Medicare-For-All would likely hurt rural areas more

[Auburnfan91 1,407]

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Would Medicare-for-all actually crush hospitals, as its opponents argue? It probably depends on where they’re located.

The fate of hospitals in the United States — particularly in rural areas, where they’re closing in droves — has become a top point of contention in the political debate around Medicare-for-all. Depending on who you listen to, hospitals are either full of waste, bloat and profit-seeking — or stretched so thin that their ability to stay open is jeopardized.

The dual positions surfaced in last week’s Democratic presidential primary debate, in a series of exchanges between Medicare-for-all author Sen. Bernie Sanders (I-Vt.) and former congressman John Delaney (D-Md.). Delaney charged that paying hospitals lower Medicare rates would force them to shutter. Sanders shot back that his simpler, more streamlined system would save them hundreds of billions of dollars in administrative costs.

“Hospitals will be better off than they are today,” Sanders said.

“Listen, his math is wrong,” Delaney responded. “… It's been well-documented that if all the bills were paid at Medicare rates … then many hospitals in this country would close.”

“I've been going around rural America, and I ask rural hospital administrators one question: ‘If all your bills were paid at the Medicare rate last year, what would happen?’ ” Delaney added. “And they all look at me and say, ‘We would close.’ ”

The fundamental question is whether hospitals have deep enough operating margins to swallow lower payments for their commercially insured patients. Under Medicare-for-all or even a public option approach, some or all of these patients would be transferred from the commercial market to government plans.

Medicare pays hospitals only 87 cents on the dollar of their estimated average costs, while private payers pay hospitals a hefty 145 cents. The gulf has only grown wider over the past few decades, meaning hospitals increasingly rely on the revenue from caring for patients with employer-sponsored or individual market coverage — coverage that would be eliminated under Medicare-for-all.

But the issue is more complex than it first appears. That’s because hospitals are now in two different categories: the well-endowed major hospital systems (think the Inova hospitals in Northern Virginia or the Mayo clinics) and hospitals in underserved rural areas.

It’s the rural hospitals that are most in danger under Medicare-for-all.

They’re already in trouble, often caring for more Medicaid patients (who bring even lower reimbursements than Medicare) and referring to other hospitals for the most revenue-generating surgical services. And they’re on the decline. More than 100 have closed since 2010. Out of 7,000 areas with health professional shortages in the United States, about 60 percent are in rural areas.

So it’s not surprising that hospitals and the rest of the expansive health-care industry have also seized on the narrative that any new government-backed plan — from Medicare-for-all to a public option and everything in between — would shutter these types of hospitals.

 

An industry coalition that has been running ads against Medicare-for-all and public-option proposals released a studyyesterday seeking to prove that point. The analysis, conducted by Navigant, predicts that up to 55 percent of rural hospitals could be at high risk of closing if many people with workplace and marketplace coverage switched to a public-option plan paying Medicare rates.

The analysis looked at the effects on hospitals’ revenue and their subsequent risk of shuttering under several different scenarios. The most dramatic scenario assumed that half of everyone on workplace coverage and 85 percent of those in the individual market moved to a public option.

“The availability of a public option could negatively impact access to and quality of care through rural hospitals’ potential elimination of services and reduction of clinical and administrative staff,” says the report, commissioned by the Partnership for America’s Healthcare Future.

From the American Hospital Association:

Offering a government insurance program reimbursing at Medicare rates as a public option on the health insurance exchanges could place as many as 55% of rural hospitals, or 1,037 hospitals across 46 states, at high risk of closure.#AHAtoday https://t.co/SD6VcBhI1Y

— American Hospital Association (@ahahospitals) August 7, 2019

But it’s a different story with urban hospitals with hefty endowments. They would definitely feel effects from Medicare-for-all, but they also might have the capacity to do more with less.

 

As these hospitals have consolidated into large systems, they’ve gained more negotiating power with insurers. And independent analyses of Sanders’s Medicare-for-all plan say it would save hospitals some administrative costs to help make up the difference.

And then there’s this: Per-person spending on health-care in the United States is roughly double of that in other high-income countries. There are many reasons for the troubling reality, but one inescapable fact is that hospitals can get away with charging far more for surgeries and procedures.

