charitable foundation ultimately paid Echols’ bills. But he still feels that he was taken advantage of.

“It seems like a scam that they’re running. They’re running the jail at the lowest possible cost at the expense of everyone else.”

Ana Franklin, who was sheriff at the time of Echols’ incarceration and hospitalization, declined to comment on Echols’ experience. But she said her “first consideration in whether or not to release someone on a medical release was never the budget.” She said the primary factors that drove such determinations when she was sheriff included criminal history, risk of reoffense and whether the jail was equipped to provide adequate medical care.

“It’s great to just say the sheriffs cut them loose because it saves them money on their medical,” said Franklin, who pleaded guilty last year to a federal charge of failing to file an income tax return. “But it’s just as big a liability issue that an inmate is going to say that we didn’t provide adequate treatment for them in the jail as it is that he’s going to sue us and say we cut him loose and they had to pay their medical bills.”

In March 2016, just a few weeks after Echols’ heart attack, the sheriff’s office attempted to obtain a new warrant to arrest him for contempt of court for his continued failure to pay the thousands of dollars worth of back child support he still owed.

Morgan County District Judge Charles B. Langham issued an order stating that Echols “is still under medical care” — he was attending cardiac rehab sessions at the time — and denied the sheriff’s office’s request. A year later, Langham issued an order for a new warrant for Echols’ arrest. At the time, Echols was unable to work, had applied for federal disability and was living with relatives.

Echols’ sister, Lashundra Craig, said she takes issue with the sheriff’s office’s persistent attempts to arrest her brother despite his continuing health issues.

“They are responsible for whatever happens to the inmates. … If they don’t want to be responsible for the medical costs but they want to put you back in jail to face your responsibility, to me it’s showing they just still want their money,” she said.

“They Said They Would Release Me”

It has historically been difficult for inmates to prevail in lawsuits alleging that sheriffs violated their rights by releasing them while they required medical attention.

On July 3, 1996, four inmates beat Leroy Owens with a metal pipe; stabbed him with a screwdriver; kicked, stomped and punched him; and left him in a pool of blood in a common room on the second floor of the Butler County Jail in Alabama’s Black Belt.

Owens described the events of that evening in a recent interview, and they are laid out in detail in the records of the federal court case he and a fellow inmate who was also beaten would later file against then-sheriff Diane Harris, the county and the county commission in Alabama’s Middle District in Montgomery.

For nearly an hour, no one answered Owens’ cries for help or those of other inmates who banged on the jail’s walls, one of whom yelled, “They’re killing him up here,” according to the court records.

Finally, Harris’ chief deputy, Phillip Hartley, was called to the jail. Twenty minutes after the attack ended, Owens was taken downstairs and then driven to a nearby hospital, where he was treated for his injuries.

The hospital released Owens into the custody of two sheriff’s deputies, who were given a discharge document detailing “specific procedures to care for Owens’s head wounds and other injuries. It instructed them to monitor his level of consciousness, pupils, vision, and coordination, and to call the hospital immediately if any change occurred,” according to a summary of Owens’ allegations included in the U.S. Court of Appeals for the 11th Circuit’s ruling on the appeal of his federal case.

Instead, after they arrived at the jail, Hartley insisted that the bloodied inmate sign a bond granting his release, according to Owens and the court records.

“I signed out of the jail. All I know is it was a piece of paper I signed. I was bleeding and I was coming in and out of consciousness,” Owens, who is now 56, said last month. “They said they would release me if I signed it.”

After Owens signed the bond, Hartley drove him almost to the county line and dropped him off at about 3:30 a.m. on July 4, 1996, on the side of a desolate stretch of highway, without shoes, according to Owens and the court records.

“When he released me from the jail, he took me to the edge of the county and he said, ‘Your best bet is to leave town,’” Owens recalled.

After spending the night in a hotel, Owens awoke “in terrible pain” and was taken by ambulance back to the emergency room, according to the court records. He returned to the hospital again on July 8 for further treatment, the court records show.

