[{"slug":"commentary-correctional-health-is-public-health","ideas_cat":"Recommended","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2020\/04\/camilo-jimenez-49h5yXieSSM-unsplash-e1714446646440.jpg","page_title_en":"Commentary: Correctional health is public health","page_title_es":"Comentario: la salud correccional es salud p\u00fablica","page_title_fr":"Commentaire: La sant\u00e9 correctionnelle est la sant\u00e9 publique","page_content_en":"<p style=\"font-size: 85%;\">Note: Please be advised that as things are changing quickly during this pandemic, the information available on the conditions inside will continue to grow exponentially. It is and has been increasingly difficult to keep up with the developments and information. Nevertheless, the message is clear: thousands of lives are at risk. This brief commentary on the great risk looming over our correctional facilities urges the need to act immediately and transparently to ensure the safety of one of our most vulnerable populations.<\/p>\n<p style=\"font-size: 85%;\">This story originally appeared in QC Voices, a collaborative publication featuring writers from Queens College in New York City. <a href=\"http:\/\/qcvoices.qwriting.qc.cuny.edu\/\">Check them out here<\/a>.<\/p>\n<p>&nbsp;<\/p>\n<p>As of April 07, Chicago&#8217;s <a href=\"https:\/\/www.nytimes.com\/2020\/04\/08\/us\/coronavirus-cook-county-jail-chicago.html?action=click&amp;module=RelatedLinks&amp;pgtype=Article\">\u00a0Cook County Facility has become the top hotspot for the virus in the U.S<\/a>. According to data\u00a0<a href=\"https:\/\/www.nytimes.com\/interactive\/2020\/us\/coronavirus-us-cases.html\">compiled by The New York Times<\/a>, the jail in Chicago is now the nation\u2019s largest-known source of coronavirus infections. Why is this a problem? More importantly, why should we care about what occurs inside these institutions? The short answer to these questions is this: correctional health\u00a0<em>is<\/em>\u00a0public health.<\/p>\n<p>What happens inside will\u00a0<em>inevitably<\/em>\u00a0influence what happens outside. Any outbreak within our jails and prisons can cascade into the community. Once COVID-19 spreads throughout a facility, the burden of caring for these sick individuals will necessarily shift to local community medical facilities. Large numbers of seriously ill incarcerated individuals would strain the already taxed hospitals, increasing the morbidity and mortality of all people in NY.<\/p>\n<h4><\/h4>\n<h4>Correctional Facilities Create Optimal Conditions for an Infectious Disease Outbreak<\/h4>\n<p>After spending seven years in New York\u2019s jails and prisons, I am all too aware that the inadequate healthcare and hygiene in correctional facilities create optimal conditions for an infectious disease outbreak. During my time at\u00a0<a href=\"https:\/\/doccs.ny.gov\/location\/bedford-hills-correctional-facility\">Bedford Hills<\/a>\u00a0and\u00a0<a href=\"https:\/\/doccs.ny.gov\/location\/taconic-correctional-facility\">Taconic<\/a>, waiting days or weeks to have my sick-call slip addressed by a doctor was nothing out of the ordinary. I would first have to see a nurse who would determine whether I needed to see a doctor another week from then. Access to cleaning supplies were limited, leaving us to rely on our peers to acquire larger quantities of stolen bleach. With these dynamics at play, should any be surprised to learn that many inmates are currently self-manufacturing sanitizer to clean phones with diluted soap and shampoo that may afford them little to no protection against the virus? Sanitizers remain inaccessible to most inmates due to its high alcohol content.\u00a0 To what extent can inmates stay healthy and keep their living quarters clean under such conditions during this pandemic if it is hard to do so under normal conditions?<\/p>\n<h4><\/h4>\n<h4>Spread of the novel coronavirus is now accelerating within our jails and prisons<\/h4>\n<p>This post follows the first reported death of an in inmate in NYC. \u00a0As of April 08, &#8220;<a href=\"https:\/\/www.newsweek.com\/rikers-island-covid-19-new-york-city-1496872\">more than 700 people have tested positive for coronavirus on Rikers Island, including over 440 staff.