Closed Hospitals Leave Rural Patients ‘Stranded’ as Coronavirus Spreads

Map of where the nearest hospital is more than 30 minutes away.

Many red states chose to NOT expand Medicaid under the Affordable Care Act and one consequence has been the closure of many rural hospitals, leaving many rural residents with no nearby hospital.  In a medical emergency, having a hospital nearby is literally a matter of life and death - something I learned years ago when one of my children was stricken with bacterial meningitis.  We lived at the time about 5 minutes from a large hospital with a trauma center ER.  We had a positive result and full recovery.  Had the hospital been 30 minutes or more away, things would have been horrifically different. Now, with the Covid-19 pandemic still raging - cases are still rising in Virginia and many other states - many rural residents are finding a serious lack of hospital access.  The irony, of course is that many of these same areas support Republicans (usually because of GOP calls to racism and religious extremism) whose policies have exacerbated the lack of local hospitals. Talk about voting against one's own best interests! A piece in the New York Times looks at the predicament rural Americans are facing.  Here are highlights: 

Michael Nuzum had spent weeks fighting coronavirus-like symptoms — a wracking cough, terrible chills, an exhausting fever — before collapsing at his home in rural West Virginia.

Mr. Nuzum, a 54-year-old animal control worker, was already in cardiac arrest when the emergency workers arrived on April 3. That left them with a difficult decision: Should they transport their patient to the nearest hospital, 30 minutes away?

“There’s only so much one paramedic can do in the back of an ambulance,” said Michael Angelucci, who leads the Marion County rescue squad that cared for Mr. Nuzum. The two-person team that responded decided it couldn’t risk the long ride and instead tried to revive the patient at the scene. But the workers couldn’t save him.

Two weeks earlier, the options would have been different. Fairmont Regional Medical Center, just five minutes from Mr. Nuzum’s home, would still have been open. Mr. Angelucci, who is also a state representative, can’t help wondering if the hospital and its emergency room could have given the man a fighting chance.  “It’s incredibly frustrating that this entire community is stranded without a hospital,” he said.

Fairmont was one of three hospitals that have shut down in this corner of rural West Virginia and Ohio since September. They delivered hundreds of babies each year, treated car crash and gunshot victims, repaired hearts and knees and offered addiction treatment and psychiatric care.

They had been acquired by a for-profit company, Alecto Healthcare Services, beginning in 2014. Employees expected the new ownership to put the institutions on solid footing after years of financial struggle. Instead, decisions made by Alecto wound up undercutting patient care and undermining the hospitals’ finances, according to more than two dozen interviews with doctors, nurses, other staff members, government officials and patients, as well as a review of court records.

Finally, one after another, the three hospitals ceased operating. At the request of the governor, the West Virginia attorney general’s office is investigating the company’s decision to close them. The shutdowns . . . . have forced the region to fight a coronavirus outbreak with 530 fewer licensed hospital beds than it had a year ago. Across the United States, hospitals serving rural areas have spent decades trying to provide medical care and produce enough revenue to stay open. They have closed in increasing numbers in recent years as local populations have declined. About 170 rural hospitals have shut down since 2005. [F]or-profit hospitals are more likely to close than the others, one recent federal study showed. It found that for-profit facilities accounted for 11 percent of rural hospitals but 36 percent of closures among the group. Within the past year, rural hospitals have closed in Pennsylvania and Tennessee after selling to for-profit chains. Ms. Horwitz’s research found that for-profit rural hospitals were less likely to offer needed but unprofitable medical services, such as hospice and inpatient psychiatric care.

“The goal of the for-profit is to make money,” Ms. Horwitz said. “That doesn’t mean they’ll do anything to make a buck, but they have a different goal from nonprofits.”

Alecto’s hospitals generally serve low-income communities, with most patients covered by Medicare or Medicaid. In Marion County, for example, the population once served by Fairmont has higher-than-average smoking and obesity rates. The state also had the country’s highest rate of drug overdose deaths in 2018. West Virginia University’s health system, about 12 miles from Fairmont, plans to reopen part of the Fairmont hospital but will not be able to do so until late May.

For now, the three communities face a stretch of months where hospital beds could be scarce in the midst of a global pandemic. Jennifer Henderson Hayes, who was the chief pharmacist at East Ohio, now works at the remaining hospital in Wheeling.

She has already seen greater strain on the emergency room there. “You see people, potentially sick with Covid-19, waiting for eight or 12 hours just to be seen.”

For profit hospitals are a problem in my opinion.  Years ago when I worked for a law firm that represented a non-profit hospital system, administrators regularly complained that the for profit Humana hospital 20 minutes away would send uninsured patients by taxi to the non-profit hospital rather than treat them. 

Appalachian Coal Communities Brace For Coronavirus

Appalachia - including large swaths of Southwest Virginia - is to a large extent an economic basket case due to multiple factors two of which are (i) the decline of the coal industry (which continues to shrink despite Trump's ridiculous claims to bring it back), and (ii) the region's reactionary politics and embrace of right wing Christianity that discourages new, progressive business from even considering relocating to the area. Now, Covid-19 may be poised to wreak havoc on a population that in general has poor health and a shortage of hospitals and medical care access, especially since many lack heath care insurance (unlike most Appalachian states, Virginia and Kentucky have expanded Medicaid).  A piece in Huffington Post looks at  the potential catastrophe if coronavirus moves into into Appalachia in a major way.  Here are highlights:

Coal is no longer the commodity it once was, but its legacy in Appalachia remains: scores of miners with black lung disease who are now at a high risk of suffering from the coronavirus.

Coal workers’ pneumoconiosis, better known as black lung, is a scarring of the lungs caused by years of coal dust inhalation. At least one in 10 underground miners has black lung, according to the Centers for Disease Control and Prevention, but experts say the actual number could be much higher. As the lungs scar, it becomes harder to breathe, so the thought of adding COVID-19, the respiratory disease caused by the coronavirus, to the mix is terrifying to these workers. 

[M]any fear it’s only a matter of time until the virus contributes to a triple-whammy in Appalachian mining communities: a population with elevated health risks, an economy in free-fall and limited health care resources. . . . . “It’s probably just going to wipe us out.”

