Editor’s Note: This article was originally published as the Spring 2019 magazine’s cover article.
Rural America faces a crisis in healthcare, leaving thousands without access to basic healthcare services, including a primary care physician. Rural hospital closures across the United States have risen dramatically in the last decade, numbering 87 closed facilities since 2010. While this trend has impacted the U.S. as a whole, the crisis unequally affects southern states, including Texas, Tennessee, and Georgia, the three states with the most rural hospital closures since 2010. Texas, with 15 hospital closures in the last nine years, exemplifies this crisis, as its closures disproportionately affect minority and immigrant communities, creates a shortage of primary care doctors, and demonstrates the effects of limited transportation and financial resources. Georgia, a state with similar characteristics to Texas, faces many of the same challenges.
Seven rural hospitals have closed in Georgia since 2010. Most recently, in July 2018, when Chestatee Regional Hospital in Dahlonega closed, leaving Lumpkin County without a functioning emergency room. While ongoing plans between Northeast Georgia Health System and the University of North Georgia propose a future facility in Dahlonega, for now, residents of Lumpkin County must endure the additional time and cost to travel 45 minutes away to Gainesville, GA, where the nearest emergency room is located.
Similar circumstances have plagued Richland, a small rural town in Stewart County, GA with a population of just under 2000, when its local hospital closed in 2013. When Stewart Webster Hospital, a 25-bed “critical access” facility closed, Dr. Alluri Raju, a Richland physician, believed that the most devastating effect of the hospital closure was the impact on acute emergencies. Without the facility, for several years, Richland citizens have travelled more than an hour to Columbus to access treatment. Additionally, only two ambulances serve Stewart County, compounding the distance and difficulty in obtaining immediate emergency care.
Not only are communities dependent on hospitals for care, but many rural hospitals serve as the largest employers in their regions. While it only provided 25 beds, Stewart Webster Hospital was the largest employer in town. In Dahlonega, Chestatee Hospital left over 200 former employees jobless. Again, this story resonates across the state: once the hospital closed, several local businesses were forced to shut their doors for good and those who survived experienced significant losses in business. An interest in health policy and improving health outcomes is not only moral, but imperative to uplifting rural Georgia.
Richland and Dahlonega’s stories are not the exception, but rather the status quo for rural Georgia. Without immediate access to emergency care departments, each extra minute can constitute the difference between life and death. In a state with vast geographic disparities in healthcare access, rural hospital closures have led to worsening circumstances for many rural Georgians.
Hospitals
The effects of these rural hospital closures are staggering, as they often lead to a rise in the cost of emergency medical services, greater transportation time for patients to healthcare services, and job losses for staff previously employed by the hospitals. The ripple effects of hospital closures continues with much broader reach, including outward migration of community members and overall diminished community health due to a lack of preventative care. Additionally, minority groups and other vulnerable populations experience heightened impacts related to transportation challenges and other barriers to healthcare access, including financial and time constraints.
Minority populations already deal with unique obstacles to effective healthcare, including language barriers, social stigmas, and cultural differences, and these are compounded by the broader healthcare crisis. If a community has a limited number of physicians, the chances of those physicians being culturally competent are slim. The lack of cultural competence among medical professionals constrains the efficacy of care, and adding the pressure of the urgent overall crisis, minority communities are doubly impacted by the costs of both.
Despite the dire statistics, resilient communities have found ways to save their healthcare as a variety of different methods have proved successful in keeping hospital doors open in rural Georgia. These innovative strategies have included specializing in a niche area of healthcare, implementing telehealth technology programs, and merging with larger healthcare systems.
In Miller County, a small, rural county in South Georgia, a decision to specialize in ventilator care saved the Miller County Hospital, and now, around 60 patients receive care at the Miller County Nursing Home. This development was cost-heavy initially, but after nine months, the hospital saw returns on that investment. In addition to attracting a wider pool of patients through its new ventilator care specialization, Miller County Hospital installed its own pharmacy, which saved money on outsourcing prescriptions, and gave free doctor visits to local businesses in order to appeal to insured clients. The hospital also expanded the services it offered at a rural clinic, which reduced unnecessary visits to the emergency room. These efforts proved fruitful for Miller County Hospital, its 500 employees, and nearly 6,000 Miller County residents.
In Sumter County, home to former President Jimmy Carter, the recent closure of Plains Medical Center in March 2018 left residents of Plains, GA without access to a doctor’s office, and therefore, a primary care physician. For the next four months, this gap in healthcare presented a major challenge to community health. However, with the help of President Carter, a partnership formed between Mercer Medicine of Mercer University and the small, rural town. Although Mercer Medicine is located approximately 90 miles northeast of Plains in Macon, GA, technological developments have allowed for a new strand of medical care to take root. The concept of telehealth is connected to the greater effort of providing rural Georgia with access to broadband Internet, and it allows patients to meet online with medical professionals across the state. Currently, the Mercer Medicine Plains clinic offers mental health services via telehealth conference, and Mercer Medicine is exploring plans to expand into other healthcare specialties. Thanks to technology and resourceful regional leaders, residents of Plains, GA now have access to basic healthcare, and the added connectivity could lend its benefits in the realm of rural broadband access as well.
The improvements made by Georgia hospitals themselves have been a key factor in keeping facilities functional throughout rural areas, but these strategies are not enough to reverse the effects of the healthcare crisis. Any solution must have a multi-faceted approach, as the healthcare crisis finds its roots in the systematic problems with healthcare policy in America, and part of that solution could be an expansion to Medicaid.