Medicaid ultimately paid the hospital bills Owens incurred after he was bonded out from the jail.

Danny Bond, the current sheriff of Butler County, did not respond to repeated requests for comment.

In 2001, the 11th Circuit reinstated Owens’ case against the county, the sheriff and others after a lower court had dismissed it. The court ruled that though Owens and the other inmate did not prove that Harris or the county were deliberately indifferent to their medical needs, they “sufficiently stated a claim against the County and the Sheriff for the conditions at the Butler County Jail.” The court, however, also found that Harris was “entitled to immunity for her policy of releasing sick and injured inmates.”

Judge Rosemary Barkett, writing for a four-judge minority, disagreed, saying that the allegations of deliberate indifference against Harris should not be dismissed. Barkett wrote that Harris and her staff should have known that releasing Owens and leaving him on the side of the road after 3 a.m. could be a constitutional violation.

Harris and the county denied wrongdoing; Owens and the other inmate plaintiff ultimately settled the suit.

Meanwhile, legal experts who reviewed relevant portions of Alabama’s state code said they were able to find only two vague references to the issue: a statement that certain fees shall not be assessed “if a person is released on judicial public bail or on personal recognizance for a documented medical reason” and a stipulation that “the sheriff or jailer, at the expense of the county,” must provide “necessary medicines and medical attention to those who are sick and injured, when they are unable to provide them for themselves.”

Despite that, some lawyers and experts say inmates often have a hard time winning cases against sheriffs on those grounds.

“If a county sheriff threw someone out of the jail who’s unconscious and said ‘good luck,’ you could possibly make a civil rights violation or negligence claim,” said Paul Saputo, a Dallas-based criminal defense attorney who has represented multiple clients who have been bonded out of jail for medical reasons.

“If you have a heart attack and are taken to a hospital, and the question at the end of the day is who’s gonna pay for it, that’s a little bit closer of a call.”

“They’re Technically Still in Custody”

Lauderdale County, in Alabama’s northwest corner, has taken official action to expand the use of medical bonds.

During its April 25, 2017, meeting, the Lauderdale County Commission agreed to enter into a contract with a Tennessee company to provide ankle monitors and monitoring services for inmates who are permitted to leave the county’s jail to obtain expensive medical treatments.

Lauderdale County District Attorney Chris Connolly explained the concept during a discussion of the ankle monitor plan earlier that month, as Florence’s Times Daily newspaper reported at the time.

“Putting them on an ankle monitor and then releasing them on medical furlough or a recognizance bond would still allow us to have control of them, but also it would make them responsible for any medical treatment or expense,” Connolly said.

The new approach to reducing the jail’s medical costs has been used 12 to 15 times since the contract was signed, Singleton, the Lauderdale County sheriff, said in a telephone interview last month.

“I guess you’d consider it like house arrest,” he said. “They’re technically still in custody” and must immediately return to the jail once they are deemed healthy enough to do so. But instead of adding to the $500,000 of medical care the jail averaged annually as of 2017, the inmates must pay the bill. That means the program has been a success, according to Singleton.

“It’s accomplished what we wanted to accomplish,” he said. “It’s saved us some money.”

Singleton also emphasized that the program does not affect public safety because ankle monitors are only used in cases involving nonviolent inmates who are not considered threats to the community.

Lauderdale County District Judge Carole Medley, who rules on small-time criminal cases nearly every day in her courtroom, said she often grants bonds so inmates can obtain medical care, which they must then pay for themselves. She said that she is “very pro-ankle monitor,” and that she considers the program “a win-win” for inmates and for the jail and the county’s finances.

“I release people on [own recognizance] bonds every other week for medical issues. Do I take into consideration the charge? Of course. And there are times where we release them on an ankle monitor to get their medical needs addressed, and then some of them do return to jail.”

