Wednesday, November 23, 2016

Health Care Reform Articles - November 23, 2017

Even After Trump Is Gone, Fallout From Democratic Primaries May Haunt Single-Payer Efforts

by Michael Corcoran - Truthout

Twenty years from now, if Americans are still fighting for a single-payer health care system, opponents will still be citing Ken Thorpe's published critique of Bernie Sanders' Medicare for All plan from 2016. That is how damaging the analysis was to Sanders' presidential candidacy and to the single-payer movement, according to several health reform advocates.
Thorpe, a health policy professor at Emory, has devoted much of his career to touting the economic benefits of single-payer on the federal and state levels. But in 2016, in the thick of the Democratic primary, he suddenly took the opposite stance. In his January 27 analysis, Thorpe argued that Sanders' Medicare for All plan was too expensive and would hurt poor people, young workers and the elderly.
The paper was amplified by a barrage of favorable media coverage, almost all of it emphasizing Thorpe's pro-single-payer credentials. "Thorpe isn't some right-wing critic skeptical of all single-payer plans," wrote Vox's Dylan Matthews. Clinton's camp, and the dominant media, manufactured an illusion of consensus among left-leaning economists.
For more original Truthout election coverage, check out our election section, "Beyond the Sound Bites: Election 2016."

Advocates familiar with Thorpe's past work were perplexed as to why he undermined his own past research. Now, nine months after the publication, we may have an answer. Leaked emails from Clinton campaign staffers, published by WikiLeaks, suggest Thorpe may have been acting not as an independent analyst but rather as a political mercenary in collaboration with the Clinton campaign. In doing so, Thorpe has created a document that not only hurt Sanders' candidacy but could hurt prospects for a truly universal health care system in the future. This is even more disappointing now that we know the Clinton campaign would lose the general election to Donald Trump; Thorpe was not just a mercenary but one on an ultimately failed, counterproductive mission.

In an email dated January 19, 2016, members of the Clinton campaign, along with some outside advisors, were discussing the effectiveness of attacking Sanders on single-payer. Jake Sullivan, a policy advisor for Clinton, wrote: "The idea would be to get someone (Ken Thorpe?) to join Brian Fallon to make the following points ... [it hurts many] poor people on Medicaid right now ... working seniors ... [and] many young people under 26."
Just eight days later, Thorpe published "An Analysis of Senator Sanders Single Payer Plan," which, in addition to attacking Sanders on cost, included the three primary points of emphasis the Clinton camp had suggested: the plan's impact on "working young adults," (or "people under 26," to use the Clinton camp's language), "Medicaid households" (poor people on Medicaid right now) and "Medicare beneficiaries" (seniors). A few days after that, according to another leaked email dated February 3, 2016, which included the line, "here is a round-up thus far"), the staff were monitoring responses to Thorpe's paper in the media. The timeline of the emails in relation to Thorpe's piece is illuminating:
Truthout reached out to Thorpe and the Clinton campaign to invite them to address the content of the leaked emails, but neither responded.
"We are disappointed that Ken [Thorpe] failed to disclose his relationship to the Clinton campaign," said doctors David Himmelstein and Steffie Woolhandler, in an email to Truthout. "We understand that politics is a combat sport, and expect behavior of this kind from politicians.  But scholars should be held to a higher standard."
Himmelstein and Woolhandler, professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School, were two of the few voices in the wilderness to scrutinize Thorpe's paper. Thorpe's analysis rests on "several incorrect, and occasionally outlandish, assumptions," they wrote in The Huffington Post. "Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past writing a response for arguing."
A Truthout analysis of media coverage of this debate in February, however, showed that the media ignored Woolhandler's paper or any other paper that reflected positively on Sanders' plan. The New York Times cited Thorpe's article five times in the week following its release, while Woolhandler and Himmelstein's response was not mentioned at all.
The Vindication of Gerald Friedman
Woolhandler and Himmelstein weren't alone in having not been given a voice in the dominant media. University of Massachusetts Economics Professor Gerald Friedman, who offered his own independent analysis of Sanders' plans -- which had far more favorable conclusions about its impact -- became the subject of attacks and ridicule by liberal economists and the dominant media.
Citing Thorpe's paper, four former chairs of the Council of Economic Advisers (CEA), wrote a letter to Friedman and Sanders, saying Friedman's projections were "fantastical claims," and "undermine the credibility of the progressive agenda." This prompted another wave of articles further painting Sanders' proposals as "voodoo economics," as Paul Krugman described it.  Friedman's name was being dragged through the mud, and Thorpe's work was frequently cited in these smears.

"When I saw all of this, the first thing I thought was, 'wow I am glad I have tenure,'" said Friedman in an interview with Truthout. "I knew Thorpe's work was sloppy. I tried to communicate with him to help sort it out. I sent him my spreadsheets and asked for his, but he ignored me."

The media, for the most part, ignored Friedman's voice, too. The CEA letter was cited on five occasions in the Times, while Friedman's response to that letter was never mentioned. The Times' news department wrote an entire article filled with so-called "left-leaning economists," critiquing Friedman's numbers and Sanders' plan as "puppies and rainbows." A letter from James Galbraith defending Friedman's forecasting models was also ignored by the media. "I feel a little vindicated," Friedman said, referring to all the criticism he was subjected to, in large part based on Thorpe's work. "These revelations do not make Thorpe look good."

One problem was that after the release of his paper, Friedman said, "no one in the media bothered to ask 'why is Thorpe doing this study right now?'" Indeed, Thorpe's independence was rarely, if ever, questioned in the dominant media. The same could not be said of Friedman. Krugman, for instance, suggested that Friedman was trying to earn himself a "seat at the table," in a potential Sanders administration.
At one point Friedman told a CNN reporter during an interview that he was drinking from a Bernie Sanders mug. "They called me back to ask how I got it," he said, noting he paid $35 for it. This scrutiny is what the media should do, of course, but the double standard is that no one bothered to see whose mug Thorpe was drinking from.

The Damage Already Done
Of course, the Clinton-Sanders race is now history. But Thorpe's lambasting of single-payer may well have done long-term damage.
"It left an impression that the economic case for single-payer reform was weak," said Himmelstein and Woolhandler to Truthout. "It allowed Secretary Clinton to claim that 'the numbers don't add up' and risked undermining efforts for such reform not just during the campaign but in the longer term."

Friedman agreed and compared Thorpe's turnaround to Gov. Peter Shumlin's abandonment of single-payer in Vermont as among the biggest setbacks for the movement in a generation. "Single-payer activists will be dealing with the aftermath of this paper for the rest of our lives," he said.

The public, however, remains broadly supportive of a Medicare for All plan, despite these coordinated attacks. According to Gallup polling from May, 59 percent of the public and 72 percent of Democrats support "replacing the ACA with a federally-funded system." Certainly Sanders' impact on the national discourse has helped educate the public about single-payer.

"Fortunately, it appears that most of the public didn't believe [Thorpe and Clinton's] claims," said Himmelstein and Woolhandler, "although many respected academics and pundits (e.g. Paul Krugman) swallowed them whole."

