Criminalizing patients could have adverse consequences, experts warn
Criminalizing patients could have adverse consequences, experts warn
By Luke O’Neil
Welcome to Hell World
April 23rd, 2023
Today we have an excerpt from the book On Medicine as Colonialism by Michael Fine which you can find here via PM Press.
“What if communities where the pandemic hit were just the raw materials of this process, the place where the gold is mined, the oil is extracted, the rubber or banana trees are grown, and the people are just the providers of labor and consumers of manufactured goods made elsewhere?” Fine writes.
“What if medicine wasn’t about health or health care or the pursuit of happiness or democracy at all? What if medicine was just colonialism?”
by Michael Fine
In Central Falls, Rhode Island, where I work, the COVID-19 pandemic hit hard. People who live in Central Falls, the smallest and poorest city in Rhode Island, live in densely packed houses, often eight or ten people to a two-bedroom apartment, sharing one bathroom and kitchen. Many are undocumented immigrants. Most work two or three jobs to feed their families and send money home to family members in Central America, the Caribbean, or West Africa.
When Rhode Island shut down in March 2020, everyone forgot about the people in Central Falls. When Governor Gina Raimondo closed the state, she did everything she could to preserve the economy. That meant keeping essential services and factories open. Teachers, bureaucrats, administrators, lawyers, and even doctors started working from home. But the people of Central Falls kept working away from their homes—working with other people. Construction workers. Factory workers. Bus drivers. Certified nursing assistants. Store clerks. Landscapers. These people went to work every day, in part because they had to. Undocumented people don’t qualify for unemployment insurance or stimulus checks. People in Central Falls kept working so they could pay the rent and the phone bill and buy food. Among people of color in Central Falls—who make up the majority of the city’s population—only about 10 percent have the kinds of jobs that would allow them to work from home. Even so, 20 percent of the city’s workers became unemployed, at least legally. Most people, employed or not, continued to work under the table if they could, just to make sure their families were fed.
So people went to work, and they got sick. By April 2020, Central Falls became the most infected place in the United States and one of the most infected places in the world. More infected than anywhere in New York City. More infected than Italy or Great Britain. More infected than Wuhan. We found out about how the virus was spreading the hard way, because there was almost no testing in Central Falls, at least at first. People died in their homes, afraid to seek medical advice. Whole families got sick. In those apartments of eight or ten people, many workers got sick at work, brought the virus home, and spread it to everyone in their households. In April 2020, there were four deaths at home from COVID-19, and doctors’ offices were overwhelmed by the number of people who were ill and had no place to go.
In late April, after weeks of begging for help from the state health department, the state government, and the federal government, the cities of Central Falls and Pawtucket got together and stood up to create an Incident Command System (ICS), the usual response of emergency personnel to emergencies of various sorts, from fires and hostage taking to hurricanes. In those cities of one hundred thousand people combined, likely fifty thousand lacked primary care doctors. The local hospital had closed the year before after years of low occupancy, the result of changing demographics, poor management choices, and market-driven competition from larger hospitals just a few miles away. There was no one else to care for the population and no one else to fight the pandemic in the two cities. These cities had no public health experience and had never used ICS for a public health emergency, but there was no other choice: after weeks of begging, pleading, and cajoling state and federal officials, it had become clear that no help was on the way.
We’ll do it ourselves, the cities said. We’ll use volunteers and city employees. We’ll collaborate with community organizations, who we’ll invite to the ICS from the outset. We’ll build our own testing system. Our own phone consultation service, so that people who are sick can get medical help. Our own family support system, so that undocumented people can get food and cash to sustain them should they get sick. Even our own public health process to help people who are sick and in isolation and quarantine, because the state’s isolation and quarantine systems have miserably failed. Our own data system, because there isn’t much good data available about how the virus is infecting people in Central Falls and Pawtucket.
The cities brought together those city workers and volunteers and built that system around a hotline inside of two weeks. I was the chief health strategist for the City of Central Falls as well as the health advisor to the mayor of the City of Pawtucket. I knew both cities well, and I also knew the health policy landscape at the state and federal level like the back of my hand. I had done my residency in the hospital that had closed, had practiced in both cities, and had served as the director of the Rhode Island Department of Health after that.
The ICS process worked like a charm. Inside of two weeks, we built a little health care system for one hundred thousand people that brought telephonic medical care, isolation counseling, testing, and family support to the people who got infected in the first wave of COVID-19. Four languages— English, Spanish, Portuguese, and Cape Verdean Creole—were available by phone. Our little health care system required only a phone number and a nickname from each caller—not even a real name, so we wouldn’t scare off undocumented people. We had volunteer doctors, nurse-practitioners, and midwives on the phones. Volunteer pre-med students did isolation and quarantine counseling, helping people who were sick understand how to separate themselves from others so they didn’t spread the disease.
The cities funded the process themselves in the short run— and requested $800,000 in state aid to make it sustainable. Over a billion dollars of federal pandemic aid flowed into the state in that period. Central Falls and Pawtucket hoped that a tiny portion of that $1 billion—less than one-tenth of 1 percent— would come to their cities so they could continue the critical public health work they had started pretty much on their own, when neither the state nor the federal government could organize itself to help protect the two cities’ citizens.
But everything changed as soon as money came into the picture. There were meetings on top of meetings—not to respond to the public health emergency, but now to discuss the cities’ request to fund their public health response. All of a sudden, as a budget was negotiated, there were lots of people on lots of Zoom calls. A new entity appeared in these virtual meetings: the local branch of a national organization called Local Initiatives Support Corporation (LISC), which is a housing organization, had contracted with the state to run something called the Pawtucket–Central Falls Health Equity Zone (HEZ). The state had decided to send all funds to LISC, not to either city. Everyone involved in the ICS process lived in or worked for the cities of Central Falls and Pawtucket, and most people (except me!) both lived and worked in one of the cities—and most involved were people of color who spoke either Spanish or Cape Verdean Creole. But none of LISC’s employees lived in either city, and none of the LISC employees or any of the other state contractors—who worked for national consulting groups like the Boston Consulting Group or Alvarez & Marsal and who sometimes appeared as if from nowhere on these calls—either lived in one of the cities or spoke Spanish or Creole.
Finally, after three months of these calls, the state sent LISC $175,000 to use for the cities’ pandemic response. Only $175,000, instead of the $800,000 the cities thought it would cost to run a full-fledged public health response. LISC made a deal with a large politically connected (and privately held) business headquartered in the one of the cities, a business that had been idled by the pandemic, to supply the 800 number and the information technology needed to run the hotline, and it also doled out money to community organizations that had been part of ISC and had been doing this work all along.
But when the $175,000 finally started to flow, it was too little and too late to stop the fall surge of COVID-19. And the money went not to the people of Central Falls and Pawtucket, but instead mostly to that large privately held corporation (a campaign contributor to one of the mayors), whose owners and most of whose employees lived in other places.
