“This Is All Too Real Folks”: The Future Of Rural Hospitals And The Failure Of Medicaid Expansion In Maine

Health is the first wealth, however Congressional Republicans could care less. “Repeal” of the Affordable Care Act (ACA) is a senseless, ideological and irrational act unto itself. As a part of the ACA, Maine has been derelict in its duties and responsibilities to protect the public health. With the Governor’s repeated ideological decisions not to expand Medicaid and now Congressional republicans attempts to derail the Affordable Care Act, things are about to get even worse for all Maine patients and their local rural hospitals. Now is as good a time as any to take a look back at where and how rural hospitals in Maine will be affected by these decisions:

The Future of Rural Hospitals and the Failure of Medicaid Expansion in Maine (August 6, 2016)

There are some subjects that many would simply prefer not to talk about. That doesn’t mean however that we should bury our heads in the sand and simply hope those issues go away. When elephants fight, it’s the grass that gets trampled. When we talk about health care, we are talking about people’s lives. This is not an issue that we can skirt around or ignore.

Maine is a very rural state with a population of approximately 1.3 million residents. The poverty rate, that is the number of people who had incomes below the poverty line ($23,834 for a family of four) in 2013 was 14%, ranking 20th in the nation. The percentage of all workers who were unemployed in 2013 was 6.7%, 23rd in the nation. The percentage of households who were food insecure on average from 2011 to 2013, meaning that at some point during that year, experienced difficulty providing enough food due to a lack of money or resources was 15%, ranking 34th in the nation. The percentage of people under age 65 and below 138% of the poverty line who did not have health insurance at any time in 2013 was 18.2%, ranking 7th in the nation.

Approximately 51 million Americans live in rural areas and depend upon the local hospital in their communities for their health care needs. Their remote geographic locations, small size, limited workforce and often constrained financial resources pose unique challenges for rural hospitals. More often than not, the patient mix of rural hospitals makes them more reliant on public programs and thus, particularity vulnerable to Medicare and Medicaid cuts. With deficit reductions and a continued threat from Washington, the continued viability of small and rural health care providers remains in jeopardy.

To date, more than 70 rural hospitals spread across 20 states, have closed since 2010, and many more may be headed down the same path. Rural hospitals are facing a myriad of financial challenges, and those in states that have not expanded Medicaid are feeling the most financial pressure, According to a report by iVantage Health Analysis, 673 rural hospitals are vulnerable to closure. Sixty-eight per cent of these hospitals are Critical Access Hospitals, a designation that requires certain conditions be met, including being located at least 35 miles from another hospital. Hospital closure, as defined by the North Carolina Rural Health Research Program (NCRHRP), is the cessation of a hospital to no longer provide inpatient services. Many of these hospitals however are still able to offer services, including outpatient care, imaging, urgent care, primary care and some rehabilitation services. In Maine, there are approximately 37 hospitals, 16 of which are Critical Access Hospitals. The bottom line is that many of these hospitals may no longer be able to provide inpatient care, and in a state like Maine, this would impose significant stresses and strains on patients and families alike.

It is clear that in states that have expanded Medicaid, there has been a positive effect on state and local budgets. On average, states that expanded Medicaid in January 2014 saw jobs grow by 2.4%. The Bureau of Labor Statistics projects that health care and social assistance jobs will grow to nearly 22 million by 2022 due to Medicaid Expansion

Because the waters are calm on the surface doesn’t mean there are no crocodiles. Already on the table is a proposal by the Centers for Medicare and Medicaid Services to reduce Critical Access Hospital’s reimbursements from 101% to 100% of reasonable costs in fiscal year 2017. This proposed reduction neglects to take into consideration the cost reimbursement reductions imposed by sequestration. Should these further reductions go into effect, the ability of Critical Access Hospitals to provide necessary health care in rural communities would be severely compromised.