Surprise! Insurance Paid the E.R. but Not the Doctor

by Margot Sanger-Katz and Reed Abelson

Doug Moore was out of town at a Florida conference on information technology in October 2015 when he was struck with terrible abdominal pain. He tried to go to an urgent care center and called several local doctors. No one could see him. So he headed to the nearest emergency room. On the way, he called his insurance company to make sure the visit would be covered.
Once he got to the Palms of Pasadena Hospital emergency room, a doctor gave him some medication and tests, and let him go. A month later, feeling better and back at home in Baton Rouge, La., Mr. Moore, 34, received an out-of-network bill from the doctor who treated him — for $1,620.
“That really makes me mad, and kind of breaks my heart,” he said.
When people go to the emergency room, they are often stunned to discover that doctors who treated them are not employed by the hospital and bill their insurance company separately. These doctors negotiate separate deals with insurance companies for payment. If the doctor and the insurance company never strike a deal, the visit is billed at much higher out-of-network rates. While the insurance company sometimes pays the higher amount, unlucky patients like Mr. Moore can be caught in the crossfire. They receive care and have no idea what it will end up costing them.
New research published in The New England Journal of Medicine on Wednesday found that more than one in five patients visiting the emergency room may face the same financial shock. The study looked at billing data from one large national insurer and found that 22 percent of the time, patients who went to a hospital covered by their plan still received a bill from a doctor who was not in the insurance company’s network. The average such bill cost more than $900, though there was a wide range; the highest was for more than $19,000. This is not the first timeresearchers have examined surprise medical bills, but it’s the broadest analysis to date of the problem nationwide.
The study found wide variation across the country over the likelihood that someone would get a surprise medical bill. In McAllen, Tex., for example, the rates of surprise billing were 89 percent, compared with Boulder, Colo., where it was near zero.
Once patients get to the emergency room, they have little choice over who treats them. “To put it in very, very blunt terms: This is the health equivalent of a carjacking,” said Zack Cooper, an assistant professor of health policy and economics at Yale University, and a co-author of the paper. Mr. Cooper argues that the problem could be solved by Congress, which could make the visit a package that includes both the doctor and hospital.
Consumer advocates, and scholars like Mr. Cooper, see the surprise bill as unfair. It’s nearly impossible for patients to uncover the contract arrangements of individual physicians once they walk into an emergency room — or are brought by ambulance.
“People are, by and large, not aware that they’re playing that type of financial roulette,” said Chuck Bell, the programs director at Consumers Union, an advocacy group that has been urging states and Congress to help solve the problem. “They follow the rules, and they go to the in-network hospital, and then it’s just like a bait-and-switch.”
Several states have passed legislation aimed at tackling the problem, including New York, Florida and California, where a law recently went into effect. But the state laws affect only a fraction of insurance customers. Insurance offered by large companies, like Mr. Moore’s employer, is regulated under federal law. And most of the laws work by setting up a dispute resolution system for patients, which means they need to know they can go to state authorities to fight a big bill.

Where You’re Most Likely to Get That Surprise Bill 

Congressman Lloyd Doggett, a Democrat from Texas, introduced legislation last yearto tackle the practice nationwide, but he said he experienced “a healthy dose of indifference” from his colleagues on the Ways and Means committee. Mr. Doggett had heard complaints of surprise bills from constituents, and it turns out that the new study found that Texas is a hot spot for the practice. Mr. Doggett said he would introduce the legislation again next year. “I think that there’s got to be a way to get consumers out of this trap,” he said.
President Obama included proposals to limit out-of-network emergency room bills in his budget proposal, and recent regulations have made it more difficult for doctors to collect certain bills, though those rules are being fought in court by physicians. The acting administrator for the Centers for Medicare and Medicaid Services has said that surprise bills are a policy priority for him.
The data in the study come from one large commercial insurer, but the researchers agreed not to name it in exchange for access. Mr. Cooper said there was only a little difference in the share of surprise bills in places where the insurance company had a lot of customers, compared with those where it did less business.
Emergency room doctors criticized the study’s findings and were quick to blame the insurers. The American College of Emergency Physicians, the medical society that represents the doctors, said patients are much less likely to face large unexpected bills than the study suggested, citing an analysis the group did in Florida of patients who were “balance billed,” or asked to make up the difference between what the insurer pays and what the doctor bills.
“Our balance bills are less than a couple of hundred dollars, on average,” said Dr. Rebecca Parker, the group’s president. She said that most doctors want to be included in networks but that they are not being offered reasonable fees.
“This is insurance company bad behavior,” said Dr. Parker, whose group this week put out a parody video that accuses the insurers of paying too little for their work.
Insurance companies like to blame the physicians, arguing that while they can reach a deal with the hospitals, there are many doctors who refuse to be part of the network they offer under a plan.
And the insurers argue hospitals have a responsibility to make sure the outside doctors they use to staff their emergency rooms sign contracts with the same health plans they do. “This would go a long way to reduce and prevent consumers from receiving a big surprise balance bill,” Kristine Grow, a spokeswoman for America’s Health Insurance Plans, a trade group, said in an email. The new paper’s authors agree.
When Mr. Moore received his doctor’s bill, he tried appealing the charge to his insurance company. “We understand that you went to a preferred provider facility and did not have a choice of the emergency room physician who treated you,” his insurer wrote back — but denied the claim. Then he went to the private practice that had sent him the bill. It was willing to negotiate.
“They knocked off half the bill,” he said. “Which is great. It’s like, would you rather get punched four times or two times? I guess two times is better.”

I had a health crisis in France. I’m here to tell you that ‘socialized medicine’ is terrific
by Jake Lamar - LA Times

On Sunday, March 29, 2015, two days after my 54th birthday, I came very close to dying. I was sitting in an armchair in my Paris apartment, reading a newspaper, when I became dizzy. The next thing I knew, my heart was beating violently. When the paramedics arrived, it was racing at 240 beats per minute.
I was taken to Lariboisière, a major hospital in the north of Paris. In the intensive care unit, I learned that I had been born with a defective aortic valve. Basically, I’d been walking around my entire life with a ticking time bomb in my chest. How could I not have known? In high school, I ran track and played football; every summer, my wife and I took long hikes in the Swiss Alps. But an experienced nurse was not surprised. “With your condition,” she said, “the first symptom is often sudden death.” OK, I replied, what’s the second symptom?
So began my sojourn in the French healthcare system. In the United States, opponents of the Affordable Care Act often raise the nightmarish specter of European “socialized medicine.” For what it’s worth, here is a brief account of my experience with a single-payer system in the face of a life-threatening crisis.
On March 31 of last year, the morning of my second full day in the ICU, I was chatting with my wife, Dorli, when I became dizzy again. This time, my chest was plastered with electrodes and the heart monitors unleashed a screaming electronic alarm. Dorli was hustled out. Someone tore open my hospital gown. A doctor stood over me, the defibrillator raised in his hands. I felt like I was in one of those hospital shows I almost never watch. I thought the doctor was about to yell “Clear!” or whatever one yells in French when, suddenly, my heart, of its own accord, calmed down. The roomful of cardiologists stared at me with a mix of empathy and professional curiosity.
I spent a total of 15 nights in intensive care units while a team of cardiologists put me through a battery of tests and tried to determine how best to treat my case. In addition to the tachycardia (accelerated heart rate) and the leaky aortic valve, the aorta itself was overgrown. I would need open-heart surgery.
On May 11, 2015, Dr. Emmanuel Lansac of the Montsouris Institute performed the six-hour operation, sewing my valve into shape and replacing a chunk of my aorta with a synthetic tube. The day after, I asked Dr. Lansac how weird my problem had been, on a scale of one to ten. He replied: “About a nine.”
After eleven days, I was transferred to a clinic for patients recovering from open-heart surgery. The grounds looked like a Monet painting. At any given time, there are about 65 patients at the clinic undergoing tests, monitoring and gentle exercise. Among my fellow cardiac cases, I met an arts administrator, two taxi drivers, the British former CEO of an airline and patients from France’s former colonies in Africa, the Caribbean and Asia, including a Vietnamese history teacher who became my regular chess partner. And then there was me, an African American writer who is not even a French citizen but a long-term official resident. All of us, regardless of class, religion, national or ethnic origin, received the same top-notch treatment.
Let's get to the bottom line. In addition to my surgery, I underwent an MRI, had a probe inserted in my upper thigh and extended into my heart, twice had a camera shoved down my throat to take photos of my valve, and more blood tests, electrocardiograms and sonograms than I can count. For all this, I was charged nothing.
I did have to pay for my hospital beds, TV, telephone, WiFi and meals. I spent a total of 47 nights in hospitals and rehab. During the second half of my stay at the Grands Prs, I switched from a double room to a single so that I would have more privacy to write. Naturally, that was a bit more expensive. In the end, this entire ordeal set me back about 1,300 euros, or $1,455.
Granted, it’s taxes that make such low out-of-pocket costs possible. My individual burden, however, is far more reasonable than an American might assume. I pay an annual income tax of about 23%. All things considered, that’s fine by me.
I sometimes wonder how my health crisis would have played out had I returned to America instead of deciding to stay in Paris more than 20 years ago. Me, a journeyman writer with no university or corporate insurance coverage. Would I have been kept under observation in intensive care for two weeks? Before Obamacare, my valve problem could have been considered a “pre-existing condition,” allowing insurers to deny me support for the surgery.
Of course, I will never know what would have happened had I chosen to settle in my native country instead of in France. But the choice I made might well have saved my life.