Appalachia, which stretches from New York to Alabama and once produced most of the nation’s coal, is particularly at risk from the pandemic because of its residents’ poor health. Appalachians are more likely than other Americans to have ailments such as cancer, heart disease and diabetes, due in part to smoking and a more sedentary lifestyle, according to the Appalachian Regional Commission, all of which could exacerbate the effects of COVID-19. . . . COVID-19 “would be a nail in the coffin.”

The Appalachian region has also lost dozens of rural hospitals in recent years, according to the University of North Carolina ― a trend in rural areas across the country. Black lung patients often travel an hour or more to visit doctors, Go said.  . . . And coronavirus has already stretched regional health care resources even thinner.

Telemedicine, which allows doctors to use video and other interactive tools to treat patients from afar, would be helpful during the pandemic, Doyle said. But, he added, many rural black lung patients have neither the technology nor broadband service for telemedicine.

The National Mining Association, which lobbied for these cuts, told HuffPost in a written statement that companies are “adjusting to this new reality and following government guidelines, with distancing measures being taken, increased cleaning schedules ... and limits on gatherings of groups.”

But in southern West Virginia, Doyle said he hasn’t seen much change in mining operations in recent weeks. Mine workers, recognizable in blue outfits with reflective stripes, are still walking around town as usual, he said, possibly spreading the virus without knowing.

“It looks to me like they’re going about their business,” Doyle said. “Until their co-workers start falling ill, I don’t think they’re going to change. A lot of people here are not convinced they need to do anything.”

The Trump/GOP Bludgeoning or Rural America

Harvesting a crop of soybeans at a farm in 

Hickory, N.C., in 2018. Charles Mostoller/Reuters.

For decades the GOP - and more recently, Donald Trump - has used religion and racial hatred and a smoldering feeling of inferiority/resentment to induce rural voters to vote for GOP candidates and against their own long term economic and financial interest.  I have used a cartoon on past blog posts that shows a red state voter stating that "they hate the same people I do" as a basis for voting Republican.  Sadly, there is much truth in the cartoon's message.  Now with the Trump tariffs, many rural voters find themselves and their communities reeling economically.  Trump wants to give farmers a bailout but lies about the revenues to be used to fund the bailout and omits the fact that the tariff revenues will be paid by AMERICANS and not China.  As is always the case, Trump and the GOP hope voters are too stupid to see that they are being conned and in some measure, it is GOP policies that are accelerating economic stress in rural areas.  Enterprising Democrats need to seriously come up with proposals to address the growing economic malaise in rural America and work to educate rural voters to the reality that the GOP and its policies is harming them and that these need to stop taking the GOP race-baiting and appeals to far right Christian extremism.  A column in the New York Times looks at the ongoing decline of rural America and how a new set of solutions is needed.  Here are excerpts: 

[Donald] President Trump’s feckless trade war is bludgeoning the bottom line of the Republican Party’s reliable rural base. But the party’s disregard for the economic interests of its own constituents goes well beyond barriers to Chinese markets.

Small towns and rural areas, along with some Rust Belt metros, are falling ever further behind booming urban dynamos — leaving many heavily Republican regions in a deepening morass of economic deterioration, joblessness, substance abuse and declining life expectancy. The lower-density places most Republicans call home produce barely half as much wealth as our biggest cities — and it’s showing.

Yet the travails of America’s struggling red regions, and practical ideas about might be done to alleviate them, are barely mentioned in right-leaning policy circles. For example, “The Once and Future Worker,” a widely discussed book by Oren Cass, a former economic policy adviser to Mitt Romney now at the Manhattan Institute, focuses on initiatives to expand employment and wages for American workers but largely neglects the changing geography of economic output and opportunity behind the woes of heartland workers.

Worse, the Republican Party under Mr. Trump has blundered into a positively anti-rural economic agenda, leaving the soybean fields littered with $20 bills for enterprising Democratic presidential hopefuls to pick up. The president’s nativist immigration agenda deprives farms and small factories of workers local economies can’t otherwise supply, while the administration’s latest budget proposal continues the Republican assault on the health care and social insurance programs rural populations increasingly rely on to survive.

For decades, poorer areas had been converging economically with wealthier ones, but that stalled in the early 1980s as employment began to shift away from widely distributed agriculture and manufacturing jobs toward the service sector and high-skill “knowledge work” in the city-centered information economy. Since then, inequalities in regional productivity and living standards have been widening. The declining capacity of smaller towns and cities to bounce back from job loss — whether because of recession, automation or offshoring — means that the regional economic gap grows wider with every downturn, “disruptive” technological advance or uptick in global economic integration.

As smaller towns lost population and viability as centers of commerce, the families of workers who remained in rural hamlets came to rely on trips to larger nearby towns and cities for their shopping, education and health care.

But then many of the factories supporting these regional hubs downsized, moved overseas or folded under competition from countries with cheaper labor. Assembly-line workers who lost jobs mostly shifted to lower-paid service jobs or dropped out of the work force. Crucially, the college-educated workers who ran these factories — the engineers, managers and lawyers — began to flee with their families to the opportunities in bigger cities, and took their money, civic energy and organizational know-how with them.

Scholars at the Brookings Institution’s Hamilton Project have devised a county-level “Vitality Index” combining weighted measures of median household income, poverty, life expectancy, housing vacancy and rates of unemployment and prime-age employment from 1980 to 2016. They find that the fifth of the American population living in counties with the highest share of rural population suffer the lowest levels of vitality — by a long shot. Americans in these low-vitality counties are far more likely to live in poverty, suffer health problems, die early and lack a job. These places, it bears emphasizing, are overwhelmingly majority Republican.

So what can be done? Here are five ideas:

·         States with flagging economies and declining populations lack the tax base to finance the programs needed to maintain healthy economies. We should adopt fiscal measures to “equalize,” or share, national wealth, which are standard in other advanced countries. This would help prop-up state budgets and ensure the healthy functioning of our decentralized federal system.