And then things got worse. While this process had been running with volunteers, a Latino guy who worked for the privately held corporation and lived in one of the cities had over seen organizing and staffing the 800 number and the processes around that. As soon as the money started to flow, however, that corporation replaced him with a white guy who was the son of a friend of the owner and who lived in Rumford, a wealthy suburb a few miles away. While the process was running with volunteers, all the volunteers came from one of the cities. The moment the money started to flow, the privately held corporation wanted to use that money to bring back their own long-term employees, all of whom lived elsewhere, and it took a pitched battle to make sure that at least some of the people hired were from the cities, spoke the languages, and knew the culture of the places in which we were working. As soon as the money started to flow, the planning process went from almost all volunteer community people, deeply involved in the cities and community, to all white people who barely knew the cities at all—but who were all getting paid.
In a few months, then, the little cities of Central Falls and Pawtucket saw a change from a mostly volunteer, locally initiated, locally run process of public health and self-defense to a poorly funded bureaucratic exercise that allowed state officials to claim they were doing something and that resulted in cash flowing to people who lived outside the community and didn’t really know the cities at all. People organized themselves to protect themselves and their neighbors. But as soon as the state became involved and money started flowing, the focus of the response flipped around. All of a sudden, the Incident Command System of Pawtucket and Central Falls, which had produced a little public health system called “Beat COVID-19” that addressed itself to a pandemic caused by a new disease that was infecting, hospitalizing, and killing too many people, many of whom were poor and working people, had become focused on contracts and cash flow, and most of the now-well paid people who were involved were interested in the contract deliverables, not simply in what the community needed. Large sums of money were being moved about. But the process wasn’t about the common good anymore. Or democracy. Or even about the incidence and prevalence of disease.
That was when a light went off in my brain. I had long understood that health care in the United States is a business, not a service provided for the public good, and that we have a medical services marketplace, not a health care system that cares for all Americans. But this experience let me see health care in a new way. What if health care was more than just a business? What if health care had become a false flag, a Trojan horse, a game of three-card monte? A way to use this pandemic to create income, a way to extract wealth from a community, or, worse, a way for politicians to attract attention to themselves so that they could advance their careers? The pandemic had attracted attention and money. When that money arrived, the smart set—people with one kind of power or another—figured out how to get that attention and money to flow their way. What if communities where the pandemic hit were just the raw materials of this process, the place where the gold is mined, the oil is extracted, the rubber or banana trees are grown, and the people are just the providers of labor and consumers of manufactured goods made elsewhere? What if medicine wasn’t about health or health care or the pursuit of happiness or democracy at all? What if medicine was just colonialism? An excuse to extract the wealth of communities, one that destroys their ability to care for themselves in the process.
In a pandemic, and generally, we think of health care as a public good, a service communities need to be stronger and more resilient. But from research for my previous books, The Nature of Health and Health Care Revolt, I knew that health care in the United States has another function altogether. In the US, health care is a business that tends to make the rich richer and keep the poor impoverished. I learned this by following the money and by seeing who makes how much doing what—by seeing, for example, how hospital, pharmaceutical, and insurance executives and their shareholders make a ton of money while family doctors do okay but have to work all the time, while the nation struggles with income inequality, dropping life expectancy, and downright terrible health outcomes, especially among poor people and people of color.
But in the pandemic, I learned that the US faces a worse problem yet. In the pandemic (and for fifty years before that), people with power and money co-opted federal and state government and used state power to exploit the pandemic to make more money for themselves. The pandemic revealed what had been hidden from Americans in plain sight: that the health care profiteers have turned government into an agent of wealth extraction and have turned medicine itself into the excuse for government to do so. State power has turned healthcare profiteering, objectionable enough in itself, into colonialism—into a process that strips the resources from communities and leaves those communities with no agency and no ability to protect themselves, exactly what the old colonial powers did across the developing world.
I had been working part-time at a community health center in Central Falls and Pawtucket, Rhode Island, for the four years just before the pandemic struck. Community health centers were invented in the mid-1960s (by Jack Geiger, MD, a mentor and hero) to help address the health impacts of racism by providing primary health care to the poor, to working people, and to anyone without a family doctor, many of whom are people of color. The community health center’s staff was diverse. Most of the medical assistants, receptionists, and other frontline staff lived in Central Falls and Pawtucket. Some of the nurses did as well. But very few of the doctors, nurse-practitioners, or physician assistants lived in either city, and very few were people of color. None of the more highly paid administrators lived in the community, and none, not even one, were people of color. Too few members of the community health center’s board were actual community members, and too few were people of color, even though by federal regulation, 51 percent of the board had to be “users” of the health center, a regulation the health center satisfied by the letter but not the spirit of the law. To its credit, and with a little pushing from me, the board had added four people of color from within the community, but it was still majority white, even though the main site of the health center itself is in Central Falls, which is 80 percent people of color.
This pattern—that the people who work in healthcare administration and leadership in hospitals and health centers live in other communities—pops up wherever medicine is practiced and wherever hospitals and doctors exist in the US (except, perhaps, in rural parts of the country, where there is no practical way for administrators and doctors to live in other communities).
Take hospitals. The executives of hospitals, their boards, and most of their doctors typically live in wealthy suburbs, while the poor and working people who make up the bulk of their patients live in poor and working communities near the hospital itself.
It’s like that in community hospitals. But the pattern is much more apparent in academic teaching hospitals, which are often located in the midst of urban poverty: hospitals like Mount Sinai Hospital and Columbia University College of Physicians and Surgeons in New York, Johns Hopkins in Baltimore, Yale in New Haven, the Cleveland Clinic and University Hospitals in Cleveland, Boston Medical Center and Boston University Medical Campus, Rhode Island Hospital in Providence, and Hahnemann Hospital in Philadelphia (before it was bought and closed by a venture capitalist).
Though not all academic hospitals are in poor urban areas, the number of academic hospitals that are located amidst urban poverty is remarkable. Are those hospitals located in poor places just because poor communities have lots of sick people? Or is there something about academic hospitals that makes or keeps poor places poor? Most poor and sick people have Medicare and Medicaid, which pay for the care of the sick. If we think about Medicare and Medicaid as representing part of the wealth of those poor places—in 2022, they represent between $5,000 and $12,000 or more per person per year in most states—are hospitals stripping away some of that wealth, which could otherwise be spent locally, and carrying it to other places? Could it be that, yes, while those hospitals teach medical students and residents, they also use the cover of illness to extract funds from the federal and state governments and then send those funds elsewhere? Could it be that those hospitals are not just in the business of health care but are also in the business of extracting wealth from the communities in which they are located and moving that wealth elsewhere? Hospitals extracting wealth from communities? Impossible! But if so, that would make hospitals something other than health care or medicine entities. That would make them like the gunboats in the colonialist enterprises of yore, and it would make the whole United States health care mess almost sound like… colonialism.
The post Hospitals extracting wealth from communities appeared first on PM Press.
The Column (4/3/23): “Because the gutting of pandemic-era welfare programs is bipartisan in nature—and President Biden is making no case to protect them—the topic is thus not a partisan conflict.”
Last spring, the Biden administration and a Democratic House approved a policy that would kick 15 million people off of Medicaid. States are now set to begin dropping people from the rolls, reversing the record-low uninsured rate reached early last year. But if you were watching TV news, you might have missed it.
Adam Johnson, a former FAIR contributor and co-host of the media criticism podcast Citations Needed, analyzed the coverage in an article for his Substack (The Column, 4/3/23). As Johnson notes:
None of the agenda-setting Sunday morning shows—NBC’s Meet the Press, CBS’s Face the Nation and ABC’s This Week—mentioned the expiration of Medicaid coverage for the poorest, most vulnerable Americans in recent weeks.