According to the North Carolina Rural Health Research Program, several hospitals in Maine have already been significantly impacted due to Governor LePage’s ideological decision not to expand Medicaid. Hospitals affected to date are Parkview Adventist Medical Center in Brunswick, Southern Maine Health Care-Sanford Medical Center and St. Andrews Hospital in Boothbay Harbor. Earlier this year, besides hurting thousands of uninsured Mainers, the effects of Maine’s rejection of Medicaid Expansion was quite evident and contributed to immediate layoffs of 22 employees from the Farmington based Franklin Community Health Network. In addition, 40 full-time positions were eliminated at Franklin as a part of its cost-reduction plan, just to stay afloat. At Franklin and other Maine hospitals, Maine’s failure to broaden Medicaid is seen as a primary driver in soaring health care costs, from over $100 million in 2000 to over $570 million in 2014. Not expanding Medicaid is clearly a factor in the financial hardships of Maine hospitals. Over the next 10 years, Maine hospitals will lose about $900 million unless the state expands Medicaid.

This brings me to our local Critical Access Hospital in Dover-Foxcroft. Despite the pro-active efforts of the Hospital Board, the Administration and the Medical Staff, like other Critical Access Hospitals across the state, Mayo Regional Hospital is also being impacted and struggling for its existence because of the lack of Medicaid Expansion. Of the federal monies that would come to the state for enhanced patient coverage through expansion, roughly $90 million would go to hospitals based on their current spending rate. About $1.4 million of that would come to Mayo based on its current Maine Care volumes. Medicaid Expansion would go a long way in bolstering our struggling hospital as the hospital currently has a negative operating margin of $1 million and is on track to provide $3 million in charity or free care to the local community this year. Will Mayo be forced to implement layoffs or worse yet, eliminate full time positions?

By not accepting Medicaid Expansion and its federal funds, there remains a coverage gap for many of our poorest friends and neighbors. In 2013 the Maine Legislature voted to accept those funds, however Governor LePage vetoed that decision. As a result, 25,000 Mainers lost MaineCare coverage in 2013, including 10,000 childless adults below the poverty line and 14,500 parents making 100%-138% of the federal poverty level. If Maine had accepted those federal funds, it would have restored health care for those individuals and covered an additional 45,000 Mainers who would have been eligible for insurance for the first time. This year, the Maine Legislature had another opportunity to override the Governor’s veto but fell 2 votes short of an override.

If our society allows these wrongs to go unchallenged, the impression is created that those wrongs have the approval of the majority. Lawmakers who refuse the opportunity to cover uninsured people are telling those people that their lives don’t matter. For the republican lawmakers who say, “Well, I voted for expansion”, I say that’s not good enough. We all know that in politics, if the majority party whip is certain that he or she has the votes needed to pass a bill, or in this case, override the Governor’s veto, those representatives in that party who may be vulnerable for re-election are given the green light to vote with the minority, simply so they can go home to their constituents and say “Well, I supported expansion, but it just didn’t pass. There was nothing more I could do”. This on its face is deceptive and hypocritical. This is what happens when lawmakers decide issues purely on political and self- merits.

More is required of public officials than slogans, handshakes, press releases and a wink and a nod. They must be held strictly accountable. Legislators must not only provide a vision for the future, they must share in the responsibility and delivery of that vision, and be willing to implement and uphold what they know is right for the common good of our communities. Quality healthcare expands well beyond political boundaries and should not be dependent on the whims of ideological political positions.

Gov LePage, A Student Of History: Repeating The Same Mistake Renders No Additional Value

There is an old Congo proverb that says, “The teeth are smiling, but is the heart?” We expect to pass through this world but once. Any good that we do to aid our fellow creatures, we must do so now. We cannot deter or neglect it, for we will not pass this way again. If we desire to be useful, we can. If one is going to play the game properly, you’d better know the rules. One thing is perfectly clear: We, as human beings, must be willing to accept people who are different from ourselves.

I leave the state for one week, just one mere measly week to attend the American Medical Association’s Interim Meeting in Florida, only to return to find that once again, our beloved Gov. Paul LePage has walked a little further out on the plank. It seems that he is either infatuated by the drama or he is entranced by his own self-importance.