·         Basic scientific research and infrastructure investments pay big, long-term economic dividends, yet they are underfunded. A network of federally chartered regional development banks could support weak local economies by issuing tax-favored bonds to finance infrastructure upgrades and promising Research and Development projects spearheaded by currently struggling state universities.

·         The Small Business Administration could be refitted to expand small firms that generate growth in exports and high-value-added sectors, as the economist Dani Rodrik has suggested, rather than simply supplying cheap credit to mom-and-pop shops that sustain, but don’t expand, local employment.

·         A new federal Office for Struggling Regions could facilitate interstate compacts and agreements to help attract firms to flagging local economies on terms that prevent the race-to-the-bottom tax-incentive bidding wars.

·         Granting states some authority to mint visas to meet their specific labor market needs would help dry up demand for undocumented workers, stave off depopulation, keep businesses in place, and fill in fiscal gaps.

Conservatives who have come to embrace economic nationalism have misdiagnosed the problem, and therefore fail to see why bullying trade partners and indiscriminately cracking down on immigration won’t bring back jobs and increase wages.

But the reality of widening geographic disparities has been slow to penetrate Democratic politics and policymaking. Elizabeth Warren’s plan to protect family farms and check the market power of agribusiness giants takes rural woes seriously, but it’s a band-aid on a hemorrhage.

Politically, if Mr. Trump once again chooses divisive culture-war theatrics over an honest attempt to shore up the places that, for now, still prefer Republicans — probably a good bet — Democrats could flip rural House and Senate seats Republicans have long considered “safe.”

This mere possibility could even become likely if only Democratic primary contenders, now seeking favor in rural states, would finally spot the glittering opportunity that Republican misrule has laid at their feet.

 One can only hope that (i) Democrats will recognize and seize this opening and (ii) rural voters will finally wake up to the reality that being duped by GOP culture war memes is not in their best interests or in the best interests of their children and grandchildren.  Indeed, clinging to the culture wars and far right religion makes rural areas anathema to many progressive and innovative businesses - businesses that rural America desperately needs. 

The GOP Elite Despise the American Heartland

An abandoned gas station in East Lynn, W.Va., a coal mining town (NYT).

While Democrats struggle to determine which of their multitude of presidential nominee candidates can win the American Mid-West and perhaps pinkish red states, Donald Trump continues to play the racism card and panders to evangelicals' extremism even as he and his party continue to push policies that harm working class workers and farmers in these areas of the country. Between the Trump tariffs which have hurt both farming and manufacturing and the Trump/GOP tax cut give away to the extremely wealthy and multi-national corporations.  Then, of course, there is the GOP effort to gut Medicaid and decrease Medicare spending which prove catastrophic to rural areas in so-called flyover country.  The consistent losers under the GOP agenda?  The middle and working classes and farmers, many too blinded by their anti-non-white bigotry and their homophobia to realize that they continued to be played by fools not only by Trump but also the so-called GOP elite who hold them in contempt despite occasional lip service to the contrary.  A column in the New York Times looks at how the GOP really views this element of the party's base.  Here are column highlights: 

“If you live in the Midwest, where else do you want to live besides Chicago? You don’t want to live in Cincinnati or Cleveland or, you know, these armpits of America.” So declared Stephen Moore, the man Donald Trump wants to install on the Federal Reserve’s Board of Governors, during a 2014 event held at a think tank called, yes, the Heartland Institute. The crowd laughed.

Moore is an indefensible choice on many grounds. Even if he hadn’t shown himself to be extraordinarily misogynistic and have an ugly personal history, his track record on economics — always wrong, never admitting error or learning from it — is utterly disqualifying.

His remarks about the Midwest, however, highlight more than his unsuitability for the Fed. They also provide an illustration of something I’ve been noticing for a while: The thinly veiled contempt conservative elites feel for the middle-American voters they depend on.

This is not the story you usually hear. On the contrary, we’re inundated with claims that liberals feel disdain for the heartland. . . . what’s the source of that narrative? Look at where the belief that liberals don’t respect the heartland comes from, and it turns out that it has little to do with things Democrats actually say, let alone their policies. It is, instead, a story line pushed relentlessly by Fox News and other propaganda organizations, relying on out-of-context quotes and sheer fabrication.

Conservative contempt, by contrast, is real. Moore’s “armpit” line evidently didn’t shock his audience, probably because disparaging views about middle America are widespread among right-wing intellectuals and, more discreetly, right-wing politicians.

There is a real economic and social crisis in what one recent analysis calls the “Eastern Heartland.” This region suffers from persistently low employment among working-age men and has seen a surge in mortality from alcohol, suicide and opioids — “deaths of despair,” in the phrase of Anne Case and Angus Deaton.

What lies behind this crisis? The view of most liberals, as far as I can tell, is that it reflects declining economic opportunity, changes in the economy that have favored metropolitan areas over rural communities.

Many conservatives, however, blame the victims. They attribute the heartland’s woes to a mysterious collapse in morality and family values that somehow hasn’t affected coastal cities. Moral collapse is the theme of books like Charles Murray’s “Coming Apart: The State of White America,” and of innumerable articles. One widely read essay in National Review went so far as to label the troubled Eastern Heartland “the white ghetto,” whose people are too indolent to move to where the jobs are.

When it comes to politicians, of course, what they say is much less important than what they do. So what do the policy choices of liberal and conservative pols say about how they value the heartland?  Some Democrats, notably Elizabeth Warren, have been offering real proposals to help rural areas.

Meanwhile, all that Republicans have to offer are fantasies about bringing back lost jobs in things like coal mining and manufacturing. In reality, coal mine closures have continued and the manufacturing trade deficit has widened since Trump took office.

More important, think about what will happen to troubled parts of America if Republicans manage to do what they tried to do in 2017, and impose savage cuts on Medicaid and other safety net programs.

I always think about West Virginia, where Medicaid covers almost a third of the nonelderly population. And it’s not just about receiving care, it’s also about jobs. More than 16 percent of West Virginians are employed in health care and social assistance, compared with less than 3 percent in mining. Hospitals are the biggest employers in many parts of rural America. What do you think will happen to those jobs if Medicaid is hollowed out?