<\/a>&#8221; At least\u00a0<a href=\"https:\/\/www.nydailynews.com\/coronavirus\/ny-coronavirus-correction-officers-dead-20200407-7p7ipsyss5dw3jy6bjeb6xkhxe-story.html\">seven correction officers have died<\/a>\u00a0as well. Across NYS, at least two inmates, two parolees and a civilian have died.\u00a0\u00a0<u>A<\/u><a href=\"https:\/\/auburnpub.com\/news\/local\/govt-and-politics\/more-covid-19-cases-in-ny-prisons-groups-urge-cuomo-to-release-high-risk-inmates\/article_c616d0b8-71cd-56f3-b108-402c1abd282e.html\">t\u00a0least 55 inmates have contracted the virus<\/a>.<\/p>\n<p>Will these numbers finally force us to pick up pace in releasing more inmates? The spread of the novel coronavirus is now accelerating within our jails and prisons across the nation. In fact, as of April 07, <a href=\"https:\/\/legalaidnyc.org\/covid-19-infection-tracking-in-nyc-jails\/\">the infection rate inside Rikers Island<\/a> was reported to have been at 6.59 percent, considerably higher than the infection rate of New York City, 0.89 percent. As expected in confined spaces, rapid spread of the virus is much more pronounced for inside the jail than outside.<\/p>\n<p>The number of individuals testing positive for coronavirus has surged in the past two weeks but New York&#8217;s strategy for battling a potentially disastrous outbreak within our jails and prisons has lagged far behind. In fact, a\u00a0<a href=\"https:\/\/nypost.com\/2020\/04\/04\/nyc-must-give-coronavirus-gear-to-corrections-officers-judge\/\">New York judge has only very recently mandated all correction officers to receive nonsurgical masks and rapid COVID-19 tests before every shift<\/a>. This decision came on the heels of a lawsuit filed against the city by the Correction Officers&#8217; Benevolent Association. Considering that it is far less likely that an inmate would bring coronavirus into a facility than would the daily ingress and egress of staff, this delay to protect inmates is rather disturbing.<\/p>\n<p>Despite the vulnerability of this population, news coverage on jail and prison conditions remain minimal.<\/p>\n<p>In fact, one of the first lengthy dialogues on COVID-19 and NY&#8217;s inmates was entirely devoted to quelling public panic about a statewide shortage of sanitizer. On March 9th, Governor Cuomo readily announced that\u00a0<a href=\"https:\/\/abcnews.go.com\/Health\/prison-inmates-ny-produce-100k-gallons-hand-sanitizer\/story?id=69501815\">NYS inmates were mass producing sanitizer<\/a>\u00a0for the state as a response to this shortage. Needless to say, his attempt to comfort the public was devoid of any reassurances about our inmates&#8217; health. There was comparable silence on the details of the protective measures for inmates as we learned that\u00a0<a href=\"https:\/\/www.gq.com\/story\/rikers-island-mass-grave\">inmates at Rikers Island were being offered $6.00 an hour and PPE to dig mass graves on Hart Island<\/a>.<\/p>\n<h4><\/h4>\n<h4>Transparency breeds trust<\/h4>\n<p>Now, it should seem that at a time of panic, pressure, and uncertainty, receiving more transparency from our leaders would be common sense. We need to know more than just how our loved ones inside are being exploited to meet the needs of the pandemic. Visitation bans across all facilities within NY makes it more pressing necessary for the news to keep us updates and informed about preventive and mitigating measures being taken inside. The following are some of the questions that need addressing.<\/p>\n<ul>\n<li>How is social distancing being promoted in crowded housing units?<\/li>\n<li>What measures have been taken to strike a balance between protecting inmate health and rights?<\/li>\n<li>How many inmates are being tested?<\/li>\n<li>What will happen in the event that medical staff or correctional staff fall ill to the virus and have to quarantine?<\/li>\n<li>How will that shortage be addressed?<\/li>\n<li>How are the medical needs of those who were sick in long term care prior to the pandemic having their needs met?<\/li>\n<li>Are inmates being given access to sanitizer, soap, and bleach?<\/li>\n<li>How are inmates that have to regularly leave their facilities to receive medical care at hospitals or other facilities being accommodated medically?