“There is no way of reducing the cost of health care unless we reduce the cost of hospital services,” said Stanford University professor Kevin Schulman, who recently published an articlelooking at the effects of Medicare-for-all on hospitals.

But he acknowledges they would pay a steep price. Under Medicare-for-all, hospitals could see their average 7 percent profit margins fall to negative 9 percent — a $85.6 billion annual loss, Schulman wrote.

“Supporters of Medicare-for-all should anticipate strong hospital political opposition,” he wrote.

https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2019/08/08/the-health-202-medicare-for-all-opponents-claim-hospitals-would-shutter-but-it-depends-where-they-re-located/5d4b374f602ff1306728b096/

[AU64 10,122]

Sanders has no clue about the cost of his programs or the impact on the country.   His effort is to get elected and then try and sort it out later.....which of course would be too late for the tax paying public....or the millions of people who depend on small local/regional hospitals for their emergency care.   Other than BS, I can't recall anyone who actually thinks that the "medicare for all" would not result in the closing of hundreds of hospitals.   The death toll from those closures will be huge…..mostly old and rural people.

Strangely, Sanders has no party to support him if he were to get elected.  He's in the process of pirating the Democrat Party leadership without even being a dues paying member.   I'm wondering how or why the traditional Dems would fall in behind Bernie.  I guess their thirst for power could over-come any principles they might have about him not being a Democrat. 

 

[aubiefifty 16,846]

rural hospitals are closing at an alarming rate. i have seen two or three news clips on it. so i disagree 91. i believe if anything it might help those struggling. no one knows for sure.

[Grumps 3,704]

A question about Medicare/Medicare-for-all. It seems to me that people who have been paying taxes that go to fund Medicare have, to a certain extent, "earned" Medicare benefits when they get to retirement age. It also seems like Medicare-for-all will entitle EVERYONE to the benefits paid for, and earned by relatively few. In other words, it seems more "fair" that instead of "Medicare-for-all" they would develop a new plan that can be run like Medicare but paid for from different funds. With Medicare-for-all, current Medicare recipients may end up getting the shaft.

[AU64 10,122]

10 hours ago, Grumps said:

A question about Medicare/Medicare-for-all. It seems to me that people who have been paying taxes that go to fund Medicare have, to a certain extent, "earned" Medicare benefits when they get to retirement age. It also seems like Medicare-for-all will entitle EVERYONE to the benefits paid for, and earned by relatively few. In other words, it seems more "fair" that instead of "Medicare-for-all" they would develop a new plan that can be run like Medicare but paid for from different funds. With Medicare-for-all, current Medicare recipients may end up getting the shaft.

I think the "fund" is not the issue of the OP...it is the low reimbursement rate that would not cover operational costs for many small hospitals that could not survive on the meager payments from government.   Medicare is underfunded but that is a different issue.

[Texan4Auburn 1,626]

On 8/13/2019 at 7:11 AM, AU64 said:

I think the "fund" is not the issue of the OP...it is the low reimbursement rate that would not cover operational costs for many small hospitals that could not survive on the meager payments from government.   Medicare is underfunded but that is a different issue.

Rural hospitals are dying as it is and will continue to do so. With demographic shifts and jobs being located in cities it will continue. Rural hospitals survive barely off of medicaid/medicare. Then they see many uninsured patients that they will end up writing off cause of the use of the ER as a primary care in those areas. Many of your major surgeries that generate revenue can not be performed at these facilities and are referred elsewhere. You are even going to see the type of discrepancies within cities that the article is talking about. A hospital ER in the Georgetown/Bee Cave area of Austin is gonna see more patients with private insurance and that have copay abilities than say one in South toward the east side of 35. 

That of course is different in say a area like Austin. They have a Trauma 1 and Trauma 2 hospital within 10 or less miles of each other. These offset their ER costs with their surgical day which is mostly private pay insurance. Also like the article mentioned they have become part of major organizations. St Davids system is through HCA which has multiple systems in multiple states. Seton just within the past two years became part of the Ascension system which puts them into multiple states. Then Baylor Scott and White is about to just start tearing through the Austin area with new facilities. Lol, I got applications in for some those myself.

Friend of mine just took a position with a startup that is looking to use a combination of tele-health and home care as a method of overcoming general care in rural areas.