[I]f you look at what conservatives say to each other, as opposed to what they pretend to believe, it becomes clear that contempt for middle America is much more prevalent on the right than on the left. And this contempt is reflected in the right’s policy agenda, which would badly hurt the people it claims to consider the only real Americans.

I know that this will be a hard point to get across. Indeed, I’m sure that some people in the heartland will take any effort to convince them that they’re being misled as just another example of liberal disrespect. But all Americans, wherever they live, deserve to be told the truth.

What Trump's Tariffs Have Unleashed for Farmers

Like most would be autocrats - and certainly most malignant narcissists - Donald Trump, a/k/a Der Trumpenführer, thinks he knows everything about all things.  As a historical note, Hitler and Nicholas II both thought they knew more than their top generals and the end results ended badly for both of them.  In Trump's case his Waterloo - for Fox News viewers, that was a horrific military defeat suffered by Napoleon - may be in the Mid-West in the center of "Trump country" and so-called flyover country.  The match that started the conflagration will likely be Trump's self-created trade war that is well on the way to decimating farming operations in places like Iowa.  States where the populace fell for Trump's siren song of racism and xenophobia and voted against their economic self-interest.  A piece in the New York Times by the  news director for the radio stations KNIA and KRLS in Marion County Iowa looks at the economic coming disaster Trump has unleashed, the beginnings of which should be evident before the vote in the midterm elections in November.  Here are excerpts:

Today President Trump is visiting Dubuque, Iowa, where every year at harvest time, millions of tons of grain come via rail and truck to be loaded onto barges on the Mississippi River and shipped to Mexico, China and much of the rest of the world. Harvest puts coin into the hands of farmers, and they and their communities — indeed all of America — profit. Not this year.

The president is here to trumpet a $12 billion plan to aid American farmers. Why do they need aid? For Iowans, it’s because 33 percent of our economy is tied, directly or indirectly, to agriculture, and Mr. Trump recklessly opened trade wars that will hit “Trump country” — rural America — hardest and that have already brought an avalanche of losses. Indeed, the impact of his tariffs will probably be felt by family farms and the area for generations.

The cost of being shut out of overseas markets for soybeans, beef, pork, chicken and more will be in the billions. Once those markets are gone, they will be difficult to recover. Commodity prices continue to drop, and good weather suggests an excellent crop is in the making, which will drive prices further down.

Brazil is ready to step in with increased soybean production, and China has already shifted its purchasing power there.

In farm country, U.S.A., the Trump tariffs have poured gas on what has been a slow-burning conflagration.  Rural America is about to undergo a major demographic shift. President Trump didn’t start it, but he has accelerated a crisis that might have taken a generation or two to play out. Now it might take only a few years. Rural America is going to be hollowed out very quickly. Farms will become consolidated, and towns that are already in trouble will certainly die.

Iowa’s farmers are aging, and younger farmers aren’t replacing them proportionately. Sixty percent of Iowa farmland is owned by people 65 years or older, and 35 percent of farmland is owned by people 75 or older. . . . This isn’t because young people in rural America don’t want to farm; it’s because, if it isn’t already the family business, the costs are much too high to allow many of them to get into it.

A friend, a small-town Iowa banker who specializes in working with farmers, offered a local example. It’s time for Mom and Dad to retire, get off the farm and move to town. Much of the time, if no heir is interested in continuing the operation, the farm is auctioned to the highest bidder. . . . but a big operation “bid it up more than it was worth, some guy from out of town no one knew — probably from one of the big operations up north. The kid didn’t have a chance. It was heartbreaking.”

I use Iowa in my examples, but much of rural America will be affected in a similar way. In the worst possible outcome of this scenario, losses and farm consolidation accelerated by Mr. Trump’s tariffs will make the devastating 1980s farm crisis look like a bump in the road as it drives a significant rural-to-city migration.

In my community, I learned this week that a hog operation I drive by every day is folding. The confinements are being dismantled, and anything portable can be found on Craigslist. A friend close to the family told me pork prices have been down for years, and with the tariffs it’s just not worth it anymore.

Another casualty: our community banks. As farms get larger, farm loans are less likely to be local. A big operation with farms in dozens of counties that maybe even cross state lines probably won’t use local banks for credit.

At a certain point, populations won’t be enough to support rural hospitals and clinics, and they, too, will be gone. Rural hospitals are one of the major employers in the community. Even if you have a good manufacturing company in town, if you lose the hospital, they won’t be able to attract the employees they need.

Those plants may be forced to leave as well — especially since the tariffs have hit them hard also. One friend who has a small manufacturing business says his costs have doubled since Mr. Trump announced tariffs on aluminum and steel, and that his business is down 40 percent.

Some of the farmers I speak with are unwavering in support of the president; they’d vote Republican even if Mr. Trump personally slapped the heck out of the preacher at the church potluck. But others are starting to recognize how the economic impact of the tariffs is hitting them personally.

This is why, earlier this summer, Vice President Mike Pence came to the Midwest for a reassuring visit and why Sonny Perdue, Mr. Trump’s secretary of agriculture, offered his $12 billion band-aid of a handout Tuesday. . . . Trump is here now, crowing of those billions. What farmers really want are the markets restored.

Farmers take out lines of credit in the spring — usually due the following Jan. 1 — to pay for seed and other input costs, and then pay the loans back after harvest. Like any other loan, there are consequences to not paying, including losing the farm. Farmers are going to know before the midterm elections if they are going to be able to pay back loans.

[W]hen the Trump payments are made to farmers, the larger operations will be the ones that gobble them up.

Mr. Perdue, and likely President Trump, know the $12 billion won’t make a difference, even in the short term. Farmers and others in the industry know the offer is meaningless. But most rural Republicans aren’t farmers, and many are Fox News devotees.

The destruction of a way of life cuts as deep now as it did back then, especially when it comes from this president. The only thing he knows about food is that it always comes served to him on a silver, or maybe gold, platter.

As I have noted before, while I worry about children and youths in these areas and what happens to them, for the adults who voted Trump/Pence, they need to reap the whirlwind of their actions and the suffering needs to be intense. 

