Tag: Medicaid

Remote Area Medical, Pop-up Clinics, and the Canary in Virginia’s Healthcare Mine

What awaits rural Virginians now that the big, beautiful bill is now law?  Now comes the hard part for vulnerable rural Virginians with limited incomes as safety net programs such as Medicaid, SNAP, and Medicare benefits shrink or disappear.  This is compounded by cuts in programs that provide meals to school age children whose families can’t afford to pack school lunches much less pay for the ones provided at school.  Even the anti-immigrant sentiment will have long term impacts to America’s healthcare system.  There is a tsunami of despair that will sweep rural America, compounding existing systemic troubles accessing timely health care for millions of un- or under insured Americans.

During the COVID epidemic my source for this essay – my wife – volunteered with the Remote Area Medical Volunteer Corp, a non-profit that provides dental, medical, and vision care at pop-up clinics across the U.S. (RAMUSA.org).  RAM was founded in 1985 with the mission to provide mobile clinics at remote locations outside the U.S.   It later began organizing these pop-up clinics to fill a need for underserved Americans that live in healthcare deserts.

The mobile clinics that my wife volunteered at were in Southwest Virginia.  She provided logistical support to the medical teams, such as registering patients.  Her stories are both sad and harrowing, they’re about folks that serve their communities, and the fortitude of the communities they serve. 

 At a typical pop-up clinic, the patients arrive at mid-night when they arrive at the designated facility’s grounds, such as a county fairground.  They are given a numbered ticket and asked to stay in the designated parking area overnight.  It is first-come-first-served, and the tickets go fast.  The number of tickets is based on the number of volunteer doctors, dentists, nurses, other clinicians, and administrative folks.  The administrative task of registering patients begins first around 6 the next morning.

At the mobile clinics where she volunteered, the patients represented a wide spectrum of ages and life experiences, according to my wife, but mostly 50 and up, with young adults being the second largest group.  She recalled one young family — a woman and her three kids ages from 4 to 13.  They came for dental care but were quickly referred to the medical clinic.  The youngest shaking uncontrollably.  He hadn’t eaten breakfast and when he had his last meal was anyone’s guess.    At the medical conex, the crew scrambled to get breakfast for the kids and started to gather care kits:  toothbrushes, toothpaste, soap, combs, shampoo. Their home had no running water it was learned.

For many these mobile clinics are the only healthcare they get.  The services include eye exams, and if needed glasses donated by the Lions Club; hearing tests, and if necessary, hearing aids donated by a local audiologist; dental care is provided by dentists and student volunteers from dental colleges; prescriptions (one course) and follow up care scheduling; mammograms provided in a mobile RV provided by a non-profit hospital system.  

My wife noted that many of the medical students assisting the doctors were from South Asia and the Middle East.  That is international students attending American medical universities.  More on that later.

Most patients were on or had gone off the financial precipice:  Little to no health care insurance.  Per RAM, 50 percent of their patients have no health insurance.  It’s much worse for vision and dental insurance coverage.  There were elderly on Medicare seeking care.  They could pay their premiums but could not afford the co-pays for doctor visits.  Because the payment assistance program for Medicare premiums was severely cut in the big, beautiful bill, those that could not even afford co-pays will most likely loose complete access to Medicare health insurance.  

Another lifeline for these folks is Rural Health Clinics.  Medicare Part B and Medicaid payments subsidize these clinics, but billions in cuts will mean many of these rural health clinics, to include the one in Louisa, may close, worsening the crisis in rural health care. 

As context, the federal government’s first foray into healthcare came in 1946 with the Hospital Survey and Construction Act.  By 1981 there were 3000 new healthcare facilities and an additional 6600 beds.  60 percent of those beds were in communities of less than 25,000.  Medicaid and Medicare were created in 1965 followed by the Rural Health Clinic Services Act of 1977.  These were all bipartisan Acts; however, the zenith of rural healthcare seems to have passed long ago.  The partisan big, beautiful bill guts a neglected and crumbling rural healthcare infrastructure, eventually millions will be without timely adequate healthcare.  And for what, $40 billion in migrant concentration camps and a trillion-dollar defense bill, 10,000 more ICE agents, and $3.4 trillion in tax breaks to the top 10 percent?   

Profit driven hospital systems and insurers will not fill the gap.  No profit in it for them. Sad because of the top 20 hospital systems all but one reported net revenue gains.  The top company measured in total revenue – Kaiser Permanente — reported a whooping 15 percent increase in 2024.  Some smaller companies reported even greater increases.  Net revenue from patients also grew, according to Hospistalogy.com. Interestingly, the National Association of Insurance Commissioners, reported a 14 percent decline in net income for health insurers in the first half of 2024.  On a side bar, the NAIC statistics showed that claims per month per member for Medicaid and private insurance was about the same for Individual, Group, and Medicaid:  $408, $482, $481 respectively.  Medicare claims per member per month was $1146, almost triple.  But that is to be expected from an older age group.