He did find scattered mentions on TV news: MSNBC ran a two-minute segment that mentioned it, ABC News aired a minute-and-a-half segment, and CBS Evening News spent all of 19 seconds on it. But reporting on the Medicaid cuts was almost nonexistent compared to the mountains of coverage given to Trump’s indictment and arraignment–the top media story of the week.
One analysis from Media Matters (4/3/23) found that over an hour-and-a-half period before Trump’s arraignment, CNN aired 48 minutes of B-roll of the idling Trump plane and motorcade, along with shots of Trump Tower and Mar-a-Lago. MSNBC aired 66 minutes of similar footage. As Media Matters noted, this kind of coverage is similar to when networks regularly aired footage of Trump’s empty podiums (FAIR.org, 3/16/16).
The reader can decide what’s more important: A Democratic administration taking healthcare from 15 million, or a con-man war criminal being indicted for some of the least important of his crimes.
Writing in Current Affairs (3/30/23), Rhode Island state Sen. Sam Bell pointed the finger at progressives who didn’t even try to make this a central issue:
A few brave policy experts did speak up, but there was no real, organized campaign. Progressive lawmakers didn’t send out a flood of tweets, speeches and op-eds. They didn’t even threaten to vote no and then cave. They made no noise. The big progressive advocacy groups didn’t run campaigns. Even Representative Ocasio-Cortez, the only Democrat to vote no, didn’t discuss the Medicaid and SNAP cuts at all in her statement on her no vote.
While Trump’s arraignment is historic news, it has almost no effect on the lives of ordinary Americans. Stories that affect millions of lives deserve far more than a few collective minutes of coverage. Media have long privileged sensational news over important policy shifts, leaving audiences in the dark about the forces that shape their lives. This, like many other instances, demonstrates the importance of alternative and adversarial media organizations and outlets.
Featured image: CNN (4/4/23) via Media Matters.
The post Trump’s Idling Plane Got More TV Coverage Than Biden Cutting Healthcare for 15 Million appeared first on FAIR.
Starting April 1, states will begin removing millions of people off Medicaid’s rolls as a pandemic-era program that kept them enrolled expires.
Perhaps the greatest success of the American health care system these last few benighted years is this surprising fact: The uninsured rate has reached a historic low of about 8 percent.
That’s thanks in part to the pandemic — or, more precisely, the slew of emergency provisions that the government enacted in response to the Covid crisis.
One policy was likely the single largest factor. Over the past three years, under an emergency pandemic measure, states have stopped double-checking if people who are enrolled in Medicaid are still eligible for its coverage. If you were enrolled in Medicaid in March 2020, or if you became eligible at any point during the pandemic, you have remained eligible the entire time no matter what, even if your income later went up.
But that is ending — states will now be re-checking every Medicaid enrollee’s eligibility, an enormous administrative undertaking that will put health insurance coverage for millions of Americans at risk. Starting April 1, states can begin disenrolling people from the program.
The Biden administration estimates upward of 15 million people — one-sixth of the roughly 90 million Americans currently receiving Medicaid benefits — could lose coverage, a finding that independent analysts pretty much agree with. Those are coverage losses tantamount to a major economic downturn: By comparison, from 2007 to 2009, amid the worst economic downturn of most Americans’ lifetimes, an estimated 9 million Americans lost their insurance.
Some will lose coverage because they are no longer eligible due to a change in income or circumstance, such as a child turning 18. States are supposed to direct these people toward other insurance options, such as the Affordable Care Act marketplaces.
But many of the people who end up losing their benefits — even most, according to some projections — could be people who are actually still eligible for Medicaid but slip between the cracks of the system. People who have recently moved are one particular concern, as are children and people with disabilities.
For people who watch health policy closely, the coming “redetermination” process is one of the biggest stories of the year, with major ramifications for Americans’ health.
A lot of people are going to lose coverage no matter what. That is inevitable. The emergency “continuous coverage” provision, which cost nearly $150 billion over the past three years, was never going to be indefinite. The US health system is not set up to provide that many people, some of whom are no longer eligible for the program, with indefinite health benefits, unless they are old enough to qualify for Medicare.
But the goal, according to people who advise and advocate for people on Medicaid in states across the country, should be to minimize the number of Americans who lose their Medicaid benefits even if they are still eligible for them, and to make sure that the people who no longer qualify for Medicaid get other coverage.
Don’t let too many people fall through the cracks. Otherwise, the coverage gains of the past few years could be quickly eroded.
“If people lose Medicaid, whether they’re ineligible or remain eligible for Medicaid, and they’re not connected with another form of insurance, that’s potentially devastating for individuals,” Emma Morris, a policy analyst at the Oklahoma Policy Institute, told me. “This is a really pivotal point.”
This year’s coverage losses could be particularly dramatic. But they’re also a symptom of a bigger, more persistent problem that predated the pandemic: People cycle on and off Medicaid coverage all the time, including for reasons as mundane as paperwork. It’s a problem that, historically, many states have shown little interest in solving, and one that is now reemerging with a vengeance.
The task in front of public officials is enormous: Check the eligibility of every single one of the 90 million people currently on Medicaid to confirm they still meet the criteria for their benefits.
And if they don’t happen to reach someone because that person moved, or they think a notice from the state is junk mail? That person will find themselves out of luck — and out of Medicaid.
Preventing that worst-case scenario will depend on states getting the word out early and often and using all of the tools available to them to reach people. Whether they will actually do that is already creating some concern. Congress has given states up to 12 months to complete the redetermination process. But in Texas, where as many as 1 million people may lose coverage, state officials have said they want to finish it in eight months.
“That raises a concern of trying to do this fairly complex job in a shortened timeline and the risk that might lead to adverse redetermination outcomes for people that that still are entitled to being in Medicaid,” Jason Terk, a physician and chair of the Texas Public Health Coalition, said.
In an ideal scenario, many beneficiaries won’t have to do anything to affirm their Medicaid eligibility. States can check existing data sources to verify a person’s income. If they are still eligible, they will keep their benefits. If they are not, the state should let them know what their insurance options are. (We’ll come back to that.)
The problem is these automatic checks are something a lot of states were terrible at doing prior to the pandemic.
Almost all states say they conduct what are known as ex parte renewals, meaning they use existing public data to verify people’s eligibility without the person having to do anything.
Ex parte renewals were supposed to be mandatory under the Affordable Care Act. But, according to Jen Wagner at the Center on Budget and Policy Priorities, enforcement has been lax: A few states don’t do them at all, and 20 of them said they completed less than half of their renewals this way. Some states, including Texas, have decided not to adopt policies that make ex parte renewals easier, such as assuming people who are eligible for SNAP, or food stamps, are also eligible for Medicaid.
Now states’ ability to perform those tasks is crucial. Most states say their redetermination plans start with ex parte renewals, which will test the effectiveness of their databases and IT systems. And many Medicaid offices are beginning this process understaffed: in five jobs posted at state Medicaid offices were unfilled, according to the National Association of Medicaid Directors. In some states, nearly half of the jobs, more than 40 percent, were unfilled.
“We’re seeing states struggling right now to keep up now, when you’re not doing renewals,” Wagner said.