Gov. LePage has unilaterally decided that Maine will no longer participate in the federal government’s refugee resettlement program. I guess this decision is consistent with his obviously well-known anti-immigrant and anti-others sentiments. In a statement released by Gov. LePage, he indicated that “I have lost confidence in the federal government’s ability to safely and responsibly run the refugee program and no longer want the state of Maine associated with that shortcoming”. He went a step further during an interview on the conservative Howie Carr Show where the good governor pledged to send any “illegal” immigrant packing from Maine. “If we find any undocumented people in the state of Maine, which I cannot put in jail, I am going to buy them a bus ticket, I am going to buy them a lobster roll, and I am going to send them to 1600 Pennsylvania Avenue”
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Gov. LePage says he is a “student of history”. That statement alone should be a flaming red flag. In 1939, one of the most shameful periods of American history occurred, later becoming known as “The Voyage of the Damned”. During this time, the United States denied entry of an ocean liner carrying more than 900 Jewish refugees fleeing Adolf Hitler’s Germany hovered aimlessly for 72 hours just a couple of miles off the Florida coast, while Jewish leaders in Washington frantically begged President Franklin D. Roosevelt to let the passengers into the United States. Roosevelt said no, and the SS St. Louis sailed back to Europe, where World War II was just weeks away. Many of the passengers would fall back into the hands of the Nazis they were trying to escape. About 250 of them did not survive the war. The decision to turn away the St. Louis was a grotesquely ugly moment in American history, one for which Congress and the U.S. State Department would eventually apologize.

Another historical fact that seems to escape the governor is that Refugee resettlement is a federal program, and state governors have no more authority to deny residents from Syria, Iraq, Somalia or any other country into Maine, than they have to deny entry of residents from any other state in the union. The governor seems to be placing all of his eggs in one basket, invoking a rule that allows states to withdraw from administering welfare, health and social programs to refugees. Those rules say that in the event of a state’s withdrawal, the federal government can simply designate another entity to administer the program. If public assistance is such a great concern for the governor, this might be a good time for him to reconsider his stance against Medicaid Expansion.

The governor also needs to understand that there are differences in the definitions of refugees and asylum seekers. These differences were articulated by the United Nations Convention on the Status of Refugees in 1951 and in its 1967 protocol, as well as U. S. national laws and procedures. The Refugee Convention obligates states that are party to the convention, the United States being a signee, grants protection to those “who have been persecuted on account of race, religion, nationality, and/or membership in a particular social group or political opinion”. Refugees meet the definition laid out in the formal convention as noted above but seek their refugee status from outside the country. These refugees are coming to Maine and other states fleeing murder, torture, persecution and extreme violence.

Refugees coming to the U.S. go through a multi-phase screening administered by the United Nations, the U.S. State Department, the Department of Homeland Security and several other government agencies’. The process includes lengthy interviews with trained Homeland Security officials and running the refugees’ fingerprints and biographic information through federal criminal and terrorism databases. Syrians receive an extra level of scrutiny, the details of which are classified. The vetting is done abroad and generally takes between 18 and 24 months.

Asylum seekers on the other hand are already in the United States, seeking admission at a port of entry. They must meet the same requirements as refugees but declare their intention to seek asylum upon entering the United States. The credibility of their case for asylum is assessed by an asylum officer or immigration judge and this process typically takes at least six months. Those who are found not to be refugees or in need of any other form of international protection can be sent back to their country of origin. Federal law also prohibits asylum seekers from working for at least 6 months after they apply for asylum.

Courts have consistently ruled that the federal government is responsible for refugees and immigration. Just this past June, a federal judge rejected Texas’ attempt to block the resettlement of Syrian refugees in that state. One month ago, a federal appeals court blocked Vice-President Elect Mike Pence from interfering with the disbursement of federal funds to refugees.

Anyone who has spent time in the state of Maine is aware of the state’s demographic situation—an aging population, young people moving away, and the corresponding challenges for the labor force, school systems, municipal and state revenues, and the vitality of our communities. Maine’s future will largely depend on the steps we take today to ensure that we reverse the demographic decline that has been unfolding in slow motion for decades.

Reckoning with our demographic challenges requires finding ways to make Maine’s population more diverse. In short, the future of Maine depends upon the steps we take to make Maine a welcome destination for those from beyond our national borders: immigrants, asylum seekers, and refugees. Finally, it is imperative that Gov LePage recognize that inclusion benefits and celebrates us all. Slamming the door would be a betrayal of our values. Our nation can welcome refugees desperately seeking safety and ensure our own security at the same time. We can and must do both.

The Mystery Of A New Administration: Complexity Is Never Of Value Where Simplicity Will Suffice

The brightest stars see beyond the obvious to the signals that precede the obvious. They observe with equal attention what works and what does not work. They are careful to remember failures for their special power to instruct. The difference between good and great is attention to detail.