The major way to lower the cost of healthcare..... improve the overall health of America. People don't like that, but our obesity and cardiovascular disease issues will continue to increase the costs in the ways of surgery, pharmaceuticals, insulin, etc. Then you add in transparency.

Here is an example of some of what is going on. UAB and United Healthcare almost went their separate ways over reimbursement. Course do you really think UAB cared if it lost United considering BCBS of Alabama's control in that state?

https://www.uab.edu/news/health/item/10580-insurance-contracts-with-united-healthcare-set-to-expire-negotiations-continue

[AU64 10,122]

1 hour ago, Texan4Auburn said:

R

Here is an example of some of what is going on. UAB and United Healthcare almost went their separate ways over reimbursement. Course do you really think UAB cared if it lost United considering BCBS of Alabama's control in that state?

https://www.uab.edu/news/health/item/10580-insurance-contracts-with-united-healthcare-set-to-expire-negotiations-continue

major hospital in Asheville went to war with Blue Cross...would not take their coverage which caused havoc in the area.  We have a small hospital in my town which nobody wants to go to....but if you have a major injury (fall for example) stroke or heart attack,  you don't want to have EMS arriving in 5 minutes but then take 40-45  minutes to get to an ER in a distant city with a large hospital.    Close small hospitals like ours and you are gonna see lots more deaths caused by inability to get prompt attention to potentially fatal issues. 

Demographics maybe changing in some ways but much of the country and population is still dispersed.  What has made the US somewhat unique over the past 100 years is that people did not have to move to a big city to receive quality services like safe water, reliable electricity, personal safety and even good medical care.    Most of those reasons to live in small towns still exist though it appears that government and insurance companies are collaborating to take the assurances of reliable heath away from less populated areas of the country. 

[Texan4Auburn 1,626]

1 hour ago, AU64 said:

major hospital in Asheville went to war with Blue Cross...would not take their coverage which caused havoc in the area.  We have a small hospital in my town which nobody wants to go to....but if you have a major injury (fall for example) stroke or heart attack,  you don't want to have EMS arriving in 5 minutes but then take 40-45  minutes to get to an ER in a distant city with a large hospital.    Close small hospitals like ours and you are gonna see lots more deaths caused by inability to get prompt attention to potentially fatal issues. 

Demographics maybe changing in some ways but much of the country and population is still dispersed.  What has made the US somewhat unique over the past 100 years is that people did not have to move to a big city to receive quality services like safe water, reliable electricity, personal safety and even good medical care.    Most of those reasons to live in small towns still exist though it appears that government and insurance companies are collaborating to take the assurances of reliable heath away from less populated areas of the country. 

Close them. Put in extensions that only have about a 10 bed ER with no inpatient capability. Stabilize there then take the 40 minute ride if inpatient facilities is needed. If they are in a situation that doesn't allow that then you helicopter them into one of the mains in the city. Both systems in Austin already use this model for surrounding areas.

Free standing ER will be capable to handle emergencies. Tele-health and home health (providers coming to the patient) will be able to do the job of primary care.

[AU64 10,122]

29 minutes ago, Texan4Auburn said:

Close them. Put in extensions that only have about a 10 bed ER with no inpatient capability.

You are talking thousands of hospitals ….and millions of hospital workers that would be displaced.....and mostly the city hospitals are at their limit. ...and how do you staff and pay for a ten bed ER 24/7/365 with qualified ER type personnel?    and inconvenience to patients ?   you are not even thinking about that.  The holes in your plan are too numerus to count.       

[Texan4Auburn 1,626]

22 hours ago, AU64 said:

The holes in your plan are too numerus to count.       

Not my plan. I do work for a medical organization that is successfully using it though. Also know that an organization that uses the same type of system has bought out the Mission Hospital system in Asheville. So it might be heading your way.

 

22 hours ago, AU64 said:

You are talking thousands of hospitals ….and millions of hospital workers that would be displaced

Since 2010 there has been 113 closing with the majority of them being in Texas, so we can see where these closures are going on.

https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/

On 8/15/2019 at 7:07 PM, AU64 said:

We have a small hospital in my town which nobody wants to go to

So nobody wants to go to it. Probably because its been found that those with private insurance are going to drive 40 minutes anyway to a larger, more up to date facility, due to the perception that the care is going to be better. Even uninsured will drive farther based on perception of care. Sounds like a free standing ER would solve the problem. EMS them to the free stand, stabilize, assess the situation, then move to the parent facility if required.