Trumpcare: The Face of Republican Evil

Yesterday the GOP Senate healthcare bill saw the light of day and what could be seen was hideous if one feels any concern for children, the non-wealthy elderly and people with disabilities.   When disabled protesters in wheel chairs massed outside the office of GOP Senate Majority Leader Mitch McConnell to protest the bill, as reported by Think Progress and many other news outlets, Capitol police dragged them out of their wheel chairs, handcuffed and arrested.  Perhaps such treatment of the disabled is just a glimpse at what many disabled will suffer if the GOP Senate "healthcare reform" bill is enacted.  This bill is nothing than a humanitarian disaster to quote several critics.  Not surprisingly, the American Hospital Association has been quick to condemn it, recognizing that it would be a catastrophe for many hospitals, especially those in rural areas.   As explained below, this is very personal to me.  A piece in the New York Times looks at what we now know Republicans seek to inflict on millions of citizens in order to give massive tax breaks to the very wealthy.  Here are excerpts:

The bill is aligned with long-held Republican values, advancing states’ rights and paring back growing entitlement programs, while freeing individuals from requirements that they have insurance and emphasizing personal responsibility. Obamacare raised taxes on high earners and the health care industry, and essentially redistributed that income — in the form of health insurance or insurance subsidies — to many of the groups that have fared poorly over the last few decades.

The draft Senate bill, called the Better Care Reconciliation Act, would jettison those taxes while reducing federal funding for the care of low-income Americans. The bill’s largest benefits go to the wealthiest Americans, who have the most comfortable health care arrangements, and its biggest losses fall to poorer Americans who rely on government support. The bill preserves many of the structures of Obamacare, but rejects several of its central goals.

Like a House version of the legislation, the bill would fundamentally change the structure of Medicaid, which provides health insurance to 74 million disabled or poor Americans, including nearly 40 percent of all children. Instead of open-ended payments, the federal government would give states a maximum payment for nearly every individual enrolled in the program. The Senate version of the bill would increase that allotment every year by a formula that is expected to grow substantially more slowly than the average increase in medical costs. States would continue to receive extra funding for Obamacare’s expansion of Medicaid to more poor adults, but only temporarily. After several years, states wishing to cover that population would be expected to pay a much greater share of the bill, even as they adjust to leaner federal funding for other Medicaid beneficiaries — disabled children, nursing home residents — who are more vulnerable. High-income earners would get substantial tax cuts on payroll and investment income. Subsidies for those low-income Americans who buy their own insurance would decline compared with current law. Low-income Americans who currently buy their own insurance would also lose federal help in paying their deductibles and co-payments.

The bill does offer insurance subsidies to poor Americans who live in states that don’t offer them Medicaid coverage, a group without good insurance options under Obamacare. But the high-deductible plans that would become the norm might continue to leave care out of their financial reach even if they do buy insurance.

Under the bill, states would be able to apply for waivers that would let them eliminate consumer protection regulations, like rules that require all health plans to cover a basic package of benefits or that prevent insurance plans from limiting how much care they will cover in a given year.

States could get rid of the online marketplaces that help consumers compare similar health plans, and make a variety of other changes to the health insurance system. The standards for approval are quite permissive.

Americans with pre-existing conditions would continue to enjoy protection from discrimination: In contrast with the House health bill, insurers would not be allowed to charge higher prices to customers with a history of illness, even in states that wish to loosen insurance regulations.

But patients with serious illnesses may still face skimpier, less useful coverage. States may waive benefit requirements and allow insurers to charge customers more. Someone seriously ill who buys a plan that does not cover prescription drugs, for example, may not find it very valuable.

Subsidies under the bill would help middle-income consumers buy insurance that pays 58 percent of the average patient’s medical costs, down from 70 percent under Obamacare; it would also remove a different type of subsidy designed to lower deductibles further for Americans earning less than around $30,000 a year. Out-of-pocket spending is the top concern of most voters. The insurance they would buy under the bill might seem cheap at first, but it wouldn’t be if they ended up paying more in deductibles.

To me, this displays complete moral depravity - by those who claim to embrace "Christian values" and their supporters like evangelical Christians.  A piece in  Salon looks at how the GOP got this morally bankrupt.  Here are highlights:

In the hellish months since Donald Trump’s inauguration, a dark parlor game of sorts has cropped up in liberal circles that I like to call “Would an Impeachment Even Be Worth It?” With the full acknowledgment that it’s unlikely to happen as long as Republicans are in charge, participants still sip cocktails and ponder out loud the question of whether booting out Trump on his butt would be enough to save our democracy, considering the fact that the Republican slimeball taking his place would invariably sign a bunch of retrograde legislation setting back this country decades.

These discussions break down into two camps: those who think Trump presents a unique threat to our democracy and replacing him with someone in the succession line, like Vice President Mike Pence or House Speaker Paul Ryan, would at least preserve our democratic norms; and those who think the corruption started long before Trump and has spread throughout the Republican Party, rotting it from the inside out.

[M]y view that the Republican Party as a whole is irredeemably antidemocratic has been borne out, yet again, in the process that Senate Majority Leader Mitch McConnell has put into motion to destroy the Affordable Health Act, a process that will likely take out the U.S. health care system as we know it. One could even argue that bog-standard Republicans, under the leadership of Ryan and McConnell, represent an bigger threat to our democracy than Trump, possessing as they do more competence and cunning than the TV-addled overgrown toddler in the White House. McConnell has arranged to have the Senate version of the House’s American Health Care Act . . . . written in secret, with no hearings, no public discussion and no real debate. Republicans are barely even pretending the reason is anything other than the obvious: The bill is so terrible that it defies the will of people of all political stripes and sensibilities, whom legislators supposedly were elected to serve. McConnell’s contempt for the processes, much less the defining principles, of democracy couldn’t be more apparent. But he doesn’t really care. No doubt the election of Trump helped confirm the rising sense among Republicans that they can wipe their collective butts with the Constitution, flip the bird at their constituents and not really worry about losing many seats. Republican voters might not like it, but they like liberals, black people and feminists even less, so they will show up and dutifully vote against the Democrats every time. Losing health care access isn’t great, but for conservative voters, admitting that liberals might have a point is a hell from which there is no escape. . . . bedrock conservative voters don’t care about niceties like the rule of law or government by the people. They just want to punish women for having sex and gripe about “Obama phones,” and don’t care if the price paid is the ultimate ruin of this country.

