Access to health care in areas like rural Georgia has become more of a challenge, but a new law may keep health care accessible and affordable for people who live outside big cities. USA TODAY NETWORK
Brittany Young, 23, talks to Dr. Anthony Marchetti in the emergency room at Upson Regional Medical Center in Thomaston, Ga.(Photo: Jayne O'Donnell, USA TODAY)
THOMASTON, Ga. — Blocked sweat glands turn into searingly painful growths that send Brittany Young rushing back to the emergency room at Upson Regional Medical Center here.
Young also has the chronic intestinal disease Crohn's to contend with. Without a job or health insurance, the single mother can't get the ongoing treatment needed to keep her Crohn's from progressing. She's visited the ER six times since losing her Medicaid coverage after her baby was born in June.
Young says she has no money, so she pays nothing.
"I guess someone ran the numbers and figured out it saves money to do it this way," says Anthony Marchetti, an Upson emergency physician who has treated Young.
If they have, they haven't quantified the pain faced by people including Young or the plight of rural hospitals like Upson that are required to at least stabilize everyone who walks in the door, regardless of their ability to pay. Republican Georgia Gov. Nathan Deal's decision not to expand Medicaid coverage to those under 138% of the federal poverty limit — as allowed and funded almost entirely by the Affordable Care Act (ACA) — left patients and hospitals in this and 18 other states in precarious situations.
At least 80 hospitals have closed nationally since 2010, according to the North Carolina Rural Health Research Program. In that time, six hospitals have closed in Georgia and about 10 more are in jeopardy of closure, says Jimmy Lewis, CEO of the rural hospital group Hometown Health.
Republican control of the White House and Congress next year opens the door to new approaches to health care financing that could turn states into the "laboratories of democracy" the late liberal Supreme Court Justice Louis Brandeis wrote they should be in 1932. Congressional leaders and President-elect Donald Trump vowed to repeal the ACA early next year, which would likely remove funding for Medicaid expansion and the financial assistance others need to buy Obamacare plans. That could leave about 20 million people without health coverage.
If the ACA repeal legislation includes the expected built-in delay, Kaiser Family Foundation executive vice president Diane Rowland predicts states will propose more waivers from Medicaid expansion's requirements in advance of the fixed "block grants" likely to be proposed by the new administration.
Read more:
ACA supporters worry that could expose many hospitals and patients to erratic funding and dangerous lapses in care. The patchwork quilt effect of Medicaid expansion has already meant people with the same conditions across state borders may get good care or no care for their health problems.
When it comes to the block grants, "some claim it creates flexibility," Health and Human Services Secretary Sylvia Burwell said Wednesday. "The downside...is when it limits the money that can go to the state." That can leave states with three choices, she said: Kicking people off Medicaid, cutting benefits and finding the money in their own budgets.
Many Republican ACA opponents, however, say the funding and decisions about what to do with it needs to be further distanced from Washington.
"It's important to just not jam a specific idea down a community's throat, " says Geoff Duncan, a conservative Republican state representative from an Atlanta suburb. "You've got to have a more community-focused approach to solving health care problems."
Duncan, CEO of a Tennessee-based wellness company who may run for governor in 2018, sponsored a potential solution that takes effect Jan. 1. The new law will allow businesses and residents to make donations to eligible rural hospitals and claim a state tax credit equal to 70% of the donation. It's part of the alternative to big government that Duncan likes to call the four C's — churches, charities, corporations and citizens.
Republican State Rep. Geoff Duncan, left, meets with Todd Shiflett, CEO of Georgia Highlands Medical Services, which runs community health centers in the state. (Photo: Jayne O'Donnell, USA TODAY)
To long-time rural hospital lobbyist Lewis, the law is a godsend. The day after Duncan introduced his bill, Lewis introduced himself to the 41-year-old legislator and said, "I've been waiting for an idea like this to show up at the Capitol for the last 30 years," Duncan recalled.
Former HHS official Hilary Haycock, who consults for California's health department, doesn't share his enthusiasm.
"It’s an incredibly unstable way to fund health care for low-income populations," says Haycock, president of the health care firm Harbage Consulting. "The whole challenge of the economic cycle is that during periods of economic recession, there's the greatest need to support the most vulnerable."
While it may not be the "perfect fix," Duncan says his plan "creates a much needed conversation."
The next step, he says, may be to bolster and link the network of community health centers to hospitals so low-income patients get more regular care and the burden on hospitals is eased.
It's the kind of thinking expected to appeal to states if Medicaid block grants or per-person expenditures become the Trump administration's approach. Seema Verma, Trump's nominee to head the Centers for Medicare and Medicaid Services, designed Indiana's variation on Medicaid expansion, which has what Rowland calls "most stringent requirements for gaining and maintaining coverage."
Says Haycock: "We’ll certainly have the opportunity to experiment."
Here's what we'll likely see more of:
• Cost sharing. Those eligible for Medicaid through the ACA expansion in Indiana owe 2% of their incomes or $1 in monthly premiums if they earn less than $50 a month. The money goes into a type of "health savings account" like those offered by employers. Some other states also require small premiums and co-payments. In addition, Indiana requires Medicaid to share more of the costs of non-emergency visits to the ER to discourage the trips. Also popular: Premium breaks if patients meet certain healthy behavior goals like those offered by many employers.
• Work requirements. No state is currently allowed to require people to work to get Medicaid benefits under the ACA's expansion of the program, but Indiana can refer recipients to resources to help them find and train for jobs. Kentucky Gov. Matt Bevin proposed a Medicaid alternative in August that would require recipients to work or perform community service. More than half of the people who would be eligible for Medicaid if their state expanded the program already work, the non-profit group Families USA reported last year.
• Fewer rides. Covered transportation for non-emergencies could be eliminated, as it has been in several states with waivers. Those who make under the federal poverty limit — about $15,000 for a family of two like Young's — often have the biggest challenges with transportation, especially in rural areas where public options are minimal.
• More care coordination. Obamacare may get a lot of flak from its namesake's opponents, but its broad mission of lowering health care costs by improving quality over the quantity is expected to survive. Sliding-scale community health clinics were supposed to be largely unnecessary once the ACA got everyone signed up for insurance, but that's not the case with millions still uninsured. So now Duncan and Todd Shifflet, CEO of a chain of Georgia health centers, are discussing how to link their preventive and primary care services with hospital ERs.
Geoff Duncan had never been to a rural hospital when he pulled up, tears in his eyes, to the one here earlier this month.
Seeing the full parking lot, the state representative was emotional because of what could happen to everyone's health if a hospital like Upson were to close. Duncan said he kept hearing about the plight of rural hospitals during legislative meetings and was prompted to act.
Now, he says, "I can't go a single day without getting a call," from someone in another state inquiring about the new way of funding health care. He modeled it on a program to fund private school scholarships with income tax credits, which has hit its $58 million cap in a day for the last two years.
Duncan also didn't know about the quality of services at community health centers like the one run by Georgia Highlands in Cumming, in which he's lived since high school. Or that people with "real insurance" could use them, he says. They can and need more people with commercial insurance, said Shifflet. Soon they will have 11 "real doctors," Shifflet laughs.
"We could expand the footprint of these in a way that doesn't compete with the hospitals but helps to reinforce them and open up access," Duncan said during a recent visit to the center.
"Maybe you could incentivize those kinds of partnerships to jump start it," Shifflet added hopefully.
Even if the centers only took over managing the care of 100 of the most frequent local ER visitors, "that would save the system a bunch of money," he adds.
EmoticonEmoticon