Republican Falsehoods About Obamacare

by Teresa Tritch - NYT

A repeal of the Affordable Care Act, which the Republicans have been threatening for years, would obviously be unpopular with the 20 million people who have received coverage under the A.C.A.
But Republican leaders don’t seem too concerned with those people. Instead, they are trying to convince people who don’t rely on the A.C.A. that repeal of the law would leave them better off.
Paul Ryan, for instance, said on on Fox News on Thursday, that “because of Obamacare, Medicare is going broke.” That statement is false. According to the Medicare trustees, cost controls in the A.C.A. are one of the reasons that the system’s hospital trust fund is projected to remain solvent through 2028 — 11 years longer than before the A.C.A. was enacted.
A similar claim by critics of the A.C.A. is that the law is driving up the cost of employer-provided insurance, which covers 154 million people. A new study by the Commonwealth Fund, which compares costs in the five years before and after 2010, when the A.C.A. was enacted, rebuts that claim.
In most states, the pace of growth in premium costs and deductibles has slowed since 2010. Nonetheless, employees do spend a greater share of their incomes for health coverage because of continued slow wage growth through 2014. Another big factor, especially across the South, is that employers in low-income states tend to offer workers plans that are costlier in terms of employees’ premium contributions and plan deductibles. The result is a rise in the share of income going toward health coverage.
In Mississippi, for example, 14.7 percent of median household income went to pay for premiums and deductibles on employer-provided polices in 2015. In Texas and three other southern states, plus Arizona and New Mexico, households paid 12 percent or more. By contrast, in the high income states of Maryland and Massachusettes, such costs were less than 8 percent of median income; in California, Connecticut, New York and several other relatively affluent states, they ranged from about 8 percent to less than 10 percent.
There are no good reasons to repeal the A.C.A. It is helping 20 million people directly and it is not harming hundreds of millions who are insured outside the A.C.A.

Let’s Say Obamacare Is Repealed. What Then?

by Aaron Carroll and Austin Frat - NYT
The election of Donald J. Trump gives the Republicans in Congress a chance to act on their often-stated desire to get rid of Obamacare, a wish that Mr. Trump mostlysays he shares. Aaron E. Carroll and Austin Frakt, our health policy columnists, discuss: Then what? 
Aaron: I think it’s safe to say few in Congress thought they’d have this opportunity. But like the proverbial dog who has finally caught the car, after untold futile attempts, Republicans have finally come within reach of repealing the Affordable Care Act. Now comes the essential question: Will they actually do it? They’ve been promising it forever, but I am still skeptical that it will happen. I believe you disagree. I’m going to let you go first. Why do you think they’ll do it?
Austin: I think they’ll do it because they so thoroughly own the idea of repeal, having passed bills to repeal, partly repeal, delay or defund the A.C.A. in the House something like 60 times. Just the other day Senator Mitch McConnell endorsedrepeal (again). The House and Senate also agreed to do so, in large part, in a budget reconciliation bill earlier this year. The only thing that prevented it was that President Obama vetoed it. I doubt Mr. Trump would do the same if given a similar opportunity.
Now, I know that a budget reconciliation dismantling of the law is not a full repeal, because according to the rules it can only touch budget-related provisions. This excludes things like requiring insurers to take all comers for premiums that vary only by age and smoking status or preventing them from imposing coverage caps and lifetime limits, among other measures.
I also must add that I’m much less confident of a repeal (or partial repeal) without agreement on a replacement. But I’ll turn it back to you, Aaron. Do you think the G.O.P. has to offer a full replacement to get its members to sign on to repeal? Or can it offer something that would cover fewer people and with fewer benefits?
Aaron: I think they can get away with slightly fewer people and somewhat skimpier benefits, but not too much. There’s a part of me that thinks many in Congress were always so willing to vote for a “repeal” because they knew it had no chance of being signed into law. They got credit for the vote without ever having to face the downside. Actually repealing without replacing would mean effectively stripping more than 20 million people of their health insurance, without anything in return.
This would be an unmitigated political disaster. The stories — of people with cancerdiabetes and more who were suddenly stripped of their insurance and left out in the cold — would very likely dominate our discussion for months. That leaves more than enough time to lead to significant repercussions in the 2018 midterm elections. With no Democratic leaders in any branch of government to blame, I think this would be akin to what happened in the 2010 elections, but in reverse.
Now, if they can coalesce around a “replace” plan that doesn’t leave too many people out, then I think they could move forward. But in all the years since the A.C.A. was passed, Republicans haven’t been able to do that. Do you think they can? What do you think that plan would look like?
Austin: One way to get from repeal to replace that minimizes immediate downside political risk is to pass a plan that doesn’t call for repeal for several years, at least after the 2018 midterms, though possibly after the 2020 election. Between now and then, there would need to be some kind of transition to whatever replaces Obamacare that didn’t just dump people off coverage with no alternative.
But the alternatives could just be not as comprehensive or costly. Absolutely there will be bad stories. But keep in mind, there will be bad stories under Obamacare, too. Rocketing premiums, huge cost sharing and markets with few choices is not a recipe for political success. Republicans now own the task of fixing those things and doing so in a way that does not look as if they’re making Obamacare better.
They’re actually in a tough policy spot. They’ll get the blame if they don’t fix or repeal the A.C.A., and they’ll get the blame if they don’t replace it with something people like better. Health policy is a very difficult and thankless task. I think they’ll opt for something they can call repeal and replace, but they could also just let Obamacare struggle and die. Neither looks good.
One other way to get out from under the issue is to kick it to the states. Do you think a Trump administration, working with a G.O.P. Congress, will offer greater flexibility to states to design their own coverage plans that could diverge from Obamacare? If so, what are some ideas states might try?
Aaron: I think it’s very likely those in Congress could punt Medicaid to the states. For years, they’ve been trying to change Medicaid funding to a block grant that they can then constrain over time. This will be enticing for them because it will allow them to reduce Medicaid spending in the future, while forcing states to make the tough decisions — and take the blame — for cuts in either beneficiaries or services.
Fixing the markets for those who are getting health insurance through the Obamacare exchanges, though, is a different story. Without some sort of market regulation, which they’ve generally been opposed to, the same problems that existed pre-A.C.A. with respect to pre-existing conditions and individual ratings will exist. Many people will become uninsured. Annual and lifetime limits could reappear. Lots of people will have problems getting insured.
Moreover, I have yet to be convinced that a significant number of Republicans in the House might coalesce around such a plan. Maybe for Medicaid, but I’m not sure about the exchanges. Even if they could, it’s likely the Democrats in the Senate would try to filibuster either of these plans. Don’t you think?
Austin: Yes, I think Democrats would filibuster anything they could. The filibuster is not set in stoneA Senate majority can change it, and some are already calling for the G.O.P. to do so. But that doesn’t appear to be what the Senate will do — they’ll retain the filibuster. This could play to their favor, since they can propose things they like, let the Democrats filibuster them and take the blame when repeal kicks in with no replacement. Perhaps that’s another way for Republicans to get out of their political bind.
Aaron: I’m sure we’ll have more to discuss as President Trump’s administration comes into power.