In 1999/2000 one of my children was stricken with bacterial meningitis.  We were lucky, had purportedly "excellent healthcare coverage"  and my child had a miracle recovery (even if it wiped us out financially).  A key part of her survival was being in close proximity - less than 10 minutes - to a first rate hospital that could stabilize my child before a transport to a world class children's hospital.  If rural and inner city hospitals close thanks to Trumpcare, people will literally die for lack of close proximity to a hospital.  Mere minutes can make a life and death difference.

More recently, one of my grand children was born 2 months early.  He ended up staying in the hospital for a month.  A month earlier, my daughter had been ordered to do bed rest to try to delay his birth. Since Virginia and the USA do not have mandatory paid maternity leave, my daughter lost her heathcare coverage.  Thankfully, she signed up with Medicaid and my grandson had coverage. Without it, he may have died.

Sadly, average Americans simply no longer matter to the GOP, especially those like Mitch McConnell and Paul Ryan.   I'm sorry, but to me, voting Republican is now synonymous with moral bankruptcy. 

What Trumpcare Could Mean for Rural America - Is Southwest Virginia Listening?

Having been involved in Virginia politics for decades one thing that has always been striking is how rural areas of the state - especially Southwest Virginia - regularly votes against their own economic interests.  Appeals to Christian extremism and racism time and time again cause the rural areas to support Republicans who are great at promoting dog whistle racism and swearing fealty to the Christofascists at The Family Foundation but who do nothing to help the failing economy in these areas.  Making matters worse, the downward spiral in reactionary social norms make the areas less and less attractive for modern, progressive businesses to consider locating to the regions.  Now, with Republicans set to either repeal the Affordable Health Care Act or sabotage it further, rural America is on the verge of reaping what it has sown.  A piece at Vox looks at Tennessee as a case study of what may be coming to these Trump/GOP supporting areas of the country.  It isn't pretty and it is self-inflicted.  Here are excerpts:

Tennessee is a preview of what an Obamacare collapse could look under President Trump, where the law technically remains standing but people don’t have access to the programs.

The areas most at risk for this type of collapse are those that voted for Trump: places that are lower-income and rural, which aren’t attractive markets to health insurance companies.

These are places that have struggled to attract robust insurance competition both before and after the health care law’s implementation. “In general, rural areas have always been the places where it’s hard to attract a competitive insurance market,” says Aditi Sen, an assistant professor at the Johns Hopkins Bloomberg School of Public Health who has studied the health law marketplaces. “The incentives to enter just aren’t that strong.”

The Obama administration worked hard to recruit health insurers to sell to those areas. The Trump administration, however, seems to want to stand aside and let Obamacare run on autopilot, so it can explode or survive on its own.

In eastern Tennessee, that could have the practical effect of leaving 40,000 current Obamacare enrollees without coverage.

The stretch of eastern Tennessee where no insurers want to sell coverage includes 6,700 square miles of rolling Appalachian hills and rural roadside towns. It has 16 counties and 1.1 million residents.

Rural areas have long struggled to attract robust health insurance markets. The scarcity of doctors and hospitals makes it hard to build a network. Smaller populations mean there are fewer customers for insurers to sell to than they might find in more urban places.

The whole theory of Obamacare relied on both healthy and sick people signing up for marketplace coverage. The healthy people are crucial to balance out the bills of the sicker enrollees.

The Tennessee marketplace ran into trouble because it gave healthy consumers lots of ways to avoid joining the marketplace — a perfect storm of state and federal policy decisions that undermined the business case for insurers to sell Obamacare policies in the region. . . . It’s a self-inflicted wound.”

Tennessee layered on other policies that made it easier for healthy people to opt out of Obamacare. It appears to be the only state in the country that still allows some insurers to reject or charger higher prices to sick customers. This practice, called underwriting, was generally banned by the Affordable Care Act. A loophole in Tennessee law allows membership-only Farm Bureau plans to continue offering these products.

Georgetown University’s Sabrina Corlette has researched the Farm Bureau plans and estimates about 55,000 Tennesseans are currently purchasing non-ACA-compliant plans through the insurer.

The Farm Bureau plans, the weak individual mandate, the “if you like your plan you can keep it” promise — none of these policies on their own could take down the Affordable Care Act marketplace. But taken together, over the course of three years, they made it significantly easier for healthy people to decide not to enroll in the marketplaces. More than anyone, that hurts sick people.

Congressional Republicans led by Sen. Marco Rubio (R-FL) dubbed it the “Obamacare slush fund,” and in 2014 they inserted a provision into the 2015 federal budget requiring this program to be revenue-neutral.

Because health insurers experienced significantly more losses than payments, the program was only able to pay out 12.6 percent of the bills it owed. Small insurers like Community Health Alliance, a nonprofit planned that launched with a loan from the federal government, couldn’t survive that hit.

“They sort of knocked the breath out of us by taking away the risk corridor,” says Jerry Burgess, who served as chief executive of that plan. Community Health Alliance quit the marketplaces and went out of business in 2015 after the federal government did not pay millions in risk corridor payments that the insurer had expected.

The future of Obamacare under the Trump administration is less certain. Some places, like Florida and California, will be fine. They have big populations and urban markets that are attractive to health insurers.

Other places like Tennessee, more rural and low-income, may struggle. President Trump has given little reassurance to health plans that might be on the fence about entering Tennessee or other markets. His administration has waffled on whether it will continue funding key Obamacare payments. He has said he expects the marketplaces to “explode” on their own.

 That's right.  Republicans have worked to sabotage the law and withheld needed funding only to then claim the program is failing.  For rural hospitals, large numbers of uninsured individuals is financially catastrophic.  Required to stabilize people, they must treat them without payment.  In turn, they charge more for those who do have coverage and drive costs up further and make insurers more likely to want to leave the local market.  The death spiral only accelerates until hospitals go bankrupt and close, taking with them some of the best jobs in the area and depriving residents of ready access to hospital facilities.  It's as if rural areas have opted for a slow form of suicide. 