The first way states are trying to minimize risk is by starting the process with certain groups of people who may be at less risk if they lose coverage, such as those who have never filed a claim while enrolled in Medicaid; for those recipients, the possibility of disrupting medical care seems lower.
In states like Oklahoma, Missouri, North Carolina, and Florida, where I interviewed patient advocates and state Medicaid officials to get a better sense of states’ preparation, the plan was usually to save more vulnerable populations — older people, people with disabilities, and children — for the later phases.
For people whose eligibility cannot be confirmed via a public database, states will have to do it manually. That will mean sending out mail and other forms of communication to ask beneficiaries to send in information so their eligibility can be verified.
That can be a difficult task. People move, some frequently. They ignore mail. They may not know this is happening in the first place. Most states allow people to report eligibility details or change their contact info on their websites or over the phone, but not all do — and those services, such as a call center, have to be adequately staffed. Otherwise, problems can arise and people may give up rather than put up with a hassle.
In Florida and Texas, two states worth watching closely given their large size and right-leaning politics, Republican leaders have not appeared very engaged on the issue, even as doctors and activists in those states credit the state health agencies with taking it seriously.
“The political leadership is not particularly enamored with or concerned about necessarily enhancing Medicaid policy here in the state of Texas,” Terk said. “I would hope, and I would try to be optimistic, that the governor’s office would be more forceful in his messaging. … It would be helpful if that were to happen. But I’m not sure that it’s reasonable to expect that.”
There are myriad ways administrative friction leads to people losing benefits when they shouldn’t. States have to be invested in preventing it.
In states like Missouri and Oklahoma, top elected officials have been actively fighting against the implementation of Medicaid expansion, which made many low-income adults newly eligible for the program; now many of the people who became eligible through the expansion in the past few years will have their eligibility checked for the first time. Policy analysts worry some of those people could lose coverage simply because they aren’t familiar with the process.
Another way people could lose coverage in the coming months is if they are legitimately no longer eligible for Medicaid but fail to get enrolled in a different insurance plan.
States could make a big difference in preventing that, by directing people to the ACA marketplaces (where they may qualify for government assistance) and the navigators who receive federal funding to help people sort their marketplace options and sign up.
Medicaid offices across the country have been planning for this for months. But it’s not clear some states are doing everything they can on to make sure people who are no longer eligible are enrolled in a new health plan. In Florida’s redetermination plan, for example, the actual mechanisms for directing people to their other coverage options are left vague and navigators are not mentioned at all.
“A lot of these plans sound excellent. The question is, what do they look like in implementation?” Alison Yager, executive director of Florida Health Justice, told me. “There are invariably going to be challenges. This is too huge for there not to be challenges.”
Some people may have no viable option for coverage at all, if they’ve had a change in circumstance that renders them ineligible (such as a child turning 18) but they live in a state that hasn’t expanded Medicaid under the ACA nor do they have a high enough income to qualify for subsidies to purchase private insurance.
Florida is one of those non-expansion states. One family there, who shared their story with Florida Health Justice, has three members who all need regular monitoring and check-ups because of complex medical conditions. They were supposed to lose their Medicaid coverage in 2020, when their son turned 18, but that was postponed through the continuous coverage provision. When that policy ends, they may become uninsured because Florida has not expanded Medicaid under the ACA.
It all adds up to a dramatic and sudden US health policy problem that has laid dormant for the past three years: churn.
It is an absurdity of the American health system, compared to those of other developed countries, that millions of vulnerable people could end up becoming uninsured in a matter of months.
But even in normal times, because of how our health system is set up, people with low incomes shift frequently between different insurance coverage, going from Medicaid to ACA insurance subsidized by the federal government or not having any insurance at all.
It’s called “churn,” and it has long been recognized as a problem. In 2018, about 10 percent of Medicaid enrollees cycled on and off the program within a year.
Sometimes, people can simply have a few months where they pick up extra work hours, boosting their income to the point they are no longer eligible, and they lose coverage. (Eligibility checks vary across states in normal times.) The next month, their earnings may drop back down, making them eligible once again — but then they have to sign back up.
It adds to the workload for those understaffed Medicaid offices and it can disrupt health care for the patients too. People don’t fill prescriptions when they have to pay more money out of pocket. They skip doctor’s appointments and other vital services.
Now, after the three-year pause on redeterminations eliminated that problem, the end of the emergency coverage will bring it back.
States could be doing more to prevent Medicaid churn — but, at least so far, they’re not. The low rate of ex parte renewals that automatically confirm eligibility was one way the US was coming up short pre-pandemic.
Some states are also not taking advantage of other optional policies that the federal government has made available. A state can, for example, extend coverage for a woman who becomes eligible during pregnancy through their first year after her child is born. According to the Kaiser Family Foundation, more than a dozen states still have not adopted that policy since Congress authorized it in 2021.
A year of continuous coverage for kids is more common, and states such as Oregon and Washington have even approved multi-year continuous eligibility for children. On the other hand, more than a dozen states have not adopted that policy either and a number of others have conditions that limit their effectiveness.
Congress has recently added some new requirements to address the problem for the longer term, including that all states provide children with 12 months of continuous coverage starting next year. That should help.
But it won’t eliminate the problem entirely. It will come back again to how well states perform in checking and re-checking people’s eligibility, now and in the future, and whether they are being held accountable when they fall short.
There has been more sustained interest in the problem of Medicaid churn with the end of the emergency coverage provision approaching. But it remains to be seen how long it will last.
A reversion to the pre-pandemic normal would put beneficiaries at a higher risk going forward of losing their coverage than they should. Research has routinely shown people have more access to health care, use more health care, and self-report better health when they are enrolled in Medicaid. That is what people are losing when they lose their benefits.
Churn is inevitable in the multi-payer structure that the US has set up to finance its health care. But we could be handling it better. The massive redetermination process will be an immense test, forcing states to re-check the eligibility of every single beneficiary. But even once it’s over, individual patients will still face the risk of losing coverage when they perhaps should not. The problems churn creates are not going away.
“Churn doesn’t have to be what it is. Unwinding doesn’t have to be a disaster,” Wagner told me.
The stakes for the rest of 2023 are enormous, and Medicaid agencies have not always performed well in the past in making sure everybody who is eligible for Medicaid gets on it. Now, health coverage for millions of Americans hinges on their being able to get it right.
Update, March 31, 2:30 pm ET: This article was originally published February 13 and has been updated to account for new developments as the April 1 start date for Medicaid disenrollments begins.
The post The Anti-Vax Movement and the Medical Freedom Hustle appeared first on The Nation.
On the morning of January 22nd, the 50th anniversary of the Supreme Court of the United State’s decision in Roe v. Wade, Madison, Wisconsin was blanketed with a fresh layer of snow. But by 11 a.m., it was clear that the weather had not deterred people from throughout the Midwest from gathering at the center of campus at the University of Wisconsin in downtown Madison. The number of attendees waiting in the cold built slowly at first, but by 11:45, the crowd had grown to several thousand people. Organizers circulated, handing out chant sheets and organizing information. A few activists stood in the bed of a rented pickup truck at the front, leading chants. The Bigger Than Roe March and Rally were underway.