Critics of the practice say it raises important questions about the very purpose of incarceration. For instance, if sheriffs and other officials claim that these inmates must be jailed to prevent them from harming others, punish them for wrongdoing and deter would-be criminals, why are those officials so quick to abandon those goals in order to avoid paying their medical bills?

Jasmine Heiss, a campaign director at the Vera Institute of Justice in New York, said if such inmates can in fact be safely released when doing so saves tax dollars, perhaps they shouldn’t have been incarcerated in the first place.

“Broadly, what we would like to see is people who can be safely released on their own recognizance being released earlier in the process rather than waiting until people have these severe medical crises,” Heiss said.

Research reporter Claire Perlman contributed to this report.

This article was originally published by ProPublica.

This article was produced in partnership with, which is a member of the ProPublica Local Reporting Network. It was originally published by ProPublica.

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

Access To Care

As Rural Americans Struggle for Health Care Access, Insurers May Be Making Things Worse



Dr. Kyle Parks, the only surgeon at Evans Memorial Hospital in Claxton, Ga. The hospital struggles to stay in business while serving large numbers of rural poor. Photo: Russ Bynum/AP Photo

Living in rural America certainly comes with a number of benefits. There is less crime, access to the outdoors, and lower costs of living.

Yet, not everything is rosy outside the city limits. Rural communities face growing infrastructure problems like decaying water systems. And they have more limited access to amenities ranging from grocery stores to movie theaters, lower quality schools, and less access to high-speed internet.

Yet perhaps most daunting are the tremendous health disparities rural Americans face, in terms of both their own health and accessing care.

As a number of my recent studies indicate, these disparities may be exacerbated by insurance carriers and the networks they put together for their consumers.

A sick system that’s getting worse

Rural hospitals such as this one in Belhaven, N.C., have closed in unprecedented numbers in recent years, leading also to doctor shortages. Insurers face challenges in developing networks of doctors to care for patients. Photo: Gerry Broome/AP Photo

At the turn of the last century, cities were known to be cesspools rampant with disease. Much has changed since then. Today, health care disparities between urban and rural America have indeed reversed. And they are growing wider.

Part of the problem is demographic. Over the last several decades, many rural areas have lost a large share of their residents. In many areas, the young are moving away, leaving an aging population behind.

Besides being older, those staying behind are poorer and have lower levels of education. To make things worse, they are also more likely to be uninsured. And they tend to be sicker, exhibiting higher rates of cancer, heart disease, stroke and chronic lower respiratory disease. It comes as no surprise that their life expectancy is generally lower as well.

The demographic challenges are made worse by the limitations posed by the health care system. For one, rural areas are experiencing tremendous health care provider shortages. Access is often particularly limited for specialty care. But much more mundane health care services that most of us take for granted, like hospitals – including public hospitals and maternity wards – are also affected.

Politics have made rural access challenges worse in many places. Partisan opposition to the Affordable Care Act has led many states with large rural populations, like Texas and Kansas, to refuse to expand their Medicaid programs or support enrollment in Affordable Care Act marketplaces. This stance is particularly damaging because the program provides a crucial lifeline to rural providers.

A stark divide

Nikki Kessler in a July 2014 photo is shown in a Lumberton, N.C. hospital. The closure of rural hospitals has not only resulted in fewer hospitals but also narrower insurance networks. Photo: Gerry Broome/AP Photo

Rural communities across the country face tremendous health care access issues. And as recent study my colleagues and I did of access to cardiologists, endocrinologists, OB-GYNs and pediatricians shows, insurance plans may further complicate the issue.

Focusing on California, we compared access between plans sold under the Affordable Care Act and commercially available plans. We also made comparisons to a hypothetical plan that included all of the state’s providers. In theory, this would be the plan available to consumers under various Medicare-for-All proposals.

Overall, we found that consumers living in large metropolitan areas faced only very limited access challenges. However, as distance from cities increased, access worsened significantly. Consumers had fewer providers to choose from, and had to travel further to see them.