<\/li>\n<li>To contain the spread of the disease, infection prevention protocols must be meticulously followed. Even if people are being quarantined in these facilities, to what extent can the CDC\u2019s guidelines for detention facilities be observed when inmates have to line up for medication and share showers, \u00a0cooking and dining \u00a0spaces, toilets, and dorms?<\/li>\n<\/ul>\n<p>Naturally,\u00a0 questions about the public safety implications of a large scale release of inmates have also surfaced. Questions about whether those released will commit crimes are valid; however, they are not the most pressing at the moment.<\/p>\n<h4><\/h4>\n<h4>Should we let high-risk inmates die?<\/h4>\n<p>At Rikers Island, a woman named Elisa expresses her concerns, illuminating the life-or-death situation inmates are facing behind bars.\u00a0<a href=\"https:\/\/www.nydailynews.com\/coronavirus\/ny-coronavirus-rikers-prison-limbo-20200327-wmbuh6ooivceriiaengkjrkwqy-story.html\">According to\u00a0<em>The New York Daily News<\/em>, Elisa was required to strip the bed of an inmate who had tested positive for the novel coronavirus.\u00a0<\/a>\u00a0Elisa, who has AIDS, was required to do so without gloves or mask, despite her immunocompromised status. Furthermore, her lawyer&#8217;s request for her release\u00a0and a slew of other secure alternate release were denied by the Manhattan District Attorney\u2019s. Despite her low security risk and preexisting conditions, the Manhattan District Attorney&#8217;s office argued that it could not consent to her bail because she was already sentenced to state prison time. Like Elisa, scores of high-risk inmates are confronting the reality that they may die in prison.<\/p>\n<h2><\/h2>\n<h4>Social distancing nearly impossible in correctional facilities<\/h4>\n<p>At the same time. releasing only those at risk of complications from the novel coronavirus will only have a minor effect on spread of the illness in the close quarters of jails and prisons.\u00a0<em>All<\/em>\u00a0inmates remain vulnerable by virtue of their environment.<\/p>\n<p>In fact, even for those who are low risk for severe illness, there is substantial difficulty to adhere to the\u00a0<a href=\"https:\/\/www.cdc.gov\/coronavirus\/2019-ncov\/community\/correction-detention\/guidance-correctional-detention.html\">Center for Disease Control&#8217;s recommendations to prevent the spread of the virus.\u00a0<\/a>While releasing more inmates certainly reduces the density within these environments and may consequently slow the spread of the virus, social distancing is nearly impossible within these facilities.<\/p>\n<p>The dynamics at Bedford Hills Correctional Facility at this very moment underscore this reality. In the spirit of quarantining and self-distancing,\u00a0 the facility has\u00a0 limited movement by canceling all programs and interactions between different housing units. Still, dozens of women are still gathered around each other on their housing units\u2019 phone, cooking, and recreational areas daily. Dormitory areas fare even worse where as many as 60 inmates sleep together in close quarters. For these women, only thin bed frames and partitions separate them from their bunkmates and neighbors. Rest assured, the idea of consistently maintaining a 6 feet distance is next to impossible in these spaces.<\/p>\n<p>To the previously posed question, &#8220;should we let inmates die?&#8221; I pose another: &#8220;what gives us the right to ask that question?&#8221;<\/p>\n<p><a href=\"https:\/\/www.law.cornell.edu\/constitution\/eighth_amendment\">The Eighth Amendment<\/a>\u00a0of the U.S. Constitution requires that \u201cinmates be furnished with . . . reasonable safety,\u201d and the Supreme Court has explicitly recognized that the risk of contracting \u201cserious contagious diseases\u201d may constitute such an \u201cunsafe, life-threatening condition\u201d that it threatens \u201creasonable safety.\u201d Thus, we have a constitutional failure looming over us if we continue to take a slow, business-as-usual approach to releasing inmates immediately.<\/p>\n<p>Regardless of what a person may have been accused or convicted of, no individuals deserve to be placed at higher risk of a life-threatening illness when reasonable preventive measures are available.<\/p>\n<p>&nbsp;<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>Translation coming soon.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Translation coming soon.