Suffering of rural poor a reminder of how much health policy debates matter

Twenty Democrats who are campaigning for president  took to network television for four hours and two nights last week to put health care as a central issue of their campaigns.

The format of this initial candidate “debate,” including hand-raised answers to complex issues, failed to allow the presidential aspirants to delve much into the details of their proposals. But tons of news coverage followed on — and likely will keep doing so up until Americans enter the voting booth — about Medicare, the government health coverage for seniors, and how it might be expanded to benefit tens of millions more. Those interested may wish to check out this podcast primer on the issue.

These future-looking discussions also already have tended to eclipse a key part of the existing Affordable Care Act, the Obama Administration initiative that remains a subject of hot dispute a decade after its passage: The expansion of Medicaid, the federal program to assist the poor and working poor with health coverage.

Under the ACA, and with its promise of federal money to do so, 37 states and the District of Columbia expanded Medicaid, meaning, as the commission that oversees the program has reported: “As of July 2018, Medicaid enrollment has surpassed [the Congressional Budget Office’s] revised coverage estimates, increasing by nearly 16 million from the pre-ACA baseline (CMS 2018). There were 13.3 million fewer uninsured individuals in 2017 compared to 2013 (Berchick et al. 2018).”

A major downside, of course, to the Medicaid expansion was the U.S. Supreme Court ruling that allowed states to decide whether they would go along or not. Fourteen states have declined to do so.

And for anyone who wants to know why the nation is obsessed about health care, an Eli Saslow story in the Washington Post provides important reading. He painted the poignant, distressing portrait of a Tennessee couple, suffering from an array of health concerns but also struggling with medical debt, and their ordeals as they seek one of their few options for accessible and affordable medical care — examination and treatment in Cleveland, Tenn., (pop. 42,000) at a free, pop-up clinic for the rural poor.

The central figures in his news story, Lisa and Steve Crider, drag into Cleveland a day early, arriving by bus. As Saslow reported, “They packed a plastic bag with what had become their daily essentials after 21 years of marriage: An ice pack for his recurring chest pain. Tylenol for her swollen feet. Peroxide for the abscess in his mouth. Gatorade for her low blood sugar and chronic dehydration.” They clutch a social worker’s referral for themselves to the clinic, a note that describes their condition: “Urgent needs from head to toe. Lacking primary care and basic medication. They have fallen into the gap.”

As the Washington Post describes it, they are not alone. They have joined an army of needy, rural Tennesseans, hundreds of people “in medical distress [who] wait for hours at emergency clinics in order to receive basic primary care.” That’s because:

“Tennessee has lost 14% of its rural physicians and 18% of its rural hospitals in the past decade, leaving an estimated 2.5 million residents with insufficient access to medical care. The federal government now estimates that a record 50 million rural Americans live in what it calls ‘health care shortage areas,’ where the number of hospitals, family doctors, surgeons and paramedics has declined to 20-year lows.”

Without giving away Saslow’s powerfully told story, readers should know that the Criders, in just one day alone, will endure a lot of suffering due to their own health problems and the beleaguered state of Tennessee’s health system.

Theirs, however, is an unnecessary and “self-inflicted medical misery,” opines Paul Krugman, the Nobel Prize-winning columnist for the New York Times. As he wrote:

“Since the focus of [Saslow’s] report was on personal experience, not policy, it’s understandable that the article mentioned only in passing the fact that Tennessee is one of the 14 states that still refuse to expand Medicaid under the Affordable Care Act. So, I’m not sure how many readers grasped the reality that America’s rural health care crisis is largely — not entirely, but largely — a direct result of political decisions. The simple fact is that the Republicans who run Tennessee and other ‘non-expansion’ states have chosen to inflict misery on many of their constituents, rural residents in particular. And it’s not even about money: The federal government would have paid for Medicaid expansion. So, if rural America is suffering, a large part of the explanation is gratuitous political cruelty. This cruelty has denied health insurance to millions who could have had it with a stroke of the pen. And rural hospitals are closing, rural doctors leaving, in large part because people can’t afford to pay for care.

Krugman contrasts the experiences of Tennesseans with their neighbors. Kentucky expanded Medicaid, and “The result was a two-thirds drop in the uninsurance rate … At this point, adults in Tennessee are twice as likely as their neighbors to lack health insurance.”

He refers to the current political battling over potential changes to alter Medicare, potentially to make it a single-payer universal health care for Americans. But he noted, “if the U.S. were like every other wealthy nation, and provided some kind of universal health care, there would be no uninsured at all. Those heart-rending scenes in Cleveland would be inconceivable anywhere else in the advanced world. But the ACA isn’t a future aspiration, it’s an already-existing program — and a lot of rural America’s medical misery could be avoided if states like Tennessee were willing to take advantage of that program.”

Why won’t politicians act to benefit those who put them in office, Krugman asks. This is his view:

“While rural Americans often tell reporters that they feel neglected and ignored by big-city coastal elites, the people preventing them from getting health care aren’t in New York or D.C., they’re in their own state capitals. And these state politicians hold power in large part thanks to the strong Republican leaning of rural voters. But why are Republican state-level politicians so determined to punish their own base? As I said, it’s not about the money: Rejecting the Medicaid expansion actually costs a state jobs and hence revenue. Some of it may reflect the general mean-spiritedness, the embrace of cruelty, that was already infecting the GOP even before Donald Trump, and has now become one of the party’s defining traits. Yes, that’s harsh, but you know that it’s true. There’s also, I suspect, an element of cynical calculation. As I said, rural voters often complain that national elites don’t care about their needs. Well, one way to make people feel hostile toward those elites is to block their access to federal benefits and hope they don’t realize who’s actually causing their misery. Is it conceivable that conservative politicians have that much contempt for their base? Yes.”

Ouch. In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This has become a daunting challenge due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which prove to be dangerous drugs. Health care shouldn’t be a privilege for the few. It should be an American right. It is unacceptable that disparities increase by the day in the health care we receive based on factors like geography, income, race, gender, and sexual orientation.

We’ve got yet more tough thinking to do and hard choices to make, especially as we think about who we want to lead us in the near term and the future. We all may want to spend extra time listening to and figuring exactly what politicians of all stripes are campaigning on, particularly when it comes to health care. Can those with hopes and aspirations enact the policies they promise will improve our health? And even if we have programs that can benefit individual’s well-being, what if partisans reject them and fail to act? We’ve got a lot of work to do in the days ahead on health care.