Also is you hospital one of the rural ones like the one in Crockett,Texas that had a staff of over 200 but their daily census is showing only 3 inpatients? Crockett btw is one of the rural hospitals that recessed its services and found ways to stay open while providing needed services.

https://khn.org/news/after-bitter-closure-rural-texas-hospital-defies-the-norm-and-reopens/

 

22 hours ago, AU64 said:

and mostly the city hospitals are at their limit.

Fair point. I've worked a 50 bed ER that had 40 waiting in the lobby, with half the ER beds being used for holding admits while waiting on rooms upstairs. These are the hospitals that get the money for expansions bed and equipment wise. But if you are coming from the free standing you are not moved, and made a priority, until there is a bed at the parent facility available. Which is also why they are looking at telehealth and partnering with home health organizations/corporations. Quality care brought into the home, lowers travel needs for patients, and also removes loads off of ER's.

 

22 hours ago, AU64 said:

and how do you staff and pay for a ten bed ER 24/7/365 with qualified ER type personnel

You do realize that there is only about 33 doctors per 100,00 capita in the population for rural areas vs 59 per 100,00 per capita in the cities. How do recruit and retain a quality staff to run a 20 bed ER/50 Inpatient facility if your operating cost can't sustain a 10 bed ER? You have lower pay, you work more, the lifestyle or even the work life isn't as exciting, the facilities have lower rankings, there is the constant threat of closure.

Least with the 10 bed facility you are providing the necessary services you complained about... fall (which if bad enough you're going helo to a trauma anyway), stroke, heart attack, diabetic shock etc. You run 12 hour shifts, 1 doctor, 2 trauma nurses, 1 administrative lead, registration done by kiosk or through a call center for virtual.

You also have the luxury of these facilities being extensions of major hospital systems under the blankets of your HCA's, Acensions etc. That equals more funding and allows for medicaid/medicare reimbursement.

22 hours ago, AU64 said:

and inconvenience to patients ?

Again, patients are already willing to travel to updated facilities or due to perception of quality of care. Lol even in Austin you can come into the ER of South, they decide based on conditions you need a different facility and then transfer you North. That is a 40 minute ride there. Patients already drive these times for surgeries or to see specialist (cause specialist usually don't hang out in rural facilities). There are plenty of people in Auburn for example that go to Birmingham or Atlanta for care.

So I ask would you rather go to your small hospital that nobody wants to go to, or something like this:

 

This is the one associated with Ascension. I couldn't find a good video. They are expanding into the rural areas outside of Austin.

https://fivestarer.com/

[AU64 10,122]

1 hour ago, Texan4Auburn said:

Not my plan. I do work for a medical organization that is successfully using it though. Also know that an organization that uses the same type of system has bought out the Mission Hospital system in Asheville. So it might be heading your way.

Yep...already has started....Mission moving in with doc in the box units in our community but mostly it affects the family practices since the emergencies they can handle are more in the order of broken bones, bee stings, colds, flue etc. as long as you get hurt between 7AM and 7PM M-F....so they are not a very good substitute for the local ER.

People will travel for planned surgeries and while not happy about it, they take it as fact of life...but around here when older people have to go for treatment at a hospital 30 miles+ away, many have problems getting transportation and friends and family can't easily visit for support.   I agree this is where it is going and pretty soon (if BS were to get his way) medical treatment for everyone will be on par with what veterans are subjected to in VA hospitals. 

I don't know what is going on in the many states between the Mississippi River and the Rocky Mountains but there are a lot of very small towns and not sure how their medical providers survive on Medicare reimbursements.  My family practice has limits on taking additional Medicare patients.   And when United decided I should change GPs to one in their network, the Doctor told me he could not take me as they were  not taking new patients.   United then wanted me to go to a GP that was 45 miles from my home.  Ultimately I kept the same doctor and just pay the "out of network" co-pay since I only see him a couple times a year.  

Nobody in the business gives a damn about what is good for the patient.