One of our starkest findings was the existence of what we called “artificial provider deserts” – areas where providers are practicing and seeing patients, but insurance carriers do not include any of them in their networks. Without access to local providers, some rural residents are forced to travel 120 miles or more to reach in-network care.

Our findings hold for both Affordable Care Act plans and those commercially available, which fared only slightly better.

The problems we found in this study extend well past plans sold on the Affordable Care Act marketplaces. Two of my other studies found similar, if not worse problems, for rural consumers of Medicare Advantage plans in New York and California.

More protections for rural Americans

There are many reasons for the growing disparities between urban and rural America. Many of these aren’t always easily or quickly remedied through government intervention. Indeed, some may be inherent to living outside of metropolitan areas.

Yet when it comes to health care access, our recent work indicates that decisions by insurance carriers may further worsen the situation. Conceivably, insurers may limit access to providers to push sicker populations to enroll with other insurers.

However, the fault may not exclusively lie with insurers. Rural providers may also demand large fees to enter into contracts with insurers, leading insurers to exclude them from their networks.

While regulating provider networks comes with a slew of challenges, it seems apparent to me that our current approach is not working for Rural America. It is time to rethink how we provide and regulate health care access to millions of Americans living in rural areas.

Simon F. Haeder, Assistant Professor of Public Policy, Pennsylvania State University

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

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Access To Care

The High Cost of Living Rural: A Q&A with a Journalist Covering Healthcare in Appalachia



Photo: Natanael Melchor/Unsplash

Rural hospitals across the country are closing in large numbers, making emergency and speciality services harder and harder to come by for Americans who don’t live in urban centers. One hundred and thirteen rural hospitals have closed since 2010, and about a third of the remaining, some 670, were at risk of closing in 2016.

Mason Adams, courtesy photo.

Mason Adams, who is based in Floyd County, Virginia, detailed the impacts of those closures on rural Appalachians in his latest report for In These Times. That includes the increased travel times that many older, poorer Appalachians now face to reach the medical services they need, sometimes requiring helicopter rides in emergency situations that can cost upwards of more than $44,000, more than the average annual income in many of the communities directly effected. 

Adams also details the difficulty communities face in finding adequate services after their local facilities downgrade the services they offer after consolidations in rural healthcare systems, such as trauma care and neonatal intensive care units (NICUs), all of which contribute to the growing cost of rural health care.

Adams spoke with 100 Days in Appalachia’s Kristen Uppercue about his reporting. 

KU: Your report details, the challenges rural Americans, especially those that are older than 65 face when trying to access health care services. Some of the biggest challenges you write about include the impact of hospital closures. But that’s not necessarily a new issue. Outlets throughout the region have been covering this issue. Was there anything you found in your reporting for this article that was new to you or that you thought was surprising?

MA: Well, first, I agree. You’re right. A lot of these issues have been around for a little while. I’ve reported on some of them myself. What I hadn’t done before this report was to really see them stacked up in one state in one story, all these different layers from access to cost to transportation, and a lot of these stacked up and so seeing that in a complex, layered way was something new to me.

I hadn’t gotten into too much before, I had thought about the emergency transportation side of it. I hadn’t thought about birth services so much. One of the interviews and the first person I quoted in the story had quadruplets that came three months early and she had to drive an hour to get to neonatal intensive care unit, which is where you need to go if you have a high-risk pregnancy or your babies need to stay over, as hers did for the next six to eight weeks after she gave birth. I think today with some of the changes that have been made to the hospital systems, she’d have been driving an hour and a half, which boggles my mind. But something else that came up in this was just the prevalence of these issues. You know, I kind of got started on it because I heard stories about these $44,000 helicopter bills, and I had trouble finding people who had had that experience and were willing to talk about it, I think in part because they signed nondisclosure agreements when they settled but it seemed like everybody I talked to had a story about it.