The Patient Protection and Affordable Care Act (PPACA) H.R. 3590, or Affordable Care Act (ACA) for short, was signed into law on March 23rd, 2010 by President Barack Obama. The law contains many provisions which grant Americans a number of new benefits, rights, and protections and ensure that more US citizens have access to affordable, quality healthcare. It also works to decrease the rate of growth of health care spending and enacts other reforms to “fix” the current healthcare system.

Progress requires change. A civil society attempts to accommodate this need through openness, transparency and inclusion. Change can generate fear and anxiety, but it can also ignite our inborn desire to explore, to flow and grow rather than remain the same. Change for the better is self-improvement. We were born to move, to move on, not so much to reach a destination, but to find one.

This brings me to the recent Interim Meeting of the American Medical Association (AMA) held in Orlando, Florida over this past week, in which I attended as the Chair of The New England Delegation to the AMA. The mission of the AMA is to promote the art and science of medicine and the betterment of public health. This mission does not apply to a select few, but to every American citizen. Election 2016 is now over. We now have a new President-Elect, a man who has created massive divisions and insecurities across the entire country and in many parts of the world. So, what do we do now and where do we go from here? There are numerous areas of concern regarding policy decisions and how we all will be affected by any new decisions put forth by this new administration.

During my recent Maine House Legislative campaign, one of the most pressing issues repeatedly voiced by many Maine citizens was their concern for the state of health care and how they would be impacted by the repeated republican threats of “repeal and replace”. In the past, gaps in the public insurance system and lack of access to affordable private coverage left millions without health insurance. Beginning in 2014, the ACA expanded coverage to millions of previously uninsured people through the expansion of Medicaid and the establishment of Health Insurance Marketplaces. Data show substantial gains in public and private insurance coverage and historic decreases in uninsured rates in the first and second years of ACA coverage. Coverage gains were particularly large among low-income people living in states that expanded Medicaid. Still, millions of people—28.5 million in 2015— remain without coverage.

Even under the ACA, many uninsured people cite the high cost of insurance as the main reason they lack coverage. In 2015, 46% of uninsured adults said that they tried to get coverage but did not because it was too expensive. Many people do not have access to coverage through a job, and some people, particularly poor adults in states that did not expand Medicaid, remain ineligible for financial assistance for coverage. Some people who are eligible for financial assistance under the ACA may not know they can get help, and others may still find the cost of coverage prohibitive. In addition, undocumented immigrants are ineligible for Medicaid or Marketplace coverage.

Most uninsured people are in low-income families and have at least one worker in the family. Reflecting the more limited availability of public coverage in some states, adults are more likely to be uninsured than children. People of color are at higher risk of being uninsured than non-Hispanic Whites.

People without insurance coverage have worse access to care than people who are insured. One in five uninsured adults in 2015 (20%) went without needed medical care due to cost. Studies repeatedly demonstrate that the uninsured are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.

During this year’s Interim Meeting of the AMA House of Delegates, representing more than 170 state and specialty medical societies from across the country, the delegates vociferously and passionately reaffirmed its commitment to health care reform that improves access to care for all patients. There were 5 separate resolutions presented to the House of Delegates (a combination of over 1,000 physician Delegates and Alternate Delegates), each of which was discussed in extensive and great detail. One of the core principles of the AMA is that any new reform proposals should not cause individuals currently covered to become once again uninsured. Our AMA has a strong foundation of existing policy in favor of support of efforts to provide coverage for the uninsured. In fact, the AMA Council on Medical Service (CMS) and the Council on Legislation has conducted numerous studies on various health system reform provisions in the ACA. Those extensive studies, policies and reports provide more than sufficient information that can be used to determine the best course of action by the incoming administration to improve on the ACA.

Those who are so adamantly ideologically and politically opposed to the ACA have wasted 7 years and missed numerous opportunities to improve on this worthy goal of ensuring the health of our nation’s citizens. It is the absolute intent of the AMA to continue to advance recommendations to support the delivery of high quality patient care to all citizens. We see this as an opportunity to actively engage doubters, the new administration and Congress in discussions to improve our health care system. It is time for us to move forward as a nation and the AMA will do so with a clear and simple statement communicating our message on health care reform to the public at large.

If republicans are truly concerned about the welfare of the people, they should put the health of the nation’s citizens first. Instead of “Repeal and Replace”, they should cease the divisiveness and fearmongering and think about “Repenting and Improving”.