While the entire event appeared to have the support of the national Women’s March organization, that organization declined to sponsor the march when organizers in Madison Abortion and Reproductive Rights Coalition for Healthcare (MARRCH) elected not to apply for a permit. In fact, while Women’s March continued to cite the day of action in its fundraising emails, it was MARRCH, a scrappy new group that formed over the last six months and already has multiple campus-based chapters in the city, that was the primary organizing force behind it. With help from Chicago-based groups like Chicago for Abortion Rights, Gay Liberation Network, and the Red Rabbits, and the endorsement of dozens of other groups, including a number of labor unions and socialist organizations, they led the way from campus through downtown Madison into the Wisconsin State Capitol, where protesters filled every floor of the building’s rotunda.
“MARRCH, a scrappy new group that formed over the last six months and already has multiple campus-based chapters in the city, that was the primary organizing force” behind the demonstration. Photo by Tessa E.
Ahead of the march, speeches and chants from the front tied Wisconsin’s struggle for abortion access to international fights for abortion rights, trans rights, and the Black Lives Matter movement. At one point, organizers led the group in chanting, “Burn the churches, burn the courts, burn the precincts!”
Christine Powell, a Madison resident and member of AFSCME Local 6000 marched with a Madison labor contingent revolving around the South Central Federation of Labor. She wrote the following account of the day:
I went solo to the Women’s March, I’ve not been to a march or a protest in…. so long. I noticed how many family groups I saw. Directly in front of me was a teenage boy and his mom. Many older ladies, some of whom had to have seen this issue move from freedom and growth of women’s rights over their bodies, to having those rights taken away.
We were slowly moving toward the Capitol building, and the organizers were as a whole energetic, young, and LOUD! I was trying to keep up with the call/response chants, but I’m not really a loud person, and it feels weird if you’re not used to ever shouting.
The crowd was being worked by political groups, with fliers, pamphlets, clipboards making the rounds. I got a pass I was holding a stonking big Labor banner, but it made me think when I saw people the next day online putting out opinions like “Marching doesn’t change anything!” It’s a March, and it’s a rolling education event. It’s a March, and WOW was there a lot of networking. It doesn’t matter that it’s not a day where they’re in session. WE were in session.
When we got to the Capitol building, we were not sure if we could bring the thick pole with the banner in, but we were, and made it up to the third floor. Some ladies who had gotten a good perch were kind enough to let us hang the banner in front of them. Chatting with them, I discovered that they’d driven up from Illinois to support the women of Wisconsin, which I found pretty awesome.
When the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade, Wisconsinites found themselves living in a state where abortion is outlawed by an 1849 ban that includes exceptions only for the life of the mother. Proximity to states where abortion is still legal, like Illinois and Minnesota, is only reassuring to those who live close enough and have the resources to make a trip.
Writing for Wisconsin Examiner, Ruth Coniff reported on the harsh circumstances pregnant people in Wisconsin are facing, including being denied abortion care to resolve miscarriages until they’re on the brink of death. This is an absolute nightmare, and a constant source of anxiety for many people who can become pregnant.
But it’s important to note that abortion access has been dwindling in Wisconsin for years. Prior to Dobbs, there were only three surgical abortion clinics left in the entire state, one in Madison and two in Milwaukee, with an additional clinic in Sheboygan providing medication abortion only. All of these clinics are located in the Southern half of the state, leaving people living up North—especially in the northeastern quadrant of the state—in an especially difficult spot. Access was further complicated by the state’s requirement that anyone seeking an abortion must first have a consultative appointment at the abortion clinic at least twenty-four hours before receiving the abortion, and a state ban on all abortions past twenty weeks. Wisconsin’s Medicaid program did not cover abortion care, except in cases of rape which the victim was required to report to law enforcement. For many in Wisconsin, it didn’t take a Supreme Court decision to put abortion firmly out of reach.
While past Women’s March events have been national days of action, with rallies and marches taking place all over the country, Madison was the focal point for the organization’s Roe v. Wade anniversary event this year. There are a few ways to understand the national Women’s March organization’s decision to single out Wisconsin.
For starters, in just a few months Wisconsin voters will take to the polls to elect a new State Supreme Court justice, the significance of which was outlined in a recent New York Times article titled “2023’s Biggest, Most Unusual Race Centers on Abortion and Democracy.” While Wisconsin’s Supreme Court is nominally non-partisan, conservative justices have held a majority on the court for the last decade, reliably acting in lock-step with the Republican-controlled state legislature, including upholding:
Maps that make Wisconsin one of the most badly gerrymandered states in the entire country, where Republicans can maintain control of the state Senate and Assembly while receiving a smaller share of the overall votes.
Attacks on voting rights, like the state’s voter ID requirement and a ban on absentee ballot drop-offs outside of election offices, which were popular in liberal Madison throughout the COVID-19 pandemic.
Republican-led legislative attacks on the powers of the executive branch which began as soon as Democratic Governor Tony Evers was elected in 2018 and persisted throughout the COVID-19 pandemic, making it impossible to implement state-wide safety regulations.
In the aforementioned New York Times article, Democratic Party of Wisconsin chairman Ben Wikler ties the outcome of the state election to national concerns by by pointing out that in 2020, the Wisconsin Supreme Court made a 4-3 decision to reject a Trump campaign effort to throw out 200,000 votes in liberal Milwaukee County and Dane County (where Madison is located). With Wisconsin serving as an important swing-state in the last two presidential elections, the implication is clear: Wisconsin’s Supreme Court could make or break the next national election.
The article also makes clear that Democratic Party leaders view abortion as a key issue to leverage in the election, which reflects a major shift in the Party’s thinking. For years, the “common sense” passed from Democrats to liberal reproductive rights groups in Wisconsin was that abortion was too controversial to mention outside of the deepest blue districts in the state. While Republicans waged war against abortion access over the last decade, Planned Parenthood Advocates of Wisconsin came up with tortured responses that danced around addressing abortion directly.
Trade unionists endorsed and joined the march, including these teachers who made the trip to from Chicago. Photo by Tessa E.
For example, in 2013 when Republicans were advancing a raft of restrictions on abortion through the state legislature, PPAWI accused the Republicans of “playing games with women’s health” and held an action at the state capitol where supporters delivered pink ping-pong balls to members of the legislature. To see Democrats in Wisconsin openly using the word “abortion” in campaign ads and on mailers in 2022 seemed stunning by comparison.
No doubt much of the change is recent, a result of the outcry against the Dobbs v. Jackson ruling and the bump that outrage gave Democrats in the 2022 election. But widespread support for abortion rights was visible in Wisconsin before last year. In fact, in 2017 just after Trump was elected president, per-capita turnout for the first Women’s March in Madison, WI was higher than anywhere else in the country outside of Washington D.C. Democratic Party operatives are finally taking notice and taking advantage of the fact that abortion is a mobilizing issue. For Women’s March, a Democratic Party ally organization, to zero in on Madison, Wisconsin before a momentous election makes sense in this context.
But there’s a lesson in this for activists, too. While reproductive rights organizations and activists in Wisconsin have been steadfast in their support for the Democratic Party, the Democratic Party did not always support abortion rights as openly or reliably. And following their lead and playing coy about abortion likely limited the ability of groups like Planned Parenthood to fight back. However, regular mass mobilization since 2017, including after the Dobbs decision was announced, has made a difference, pushing abortion rights to the top of the agenda. To ensure that restoring abortion access in Wisconsin continues to be a priority, activists must resist pressure to subvert their goals to the goals of the Democratic Party of Wisconsin.