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"As of April 07, Chicago's  Cook County Facility has become the top hotspot for the virus in the U.S. According to data compiled by the New York Times, the jail in Chicago is now the nation\u2019s largest-known source of coronavirus infections. Why is this a problem? More importantly, why should we care about what occurs inside these institutions? The short answer to these questions is this: correctional health is public health. In a special for Fair Play, writer Najet Miah explores this topic. ","page_subheader_es":"A partir del 7 de abril, las instalaciones del condado de Cook en Chicago se han convertido en el principal punto de acceso para el virus en los EE. UU. Seg\u00fan los datos recopilados por el New York Times, la c\u00e1rcel en Chicago es ahora la fuente m\u00e1s grande conocida de infecciones por coronavirus del pa\u00eds. \u00bfPor qu\u00e9 es esto un problema? M\u00e1s importante a\u00fan, \u00bfpor qu\u00e9 deber\u00eda importarnos lo que ocurre dentro de estas instituciones? La respuesta breve a estas preguntas es la siguiente: la salud correccional es la salud p\u00fablica. En un especial para Fair Play, el escritor Najet Miah explora este tema.","page_subheader_fr":"Depuis le 7 avril, le Cook County Facility de Chicago est devenu le principal hotspot pour le virus aux \u00c9tats-Unis.Selon les donn\u00e9es compil\u00e9es par le New York Times, la prison de Chicago est d\u00e9sormais la plus grande source connue du pays d'infections \u00e0 coronavirus. Pourquoi c'est un probl\u00e8me? Plus important encore, pourquoi devrions-nous nous soucier de ce qui se passe \u00e0 l'int\u00e9rieur de ces institutions? La r\u00e9ponse courte \u00e0 ces questions est la suivante: la sant\u00e9 correctionnelle est la sant\u00e9 publique. Dans une \u00e9mission sp\u00e9ciale sur le Fair Play, l'\u00e9crivain Najet Miah explore ce sujet."},{"slug":"editorial-will-you-step-up-now-to-help-clinics-for-the-poor","ideas_cat":"Solutions","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2020\/03\/obi-onyeador-PMnbMcJeftk-unsplash-e1714660475154.jpg","page_title_en":"Editorial: Will you step up now to help clinics for the poor?","page_title_es":"Editorial: Will you step up now to help clinics for the poor?","page_title_fr":"Editorial: Will you step up now to help clinics for the poor?","page_content_en":"<p>There\u2019s a famous quote by Mr. Rogers in which he recalls his mother telling him that in times of trouble,\u00a0\u201cLook for the helpers. You will always find people who are helping.\u201d<\/p>\n<p>Across the state, COVID-19 is testing all of our communities and health systems \u2013 especially those primarily serving low-income and uninsured populations.<\/p>\n<p>For our low-income neighbors, the \u201chelpers\u201d are the 98 free and charity clinics that are serving more than 250,000 Georgians today, with the number increasing about 15 percent each year.\u00a0Free and charitable clinics have always served the most vulnerable in society \u2013 and do so either for free or on a generous sliding scale. That means the clinic takes on, either fully or in part, the cost of the care. Because of this, clinics are reliant on one of three mechanisms to stay open: local donations and\/or in-kind services, grant funding (usually targeted to specific programming), or funds through the state\u2019s annual appropriation.<\/p>\n<p>Since 2016, the Georgia Legislature has appropriated money to the Georgia Charitable Care Network (GCCN) for Georgia\u2019s clinics in the state\u2019s Department of Community Health budget. Contracting with GCCN, the state has provided $2.3 million as of December 2019.\u00a0 GCCN distributes those funds directly to selected clinics through a grant program designed to build their capacity to serve people. More than 240,000 patients have been cared for through the program, at a cost to taxpayers of just $9.52 per patient. In addition to improving the health status of Georgia\u2019s poorest, this appropriation is probably one of the best returns on investment for Georgia\u2019s taxpayers.<\/p>\n<p><a href=\"https:\/\/www.georgiahealthnews.com\/2020\/03\/step-clinics-poor\/\">Read the rest of the editorial in Georgia Health News.<\/a><\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>Translation coming soon.