KU: I agree. That was one of the anecdotes that really stuck with me from your piece. You write that the cost of those helicopter rides are more than the average annual salary in the area you are or you were looking at. 

MA: Right. Well, air ambulances are, you know, that’s the term where an emergency helicopter comes in to pick up somebody and take them to a hospital. But now there’s a number of private companies running systems like that. These are out of network services for many patients and so that out of network price is you know, people will get a bill. I spoke to one lady in Rogersville, Tennessee, who’d been transported and she received a bill for more than $44,000. I will say just to qualify that, I think it’s hard to find stories of people who’ve got stuck with that whole bill. In some cases, Medicare will more or less cover it. In other cases, there’s an insurance that people purchase. I think all of the rescue squads and public safety officials in Lee County are covered by that, for instance. And they market it to people in the area because so many folks are having to be flown out. So a lot of people have that insurance that helps cover the cost. And then I think in other cases, people end up settling with the company for maybe a few thousand dollars.

KU: So your story is centered around a nonprofit healthcare provider that bought up services in a rural community, consolidated into one organization and then downgraded those services because there really isn’t any competition in the area anymore. You write that this is a trend that we’re seeing in the region. Can you explain in a little bit more detail what exactly is happening?

MA: Essentially, in northeast Tennessee and southwestern Virginia, there were two competing health care providers, Wellmont and Mountain States. And by 2014, both of them had, just covering a rural area that is increasingly losing population and the population’s older, poorer, it tends to be, you know, sick, they’re dealing with things like black lung and not to mention chronic, you know, illnesses like diabetes and heart conditions. So, they emerged under a process called a Certificate of Public Advantage, or cooperative agreement that’s in Virginia and Tennessee. And so the resulting entity, Ballad Health, basically had all of Mountain States’ and Wellmont’s assets and some of it, you know, like I said, these had been two competing healthcare systems, so they ended up with things like two hospitals in Norton, which is a city in southwestern Virginia of about 4000 people. 

And so, you know, as you’d expect, they’re looking at that larger system and looking for ways to make it more efficient. Now, some of the changes that they’ve made have really upset people who are in that coverage area. Probably the one that’s fired up people the most is they had two level-one trauma center hospitals in Kingsport and Johnson City, which are pretty close together. Kingsport, I think, is within range of more population than Johnson City. But Ballad chose to downgrade Kingsport from a level-one to a level-three trauma center, and as part of that closed the neonatal intensive care unit. They’ve essentially converted one of the hospitals in Norton into a long-term facility and they’ve moved its services to hospital and the other hospital in Norton, and then a different one in Big Stone Gap. And they’ve made changes around the edges and, you know, some people are worked up. You know, Ballad will say this makes for a more effective healthcare and they’re doing things by the book and the numbers, but at the same time, you know, the Robert Wood Johnson Foundation has done a study that found that basically hospital consolidation and these monopolies see price increases. 

And so we’re still in the early years of this Ballad procedure or this Ballad entity, so there’s still a lot to learn, but a lot of people are pretty worried about it. You know, there have been protests going on in front of that Kingsport hospital that was downgraded, Holston Valley Medical Center. They’ve been, there’s protesters there who’ve been out front 24/7 continuously for more than 200 days and are involved in, you know, some battles with Ballad just not only protesting the service changes but even kind of fighting to hold their ground now Kingsport town councils looked at some ordinances that might push those protesters out and so that’s like one ongoing front with Ballad. 

But, to its credit, you know Ballad is also reopening the hospital in the county that closed in 2013. The hospital there in Pennington Gap was one of two in Virginia that closed. Folks there have been really trying to reopen that hospital and, you know, this fall, six years after that hospital closed, its doors reopen, not as a full critical access hospital or even an ER but as an urgent care center and Ballad says they’re going to reopen it as a critical access hospital next year. And that’s met with some extra spots, but I think a lot of people in Lee County are glad it’s going to be reopening again that even if it’s not providing the services of a level one or even level two trauma center, it’s still, you know, a place where there’ll be an emergency room and in case of a trauma or other situation like a heart attack or stroke.