Political activity in Wisconsin has been characterized by a certain sense of hopelessness for over a decade now, since the 2011 Wisconsin Uprising in response to Governor Scott Walker’s attack on public sector unions was redirected into an unsuccessful recall campaign. Walker’s reign, which led to gerrymandered maps and a gutting of local control, made things worse. Since Governor Tony Evers was elected in 2018, there’s been a prevailing perception among liberals that the best we can hope for electorally is to keep a Democratic governor in place to veto the ugliest efforts of the Republican-controlled state legislature until this latest Supreme Court election.
In many respects, this has lessened the draw of electoralism, which has had some positives for the Left in Madison, and potentially elsewhere in Wisconsin, too. It created space for activist groups like MARRCH, Madison-area DSA affiliated Socialist Feminist Collective, Socialist Alternative, and earlier efforts backed by SA and a branch of the International Socialist Organization to advance more radical ideas about how to win abortion rights, and to play a bigger role in local abortion rights activism. Instead of being relegated to the side of big rallies and marches, as left-wing and revolutionary groups are in many places, these groups have all been at the front of large mobilizations over the last five years, making the case for mass movement over subservience to the Democratic Party.
This fact, combined with strong support for abortion access in Wisconsin, proximity to activists in Chicago, and the Democratic Party’s renewed interest in abortion as a mobilizing issue, all make Wisconsin an important site for abortion rights organizing and a state to watch in the years ahead.
Featured Image credit: artwork by Nevena Pilipović-Wengler.
A U.S. physician took to the op-ed pages of
The New York Times on Sunday to offer a scathing condemnation of the country’s for-profit healthcare system and his profession’s historical complicity in campaigns against universal coverage.
“Doctors have long diagnosed many of our sickest patients with ‘demoralization syndrome,’ a condition commonly associated with terminal illness that’s characterized by a sense of helplessness and loss of purpose,” wrote Eric Reinhart, a physician at Northwestern University. “American physicians are now increasingly suffering from a similar condition, except our demoralization is not a reaction to a medical condition, but rather to the diseased systems for which we work.”
“The United States is the only large high-income nation that doesn’t provide universal healthcare to its citizens,” Reinhart continued “Instead, it maintains a lucrative system of for-profit medicine. For decades, at least tens of thousands of preventable deaths have occurred each year because healthcare here is so expensive.”
The coronavirus pandemic accelerated that trend and spotlighted the fatal dysfunction of the nation’s healthcare system, which is dominated by a handful of
massive corporations whose primary goal is profit, not the delivery of care.
According to one peer-reviewed
study published last year in the Proceedings of the National Academy of Sciences, a universal single-payer healthcare system could have prevented more than 338,000 Covid-19 deaths in the U.S. from the beginning of the crisis through mid-March 2022.
“In the wake of this generational catastrophe, many healthcare workers have been left shaken,” Reinhart wrote Sunday. “One report estimated that in 2021 alone, about 117,000 physicians left the workforce, while fewer than 40,000 joined it. This has worsened a chronic physician shortage, leaving many hospitals and clinics struggling. And the situation is set to get worse. One in five doctors says he or she plans to leave practice in the coming years.”
“To try to explain this phenomenon, many people have leaned on a term from pop psychology for the consequences of overwork: burnout. Nearly two-thirds of physicians report they are experiencing its symptoms,” he added.
But for Reinhart, the explanation lies more in “our dwindling faith in the systems for which we work” than in the “grueling conditions we practice under.”
What has been identified as occupational burnout is a symptom of a deeper collapse. We are witnessing the slow death of American medical ideology.
It’s revealing to look at the crisis among healthcare workers as at least in part a crisis of ideology—that is, a belief system made up of interlinking political, moral, and cultural narratives upon which we depend to make sense of our social world. Faith in the traditional stories American medicine has told about itself, stories that have long sustained what should have been an unsustainable system, is now dissolving.
During the pandemic, physicians have witnessed our hospitals nearly fall apart as a result of
underinvestment in public health systems and uneven distribution of medical infrastructure. Long-ignored inequalities in the standard of care available to rich and poor Americans became front-page news as bodies were stacked in empty hospital rooms and makeshift morgues. Many healthcare workers have been traumatized by the futility of their attempts to stem recurrent waves of death, with nearly one-fifth of physicians reporting they knew a colleague who had considered, attempted, or died by suicide during the first year of the pandemic alone.
Although deaths from Covid have slowed, the disillusionment among health workers has only increased. Recent exposés have further laid bare the structural perversity of our institutions. For instance, according to an investigation in
The New York Times, ostensibly nonprofit charity hospitals have illegally saddled poor patients with debt for receiving care to which they were entitled without cost and have exploited tax incentives meant to promote care for poor communities to turn large profits. Hospitals are deliberately understaffing themselves and undercutting patient care while sitting on billions of dollars in cash reserves.
Acknowledging that “little of this is new,” Reinhart wrote that “doctors’ sense of our complicity in putting profits over people has grown more difficult to ignore.”
“From at least the 1930s through today, doctors have organized efforts to ward off the specter of ‘socialized medicine,'” he wrote. “We have repeatedly defended health care as a business venture against the threat that it might become a public institution oriented around rights rather than revenue.”
Confronting and beginning to solve the myriad crises of the U.S. healthcare system will “require uncomfortable reflection and bold action,” Reinhart argued, and “any illusion that medicine and politics are, or should be, separate spheres has been crushed under the weight of over 1.1 million Americans killed by a pandemic that was in many ways a preventable disaster.”
“Doctors can no longer be passive witnesses to these harms,” he concluded. “We have a responsibility to use our collective power to insist on changes: for universal healthcare and paid sick leave but also investments in community health worker programs and essential housing and social welfare systems… Regardless of whether we act through unions or other means, the fact remains that until doctors join together to call for a fundamental reorganization of our medical system, our work won’t do what we promised it would do, nor will it prioritize the people we claim to prioritize.”
Reinhart’s op-ed came as the prospects for legislative action to transform the U.S. healthcare system appear as distant as ever, despite broad public support for a government guarantee of universal coverage.
With the for-profit status quo deeply entrenched—preserved by armies of industry lobbyists and members of Congress who do their bidding—the consequences are becoming increasingly dire, with tens of millions uninsured or underinsured and one health crisis away from financial ruin.
In a study released last month, the Commonwealth Fund found that “the U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates” among rich countries, even as it spends far more on healthcare than comparable nations both on a per-person basis and as a share of gross domestic product.
“Not only is the U.S. the only country we studied that does not have universal health coverage,” the study added, “but its health system can seem designed to discourage people from using services.”
A Times investigation revealed that many of these institutions are abandoning patients and straying from their charitable missions.
Should they be taken over by a bigger system or close entirely?
Locally owned and operated community hospitals these days often face an impossible dilemma: Should they allow a larger hospital system to take over their operations, which can mean cuts to staff and services — or close entirely?