The Future of Health Care Mergers Under Trump

by Reed Abelson - NYT

The proposed health insurance mega-merger between Anthem and Cigna heads to court on Monday, as the companies face off against a Justice Department seeking to block their $48 billion deal. It will be followed in just a few weeks by the trial for another proposed insurance mega-merger, between Aetna and Humana.
Together, those two mergers would remake the industry, resulting in the nation’s five largest health insurers shrinking to just three, including UnitedHealth Group, which remains independent. And the Justice Department is set to argue that the consolidation would be bad for consumers.
“If these mergers were to take place, the competition among insurers that has pushed them to provide lower premiums, higher-quality care and better benefits would be eliminated,” Attorney General Loretta E. Lynch said in July when she announced the government’s decision to challenge these mergers.
But the election of Donald J. Trump could recalibrate how vigorously the federal government handles these two deals, as well as the many other deals now taking place in health care, according to legal experts. On Friday, Mr. Trump nominated Senator Jeff Sessions, the conservative Republican from Alabama, to replace Ms. Lynch. While it is unclear how Mr. Sessions would have the department handle antitrust cases, Mr. Trump has said that he wants less government regulation of business.
In each of the two big cases headed to court, a federal judge will decide whether consumers would be worse off after the mergers take place. The companies contend people would benefit because a bigger company would be more efficient and better able to strike deals with hospitals and doctors that result in lower prices for medical care. In its pretrial brief, Anthem argues the government’s opposition threatens to “deprive American consumers of lower health care costs.”
The insurance deals were the culmination of a deal frenzy that took place in which the giant for-profit companies were desperate not to be left behind if the biggest companies got even bigger. All four companies involved in the mergers say they are committed, although the relationship between Anthem and Cigna has been fraught. The two have accused each other of breaching the merger agreement.
Any fallout from the election would almost certainly not be felt immediately. Both cases are expected to be decided before Mr. Trump takes office in January.
But a Trump administration could still have a major say, particularly if either the companies or the government decide to appeal the initial decision.
There is little expectation that the Justice Department under the Trump administration would drop the case if the companies lost and appealed, for example, but it might be inclined to strike a settlement less onerous to the insurer. After the department under President Bill Clinton won its antitrust case against Microsoft, the officials taking over for President George W. Bush pursued a settlement that many viewed as less far-reaching than one that would have been sought by their predecessors.
There is also a distinct chance, antitrust experts said, that the approach to health care mergers will not pivot much from the current one.
“There is a history of bipartisan support for antitrust enforcement in health care,” said Leslie C. Overton, a partner at Alston & Bird and a former Justice Department official. “I don’t think we should expect a wholesale shift, based on the change from Democratic to Republican.”
The clearest sign of the new administration’s position, antitrust experts said, will come from who is appointed to crucial positions at the Justice Department and the Federal Trade Commission.
Other parts of the health care industry will also be on the lookout for any shift in stance. Hospital mergers, for example, have been aggressively challenged by the F.T.C. Last week, two large Chicago-area health systems, Advocate Health Care and NorthShore University HealthSystem, said they would continue their legal fight after an appeals court sent the case brought by the commission back to a lower court.
The F.T.C.’s position on the health care deals may change less than the Justice Department’s. The commission, an independent agency that includes both Republicans and Democrats, is somewhat less subject to the political preferences of the White House. But priorities often do change.
“The swings from administration to administration have not been as strong as they have in the Justice Department,” said Michael J. Perry, a former lawyer for the F.T.C. who is now a partner at Baker Botts. The agency has a long history of pursuing hospital mergers, he said, and “has a lot of success” in its attempts to block various deals.
In any event, few expect the deal-making that has taken place in recent years to abate. Hospitals have joined with other hospitals and bought physician practices, surgery centers and the like to bulk up. Last month, two of the nation’s largest nonprofit health systems, Catholic Health Initiatives and Dignity Health, said they were in talks to join forces.
Even among smaller insurers, mergers are likely to continue. This month, WellCare Health Plans announced its intention to buy Universal American, a smaller insurer, as a way to expand its presence in the private Medicare Advantage market.
Although the federal health care law that was passed under President Obama, which prodded both insurers and health systems to deliver less-expensive medical care, encouraged some of the merger activity, many of these entities were likely to combine anyway. “We’re in the middle of a global merger wave,” said Martin S. Gaynor, an antitrust expert at Carnegie Mellon University.
The possible repeal of the Affordable Care Act, which many Republicans are pushing, is unlikely to change those dynamics. Hospitals may feel more pressure to join forces as a way of coping with what many people think will be a difficult environment. Government programs like Medicare and Medicaid could become less generous with their payments, and hospitals may experience an increase in the number of patients who have no insurance.
What’s more, health systems need access to capital to pay for sophisticated computer systems, and insurers, hospitals and doctors prefer the negotiating clout that comes with being bigger.
Hospitals are likely to see the divide between winners and losers grow, said Dr. Sanjay B. Saxena, a partner at the Boston Consulting Group, whose clients include health systems and insurers.
“That shake-up,” he said, “is going to continue.”

Maine’s rural hospitals struggling to survive seismic changes in health care

by Joe Lawlor - Portland Press-Herald

As technology and health care trends drive patients to larger hospitals for most surgical procedures, the state's smaller, local hospitals are left with few options for maintaining their own financial health.

