May 12, 2023
Dear Interested Readers,
The Debt Limit Crisis Threatens Rural Healthcare
I admit to being a news junky. Some people don’t want to keep up with the news because they say it is so negative. I understand that for them listening to the talking heads who try to turn the news into some Tucker Carlson-type controversy or horror show-like entertainment just creates anxiety that they want to avoid. One of my sons never listens to news programs because they make him anxious. He is well-read and conversant on most of the issues of our day. He just doesn’t drink from the hose of broadcast journalism like his mother and I do.
Most evenings my wife and I first listen to the local news and then record and watch both ABC and CBS for the national and world news. On many evenings we check out the PBS News Hour. I especially like the Friday edition when David Brooks from The New York Times and Jonathan Capehardt from The Washington Post joust. On Sunday mornings, we record political commentary programs for later viewing. They all come on at about the same time so we record them and watch them sequentially. The first thing I do every morning is to check out The New York Times followed by the Washington Post, The Boston Globe, and my local paper, The Valley News. When I am reading hardcopy, I focus mostly on the editorials and the columnists, but I also check out the obits, sports, and funnies in my local paper and The Globe.
Much of the recent news falls into big buckets that seem never to be completely emptied. That said, two chronic items did get resolved this week. The pandemic was declared to be over at midnight last night and has moved off center stage, and King Charles has been crowned and is no longer news. Donald Trump always finds a way to stay in the news. This week we were mercifully delivered from some of the confusion that has existed about whether he is a sexual predator or not. A jury in New York decided that he was. Despite his conviction, he will not have to register as a sexual offender. Judged by his warm reception in New Hampshire on Wednesday after he had lost his case to E. Jean Carroll, he may well continue to benefit politically with a base that cares more about conservative judges and tax breaks than the social determinants of health, but that is the world we live in. In the CNN town hall broadcast from Saint Anselm College on Wednesday evening, he continued to say that he was the winner of the 2020 election, that he has never met Ms. Carroll and therefore could not have molested her, and that the rioters at the Capital on January 6, 2021, were mostly good people who will have their convictions pardoned when he is reelected. He surprised me when he failed to condemn Putin’s invasion and failed to affirm that he hoped Ukraine would defeat Russia. No matter what he said, the crowd cheered. Trump’s show will continue oscillating between being a candidate who defies all norms and being a defendant for the next year and a half. The ongoing saga will be great for the news folks as well as for late-night comedians like Stephen Colbert.
On other fronts, we are treading water to see what will happen next in Putin’s war of Russian aggression in Ukraine. The question is what will occur when the mud dries and tanks can move. A secondary question is whether the Ukranians have enough ammunition to launch the offensive in an effort to retake the Donbas region and perhaps Crimea. We have promised the Ukrainians a lot of “materiel”—tanks, rockets, air defense systems, and such—that is yet to be delivered. If you are tired of worrying about Ukraine, don’t forget how we comport ourselves in Ukraine may influence what happens in Taiwan.
Immigration is always a big issue, and now we are waiting to see what happens since Title 42 expired at midnight last night along with the pandemic restrictions. In New Hampshire, we don’t get a lot of migrant workers looking for a better life by coming across our Canadian border, but it is true that the dairy industry in Vermont, New Hampshire, and across the country depends on migrant workers, some of whom are here illegally. It is strange that we are both dependent on immigrants to do our messy work like milking cows, harvesting crops, mowing grass, and washing dishes, but we don’t want them because someday they might be able to vote. Floating above it all and getting worse by the moment is the weather as glaciers are melting faster than predicted and efforts to lower carbon emissions fall short of international goals.
Reports of mass shootings are received with a shrug of the shoulders that once belonged to unpreventable natural disasters like tornadoes, floods, and earthquakes. What can you do when the controlling thirty-five percent of the country believes abortion is a bigger threat to the future of our nation than mentally ill people with rapid-fire assault rifles? There are other issues in the news like the wannabe autocrat in Florida who is abolishing wokeness, shipping migrants to Northern cities, suing Mickey Mouse, and banning books in a takeover of the curricula of his state’s public schools and public universities.
