Steve August 26, 2020
the-republican-solution-to-shuttered-rural-hospitals:-zoom-calls

On the opening night of the Republican National Convention, a woman named Amy Johnson Ford made the counterintuitive case that Tweety McTreason’s actions during the coronavirus pandemic had not, in fact, led to the deaths of thousands of Americans, but had actually prevented deaths. “I can tell you without hesitation Tweety McTreason’s quick action and leadership saved thousands of lives during Covid-19,” said Ford, a nurse from West Virginia who had traveled to New York City to help fight coronavirus at the height of the outbreak there. Low-effort propaganda aside, Ford’s main role in the proceedings was to highlight Trump’s expansion of telehealth coverage for Medicare recipients early in the pandemic, which he recently ordered the Department of Health and Human Services to make permanent via executive order.

Ironically, Ford’s hometown of Williamson, W.V. neatly demonstrates much of the sickness at the heart of America’s health care system, in particular its neglect of rural health care. Williamson Memorial was the only hospital in Mingo County until it closed its doors in April—one of the 14 rural hospitals that have closed so far this year and the many more facilities that have struggled with the loss of revenue during the pandemic. The cancelation of many non-emergency procedures and the reluctance of patients to head to the emergency room during a pandemic obliterated its finances, which were already in perilous shape: The hospital had filed for bankruptcy in October.

The hospital’s closure received high-profile attention from politicians, such as Sen. Joe Manchin and Governor Jim Justice. It was surely a relief to many when the facility was purchased by a nearby facility, Williamson Health and Wellness Center, for $3.68 million. But the CEO of that company, Christopher Donovan “Dino” Beckett, told The Los Angeles Times that he doesn’t know if he’ll be able to reopen the hospital’s emergency room. “It just depends on how quickly the United States gets back to normalcy,” he told the paper.

Williamson Health and Wellness Center is, like many health care facilities, a non-profit. It is a federally qualified health center; these facilities provide community health care in underserved communities including rural areas, and offer care regardless of its patients’ ability to pay. According to its most recent tax documents, Williamson Health and Wellness Center paid Beckett over $700,000, just under 10 percent of its entire revenue, in 2018. It also paid his holding company more than $125,000 in rent. The median income in Mingo County is $31,305, about half the national median. The model is very different for these non-profit community health centers, but larger non-profit hospital organizations are often far from charitable providers of care; they are frequently the most aggressive in suing patients over unpaid bills, for amounts they will never be able to pay, and their CEOs are among the best-paid hospital executives in America.

The troubled story of Williamson Memorial encapsulates many of the problems faced by rural hospitals. In 2018, the hospital was purchased by Community Health Systems, a major for-profit hospital chain that managed to turn a profit in the first quarter of 2020, despite the impact of Covid-19. The chain has closed many rural hospitals in the last few years as it struggles with debt. In 2015, it paid a $98 million settlement to the federal government for allegedly admitting patients unnecessarily to increase revenue. (CHS has been continuing to sue hundreds of its patients for unpaid bills during the pandemic, according to Axios.) But CHS soon abandoned the purchase of Williamson Memorial, and it was instead bought by a group of local investors later in 2018, including the mayor of the town. When the hospital filed for bankruptcy in October last year, it was revealed to owe more than $600,000 to CHS.

And so we have a hospital that closed just a month after lockdowns began in the United States; that has been through a tumultuous past already, and was barely holding on before the pandemic struck; and that may or may not reopen with an emergency room. Situations like this are increasingly common over the last few years, and the impact that these closures have on the surrounding communities is impossible to overstate. Gut-wrenching stories, like those written by reporter Eli Saslow, have documented what misery is caused when these hospitals close. The data supports the obvious conclusion: Rural hospital closures lead to deaths. Mark Holmes, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill, told NPR that a hospital closure “leads to higher mortality pretty quickly.”

What about the solution Ford touted from the dais of the Republican National Convention: the adoption of telemedicine? There are obvious benefits to implementing telehealth technology in rural areas, like avoiding the necessity of patients driving to facilities that may be many miles away. This is a particularly problematic burden for patients seeking primary and preventive care—the sort of medical intervention that rural patients might not be able to make time (or gas money) for, but which potentially reveal problems before they get worse: cancers before they metastasize, high blood pressure before it causes a heart attack. Allowing a patient to talk to a doctor, or even show them their lumps and bumps via video conference, from home can drastically reduce the barriers to care. That is, if it’s covered, and if the patient is insured.