KU: We know that Appalachia is a region that’s struggling with many health issues. The rates of diabetes, of heart disease, of cancer, they’re all high here. After doing this reporting, and this might be an obvious question, but do you feel like you can say that the financial climate of rural healthcare is impacting the health of the people here?

MA: Yeah, absolutely. And I think that’s true, not just in Appalachia, but across America, especially rural America. I mean, that’s just speaking from firsthand experience, you know? I’m one of the many, many Americans who’s basically one healthcare crisis away from financial disaster. Like, we’re doing okay, but if we were to, you know, suffer an unexpected issue, you know, I think I think we’d be in financial trouble and I think a lot of people are that way, you know, and will let small things go just because they know it’s going to come with a bill, and often when they can’t afford. I mean even co-pays, you know. You can see that play out if you look at the local courts were Ballad is certainly not the only company, they’re one of many healthcare providers that will pursue patients for bills in court, you know. They go after them to enable them to chase the debt more aggressively and then they start to garnish wages. And in all the cases I checked, I could not find one case where somebody had come to court with a lawyer. Yeah, it’s, it’s, I think it’s a challenge for a lot of Americans and Appalachians. 

KU: So with those challenges and the challenges that you’ve reported on before, are there any solutions out there? Are there ways to make healthcare more accessible and more affordable in Appalachia? 

MA: That’s a good question. A lot of folks are trying different things. There are clinics that have gone out and really made a difference, like a few people made a point to me that you know, just having a registered nurse or a nurse practitioner who can see people at a spot and help them maintain their long term chronic conditions like diabetes or heart issues, that’s, that’s super important. Ballad itself is focused on a lot of community health issues, you know, helping support Parks and Rec and things that get people outside to exercise, helping support healthy eating patterns. I certainly saw Ballad trying to engage on that level and that’s something we don’t always think about, but it does make a difference in community health. 

And then you have more, I guess, more political solutions or looking at changing the healthcare…healthcare system in more fundamental ways, you know, that I talked to some people for this story that made a case that moving to a single-payer system for healthcare will take the profit motive out of it. And if you can do that, then maybe you can kind of make a more level playing field, both for providers, but also patients across the U.S. instead of into this system of winners and losers of have and have not healthcare providers that we currently have now.

KU: What can rural Appalachians who view this report, learn from you, especially those who want to push back against this divide in health care?

MA: I’m not sure they’d want to look to me to learn but I do think they can look to people in the story. There are voices in the story like Danny Cook who decided to take action against the closure of the NICU in Kingsport. Now, you know, you can argue whether or not she has been successful. Ballad still closed the NICU and downgraded the trauma center level at that hospital, but she’s certainly drawn a lot of attention to the topic, not just from me but from other reporters as well and I think probably from lawmakers. I’m sure there are a lot of elected officials who may not otherwise be thinking about this story but are thinking about it and how to handle it due to her. 

I think one thing is that did come through from this is just the sturdiness of Appalachian people. I think, most everybody I talked to, had a very stoic attitude toward it, which can cut both ways, but I do think and surviving day to day, it makes a difference and it’s a quality I’ve seen in people in the mountains throughout my career. 

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Access To Care

How Telehealth Gives A Rural School More Mental Health Services



Orleans Jr/Sr High School holds grades 7th-12th and in the 2016-17 year had 346 students. Photo: Carter Barrett/Side Effects Public Media

To tackle a growing problem among young people, and fewer mental health professionals in rural areas, school leaders have joined a pilot project where students can talk with mental health therapists via a two-way video chat.

In rural areas, access to mental health services can be limited, sometimes even more so for teens and children. And the need for these services is growing, so one Midwestern school is using technology to help bridge this gap.