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Translation coming soon.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"Free and charity clinics are long-standing lifelines for more than five million patients each year. But, in the face of Covid-19, these clinics are struggling. In an editorial published by Georgia Health News, Fair Play managing director Holly Lang describes ways we can support these clinics in Georgia, a state where uninsured levels remain high. ","page_subheader_es":"Free and charity clinics are long-standing lifelines for more than five million patients each year. But, in the face of Covid-19, these clinics are struggling. In an editorial published by Georgia Health News, Fair Play managing director Holly Lang describes ways we can support these clinics in Georgia, a state where uninsured levels remain high. ","page_subheader_fr":"Free and charity clinics are long-standing lifelines for more than five million patients each year. But, in the face of Covid-19, these clinics are struggling. In an editorial published by Georgia Health News, Fair Play managing director Holly Lang describes ways we can support these clinics in Georgia, a state where uninsured levels remain high. "},{"slug":"coronavirus-threatens-the-lives-of-rural-hospitals-already-stretched-to-breaking-point","ideas_cat":"Recommended","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2020\/04\/Rural-Hospital-1.jpg","page_title_en":"Coronavirus threatens the lives of rural hospitals already stretched to breaking point","page_title_es":"Coronavirus threatens the lives of rural hospitals already stretched to breaking point","page_title_fr":"Coronavirus threatens the lives of rural hospitals already stretched to breaking point","page_content_en":"<p>Rural hospitals may not be able to keep their doors open as the coronavirus pandemic saps their cash, their CEOs warn, just as communities most need them.<\/p>\n<p>As the coronavirus sweeps across the United States, all hospitals are facing cancellations of doctor visits and procedures by a terrified populace \u2014 profitable services that usually help fund hospitals. Meanwhile, the institutions also find themselves needing to pay higher prices for personal protective equipment such as face masks and other gear that\u2019s in short supply. Vice President Mike Pence called on hospitals nationwide Wednesday to <a href=\"https:\/\/time.com\/5805715\/mike-pence-hospitals-delay-elective-procedures\/\">delay elective surgeries<\/a> to free up capacity and resources for future coronavirus patients.<\/p>\n<p>The American Hospital Association responded Thursday by asking Congress for <a href=\"https:\/\/www.aha.org\/system\/files\/media\/file\/2020\/03\/aha-ama-ana-urge-congress-provide-funding-hospitals-health-systems-nurses-physicians-response-to-covid-19-3-18-2020.pdf\">$100 billion<\/a> for all hospitals to offset coronavirus costs, citing rural hospitals\u2019 inability to withstand huge losses for long.<\/p>\n<p>\u201cIf we\u2019re not able to address the short-term cash needs of rural hospitals, we\u2019re going to see hundreds of rural hospitals close before this crisis ends,\u201d warned Alan Morgan, the head of the <a href=\"https:\/\/www.ruralhealthweb.org\/\">National Rural Health Association<\/a>, which represents 21,000 health care providers and hospitals. \u201cThis is not hyperbole.\u201d<\/p>\n<p>Well before the COVID-19 threat, rural health care\u2019s profitability had collapsed nationwide due to a combination of narrowing Medicare reimbursements, a larger share of patients lacking high-paying private insurance and the hollowing out of rural America. Given such pressures, more than <a href=\"https:\/\/www.shepscenter.unc.edu\/programs-projects\/rural-health\/rural-hospital-closures\/\">120 rural<\/a> hospitals have been forced to close over the past decade.<\/p>\n<p>Those hospitals in small-town America that have survived rely heavily on moneymakers such as elective surgeries, physical therapy and lab tests to make their razor-thin margins work. But, according to the Chicago-based Chartis Center for Rural Health, almost half of them still <a href=\"https:\/\/www.ivantageindex.com\/wp-content\/uploads\/2020\/02\/CCRH_Vulnerability-Research_FiNAL-02.14.20.pdf\">operate in the red<\/a>.