One major problem is the poor state of broadband infrastructure in rural America. Video streaming is a bandwidth-heavy activity. Roughly a third of rural Americans don’t have broadband access; “broadband” is defined by the FCC as download speeds above 25mbps, though advertised speeds usually end up being far lower in practice, as anyone who has ever tested their home internet speeds will know. Patients with worse internet are likely to be poorer, and poorer people are likely to be sicker. Even though these people could benefit the most from regular, preventative check-ups and check-ins with a medical provider, they are least likely to be able to access it, without major and rapid investment in broadband infrastructure.

The cost of care remains a significant barrier, just as it would be for in-person visits. Rural areas have higher rates of uninsured people overall, especially in states that refused Medicaid expansion. In those non-expansion states, completely rural counties had an average uninsured rate of 14.9 percent in 2017, compared to 7.6 percent for mostly urban areas in expansion states. Some mostly or entirely rural counties in Texas, the state with the highest number of uninsured people in the country and some of the cruelest Medicaid requirements, had uninsured rates above 30 percent in 2017. In a poll conducted last year, 26 percent of rural Americans said there had been a time in the past few years where they needed health care and didn’t receive it; 45 percent said it was cost that prevented them from receiving care.

Trump’s executive actions may have expanded telehealth for Medicare, but patients on traditional Medicare plans will still have to meet their $198 deductible and pay 20 percent coinsurance for their visits. The Kaiser Family Foundation noted in a policy brief that some insurance companies will cover telehealth, but only for visits done through their own platforms, meaning patients couldn’t see their usual doctor. Other plans will cover telehealth for Covid-19-related visits, but not for other reasons—and it’s these “everything but Covid” visits that have dramatically fallen off during the pandemic, ruining the finances of rural facilities. The thousands of different insurance plans in America each have their own rules about what will and won’t be covered. And each state administers its own Medicaid plan, with its own rules about how telehealth can be conducted.

One of the questions with telemedicine that is yet to be fully resolved: Will these visits be paid at the same level as in-person visits beyond the pandemic? The New York Times reported earlier this month that private insurance plans “see telemedicine as a way to save them money,” and are likely to continue trying to pay providers less for these visits, unless the government forces them to pay at parity. This is clearly not a recipe for rescuing struggling rural hospitals; if they were already struggling before the pandemic because of their poor, uninsured populations, being paid less for the same work done over the internet won’t patch the cracks. Indeed, a New Yorker piece from earlier this year reported that rural providers are wary of telemedicine, and that their “already meagre medical staffing, and the revenues generated from procedures that can be performed on-site, will be further hollowed out by remote medicine.”

Ultimately, telemedicine can only complement, not replace, in-person care—and this can only happen if the hospitals stay open. Most medical diagnoses will still require in-person visits, and many telemedicine appointments end in the doctor telling the patient to come to the office after all. Doctors will always need to be able to see and feel the patient, extract fluids and blood for tests, check their blood pressure. And rural residents will always need to be able to get to an emergency room.

Telemedicine is the sort of thing that policymakers tend to find especially alluring, often for little reason beyond the fact that it’s shiny, impressive, and to do with computers. Anything tech-related is catnip to wonks and disruptors who seek tidy little innovations to fix problems that have deep roots and many complicated causes. But these health care inequities are far too all-encompassing to be ameliorated by such a minor upgrade, even if every rural resident got fiber internet overnight. Telemedicine can’t save a hospital that is failing because its patient base is dwindling, increasingly poor, and sicker than ever.

The problems outlined above can be fixed. We could completely change how hospitals are funded, so that they don’t depend on the whims of the market or on the fee-for-service model at all. We could build high-speed internet lines to all communities through government action, without waiting for a broadband provider to decide it’s profitable to do so. We could give money and health insurance to poor people so that they don’t die of poverty and neglect. But first, we must commit this country to the notion that every single human being deserves a good life, no matter where they live or who they are, and that starts with high-quality health care. That is something we seem to have forgotten.

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