Another threat to America’s healthcare system in general, and for rural America in particular, is the availability of healthcare providers.  According to the Association of American Medical Colleges, about 1 in 5 physicians are foreign born.  I have read other sources that indicate 25 to 26 percent of doctors in the U.S. are from abroad.  

Importantly, these foreign born and trained doctors are more likely to serve in areas with greater poverty, according to the American Immigration Council.  The Council further stated that areas with a 30 percent poverty rate, one-third of the doctors are foreign trained.  A University of California San Diego Website reported that while 20 percent of Americans live in rural areas, only 11 percent of US doctors work in these areas, and that foreign born and trained physicians fill the shortfalls.  It’s not just physicians.  About 15 percent of nurses in America are foreign born and trained.  

The current administration’s anti-immigrant fervor against migrants, whether legal, undocumented, or adjusting status, is sending chills across the globe I would think. Many are asking (I know I would), “do I want to come to America where I am unwanted, hated, potentially abused and imprisoned because of the color of my skin and accent?”   Travel bans, blanket visa denials and revocations, potential arrest and deportation for engaging in free speech on campus, all will drive away potential medical students and foreign-born healthcare providers. Imagine the impact if America lost 15 or 20 percent of its healthcare providers?  The MAGA Ebenezer Scrooges in Congress would respond, “What, are there no funeral homes and casket makers?”

While the number of international students at American medical schools is less than 2 percent, I imagine those numbers will drop significantly.  With a shortfall of 45 to 50K doctors, America is already in a healthcare crisis mode, further reducing the flow of healthcare professionals to the U.S. will only hurt the most vulnerable.

No money, no clinics, and no doctors is what awaits rural America.  Don’t buy the bit about Medicaid scofflaws or Medicare cheaters being the problem, this is about wealth and greed, income inequality and regressive Republican tax policies.  It may take a year or two for the tsunami to reach the shores of rural America, but it is coming.  If you don’t believe me, volunteer at RAMUSA.org.  They have clinics looking for volunteers.  

Worth a Read

‘Worth’ is a word that we read and hear daily.  It derives from Middle English ‘weorp,’ according to etymology online.   As an adjective it held meanings of having value, honorable, deserving, noble, of high rank.  As a noun, it had connotations of value given a commodity, associated with a monetary value, equivalent value.  As a verb not much used today, had a meaning of coming into being.

With the prefix ‘un’ worth becomes a negative, the opposite of deserving, dishonorable, ignoble, of no value.  Worthy and unworthy swirl around America’s political discourse on government social and economic assistance programs like pike hunting minnows in reeds.  Mostly unspoken, but the connotations of worthy and unworthy are there in plain sight.  Some folks are worthy beneficiaries’ others not.  A farmer having a loan cancelled through a Department of Agriculture farm assistance program is considered a worthy beneficiary, but a poor kid with a college student loan is somehow unworthy of debt forgiveness.  

I recall watching a recent question and answer exchange at a town hall meeting where Iowa Senator Grassely asked participants whether “abled bodied’’ folks should receive Medicaid.   Folks in the crowd nodded in agreement.  Instead of directly answering a question about proposed broad cuts to Medicaid, to the tune of $800 billion, he tossed out the lure of unworthiness and reeled them in.   He flipped the question of broad, sweeping cuts to one about unworthy beneficiaries.  In the process he avoided the fact that the majority of those who receive Medicaid benefits are kids, working single moms with kids.  

Nowhere in the national discourse about government safety net benefits is the discussion of why so many hard-working folks in this country need a Medicaid program to begin with.  Republicans don’t want us to point to decades of stagnating or shrinking wages, little to no medical insurance benefits, the destruction of unions, women being systematically underpaid than their male counterparts, or the link between for-profit hospital and health insurance systems and disappearing rural hospitals.   Instead, like a trickster’s shell game, politicians roll out the time-honored trope of unworthiness: It’s those damn able-bodied cheaters and thieves.

This is not new.  America has a long history of denigrating and stigmatizing the poor.  Lazy, immoral, drunks, dangerous.  Unworthy.  Even our public school system has 19th century roots in philanthropic endeavors to get poor kids into schools and away from their drunken and lazy parents and instill in them discipline, a work ethic for the factory system.   

This dichotomy between worthy and unworthy permeates other areas of our culture and society.  COVID is an example of how some made worthy/unworthy arguments about how to respond to the pandemic. To many, the elderly (no longer economically useful) or folks with comorbidities (mostly overweight or diabetic), were not worthy of protecting.

 Worthy and unworthy is also central to how we treat migrants.  Black Africans wanting asylum are told to ‘go away, no room at the inn.’  White South Africans, ‘welcome, come on in.’  Trump is particularly successful at stigmatizing and criminalizing migrants: “Rapists and murders,” “emptying out their asylums,” “The worst of the worst,” “they’re eating our pets.” The characterization of migrants as unworthy opens the door for his administration to pursue illegal and devastating actions against targeted migrants, such as invoking war time acts to detain and deport without due process or the Writ of Habeas Corpus.  The prison that hundreds were sent to in El Salvador is a one-way ticket.  An El Salvadoran minister bragged that the only way one leaves the prison is in a coffin.   According to polls, many Americans thought it okay, to my discomfort.  