Is Racism Partly Behind The GOP Push for Trumpcare?

As noted frequently, one of the big motivations behind the House Republican's vote to pass Trumpcare - or Ryancare, if you prefer - is to grant a truly huge tax cut in favor of the wealthy.  We are talking hundreds of billions of dollars given back to the wealthy.  In exchange, millions of the less fortunate will see their costs soar and health care insurance coverage slip out of reach.  Literally every health care and hospital association condemned the bill passed by the House Republicans.  Many rural hospitals are truly concerned that bankruptcy and closure will be in their future if the Senate doesn't kill this monstrous bill.  Yes, there would be an element of divine justice if rural Trump voters found themselves suddenly with no ready hospital access - and literally facing death in critical illness situations as a result.    But an op-ed in the Boston Globe argues that lurking beneath the bloviating of Republicans is racism that Obama unleashed by being black and in the White House.  Here are excerpts:

House Republicans are taking health services away from disabled children, women who give birth, and survivors of rape and sexual assault. They are consigning thousands of people with serious illnesses to death by making them uninsurable in an era of unaffordable treatment. Virtually every reputable medical organization in the country condemns the health care bill that passed the House Thursday, but the GOP clings to two reasons for passing it.

First, Republicans claim that the new legislation provides economic benefits. These benefits are unclear, though reports suggest that they entail a transfer of resources from vulnerable people to rich people.  . . . . Passing the bill without a score from the CBO is a signal that Republican legislators are not taking the economic dimensions of this issue seriously, so we can follow their lead and move on to the heart of the matter.

The other explanation given by House Republicans for passing the bill is political. These congressmen felt they had to repeal the Affordable Care Act because they promised to do so. Most Americans have no quibble with Obamacare itself, but for Republicans, repealing it is and always has always been a way to repudiate former president Barack Obama. Since taking office, President Trump has done several things that he previously chastised Obama for, but these contradictions have had little impact on his party or their supporters. This is largely because GOP voters’ disdain for Obama and support for Trump cannot be separated from findings about racism. Studies conducted after the election confirm that racial resentment directed toward people of color predicted both overall support for Trump and voters’ propensity to switch from Obama to Trump.

GOP voters know they don’t like Obama, but they do not know Obama’s legislative record, whether it pertains to the economic recovery or health care legislation. A December 2016 poll showed that 67 percent of Trump voters believed that unemployment had risen during Obama’s tenure, even though it dramatically declined. A February 2017 poll found that one third of all Americans did not even know that Obamacare and the Affordable Care Act were the same thing. Over half of the Republicans in that poll did not know whether Medicaid would be impacted by repealing Obamacare. Medicaid will be gutted by the new bill.

So the naked truth is that racial resentment directed toward Obama set off a chain of events that will likely cause 20 million people to lose their health insurance and ignite a public health crisis of unimaginable consequence. Some time ago, I wrote about one of the myths of white supremacy: the idea that its ill effects are limited to targeted groups. I explained, “What white supremacy does, eventually, is normalize and spread the abuse, trauma, and destruction initially prescribed for targeted groups.” The damage prescribed by hateful ideologies is most severe within targeted groups, but it is never contained. 

All because Trump supporters cannot see beyond the color of others' skin - or their sexual orientation, national origin and others triggers for bigotry.   I do worry about the impact on children, but for the adults who support this horrible agenda, I'd be lying if I said I did not hope they suffer greatly.

Rural America's Dying Hospitals

Congressional Republicans are talking about taking a second swipe at "repeal and replacement" of Obamacare.  What's frightening is the reality that in order to attract the votes of the misnamed "Freedom Caucus" - i.e., extreme right wingers who oppose any government spending on healthcare - any proposed bill would be even more horrific than the "American Health Care Act" that Paul Ryan pulled from consideration.  Meanwhile, (i) Donald Trump, a/k/a Der Trumpenführer, is threatening to sabotage Obamacare, and (ii) Republican controlled state legislatures (including Virginia's) are refusing to expand Medicaid under Obamacare.  The result?  Hundreds of thousands, if not millions of Americans nationwide, continue to lack healthcare coverage and their numbers could sky rocket. But individuals, including children, are not the only victims of GOP intransigence.  There are other victims dying financially: rural hospitals are particularly at risk of closure.  A lengthy piece in the Washington Post looks at what is happening in a poor rural area in Tennessee.  Similar stories are taking place elsewhere, and as numerous hospital associations have warned, rural areas of Virginia may soon be joining regions that no longer have hospitals.  Combine the reactionary nature of many rural areas that is a disincentive to new, progressive businesses with lack of hospital services and the downward economic spiral will likely accelerate.  Here are highlights from the Post article:

This town of the Tennessee Delta, seat of a county that once grew the most cotton east of the Mississippi, relied for decades on a little public hospital built during the Great Depression a few blocks from the courthouse square.

The red-brick building was knocked down in the 1970s when a for-profit chain came along and opened a modern stucco hospital on the north side of town. There, thousands of babies were born, pneumonias and failing hearts were treated and the longtime family doctor across the parking lot could wheel the sickest patients who arrived at his office right into the emergency room.

But these days, plywood boards are nailed up behind the hospital’s sliding glass entrances. Black paint is smudged across signs over its doorways. The nearest ER is more than a half-hour ambulance ride away.

The demise of Haywood Park Community Hospital three years ago this summer added Brownsville to an epidemic of dying hospitals across rural America. Nearly 80 have closed since 2010, including nine in Tennessee, more than in any state but Texas.

In every rural community, the ripple effects of a lost hospital are profound, reverberating beyond the inability of would-be patients to get immediate care. Many of the best jobs in town vanish. Local leaders trying to recruit new industry face an extra hurdle.