DOVER-FOXCROFT — The rehabilitation wing of Mayo Regional Hospital in Dover-Foxcroft bustled on a fall afternoon, as therapists worked with elderly patients to restore range of motion, balance and other physical abilities.
The room was packed with beds, medicine balls, steps with a railing to simulate a staircase, weights, stretching bands and other tools to help patients recover from injuries. Employee work stations were crammed together to keep as much space open for the patients as possible.
Occupational therapist Erica Lyford encouraged an elderly woman to move plastic pipes over her head to improve her strength while recovering from an illness.
“We are busy a lot,” said Christine Perkins, an occupational therapist who works with patients on a number of tasks, including reaching and moving items in a mock kitchen.
One floor up, the inpatient center was quiet, with not much activity. Empty rooms were abundant at the 25-bed hospital, and only 10 patients were staying on this day. Twenty years ago, the hospital routinely had about 30 to 35 inpatients per day, hospital officials say. Ten years ago it was 20. Now it averages 12 inpatients per day.
The contrasting scenes at Mayo reflect long-term trends in the health care industry that are causing seismic changes in how health care is delivered in rural Maine and across the country.
Rural hospitals like Mayo are increasingly relying on rehabilitation and other outpatient services – such as physical and occupational therapy and primary care. At the same time their inpatient count – and the revenue that goes with it – has dwindled.
“It’s a very tough time for rural hospitals. It’s going to be harder for them to make ends meet,” said Andrew Coburn, a professor of public health at the University of Southern Maine who has studied rural health care.
Rural hospitals are caught in a financial squeeze even as larger hospitals are investing in massive expansions. Mayo has a $50 million budget and is coping with an expected $1.2 million deficit for the 2015-16 fiscal year.
“We are actually one of the more financially healthy rural hospitals, and we have a $1 million hole in our budget,” said Marie Vienneau, Mayo’s CEO.
Meanwhile, Maine Medical Center in Portland last month announced a $512 million expansion, with most of the money to be invested in increasing the square footage at its West End main campus, which follows major expansions within the past few years at MaineGeneral Medical Center in Augusta and Eastern Maine Medical Center in Bangor.
Maine Med executives pointed to changes in the health care system, and how inpatients are traveling from all over the state to Portland for specialized surgery, as reasons for the expansion. Part of the Maine Med expansion will include 20 new state-of-the-art operating rooms.
Since surgeries are becoming more specialized as technology has improved, patients who need the surgeries are increasingly being funneled from outlying areas to bigger hospitals, health industry officials say. More surgeries that used to be inpatient are now outpatient procedures.
But what happens to the hospitals that used to conduct surgeries but no longer do so?
The answer is beginning to play out, as about 70 rural hospitals, including St. Andrews Hospital in Boothbay Harbor in 2013, have closed across the United States since 2010.

Maine’s hospitals

SOURCE: Maine Hospital Association
“Every year there are more closures than the year before,” said Mark Holmes, an associate professor of health policy at the University of North Carolina.
Coburn said there’s an emotional attachment to rural hospitals, often the largest employer in small towns, providing valuable good jobs. In all but two of Maine’s 16 counties, the local hospital is among the top six employers, and is the biggest employer in rural counties like Aroostook, Lincoln and Knox.
Vienneau described Mayo as the “hub of the region.”
Closing a rural hospital is perceived as a threat to the community it serves, Coburn said.
“If you close a hospital, it’s like closing a high school,” Coburn said. “These are big, important institutions in a community.”
Laurie Smith, 51, of Dover-Foxcroft said if Mayo were ever to close, it would be devastating to lose an “indispensable asset” to the town.
“There is no replacement for a local hospital that you can get to quickly,” Smith said.
She said this summer, her elderly father had to quickly be admitted to the intensive care unit at Mayo when he contracted an infection in his knee. If a hospital hadn’t been a mile down the road, she says, it would have been difficult to persuade him to make the one-hour trip to Bangor. Long car trips are difficult because of chronic conditions in his knee. Smith said her dad has been in and out of Mayo for various ailments over the past few years as he’s aged.
But many of the trends may offer some advantages to patients who are being funneled to larger hospitals. When patients do need surgery or other complicated care, specialist physicians who work at the larger hospitals can perform advanced surgeries that rural hospitals cannot and were never able to provide.
Many trends cut against rural hospitals.
In 2006, the average daily census at a rural hospital in the United States was nearly 20 inpatients. By 2015, the average daily census had declined to 15.4, a nearly 25 percent decrease, according to the North Carolina Rural Health Research Center at the University of North Carolina.
Mayo Regional Hospital has experienced a similar decline, and its daily census of 12 is expected to decrease further in the next few years, Vienneau said.
Vienneau ticked off the surgeries that are no longer performed or rarely done at the Dover-Foxcroft hospital that used to be routine surgeries done in-house: vascular, thoracic, major abdominal surgeries, general surgery.
The emergency room performs fewer operations; instead, more of its role is to stabilize patients before sending them to hospitals in Bangor or Portland.
Mayo Regional Hospital serves an average of 12 inpatients daily, down from 30 to 35 about 20 years ago. While the hospital has expanded its primary care services, “We don’t yet get paid for keeping people healthy,” said CEO Marie Vienneau. “We still get paid primarily on volume.” Shawn Patrick Ouellette/Staff Photographer
That represents lost revenue for rural hospitals as the surgeries are being done elsewhere and the hospital also loses revenue when the patients don’t stay overnight as inpatients.
Vienneau said she understands that there are good reasons why surgeries are being centralized – with specialization, the doctors need to be in larger hospitals to get the necessary volume of surgeries.
Vienneau said despite all of the national discussions about payment reform – paying hospitals for helping patients to better manage chronic diseases and live a healthy lifestyle, and for offering preventive care – the bulk of the payments to Mayo is still based on patient volume.
The payment reforms that occurred are changes around the edges and are not yet driving factors in how health services are paid for in the U.S.
“We don’t yet get paid for keeping people healthy. We still get paid primarily on volume,” Vienneau said. “We don’t get paid for it, but we still do it because we know it’s the right thing to do.” She said to that end, Mayo has expanded its primary care services to help keep patients healthy, by providing more preventive care services.
Mayo Regional Hospital is a federally designated Critical Access Hospital, which helps keep rural hospitals viable with more favorable reimbursement rates. But losing volume still hurts financially, and it has been forced to cut staff through early retirement and attrition over the past few years.
“It’s all well and good to tout population health, but nobody’s paying for population health,” Coburn said. “What pays is a patient spending a night in a hospital for pneumonia. Our financing system is still really broken.”
Mayo’s service area of about 12,000 includes rolling hills, farmlands, scattered homes and the town of Dover-Foxcroft – population 4,500 – with its turn-of-the-century homes featuring wraparound porches. Dover-Foxcroft is the home of the annual Whoopie Pie Festival.
The population is trending older and poorer – more so than urban and suburban regions – which means people need more health care, but the payments to the hospitals are lower. That’s because government reimbursements like Medicare and Medicaid pay hospitals less than what private insurers pay.
That’s typical of a rural hospital, said Holmes, the UNC researcher.
“It’s a very challenging mix,” Holmes said.
And if people come in without insurance, hospitals are required to care for them, but the “free care” has to be absorbed by the hospital. Maine has decided not to expand Medicaid, which further pressures rural hospitals because some of the “free care” patients would instead be Medicaid patients if Maine had expanded Medicaid.
“We live off of government payors,” Vienneau said.
Also, as an independent hospital with about 400 employees, Mayo doesn’t have leverage when negotiating rates with insurance companies.
For those reasons and others, Vienneau said, Mayo is currently discussing becoming part of Eastern Maine Healthcare Systems in Bangor. The two sides signed a letter of intent this summer to launch initial discussions about the idea.
The centralization of health services may not be an overall negative trend, experts say, as there are pros and cons.
On the con side, Holmes said, there are concerns that in small states like Maine, health networks gobbling up independent hospitals could result in monopolization of some health care services, driving prices up.
But consolidation could also make health care more efficient, driving prices down.
One of the long-standing criticisms of the U.S. health care industry is needless duplication of services.
As hospitals competed for patients, expensive medical equipment could be found at each hospital, sometimes within a few minutes or a 30-minute drive.
The consolidations have cut down on some of the unnecessary expenses, Holmes said. For instance, instead of each hospital having its own IT and human resources departments, those services are now often shared among hospitals in networks.
Another example is consolidating major surgeries into a few locations. The networks look to build efficiencies by funneling certain services to one or a few locations, Holmes said.
For instance, Pen Bay Medical Center and Waldo County General Hospital in the midcoast share a number of functions, including physicians, speech therapy and dental, human resources and administration. The two hospitals are part of the MaineHealth network.
And at St. Andrews, the emergency room had an average of 0.8 patients per day and the inpatient center 1.6 patients per day when it closed, said William Caron, CEO of MaineHealth, the parent company of Maine Med.
The ER was extremely inefficient and expensive, he said.
MaineHealth closed the ER and inpatient center after it acquired St. Andrews in 2012, and it has since been renamed LincolnHealth St. Andrews Campus.
Caron said most of the procedures that were being done at the ER could have been handled by an urgent care center. The ER was replaced with urgent care in 2013.
“To maintain an emergency department is four to five times more expensive than an urgent care,” Caron said.
Patricia Seybold, a Boothbay resident who protested the changes, said MaineHealth’s solution was a Band-Aid on health care in the region.
“A lot of people feel less safe and less comfortable here. We don’t have the comfort of having some place you can go to in the middle of the night if you need to,” Seybold said, pointing out that the nearest emergency room, at Mid Coast Hospital in Brunswick, is a 40-minute drive that could be treacherous or impossible in the winter.
While the ER is closed, St. Andrews has greatly expanded services in outpatient, wound care, skilled care and wellness programs since MaineHealth took over, MaineHealth officials said. So LincolnHealth, a health network in Lincoln County that includes St. Andrews, is still the largest employer in the county, according to the Maine Department of Labor.
In the past 15 years, MaineHealth has swallowed up a number of rural hospitals that used to be independent, although Caron said he doesn’t envision MaineHealth acquiring more hospitals.
Caron said many of the acquisitions were struggling hospitals that were experiencing financial difficulties.
“We view it as an obligation,” Caron said. “If not us, who? We are helping to preserve health care in these communities.”
The financial incentives in the current health care system are also causing problems at rural hospitals, which maintain largely empty inpatient centers at great cost in order to maintain their status as a hospital and the favorable reimbursement rates that go with being a hospital, Holmes said.
“Once they’re no longer a hospital, they’re no longer getting the funding for a hospital,” Holmes said.
A bill is pending in Congress that would maintain favorable reimbursement rates and hospital status for rural hospitals that maintain an emergency room and outpatient services, but no longer have an inpatient center.
Whether hospital consolidation is helpful or harmful to overall health care costs is a complex question and still being studied. A 2013 study by Harvard University delved into the proliferation of hospital networks and consolidations but did not make any definitive conclusions about what it might mean for health care costs to patients.
Another problem for rural hospitals is recruiting physicians, who often would prefer to work in more urban areas, Vienneau said. When a doctor leaves, it can take rural hospitals years to find a replacement.
“We had to go out of the country to find someone. I had to go to London to find a doctor because there wasn’t anyone in the United States willing to come to Dover-Foxcroft, Maine,” Vienneau said.
Caron said that’s where a network of hospitals can be an advantage – today’s young doctors just out of medical school generally do not want to move to a rural area, especially when they are always on call. With a network, the hospitals can share doctors so they don’t have to be on call as often.
Vienneau came to Mayo three years ago from Millinocket Regional Hospital, and was able to turn around the financial fortunes of Mayo. But because it lost physicians and couldn’t replace them, the money problems have returned, she said. Now Mayo has to pay traveling doctors, called locums, to retain services such as orthopedics.
Vienneau said locums cost three times as much as having a physician on staff. But she said Mayo can’t afford to lose orthopedics, because once word gets out in a small town that they’re no longer fixing broken bones, people will stop coming.
“Once you lose a service, it’s very difficult to get it back,” Vienneau said. “People become used to you not having the service, and they will go elsewhere and not come back.”