Two hours south of Indianapolis is Orleans, a farming and manufacturing town, population 2,000. The highway into town passes the junior-senior high school, which sits on a large lawn. Inside, a row of basketballs lines the top shelf in Principal Chris Stevens’ office.

They’re a symbol of rural Indiana, where schools — and basketball — are often the heart of community life. Many young people in these communities, and across the state, share something else: a struggle with mental illness.

Orleans Jr/Sr High School Principal Chris Stevens in his office with the telehealth equipment students will use to talk with therapists. Photo: Carter Barrett/Side Effects Public Media

To tackle this growing problem, Orleans leaders are involved in a pilot project to help students. In the corner of Stevens’ office is a mobile stand with an iPad and speaker; students can use it to talk with therapists at IU Health via a two-way video chat.

“It’s been overwhelming as far as the amount of people … who either support it or have come forward and saying, ‘I want to be on this list,’” Stevens says.

School guidance counselor Kristin Bye says students tend to struggle with depression and anxiety. Others are dealing with traumatic childhood experiences.

“A lot of our students are being raised maybe by grandparents or in non-traditional homes,” Bye says. “There’s a lot of past trauma.”

And while Orleans has some nearby options for mental health services, that doesn’t mean students can easily access them.

Orleans Jr/Sr High School guidance counselor Kristin Bye in her office. Photo: Carter Barrett/Side Effects Public Media

“Parents either work and they find it difficult to get off work, or they are worried about insurance or their child missing school,” Bye says. “If they go to Centerstone at Bedford, that’s a 20-minute drive up a 20-minute drive back, plus the session itself.”

Parental consent is required for students to participate in the new service — generally known as telehealth. The consent issue has stirred debate as lawmakers tried to tackle the rate of Indiana young adults considering suicide –– one of the highest in the nation.

Shannon Mace of the National Council for Behavioral Health says there’s growing evidence that telehealth is an effective way to deliver mental health services. However, legal and logistical red tape have slowed the rollout of these services.

“So once you get over the hurdle of just being able to invest in the infrastructure itself, then they need to find a way in order to be reimbursed for the services that they’re providing,” she says.

Reimbursing for telehealth services can be tricky, because policies vary by state or insurance provider. And initially, incentives for telehealth services were aimed at physical health.

“So since then, behavioral health providers have really been playing catch up,” Mace says.

The device allows students to video chat live with IU Health counselors. Photo: Carter Barrett/Side Effects Public Media

Insurer CareSource partnered with Orleans Jr/Sr High School to donate equipment and set up the services. The company says insurance won’t be a barrier for Orleans students who need treatment.

“We’d love to have this option available in every rural school setting if it’s successful,” says CareSource Indiana Market President Steve Smitherman.

The pilot project took about two years to get off the ground. And as schools are increasingly responsible for students’ mental health needs, it remains to be seen if this is a viable option for other districts.

“It is possible, I think you definitely still have to have the correct players in the game,” says Carrie Hesler, project manager for IU Health. “Access to funding to get the equipment, I think, would be one of the biggest barriers.”

IU Health says a school would need to purchase the $3,500 equipment, find a provider and navigate health insurance. And deal with two bureaucracies.

A mural in downtown Orleans, Indiana. Photo: Carter Barrett/Side Effects Media

We found out though, that our small school bureaucracy kind of works a little faster than some of the hospital bureaucracies,” Stevens says, laughing. “So some things took a little bit of time.”

He adds that doing this work means making sure everyone is on the same page.

Not just small schools, but in every school, the workload is tremendous, and the needs are sometimes immediate,” he says. “But I feel like by us being proactive, that’s going to pay dividends in the long run for us and our kids.”

Results of the pilot — including grades, disciplinary records, missed school days and reduced depression and anxiety — will be tracked.

People in need can call a suicide hotline number at the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) to reach a trained counselor. The national crisis text line can be accessed by texting CONNECT to 741741. 

This story was produced by Side Effects Public Media, a news collaborative covering public health. It was originally published by the Daily Yonder.

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