Former DHHS secretary says expansion of Medicaid, broadband access are essential for North Carolina
Asked to imagine the brightest picture for rural healthcare, Dr. Mandy Cohen described a scenario that included patients using telehealth, communities reconfiguring hospitals that are in danger of closing, and ensuring more people are insured.
To achieve these goals, the state will need “broadband everywhere” Cohen said, to make telehealth realistic for more households, communities conceiving healthcare beyond hospitals, and Medicaid expansion to provide health insurance to hundreds of thousands of people.
The worst case scenario, Cohen said, is “clinging to the status quo” and allowing things to gradually degrade.
Cohen, the former head of the state Department of Health and Human Services, spoke at a conference Monday entitled “Politics, Policy & A New Economic Strategy for Rural North Carolina.” The event was sponsored by Duke University’s Sanford School of Public Policy and its Polis Center for Politics.
Cohen is now CEO of Aledade Care Solutions. It is part of a company that works with independent primary care practices that have arrangements with insurers in which health care providers can earn money through proactive medical care. By keeping people healthy, they can avoid more expensive medical care.
Health access is key
In her presentation, Cohen said economic health and public health are closely linked. “We know that health is an important component of what makes rural communities thrive,” she said.
As the state emerges from the COVID-19 pandemic, it has the opportunity to invest in rural communities, Cohen said.
As she did for five years as part of the Gov. Roy Cooper administration, Cohen advocated for Medicaid expansion as a way to improve health and support hospitals. “More folks with an insurance card means more stability,” she said.
The Sheps Center for Health Services Research at UNC, which tracks rural hospital closures across the nation, reports that since 2005 most of the nearly 200 facilities that have closed or converted to provide a different health care service are clustered in states that have not expanded Medicaid.
North Carolina is one of a dozen remaining non-expansion states. Expanding Medicaid in North Carolina would allow about 600,000 low-income adults younger than 65 to get health insurance.
Medicaid in North Carolina doesn’t cover most low-income adults who don’t have children at home. Many of those without insurance fall into the health insurance “coverage gap” because they don’t qualify for Medicaid, but earn too little to qualify for subsidized private insurance plans offered through marketplaces established under the federal Affordable Care Act.
A state legislative committee charged with examining Medicaid expansion and access to health care has been considering options in recent months. As Policy Watch reported in February, one of its chairmen, Republican Rep. Donny Lambeth (R-Forsyth), has said he anticipates the committee will prepare recommendations for consideration later this year.
Patrick Woodie, president of the NC Rural Center, told the committee earlier this month that rural residents are disproportionately uninsured compared to urban residents, and that Medicaid expansion is particularly important to rural communities. He told the committee that 65% of adults without insurance are employed.
At Monday’s event, Cohen said the state’s response to the COVID-19 pandemic was hampered because so many adults are uninsured. Uninsured adults with untreated chronic diseases were more likely to get severely ill when infected with the virus and to need hospitalization.
Rural health care providers need more paying customers, and that means more people with insurance, Cohen said.
The federal government pays 90% of the cost of people who are insured through state Medicaid expansion. Under plans proposed for North Carolina, the other 10% would be raised through hospital fees.
Expanding Medicaid would mean freeing up state money for other priorities, Cohen said.
She called Medicaid expansion a “must-do” but not the entire solution.
Expanded broadband, improved planning
Rural health care must also adapt by increasing its use of telehealth, which can increase residents’ access to medical specialists and also help with more routine care, Cohen said.
And for telehealth to work, she added, the state needs to expand broadband. Medical visits via video increased during the pandemic, but a lack of universal broadband access helped divide healthcare haves and have-nots.
The state budget includes about $1 billion for broadband, and federal COVID relief money is flowing to cities and counties.
“There are not going to be a lot of other moments like this where we can take advantage of some large federal relief dollars,” Cohen said. “I think there is an opportunity to invest in a creative way.”
Cohen also noted that communities will need to have the chance to figure out what kind of health care services can still be offered if their rural hospitals were to close. Rather than close outright, some rural hospitals in the U.S. become urgent care centers, rural health clinics, primary care offices, or long-term care facilities.
At the same time, there needs to be a reconsideration of how rural medical practices are paid, Cohen said, because they can’t depend on patient volume to make money.
Cohen said her company works with 1,500 medical practices across the country, most of which have fewer than 10 doctors. Two hundred and fifty are primary care practices in North Carolina, she said, and 40% of those are rural.
Paying for care in rural communities means paying attention to data, and making sure patients are getting preventive care on time.
North Carolina has the potential to be an innovator in rural health care, she said.
“We have all the building blocks here to do it right, and we can teach others how to do it,” she said.