The enormous pop-up clinic trying to bridge America’s health divide

by Amy Woolard - The Guardian

Nearly 33 million Americans – more than 10% of the country’s population – have no health insurance. While the very poorest are entitled to Medicaid coverage, millions more narrowly fail to qualify, but remain too poor to pay for private health insurance. Among those who do qualify for subsidised plans or manage to pay insurance contributions, paying for minor treatments such as fillings and eye tests is often a problem, as they may not be covered by basic healthcare plans. Even finding local doctors who accept Medicaid can be so challenging that it can seem easier just to work through the pain or to self-medicate.
Virginia is one of 19 states refusing federal dollars to close the healthcare “coverage gap” for people not poor enough for Medicaid, but too poor for anything else. Yet at the Wise County Fairgrounds in Southwest Virginia, for one late-July weekend each year, there is a small glimmer of hope. For three days, a non-profit organisation known as Remote Area Medical (RAM) builds a pop-up clinic – the largest of its kind in the US – from the ground up, and serves more than 2,000 patients from more than 15 different states. These patients come in the hope of getting cavities filled, lungs x-rayed and new pairs of glasses made – for free.
RAM was founded in 1985 by Stan Brock, a British philanthropist, actor, author, naturalist, cowboy and former TV host. The organisation is funded entirely via private donations and – except for a small, paid staff – completely dependent upon thousands of volunteers for everything from performing oral surgery to making up bags of Cheerios to hand out to patients’ toddlers. In addition to international and disaster-relief missions, the group has held more than 800 general health-clinic events across 12 states throughout the southern and south-western United States. In the past five or six years, it has added urban stops such as Los Angeles and Chicago to its regular locations.
As I pull up to the Wise County Fairgrounds clinic this summer, dozens of rows of cars glint in the sun – patients’ vehicles in one field, volunteers’ in another. Those seeking care are given entry numbers based on the order in which they arrive, and cannot leave without forfeiting their place. Many make plans to camp out for up to two days before the gates even open – sleeping in their cars, in tents, or on the ground, to make sure they snag a low number.

By 3.30am on Friday, volunteers with torches are moving from car to tent to car in the patient lot, handing out admission numbers for the day. By the time the sun rises at 6am, they have given out 1,600 tickets to the clinic. On Saturday morning, they will give out about 600 more.
I meet Sheila Harris, a 58-year-old former paralegal, in the early hours of the opening day. Sheila has worked her whole life, but after the birth of the last two of her six children, steady legal work dried up, and she now earns only a small income taking care of children in her home. She is one of the first hundred people allowed through the gates. Hundreds more are packed outside the fairgrounds’ fences, waiting to hear their numbers announced via megaphone.
Sheila, her daughter Amy, her sister Cindy, Cindy’s daughter Elizabeth, and four other family members have travelled for three hours to arrive at Wise two days early. These eight adults and one toddler would end up sleeping in their two cars for four days. During the first couple of nights, they would drape blankets over the windows for privacy, but would take them down after it made the cars too hot to sit in, much less sleep.
It is everyone’s first time at the clinic, except for Cindy, who has been twice before and led the group on this trip. Once, she says, she arrived early enough to be the very first patient served. “It was still a long couple days, though,” she says.
Cindy is here this year to get new glasses and to support her 29-year-old daughter Elizabeth, who also needs glasses, as well as the extraction of two molars. Elizabeth also hopes to get a partial denture plate. She had a bad fall a couple of years ago and broke her top front teeth, most of which have been completely missing for years. At the time of her fall, she had decent health insurance, but still had to pay $1,000 from her own pocket, to rebuild just one tooth, which later cracked again anyway. Cindy and Elizabeth now both receive disability benefits – essentially their only source of income. Without RAM, a new pair of glasses with a current prescription would be a luxury item.
Sheila needs glasses, too, but is first set to have six teeth removed – a couple of which are already in pieces – and upper dentures made and fitted. Neither Sheila nor Elizabeth will smile open-mouthed. They haven’t smiled that way for years, out of embarrassment. “I guess I’ve kind of withdrawn from people because of it,” Sheila says. “I used to talk to anyone, anywhere, about anything – real outgoing – but I haven’t been like that in a long time.”
Sheila pulls a roll of Tums antacid tablets from her shorts pocket and says it’s the only thing she’s been able to eat since the day before, on account of her nerves. She’s brought the broken dental crown with her “in case they can use it or something”, and holds it tightly.