Haywood County’s budget has become a twisted mess as demand for the services of its ambulance authority has ballooned. “The emergency room now is the back of an ambulance,” said Bill Rawls, who grew up in Brownsville and was sworn in as its first black mayor the month the hospital closed. . . . Rawls is struggling to bring at least an emergency room back to Brownsville. In his office in the small city hall adjacent to the fire department, he has a letter from a woman whose 8-year-old nephew was playing in the family driveway on a late winter morning last year when their Dodge sedan rolled backward, pinning him under a tire. Without a hospital in town, she explained, “needless to say he did not make it.”

The Affordable Care Act has not gained much ground here. In 2016, just 664 Haywood County residents bought health plans through its marketplace for people without coverage through a job. By one estimate, 2,200 residents would qualify for Medicaid benefits if Tennessee expanded the program under the law; the Republican governor tried but was rebuffed by the more conservative legislature.

Unless a patient is transported, neither Medicare nor Medicaid will pay for the ambulance run. The ambulance authority sends out bills, but in such a poor county, “there is no way to turn them over to collections,” Smith said. Some people bring in $5 or $10 when they can. In 2016, the ambulance service wrote off more than $1 million in unpaid charges.

With no hospital in Haywood and 535 square miles to cover, the crews have been stepping up their protocols. They can insert chest tubes, start intravenous antibiotics and intubate patients to help keep airways open.

Every Republican voting resident of Southwest Virginia needs to read this piece and understand that this is what their falling for GOP appeals to bigotry and religious extremism is going to bring them. No local hospitals, the loss of the best jobs in town, and even more difficulty in trying to court businesses to moved to the area. Much of this damage is self-inflicted.  I worry about the children, but the adults are reaping the fruits of their own shortsightedness,

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Kansas Republicans Vote to Expand Medicaid Under Obamacare

Even as Republican efforts in the House of Representatives to repeal Obamacare were crashing and burning, Kansas Republicans were taking steps to expand Medicaid under Obamacare.  Why? Because it is backed by the hospital industry and the business community and because it will aid many of Kansas' poorer citizens.  This is a sharp turn around from the Kansas GOP's agenda that cut taxes and cut funding to public education and other critical programs only to leave the state a financial basket case, proving that a "pure" GOP economic plan is the road to disaster. A piece in Mother Jones looks at this ironic approach by Kansas Republicans that is moving forward in spite of the threatened veto by nutcase GOP Gov. Sam Brownback, an architect of the state's economic and budgetary disaster.  Here are excerpts:

On the same day the House was supposed to pass a bill dismantling Medicaid, Kansas Republicans took a big step toward expanding the program in their state.

In a voice vote Thursday morning, a committee in the Kansas Senate approved legislation that would enable the state to take advantage of an Obamacare provision offering Medicaid health insurance coverage to a wider group of poor people. The federal government would provide the vast majority of the funding.

Many deep-red states like Kansas have rejected Medicaid expansion based largely on their ideological objections to Obamacare. But as I reported earlier this week, a new bloc of moderate Republicans in the state—backed by the health care industry and business community—have teamed up with Democrats to push Medicaid expansion. They point out that the state has given up, to date, nearly $2 billion in federal funds that could have helped both improve the health of the state's low-income communities while also boosting its economy.

The Kansas House overwhelming passed Medicaid expansion earlier this year. The full state Senate is expected to vote on the issue Monday, according to KCUR. But they would likely need to cobble together a veto-proof majority, since Gov. Sam Brownback (R) has vocally opposed to adopting the program.

More coverage on this development is here at Mother Jones:

According to a study by the nonpartisan Kansas Health Institute, about 152,000 people would join KanCare, the state's Medicaid program, if Kansas adopted the ACA expansion. Roughly 80,000 of those people currently lack health insurance coverage, while 71,000 would ditch their current coverage to jump onto Medicaid.

Now, Eplee has joined a coalition of moderate Republicans and Democrats that is trying to make that happen. They want their state to accept everything Obamacare has to offer before their brethren at the national level can tear it apart—and they've got the state business and medical communities on their side. Voters agree, too, with 82 percent supporting Medicaid expansion in a poll sponsored by the American Cancer Society Cancer Action Network.

"I'm out here in the rural area practicing [medicine], and I see it every day," Eplee says. "When I gave my testimony [in favor of Medicaid expansion], I gave examples of the working poor and their inability to get health insurance and to get the help they need. It puts them in very dire, precarious financial situations of being made medically bankrupt by one illness or one disease. It just takes one event, and then they're wiped out financially."

When the Kansas House collected testimony on the issue earlier this year, more than 160 organizations and individuals supported expansion. Just four offered testimony that opposed the idea—mostly national conservative organizations.

Koesten was part of a group of moderate Republicans that last year reclaimed control of the state legislature from the far right of the party. Five years earlier, Republican Gov. Sam Brownback had waged an electoral war to purge the party of legislators who opposed his ambitious tax cuts, ushering in a conservative takeover executed with the help of the Koch brothers' organization Americans for Prosperity. But after Brownback's policies left an enormous hole in the state budget, the moderates roared back in the 2016 elections. Moderate Republicans primaried sitting conservatives, and Democrats knocked off others. Out of 165 total lawmakers in the state Senate and House, there are 49 new members this year.

The consequences became clear late last month, when the state House voted 81-44 in favor of Medicaid expansion. "There was just enough change in the primary and the general election that tweaked the control over to the moderate side, where this was unstoppable at this point in time," explains Robert St. Peter, president and CEO of the Kansas Health Institute.

The hospitals have good reason to be upset about the money the state is leaving on the table. Many hospitals, especially in rural parts of the state, are under increasing financial strain from treating uninsured patients. In 2015, Mercy Hospital in Independence, Kansas, closed. Independence has just 9,500 residents, but the closure attracted media coverage from around the state. . . . an industry advisory group, found that out of 107 rural hospitals in Kansas, 31 are considered "vulnerable" and at risk of closure. The report didn't name the hospitals in trouble, leaving each community worried that its hospital could be next.

Kansas is one of the last places one would expect to see Republicans regaining a grasp on objective reality and actually pushing policies that help poorer citizens.  It is the exact opposite of Paul Ryan's reverse Robin Hood agenda.