These hospitals are an essential lifeline for health care, often the only place where patients can receive hospital-level care without having to travel hours away from their homes. They are part of the fabric of the community, providing not only medical services but also good-paying jobs and other secondary benefits.
But the US health care system puts small, locally controlled hospitals at a disadvantage. Revenue is based almost entirely on the volume of medical services a hospital provides and, by their very nature, hospitals serving rural or otherwise remote communities do not see as many patients. That has put many of them in poor financial condition. Over the last 10 years, more than 130 rural hospitals have closed; hundreds more are projected to be in danger of closing soon. The pandemic took a toll on hospital finances, too, simultaneously making more small hospitals vulnerable to closure while also leading larger systems to look at potential acquisitions more skeptically.
Facilities seeking to avert the devastating effects of a full closure are left with limited options for keeping the doors open. A takeover is sometimes the only viable avenue. But that comes at a cost, as two recent episodes illustrate.
First, the deal can fall through. The Greenwood Leflore Hospital had for months been exploring a potential merger with the University of Mississippi Medical Center once local leaders decided the hospital, owned jointly by the city and county government, could no longer stay open on its own. As Mississippi Today reported earlier this month, the current owners agreed to put up $9 million to cover outstanding debts and deferred maintenance in order to make the deal more appetizing, but it still wasn’t enough to convince UMMC to take over the facility. Their options now are to find another buyer or close.
But even if a deal goes through, the pain can still come later. The community hospital in Sharon, Connecticut, was first acquired by a larger system in 2017 and then its ownership changed again in 2019 after the merger of two corporate entities. One of the conditions for state regulators approving the sale was that the new owners, Nuvance Health, agreed to maintain maternity care services. But within two years, the company seemed prepared to break that deal. Labor and delivery services could soon end. A community coalition is now fighting to prevent the loss of critical health care in their area.
The same stories have played out across the country. The Sharon hospital has been living through the same story as nearby Windham Community Hospital, almost beat for beat, just with a different owner. As larger systems continue to look for opportunities to scale up their operations, and as private equity has invested more in health care, local hospital services are increasingly subject to the whims of corporate owners who have no or little connection to the community.
Be eaten or face extinction — that is the predicament in which the US health system has placed many community hospitals. And whatever they choose, patients can lose.
The American health system makes it really hard for small hospitals serving small communities to subsist. According to a report from the University of North Carolina’s rural health research program, 30 percent of all US hospitals were operating in the red as of 2018 and a majority of unprofitable facilities are located in rural communities.
The US does not provide hospitals with a steady level of revenue, the kind of “global budget” where hospitals are given a set amount of money for their expected expenditures based on the patients they serve and the medical care they are likely to need. American hospitals have to try to bring in as much money as they can by performing as many services as they can, but without allowing their overhead to balloon.
There are federal lines of funding, such as the Critical Access Hospitals program, meant to ameliorate those challenges. But that funding has long been deemed insufficient to keep the most distressed facilities open. Additional funding for these hospitals authorized under the Affordable Care Act, through Medicaid’s disproportionate share hospital program, is set to expire soon.
These hospitals are also the most likely to see patients who are on Medicaid or uninsured, which means they end up recouping less money for the services they provide. Some of those people are uninsured because they live in a state that refuses to expand Medicaid through the ACA, another drag on hospitals’ finances.
Even those patients with employer-sponsored insurance in rural areas are more likely to have a high-deductible health plan that requires them to spend more of their own money on their health care. And the patients that these communities serve have higher rates of obesity, diabetes, and other chronic conditions.
Stir it all together and you have hospitals serving patients with a lot of medical needs but an inability to pay. That can lead to the egregious debt collection practices that have been the source of (deserved) scrutiny, as hospitals try to squeeze every penny out of patients, even those ill-equipped to cover the costs.
For the hospitals, it can be a difficult balancing act. Maintaining a labor-and-delivery department in a rural community with fewer births, one of the services commonly targeted for cuts when times get tough, can be expensive. A hospital needs nurses available to staff the unit and OB-GYNs either on staff or under contract who can be available at a moment’s notice. But you can end up spending a month’s worth of staff salary for a handful of births — and those births are often covered by Medicaid, with the lowest reimbursement rates of any US health insurer.
The pressure to find more money is real. But siphoning it from already-impoverished patients isn’t a sustainable solution. That leaves these hospitals with few options except to explore mergers in order to continue operating. But that comes with its risks, too, either if the new owner is not responsive to the community’s needs (as in Sharon) or if the deal falls through and there is no financially viable way to keep the hospital open (as in Greenwood).
Countries with more organized health care systems, where funding for hospitals is not entirely dependent on the volume of services they provide, are less likely to be faced with these problems. As public officials confront the possibility of rural hospitals shuttering for good and leaving their communities with nowhere nearby to receive medical care, they seem to recognize that a more comprehensive solution is necessary
“The financial issues facing health care are becoming universal in our state. We need a universal plan to address them,” Mississippi Lt. Gov. Delbert Hosemann said in a statement to Mississippi Today about the Greenwood facility.
When I read the reports of what was happening at the Sharon hospital, I was struck by the parallels with the situation in Windham, Connecticut, which I covered earlier this year. A small hospital had been acquired by a larger hospital system. In Windham, it was Hartford HealthCare; in Sharon, it was Health Quest, and later, after that company was merged with another to create a new nonprofit hospital network, Nuvance Health.
As part of those transactions, the larger health system pledged to maintain the current menu of services on which the community had come to rely. But that promise was quickly broken.
In Windham, the hospital first downgraded its ICU unit to a more limited “critical care” department. Then, without first seeking the necessary state approval, the Windham facility made the decision to close its labor-and-delivery department in 2020. That decision would have left expectant mothers to travel 30 minutes or more to give birth; as I reported earlier this year, at least one mom gave birth on the side of the road because her ambulance could not reach the new designated hospital for childbirth in time.
In Sharon, the hospital staff was told in 2020 that labor-and-delivery services would soon cease, in spite of a five-year prohibition on ending lines of service, according to a timeline compiled by the Save Sharon Hospital coalition. Nuvance then announced publicly in 2021 that it would close the maternity ward before it even sought approval from state regulators, just as Hartford HealthCare had in Windham. Around the same time, they revealed plans to downgrade the ICU unit in Sharon, another cost-saving measure that had previously been undertaken in Windham.
As in the first case, the Sharon hospital said that these maneuvers had been necessary because of a declining birth rate and the hospital’s strapped finances. The community coalition in Sharon has appealed to state lawmakers and regulators to try to block the closure. They are following the example of their counterparts in Windham, which had protested that maternity ward closure to state regulators and prevailed in an initial ruling that is now under appeal.
The stakes are high: Much as in Windham, the nearest hospital that provides labor and delivery services is a 38-minute drive, according to Save Sharon Hospital.
“The well-being of the hospital’s patient population is highly dependent upon its services,” Save Sharon Hospital said in a statement. “Patients in labor or experiencing obstetrical emergencies may be unable to reach an alternative hospital in time to avert a crisis.”
The Sharon hospital is living through the challenges that come with being absorbed into a bigger system. Individual sites can become increasingly specialized, and low-profit services that require scale to be profitable — such as delivering babies — end up being consolidated into specific facilities, even if that means patients will have to travel farther to receive them.