Medicaid Expansion
Since the passage of the Affordable Care Act (ACA), several states employed Medicaid expansion to boost economic growth across their states while improving overall access to health care. Medicaid programs are state-run, but Medicaid expansion allows the federal government to provide extra funds to raise income eligibility levels for the program. Once a state expands, for the first three years, the federal government will pay 100 percent of costs for newly-enrolled individuals, and over time the federal share would decrease to 90 percent of the cost.
While several red, blue, and purple states expanded Medicaid through the ACA, former Governor Nathan Deal was a strong opponent of the policy, afraid that the financial cost of the program would place Georgia in debt if the federal support for the program ended. While the financial risk of the program may seem valid, with increases in health insurance coverage, the economic impact of the program would bring billions of dollars to Georgia. To many, Governor Deal’s failure to support the legislation stems from partisanship and an inability to look past the negative stereotypes associated with programs designed to help poorer communities, predominantly communities of color.
With Governor Deal term-limited, many believed the 2018 Georgia gubernatorial race provided a unique opening for a candidate to champion Medicaid expansion. Democratic gubernatorial candidate Stacey Abrams became a staunch champion of Medicare expansion, believing it to be the quickest and most efficient way to recommit to rural Georgia.
While Abrams was a strong proponent for Medicaid expansion, Republican candidate Brian Kemp, now Governor Kemp, believed that Medicaid expansion would lead to further financial woes for Georgians. When pressured to provide tangible policies to improve the status quo for health care, Kemp campaigned on reducing health care premiums for average, working-class Georgians on the private insurance market. He also supported an income tax credit program to support rural hospital organizations (RHOs) in the state. While these policies are well-accepted, many health care advocates believed they fell short at incentivizing health care providers to return to rural Georgia.
Medicaid Waivers
Since the November elections, Republicans have shifted their views on health care in Georgia, especially Medicaid. While initially a forceful opponent of Medicaid, in his State of the State Address, Kemp promised to appropriate $1 million in funds to the Georgia Department of Community Health to explore flexibility options for state Medicaid through Section 1115 waivers.
While an enticing buzzword, “flexibility” regarding state Medicaid can be a double-edged sword. 1115 waivers provide states avenues to explore alternative systems of coverage that do not meet federal program rules. By allowing the Secretary of Health and Human Services (HHS) to waive certain provisions of major health and welfare programs, such as Medicaid, states can use federal Medicaid funds in innovative ways beyond the prescribed method. Medicaid waivers provide flexibility by allowing states to waive certain rules to accomplish certain goals, including reducing costs, expanding coverage, or improving care for communities.
Many states have used waivers for purposes, including expanding Medicaid coverage to larger populations, changing health care delivery models, and altering cost-sharing payment structures. Since the implementation of the ACA, several states have used 1115 waivers to expand Medicaid, provide additional services not traditionally covered by Medicaid, and to reduce costs while simultaneously increasing efficiency and quality of care.
In Arizona, 1115 waivers were used to create a statewide, managed care delivery system for Medicaid recipients. This allowed state’s Medicaid program to better integrate physical and behavioral health, cover adult dental benefits, and provide incentive payments to providers for increasing physical and behavioral health integration and coordination for enrollees with behavioral health needs. While innovation within Medicaid could potentially improve health care access and affordability, many states have sought waivers to create Medicaid work requirements, failing to improve health outcomes.
Medicaid work requirements encourage “able-bodied individuals” go back to work to maintain Medicaid benefits. Pregnant women and children on Medicaid may not have to meet Medicaid work requirements, but waivers coupled with work requirements can hurt many Medicaid beneficiaries. Work requirement advocates believe that if individuals are employed, many will be able to obtain insurance from their employers, rather than depend on Medicaid. However, this is based on the assumption that most Medicaid recipients are unemployed – a false claim.
Arkansas is one of eight states that has coupled Medicaid expansion with work requirements. Affecting all non-elderly enrollees, unless exempt, enrollees must engage in 80 hours of work to qualify for Medicaid benefits. Following implementation, out of 105,000 enrollees over 18,000 were disenrolled from Medicaid, failing to comply with the work requirement. Out of the 18,000 dropped from Medicaid due to work requirements, only 1,452 reapplied for Medicaid. According to HHS Secretary Alex Azar, this is an indication that “the individuals who left the program were doing so because they got a job [in] this booming economy.” However, there is no data to suggest this. In fact, according to Joan Alker, executive director of Georgetown’s Center for Children and Families, the data suggests that less than 1% of the 18,000 dropped are newly reporting work. The idea that a work requirement would push people out of poverty is short-sighted, and has little effect in increasing work or cutting poverty.
As in Arkansas, work requirements may inadvertently lead to many Georgians becoming uninsured and unable to depend on Medicaid and other public safety-net programs. Restrictions on Medicaid eligibility impede the goals of reducing uninsured rate and reducing uncompensated hospital care costs. 76% of Georgia’s non-elderly Medicaid recipients are in families with at least one worker; many of these people would lose their Medicaid eligibility under a work requirement, putting further strain on their health outcomes. Additionally, the state’s budget would be strained from the added administrative costs to monitor employment statuses and help people find work.
While innovation within Medicaid can be successful when carefully considered and analyzed, Section 1115 waivers coupled with work requirements are not the solution to Georgia’s health crisis. The largely race-based discourse regarding Medicaid and other “government handouts” perpetuates policies that have disparate impacts on Black and Latinx communities. Georgia is in the middle of a rural hospital crisis, and policymakers should seek policies that strengthen our public institutions and ensure quality health care is an option to all Georgians. From telehealth to Medicaid innovation, effective solutions exist to ensure that access to quality and affordable health care is an option to all, including rural Georgia.