<\/p>\n<p>So the added financial hit from the coronavirus outbreak could be the final straw for many rural hospitals \u2014 exposing the complicated business dynamics at play within the United States\u2019 critical public health infrastructure.<\/p>\n<p>\u201cThis virus, and what it is causing for these hospitals, is the perfect storm that will close these hospitals at a time this country critically needs them,\u201d said <a href=\"https:\/\/www.millercountyhospital.com\/tag\/robin-rau\/\">Robin Rau<\/a>, CEO of Miller County Hospital in southwestern Georgia. \u201cThis is going to be the death blow to them.\u201d<\/p>\n<p>Two weeks ago, she started eliminating all medical services that were not urgent. She estimated that has cut off at least half of the hospital\u2019s revenue. Other CEOs warned similar cuts at their hospitals mean they won\u2019t make payroll in the coming weeks.<\/p>\n<p>The National Rural Health Association, along with many rural hospital executives, is lobbying for immediate cash assistance, no-interest loans, Medicare reimbursement adjustments and other suggestions to alleviate the pain. The association favors a bailout plan being from Sens. <a href=\"https:\/\/www.barrasso.senate.gov\/public\/\">John Barrasso<\/a> (R-Wyo.) and <a href=\"https:\/\/www.bennet.senate.gov\/public\/\">Michael Bennet<\/a> (D-Colo.), which in initial drafts called for the equivalent of a three-month advance based on hospitals\u2019 previous patient numbers, according to Bennet\u2019s office.<\/p>\n<p>\u201cRural hospitals have already been closing their doors at startling rates, and this crisis will only exacerbate that fact,\u201d Bennet said in a statement to KHN. \u201cThere is an incredible opportunity for rural hospitals to shoulder some of the burdens of caring for patients and helping to meet possible bed shortages.\u201d<\/p>\n<p>Still, many rural hospital CEOs worry any assistance may come too late.<\/p>\n<p>\u201cAnd yet I hear they\u2019re going to bail out the cruise lines? Really?\u201d Missouri\u2019s Scotland County Hospital CEO Dr. <a href=\"http:\/\/www.scotlandcountyhospital.com\/about_us\/administration.aspx\">Randy Tobler<\/a> said.<\/p>\n<p>As Tobler looks at his older, sicker, underinsured patient population, he said he is afraid the hospital, located on the state\u2019s northeastern rural border, might last only until May before running out of money for payroll.<\/p>\n<p>\u201cIn the truly safety-net areas, we\u2019re being called to high duty,\u201d he said. \u201cAnd we\u2019re running on fumes.\u201d<\/p>\n<p><a href=\"https:\/\/www.candlercountyhospital.com\/news\/news-detail\/news\/candler-county-hospital-authority-has-welcomed-a-new-ceo\/?tx_news_pi1%5Bcontroller%5D=News&amp;tx_news_pi1%5Baction%5D=detail&amp;cHash=1454f73a215f50b47591cd3195f8b9cc\">Michael Purvis<\/a>, CEO of Candler County Hospital in Metter, Georgia, said he\u2019s already fallen into a negative cash flow situation in the past week. The number of patients coming to his hospital, which is about 65 miles outside Savannah, for profitable outpatient procedures has dropped by half as people in droves have canceled their surgeries, MRIs and physical therapy.<\/p>\n<p>Purvis has implemented fever checks of people at the entrance. But he remains fearful that his billing staff could be forced to quarantine themselves if they fall ill \u2014 effectively shutting off the hospital\u2019s revenue.<\/p>\n<p>\u201cIf my billers and coders stay healthy, I can make it to April, maybe end of June,\u201d Purvis said.<\/p>\n<p>On top of the massive loss of revenue, Julie Jones, CEO at <a href=\"http:\/\/www.fairfaxmed.com\/\">Community Hospital-Fairfax<\/a> in northwestern Missouri, said she can only get specialty N95 respirator masks that offer critical protection for her front-line providers for about $5 each \u2014 more than 16 times the normal cost of 30 cents.<\/p>\n<p><a href=\"https:\/\/clinchmh.org\/2018\/10\/hometown-health-recognizes-clinch-memorial-hospital-ceo-angela-ammons-as-hospital-leader-of-the-year\/\">Angela Ammons<\/a>, CEO of Clinch Memorial Hospital in Homerville, Georgia, said she has warned staff that if hand sanitizer and disinfecting wipes continue to go missing, she\u2019ll watch the video footage and fire on the spot anyone caught stealing supplies. And she is so worried about running out of protective equipment, she\u2019s asking any of her \u201ccrafty\u201d staff with sewing machines to sew cotton masks.