The research on how hospital acquisitions affect care is limited and the results are mixed. Some studies have found improved mortality for heart attacks, higher profitability, and more capital investments after an outside buyer takes over a community hospital. But other studies have concluded that patients report a worse experience at recently acquired hospitals, and an associated drop in inpatient charges may indicate that hospitals reduce or eliminate certain lines of service after they merged with another system.
What’s clear is that a merger is often the tool of last resort for a hospital that doesn’t make enough money and is accumulating debt. Because the alternative can be even worse.
In Greenwood, Mississippi, a city of 15,000 people, 90 miles from Jackson and 130 from Memphis, the locally owned community hospital is under duress. The hospital had been in talks with the larger University of Mississippi system since the summer, as its leaders sought to stave off closure.
It is a common problem in that part of the country; more than half of Mississippi’s rural hospitals are at risk of closure, according to the state health department. Greenwood has already stopped labor-and-delivery services in order to save money; another hospital in the Delta area where Greenwood is located also recently closed the only neonatal ICU unit in the area in another desperate attempt to cut costs.
The Greenwood hospital had slashed dozens of staff positions, and the local governments that currently own the facility had even authorized $9 million to cover outstanding debts that the facility owes to Medicare and for deferred maintenance in order to make the deal more appealing to UMMC.
But it wasn’t enough. UMMC said in a statement it could not make the finances work. The hospital could close by the end of the year unless a solution can be found.
“We did not have a Plan B,” Greenwood City Council President Ronnie Stevenson told Mississippi Today. “This community needs a hospital. We don’t want to have to rush to Jackson … We want to save lives here, and having a community hospital will save lives.”
The Greenwood facility is facing the final dilemma for community hospitals: merge or perish. Mergers had been rising before the Covid-19 pandemic, with a substantial uptick in activity between 2011 and 2016, the most recent period covered in a 2020 study. The pace appears to have slowed as a result of the pandemic, but the structural forces that have led more and more small hospitals to seek a buyer aren’t going away.
So long as the US health system makes it difficult for community hospitals to survive on their own, the stories that are playing out in Greenwood and in Sharon seem destined to be repeated.
Two thousand mental health care workers with the National Union of Healthcare Workers walked out August 15; their contract has been expired since September 2021. (National Union of Healthcare Workers / Twitter)
Psychologists, social workers, therapists, and chemical dependency counselors are in the ninth week of an open-ended strike at Kaiser Permanente in Northern and Central California.
The 2,000 mental health care workers walked out August 15; their contract has been expired since September 2021. They’re members of the National Union of Healthcare Workers (NUHW), which split from SEIU in 2010.
NUHW says Kaiser has failed to provide the staffing and wages to retain adequate and diverse staff — yielding unsustainable workloads and dangerous understaffing. After a mental health intake visit, even patients in crisis may wait weeks or months for a second appointment.
Clinicians also report managers pressure them to prescribe next appointments when an appointment is available, rather than when they think the patient needs it — a practice that’s dangerous for patients and demoralizing for mental health workers.
“It’s like if someone was given a cancer diagnosis, and the treatment prescribed was chemo twice a week,” said Sarah Soroken, a family and marriage triage therapist, “and we gave them a third of the chemo treatments they needed.”
Pandemic death, illness, isolation, and unemployment have yielded a second pandemic of mental illness and substance abuse, which health care providers have struggled to keep up with.
At Kaiser, an NUHW survey found that the attrition rate doubled from 2019 to 2022; 76 percent of the clinicians surveyed cited an inability to “treat patients in line with standards of care and medical necessity” as a factor in their decision to leave.
“I have never been able to have enough appointments, but now it is mostly six to eight weeks [between appointments], said Kim Hollingsworth Horner, a child and teen psychologist at Kaiser for twenty-two years and a member of the union bargaining committee.
“After COVID, it’s so much. We’re gambling with people’s lives.”
Kaiser clinicians also have no ceiling on how many patients they are assigned.
Sabrina Chaumette is one of two black clinicians at the Oakland clinic, and one of one hundred workers who struck on Martin Luther King Jr Day last winter. Kaiser had agreed to recognize the holiday then backtracked on it.
Having so few clinicians of color to serve the predominantly black population of Oakland is “racist and unsustainable,” Chaumette said, and it’s layered on top of so many other racial disparities that affect patients’ health: the impacts of COVID, discrimination, poverty, violence, gentrification, and generational trauma.
In diverse California, Kaiser has also canceled some services for Spanish-, Hmong-, and Chinese-speaking patients. The providers who supported those populations, as well as LGBTQ folks, have largely left for private practice or other work.
Another fifty Kaiser mental health workers in Hawaii joined the strike on August 29.
Across the country, labor activity among health care workers has surged since the pandemic. The praise for “essential” workers quickly rang hollow when employers did not match it with increased wages or adequate staffing for patient safety or to prevent burnout.
According to Cornell University’s strike tracker, the number of strikes in the first six months of 2022 in the health care sector (twenty-one strikes) was more than double the number for the same period in 2021 (ten strikes).
Kaiser, which is both a chain of health care facilities and the HMO that covers them, insures about 40 percent of Californians, through company and individual plans, and through the state Medicaid plan, MediCal.
That makes Kaiser’s inability to provide mental health treatment a huge public health risk, the union argues.
NUHW is pairing a legislative strategy with its bargaining fight. The union won passage of a safe staffing law for mental health services, Senate Bill 221, which took effect this past July.
The new law requires HMOs and insurers to provide mental health patients with follow-up appointments within ten days, if needed, after their intake — thus implicitly requiring Kaiser to hire enough clinicians to see all those patients.
It will be interesting to see if the union is able to pair the regulatory power of the State of California with direct action to bring a giant like Kaiser to an agreement.
It is legally Kaiser’s responsibility to make sure its patients get treatment. NUHW members are pushing Kaiser, which has canceled thousands of appointments because of the strike, to pay for out-of-network appointments in the interim.
NUHW and Kaiser have agreed on wage increases but remain at odds over proposals to give practitioners more time to complete their work outside of patient time (for instance, coordinating care for patients with other medical professionals, schools, families, and social services) and ways to reduce the time between appointments for acute patients.
NUHW president Sal Rosselli announced today that Sacramento mayor Darrell Steinberg, a longtime mental health care advocate and a former leader in the state senate, will mediate negotiations between Kaiser and the union.
“I hope within days we come to a resolution,” Rosselli told strikers at a rally in Oakland, the Sacramento Bee reported. “Our hope is a tentative agreement, and that tentative agreement must include a fundamental change in the relationship, where Kaiser executives agreed to collaborate with you, with our clinicians, to finally fix the behavioral health system.”
Since the majority of the Kaiser strikers work at smaller offices and clinics around California, they have rotated picket lines among different offices and the Kaiser headquarters in Oakland.
Patients and their families have been vocal on their therapists’ side, speaking at picket lines and rallying with elected officials for support. NUHW has been organizing patients to report canceled appointments to the state, leveraging additional pressure from the Department of Managed Health Care to push Kaiser back to the bargaining table.
The experience has already yielded a more militant membership, in Hollingsworth Horner’s estimation. “I’m a steward, and in my experience this is the most active people in Fresno have ever been,” she said. “This is one of the successes of this strike, so far. Unity among members is stronger than it’s ever been.”