Closer to home and of more interest to most Americans than the weather or foreign affairs is a combination of high inflation, rising interest rates, bank failures, and the stalemate between the president and Kevin McCarhty over the debt ceiling that theoretically makes it possible for the economy to collapse. If someone would have made a movie back in the 50s depicting what I see on today’s news, I am sure that my mother would not have allowed me to see it. Since we can’t cut spending on defense, and no Republican since the first President Bush who said “read my lips” will vote for any increase in taxes, Mr. McCarhty and the House Republicans have passed a bill that would gut the social programs that President Biden has passed and put Medicaid on a diet. Worse yet, the bill runs out in less than a year meaning that in the middle of the next election, we would face the battle all over again. There is no way that the Senate would ever pass this bill or that President Biden would ever sign it.
In terms of what to do about the debt limit crisis, I sort of like the idea of the president declaring that the 14th Amendment makes defaulting on our debts unconstitutional and seeing what happens, but Biden has rejected that advice from legal experts like Lawrence Tribe. If you are wondering where this piece is going, it is headed toward a fact that gets lost in the haze of all the issues you hear about on the news or see in the papers. The fact that doesn’t get as much coverage as Trump is that 600 of our rural hospitals are at risk of being closed this year. That fact is closely related to many issues including rising interest rates, inflation, workforce shortages, and the financial impact of how hospitals are paid. Even more distressing is that many of the potential closures are in the ten “red” states in the South and “flyover” Midwest and West that have not accepted the Medicaid expansion of the ACA and its associated financial support that arrives from the reimbursement to hospitals for uninsured patients that is often a loss of many millions of dollars a year for even very small hospitals.
I would be surprised if Mr. McCarhty has fully weighed the potential of the possible impact on our healthcare of his game of financial Russian roulette that he is playing with the president. Some of the most extreme Republican members of the House who now control Mr. McCarthy seem to want to create a worldwide financial disaster that could be the beginning of “end times.” Ironically, the rural base of older, lower-income, White, far-right populist voters from whom Trump and far-right Republicans draw much of their support is likely to be the group that contains the earliest victims of America’s default on its debts and obligations. We often wonder why much of the MAGA base votes against its best economic interest.
Most economic experts and the Biden administration believe that if the country defaulted on its debts we would see an international financial collapse that would make 2008 look like a birthday party. It is estimated that seven million jobs will be lost if there is no resolution that lifts the debt ceiling. People on Medicare and Social Security, Veterans, and most of our social programs will be profoundly affected. The government’s creditworthiness will be damaged, the stock market will tank, and the dollar will be damaged as the most important international currency. Interest rates will rise dramatically and the financial disaster would quickly become a worldwide financial pandemic. For what? There are two components to the government’s financial position–what it spends and what it takes in. Mr. McCarhty wants to cut social programs, and the president thinks taxes on the wealthy and on corporations should go up. Pick your metaphor. Is it a game of “financial chicken” or “financial Russian roulette?”
With 600 rural hospitals vulnerable to closure before the debt ceiling crisis and the increase in interest rates, what will happen if the debt ceiling question is not resolved or if the resolution impacts Medicaid programs? Looking at the situation in Mississippi could be instructive.
In late May, The New York Times published an article by Sharon LaFraniere entitled ‘We’re Going Away’: A State’s Choice to Forgo Medicaid Funds Is Killing Hospitals. This article described the concerns that were leading to hospital closures before the issue of the debt ceiling became acute. The article begins describing the troubles that face Greenwood Leflore Hospital in Greenwood, Mississippi, the 208-bed major medical center of the Mississippi Delta. She interviewed the CEO. She writes:
Greenwood Leflore lost $17 million last year alone and is down to a few million in cash reserves, said Gary Marchand, the hospital’s interim chief executive. “We’re going away,” he said. “It’s happening.”
Rural hospitals are struggling all over the nation because of population declines, soaring labor costs and a long-term shift toward outpatient care. But those problems have been magnified by a political choice in Mississippi and nine other states, all with Republican-controlled legislatures.
The problem is more political than medical:
States that opted against Medicaid expansion, or had just recently adopted it, accounted for nearly three-fourths of rural hospital closures between 2010 and 2021, according to the American Hospital Association.
Opponents of expansion, who have prevailed in Texas, Florida and much of the Southeast, typically say they want to keep government spending in check. States are required to put up 10 percent of the cost in order for the federal government to release the other 90 percent.
What might happen to many of the nation’s rural hospitals with a failure to positively resolve the debt ceiling issues is already happening in many places across the country as a function of red-state resistance to accepting the Medicaid expansion. The article continues:
Statewide, experts say that no more than a few of Mississippi’s 100-plus hospitals are operating at a profit. Free care is costing them about $600 million a year, the equivalent of 8 percent to 10 percent of their operating costs — a higher share than almost anywhere else in the nation, according to the state hospital association.