If one pauses to look and think, one can see that ‘who is worthy’ and ‘who is unworthy’ all too often shapes our beliefs and actions.  Far too often, how we treat foreign visitors, migrants, the elderly, the poor, the sick, the other, depends on whether we consider them worthy or unworthy of human dignity and respect.   

Lifeboat:  A recap of John McGuire’s call-in Town Hall

Representative John McGuire of Virginia’s 5th Congressional District held a call-in town hall meeting recently.  I don’t know how many folks attended the town hall, but I do know that when folks were selected to ask McGuire questions the majority queried him about Medicaid cuts and DOGE. Funny, no talks of eggs.

McGuire started the town hall by asking listeners to participate in a poll.  The first question was, “do they want to root out waste, fraud, and abuse? “ That’s like asking Medieval folks if they want to root out Black Death, the plague.  Of course they did.  It’s the methodology that they had quibbles over.  In 17th century England, if a household member got plague, the whole household was locked inside the house for 30 or 45 days, a guard posted outside.  That quarantine was extended as other household members sickened and died.  Normally, everyone perished.  Sounds a bit like DOGE’s methodology regarding USAID and lifesaving anti-viral drugs for millions of Africans. 

But back to the town hall.  The first question McGuire was asked sounded the alarm about the proposed $880 billion dollar cut to government agencies overseen by the energy and commerce committee.  This would entail massive cuts to Medicaid, the caller thought.  McGuire’s response was to happily, almost joyfully, point out that Medicaid was not mentioned once in the proposed budget blueprint.  Duh!  The New York Times reported that if the committee cut all other non-safety net programs under their oversight, they would still have to eliminate an additional $600 billion in funding.  That means Medicaid would be hit….hard.

Another caller, a preacher, pointed out that 24 percent of his district receives Medicaid.   I asked myself, did it ever dawn on McGuire to ask himself, “why do so many folks who work full-time jobs in my district can’t afford medical insurance or care? “ Piss poor wages dude!  Nationwide, over 64 percent of Medicaid recipients work.  In Louisa County, 17 percent receive Medicaid, and this is in a county where unemployment is just a smidge over 2 percent. According to Virginia law, if Medicaid expansion funding from the Federal government drops to a certain level, the program is abandoned.  Yes, abandoned.  That would mean 600,000 Virginians would lose access to health care, many of whom are kids.  Later callers, it was clear, weren’t buying McGuire’s Trumpian responses.

The same went for DOGE.  Near universal condemnation of DOGE’s chainsaw approach, many pointing out its cold-heartedness.  One caller, from the Charlottesville area, said folks in her organization – which she specified — were worried about the haphazard cuts and potential cuts to come.  In perhaps a Freudian slip, McGuire spoke of her position and organization in the past tense.   Which he corrected quickly.  I am sure that that slip was noted by listeners.

During overwhelmingly negative comments and questions regarding DOGE’s incompetence and draconian Medicaid cuts, McGuire’s aid interjected and offered an email question.  The email question was quite flattering of McGuire.  Really, were not dumb!

Overall, McGuire got an earful, but I don’t think he listened.  Too often he used rehearsed and prepared talking points (you heard papers shuffling) instead of genuine concern.  Given the tenure of other town halls I seen or heard about, I was surprised at how calm the questioners were.  Very civil, very polite, but direct as well.  McGuire was civil himself, but too often resorting to the same phrase, saying, ‘I still love you even though we disagree.’  

I think McGuire forgot a cardinal rule in politics:  He forgot who he works for.  We expect our politicians to omit and lie and obfuscate, but we don’t expect them to work against our interests.  It was obvious he works for Trump and not us.  Ben Franklin at the Constitutional Convention in Philadelphia in 1787 said it best I think:  “In free governments, the rulers are the servants, and the people their superiors and sovereigns.”

You may be wondering why Lifeboat” is in the title of this essay. I remember as a kid watching a black and white war movie telling the story of the survivors of a torpedoed merchant ship.  The drama takes place in the overcrowded lifeboat: too many people, not enough space, too little food or water.  As time passed people died or were killed.  I realized later with age and little bit of wisdom, that the lifeboat was a parable about class and society.  The passengers represented a spectrum of society:  a wealthy socialite, working class ship hands, upper class passengers, the young and elderly, a vulnerable woman with a dead child, an enemy portrayed by the German U-boat captain. Conflicts ensued as resources, and hope, dwindled.  Winners and losers.  Everyone dead or morally tainted.

That’s the paradigm that sticks in my mind when I think of politics in America today.  America the Lifeboat.  Billions, tens of billions in cuts to Medicaid and other safety-net programs — mostly to working class folks – to pay for $4 trillion in tax cuts, the bulk of the dollars going to the wealthiest Americans.   I think that’s not the ‘golden age’ most folks who voted for Trump envisioned or want.