It is cool outside before sunrise, but the temperature will reach a humid 35C by late morning, and get even hotter by Saturday. The site has no air-conditioned spaces, apart from the mammogram and radiology trucks. Volunteers drive back and forth across the grounds all day, handing out cold water and chilled neck wraps.
Though traffic through the medical stations is steady, the main attractions of every RAM clinic are the dental and eye-care services. At the Wise County Fairgrounds, the organisation sets up about 80 mobile dental stations under large tents – one section of tents reserved for cleanings by hygienists, a second block for fillings, and, in the back tent, four or five long rows of stations for extractions. The vision and medical services are each delivered in two large barns. The makeshift examination rooms are livestock stalls, with bedsheets hung for privacy.
The full Wise County clinic footprint is immense: one general-support volunteer working as a patient escort could easily walk 15 miles or more in a day. Specialised services such as x-rays, mammograms, and orthopaedics are provided in converted lorries or large camper vans. Other tents, offering treatment for substance abuse, counselling to help smokers quit, and mental healthcare, as well as clothing and book donations and a pharmacy, are scattered wide across the grounds. The only bathrooms – for patients and volunteers – are several dozen portaloos.
Other such RAM clinics may be smaller, but they operate under similar conditions. One in Smyth County, Virginia, is set up on the asphalt and in the emptied hangars of the local airport. Services there must shut down at a particular time so that planes can be moved back inside. One Tennessee clinic is held right on the Bristol Motor Speedway infield, a famous Nascar racing track; Stan Brock can often be seen on the track on his bicycle, vigorously pedalling angled laps.

“Poor teeth, I knew, beget not just shame but more poorness,” writes Sarah Smarsh in her 2014 Aeon essay on class and dental hygiene. One woman sitting near Sheila and her family in Extraction Row says she has recently been fired from a waitressing job after losing a couple of her front teeth. Her manager didn’t want her in front of customers. Food service has made up the entirety of her employment history, and she is having trouble getting hired permanently elsewhere for similar reasons. Even when she was working, she says, she couldn’t afford the cost or time off necessary to treat her teeth – or anything else, for that matter. The RAM clinic, once a year, is her sole source of healthcare. She now works as a temp in one of the many call centres planted in Southwest Virginia.
Dr Joe Smiddy, one of the long-time volunteer doctors on site, has seen similar scenarios play out for patients here, time and again: “Once they lose their teeth, or they have unsightly teeth, they lose part of their own marketability. They have trouble finding a job,” he says. “Course, when they lose their job, they lose any healthcare they might have had. And then you can have substance issues where people are self‑medicating with tobacco and street drugs for what is real pain and real anxiety.”
Poverty also begets limited choices. Sugar provides a cheap and legal high and caffeine does the same. Both can be used to self-medicate and as an easy way to make your kids happy when you can’t afford much else.
Nearly 100,000 people in Southwest Virginia receive Supplemental Nutrition Assistance Program benefits (formerly known as “food stamps”). A family of four receives $115 per week on average for food, or just about $16 per day. “The economics of this community,” says Terry Dickinson, executive director of the Virginia Dental Association, “are such that when they go to the grocery store and buy food, it so happens they get a lot more food when they buy highly processed, high-carbohydrate foods, and, instead of water, they pick soda pop or sports drinks, or any of that stuff that’s just as cheap.”
Unhealthy processed foods are not just cheaper: they do not spoil as quickly, and they can take less time and fewer ingredients to prepare. “What you want for everyone is personal responsibility,” says Dickinson, “but you’ve got to give people the education and tools they need to make those decisions.” And, he says, for people living in poverty, “we just haven’t done a good job of that. These are people in survival mode.”
Living in survival mode means prioritising where you spend your limited income. A 2015 survey conducted by the Federal Reserve Board to determine what practical effects, if any, the economic recovery was having on families, found that 46% of Americans did not have enough money on hand to cover an unexpected $400 expense. When that expense is a medical emergency, it often leaves only two options: use a credit card if you have one, or forgo care until the pain goes well past emergency and becomes unbearable.
Putting stock in a long-term investment such as one’s health requires hope. Embedded in preventative and rehabilitative care is the presumption of a long, fulfilling life. Health insurance is an invisible protection – it does not fill a hungry stomach, or power a refrigerator, or fill a petrol tank.

Sheila is in Dr Dan Laskin’s dental chair and is about to have her extractions done. There are picks, forceps, syringes and what looks like a hammer and small chisel on the tray beside her. Even when you’re having six teeth pulled, if your dental care is happening under a tent at a fairground, you are given some numbing lidocaine, a few large, well-placed shots of novocaine, and not much more of an anaesthetic cushion than that.
The procedure is probably as smooth as it could be, though Sheila often moans and wriggles from the pressure. The dental assistant gets her to close her eyes and talks her through some visualisation strategies involving her favourite place: the beach. It takes about 30 to 45 minutes before the procedure is finished, and the experts are ready for whoever is next in line. Numbed and frazzled, Sheila says to Laskin through the packed gauze, “You are freaking amazing!” and hugs him.
Elizabeth has already had her two extractions done, and is now at the dentures station, where another dentist has inserted a tray of paste into her mouth that will become the mould used to make her partial plate. The dentist has to keep the tray pressed tight against Elizabeth’s swollen, sore jaw for about a minute. Afterwards, she says she didn’t mind it too much: “It was easier than getting my teeth yanked out!” She heads over to the vision section to get in the long line for glasses.
Observing the makeshift clinic, it sometimes feels more like a carnival than a hospital. Occasionally, in between seeing patients, you can catch Joe Smiddy picking a banjo in the clinic bluegrass band he has pulled together with a few regular volunteers. Smiddy is a 74-year-old retired pulmonary specialist, now a full-time medical volunteer, who grew up in Wise County, the grandson of a coal miner. He got his commercial driver’s licence in order to drive the 18-wheeler that holds his mobile x-ray office to RAM clinics. Smiddy has seen it all: most of what he has to share with me begins with “And I can say this because I’m from here.”
“The people of Southwest Virginia,” he advises me, “are self-reliant, and their self-reliance and their love for their people and their land is such a wonderful thing, but it’s also what holds them here. There’s a social importance to people who are from here being really glued here. So why would we move to another part of Virginia? Why wouldn’t we move to where the jobs are? But we’re totally averse to doing that, and so we have a large population who live in an economically deprived area. The schools are struggling. The churches are struggling. Every time they build a Walmart, it puts several mom-and-pop stores out of business. Your barbershop’s gone because you get your hair cut at Walmart, your beauty salon, your auto-repair – everything Walmart. And then you’ve got people working at Walmart who don’t have health insurance, either.”
People not in poverty often ask those who are to move in various ways – off street corners when they’re homeless, away from their depressed hometowns when they’re unemployed. They are asked to move couches, off front porches and cars, off blocks.Politically, they are usually asked to move out of their own way.
All of the qualities that Smiddy describes, though, are what most people would probably say they want in a healthy community. We want people to love and care about their land and neighbourhoods and to know one another. We want a shared history, vibrant cooperation. These are all characteristics we celebrate, it seems, everywhere but communities of poverty. In places like Southwest Virginia, we do not honour these relationships, or underwrite them – socially or financially – in the same way we do in middle-class or affluent regions. Instead, what we reinforce, as a matter of policy and entertainment, are the rural stereotypes.
In his mobile rig, Smiddy will x-ray “just about anything you can put in front of the machine”. He mostly looks at lungs, though. “We’re a belt of lung disease,” he says. “Southwest Virginia is a belt of asthma, COPD [chronic obstructive pulmonary disease], emphysema, and, of course, heart attacks, strokes, and diabetes. Part of that is smoking – we in Southwest Virginia have a tradition of starting smoking at an early age. There are towns where the average age of starting smoking for current lung patients was age 10.”
But part of it, he says, is the coal dust and environmental allergens. When business was booming, coal workers were paid well and offered decent health insurance, but layoffs and closures have left many in the region with poor health, and poorer prospects for work and the healthcare coverage that used to come with it.
“All of the politicians are singing this little fairytale that coal is coming back,” Smiddy says. “They’re living in that fairytale, and so what they’re not doing is accepting the reality that we could plan, we could think ahead. We could reach broadly to incorporate everybody – schools, churches, civic organisations, mayors, community leaders – that we all pull back together and say, ‘We have a goal, and our goal is that we’re going to try to predict as best as we can the jobs of the future, and we’re going to start now.’ I don’t mean to be ugly when I say that there may be some people who will miss that curve, but we could build for their children.”
Coal is complicated in Appalachia, the mountainous region within which Southwest Virginia sits. The coal industry has torn up pieces of Southwest Virginia and the bodies of those who have mined it, but as it has declined here, the men and women it employed – many of whom have at most graduated high-school – have slipped from relying on steady middle- and upper-income salaries to prospecting for minimum wage. The classified ads in places such as Wise and Coeburn, Virginia, are thin and advertise for such positions as “Customer Service Representative 1” and “Cashier (Part Time)”. We may be able to replace coal with other comparable energy sources, but we have not yet prioritised how to comparably replace coal jobs.
“I mean, how many call centres can you put down here?” Dickinson says. All people want here, he repeats, is a good-paying job.