Expanding Medicaid would uncork a spigot of about $1.35 billion a year in federal funds to hospitals and health care providers, according to a 2021 report by the office of the state economist.
It is one thing to lose hospitals it is another thing to lose people. There are 100,000 potential beneficiaries of Medicaid expansion in Mississippi. Without Medicaid people don’t get care until it is too late which explains why Mississippi ranks as the state with the worst life expectancy at 74.6 years. A man in Mississippi has a life expectancy of 71.4 years. Mississippi is very overweight. 40.8% of adults qualify as obese. If you guessed that Mississippi has terrible maternal/ child statistics you would be right. It is hard to imagine what will happen to healthcare in Mississippi and in many other places when employment falls, the stock market tanks and interest rates go through the roof after a meltdown following a failure to resolve the debt ceiling crisis.
If you are interested in where our 600 most vulnerable hospitals are click here to see a map of the country that identifies where the 600 vulnerable rural hospitals are located. Once you see the map you can click on an individual state like Texas to discover how many vulnerable rural hospitals the state has. What you will see will look like this:
What is as important as knowing where the hospitals are is to try to imagine the impact on communities of hospital closures. Hospitals are often the largest local employer or one of the most significant employers. When hospitals close access to emergency care becomes difficult. Many hospitals don’t close they just stop providing important services that don’t turn a profit. The hospital in my town as in 8 other New Hampshire communities closed OB services between 2000 and 2018. A woman that I know in our community had a very complicated pregnancy this winter. She was forced to drive to Dartmouth thirty miles away for emergencies at least ten times before she finally lost the baby at seven months. Would local OB services have made a difference? Who knows?
When a hospital closes the whole medical environment changes. Access to emergency services deteriorates. Distance makes a difference. If fee-for-service payments will not support rural hospitals, then perhaps they should be financed by other mechanisms. We provide electrical service to most rural environments and build highways to small communities. Why do we treat hospitals like grocery stores that must close if their operating costs preclude a profit? No grocery stores are another problem in many rural communities that are “food deserts.”
In medical practice, we quickly learn that we must prioritize our approach to a patient’s problems. It is often true that a new problem pops up that requires resolution before we can return to managing the established chronic problems. I think the principle also holds with political problems. We must get through the debt ceiling crisis before we can return to all the other problems that I follow with my attention to the news. We need a resolution to the crisis that doesn’t make all of our other issues in healthcare worse.
I like to end on a positive note. Not all the news in my local newspaper has been negative recently. As you can see in the picture below, last Sunday, the headline of my local paper, The Valley News, was “Improving access to care: DMHC opens new wing. The whole front page was about various healthcare developments. Below the article about Dartmouth’s new building was an article entitled “Family medicine residency planned.” To the right of the lead article was an article about the expansion of the nursing program at Colby-Sawyer College in my town, New London. On the left was an article entitled, “It’s the little things: Bill in legislature would assist caregivers of non-family members.” I was stunned. All of the articles were quite lengthy and optimistic.
I was pleased to see so much attention paid to issues I care about. Maybe that is a good sign. We are in a moment of vulnerability, but a positive resolution is possible. We can still avoid a lot of pain for the whole nation and for our most vulnerable hospitals and the small communities they serve. At worst, we may be forced to learn a very difficult lesson that will lead to a better future.
Things Are Getting Greener By The Day
The weather has been great this week. With each passing day, my world gets greener and greener. Today’s header is just one bit of evidence to support my contention that for the moment we are enjoying Spring. Unfortunately, the picture does not reveal that we have a bumper crop of black flies and people are already picking ticks off their dogs and their own exposed skin if they venture into the green spaces. Out on the water in a kayak, there is often a gentle breeze that gets rid of most of the flies and all of the ticks.
Mother’s Day is Sunday. We are expecting good weather in New Hampshire. I hope that wherever you are your Mother’s Day will be a joy. I am one of those who will visit their mother by reflecting on pictures and memories. She was a remarkable woman who devoted her life to her children and her husband. I think of her and the lessons she offered every day. If you are fortunate enough to still visit or contact your mother, you are very lucky. If you are a mother, you deserve honor and great respect. I hope that we will all have a wonderful weekend and that through some miracle all the news that might come our way will be positive at least for one day.
Be well,
Gene