By Saturday, all eight of Sheila Harris’s family have spent four days and three nights living in two cars. They have had to stay this long to wait for their glasses and partial dentures to be finished.
Cindy and Amy walk over to a large tent where a few thousand brand-new frames – all donated – are set out on long folding tables so that patients can select the styles they like. A few regular volunteers consult on shape and fit.
The barn where the sight tests are given is a touch cooler than outside, mostly because the room has to be kept dark for the testing. The majority of patients here are getting basic checkups and prescriptions written or updated, but occasionally – as with the dentists – the optometrists diagnose more serious health issues: glaucoma, cataracts, macular degeneration, diabetes. Prior to their eye tests, some patients don’t even realise they need glasses.
Dr Victoria Molnar Weiss is the optometrist who runs all the Virginia RAM vision clinics. Weiss and the other eight or nine volunteer optometrists and ophthalmologists will see one third of the 2,200 patients coming through the Wise clinic over the weekend. She explains that the possibility of getting new glasses can be the lure that first brings patients to the clinics, and then, over time, their trust grows. “The patients see us up at 3am too, so it kind of helps them feel like we’re all in this together,” she says.
What also helps is the ability to use the money they might otherwise have spent on frames, lenses, and an eye test on other necessities. People living in poverty are often playing a losing game with whatever limited income they have: skipping a power bill to pay for a visit to the optician might work for a month, but it could put them behind for a year. Much easier to keep using old lenses, squint a little harder, and live through the migraines.

Elizabeth’s partial plate is finally ready. The dental technician is fitting it for her, taking it in and out of her mouth in between filing her teeth down to eventually arrive at the best fit. After a few revisions, they are both satisfied. The technician does not have a mirror, but holds up her iPhone with a forward-facing camera so Elizabeth can see herself. She has front teeth for the first time in years. She smiles and tries not to at the same time. She is now crying. Her mother, Cindy, is crying. The dental technician and I are both crying as we watch mother and daughter cry and hug each other. Elizabeth even hugs me. “It doesn’t feel normal to smile. It feels weird,” she says.
By Saturday evening, the whole family has got just about everything they came for: glasses, extractions, dentures, and even a few bags of clothes and shoes from the donations tent. They are nearly packed up when Sheila discovers her van will not start. She seems much less worried than I would be. This has happened multiple times before – she knows how to fix it herself, she says. She crawls underneath the van and reattaches a loose wire, and when she tries it, the engine turns over.
Late on Sunday morning, I catch up with Sister Bernie Kenny of the Medical Missionaries of Mary just as the clinic is closing down. Sister Bernie is a nurse-practitioner who first persuaded Stan Brock to bring RAM to Virginia back in 1999. “Today we had a young woman, 27 years old, who had all her teeth out,” she says straight away, before I can say a word past “Hello”. “And her hope for dentures is 2018. How can she live? How can her self-esteem, or her nutrition, or her hope of ever getting a job? It saddens me. But the wonder of being here is all these volunteers with one purpose: to help one another. All denominations, all faiths, all colours, everybody together, and we get energy one from another.”
I ask her what she would do if I gave her a magic wand that she could wave and change one thing for the patients here at RAM. She gives a version of the same answer that all the nurses and doctors and most of the patients give when I ask them: “Everybody has the right to healthcare – it’s not a privilege,” she says. “Your neighbour’s health affects you, so you want the best for your neighbour as well as yourself.”
Sister Bernie, like all the nurses and doctors and patients, says that dental and vision coverage need to be included in basic healthcare policies. Consider this: someone living in poverty with no health insurance gets a toothache, but swallows the pain for months. She finally goes to ER when it gets too bad to eat, sleep, or work. She sees a nurse or a doctor, but not a dentist, so the actual cause of the pain stays untreated. The ER doctor gives her some antibiotics and maybe some prescription pain medications. She uses up the prescription and then maybe looks for something cheaper on the street to dull the pain, because the tooth is never fixed. No one I speak to mentions heroin or methamphetamine by name – it’s always just “street drugs”. In the meantime, the abscessed tooth could go septic and turn just as deadly as an overdose.
Sister Bernie sees this repeatedly, across generations of families. “But the people who come to RAM want to be healthy,” she says. “A lot of them don’t take vacations, or can’t. They come here.” One patient I met started off from her house two days before the clinic opened. She had walked 27 miles to Wise just to have a couple teeth pulled. Then walked 27 miles back.
Access to healthcare is about more than just reducing the travel time between patients and doctors – it’s about bringing down those intangible barriers that make a distance seem impossible to cross. The stereotypes that teach that people living in poverty get what they deserve, the employment barriers that leave medical and dental students with a mortgage worth of school debt, such that they cannot afford to treat people who cannot afford to come to them for care. RAM does not solve and will not solve the US healthcare crisis – or poverty, for that matter – but it clears a path. One that starts right in our own backyards.
This article is adapted from an essay published in the autumn 2016 issue of the Virginia Quarterly Review.

Maine dentists treat almost 400 patients in charity drive

Sixty-three second-year University of New England students volunteered for the program.
Associated Press

SCARBOROUGH — The organizers of a dental charity drive say the effort treated almost 400 patients and provided nearly $100,000 in care this month.
Dr. Demi Kouzounas and Dr. Barry Saltz of Scarborough organize the drive, which is called Dentists Who Care for ME and is in its eight year.
They say 20 dentists, 23 dental hygienists, 16 specialists and dozens of staff members volunteered time for the program. They provided teeth cleanings, fillings and extractions for people who can’t afford regular dental care and don’t have dental insurance coverage.
Organizers say the program has treated more than 3,000 patients since its inception. Second-year University of New England dental students volunteered for the first time this year. Kouzounas says 63 of them took part.
Dental offices participated from Biddeford to Skowhegan.