<\/p>\n<p>\u201cI would rather staff go in with a fabric mask than no mask at all,\u201d she said.<\/p>\n<p>To be sure, rural hospitals are not as equipped as larger hospital systems to handle the most serious coronavirus cases. Many are <a href=\"https:\/\/khn.org\/news\/as-coronavirus-spreads-widely-millions-of-older-americans-live-in-counties-with-no-icu-beds\/\">not outfitted with ICUs<\/a> or enough doctors and staff to handle multiple intensive care patients. That means they have to transfer those patients to larger hospitals.<\/p>\n<p>Still, rural experts argue that their bed and health care capacity can be leveraged to keep potential coronavirus cases out of the major hospitals. Plus, rural facilities could be places for initial triage or eventual recovery care.<\/p>\n<p>And if nothing changes, Rau worries, the country is about to lose this critical public health infrastructure.<\/p>\n<p>\u201cWe can talk all we want about the cost of health care in this country in this ridiculous health care system we have,\u201d she said. \u201cBut at a time like this, who for a minute would think about getting rid of rural hospitals?\u201d<\/p>\n<p>&nbsp;<\/p>\n<p><a href=\"http:\/\/www.kaiserhealthnews.org\/\">Kaiser Health News<\/a> (KHN) is a national health policy news service. It is an editorially independent program of the <a href=\"http:\/\/www.kff.org\/\">Henry J. Kaiser Family Foundation<\/a> which is not affiliated with Kaiser Permanente.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>Translation coming soon<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Translation coming soon<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"As the coronavirus sweeps across the United States, all hospitals are facing cancellations of doctor visits and procedures by a terrified populace \u2014 profitable services that usually help fund hospitals. Meanwhile, the institutions also find themselves needing to pay higher prices for personal protective equipment such as face masks and other gear that\u2019s in short supply.","page_subheader_es":"As the coronavirus sweeps across the United States, all hospitals are facing cancellations of doctor visits and procedures by a terrified populace \u2014 profitable services that usually help fund hospitals. Meanwhile, the institutions also find themselves needing to pay higher prices for personal protective equipment such as face masks and other gear that\u2019s in short supply.","page_subheader_fr":"As the coronavirus sweeps across the United States, all hospitals are facing cancellations of doctor visits and procedures by a terrified populace \u2014 profitable services that usually help fund hospitals. Meanwhile, the institutions also find themselves needing to pay higher prices for personal protective equipment such as face masks and other gear that\u2019s in short supply."},{"slug":"how-poverty-can-kill-you","ideas_cat":"Fair Play Radio","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/09\/poverty.jpg","page_title_en":"Poverty's death toll","page_title_es":"Tasa de muerte de la pobreza","page_title_fr":"Le bilan de la pauvret\u00e9","page_content_en":"<p>For its inaugural podcast, Fair Play founder Holly Lang talks the barriers low-income Americans face in the health system, first in a three-part series looking at poverty and health in North America.<\/p>\n<audio class=\"wp-audio-shortcode\" id=\"audio-349-1\" preload=\"none\" style=\"width: 100%;\" controls=\"controls\"><source type=\"audio\/mpeg\" src=\"https:\/\/fair-play-api.webworldnow.net\/wp-content\/uploads\/2019\/10\/Mix1.5.mp3?_=1\" \/><a href=\"https:\/\/fair-play-api.webworldnow.net\/wp-content\/uploads\/2019\/10\/Mix1.5.mp3\">https:\/\/fair-play-api.webworldnow.net\/wp-content\/uploads\/2019\/10\/Mix1.5.mp3<\/a><\/audio>\n<p>Transcript:<\/p>\n<p>Hi and welcome to Fair Play Radio.<\/p>\n<p>I\u2019m Holly Lang and I\u2019m the founder and managing director of Fair Play, a nonprofit health and economic research, policy and consulting group.<\/p>\n<p>At Fair Play, we think a lot about how costs and income impact a person\u2019s health.<\/p>\n<p>After all, if you struggle to afford necessary or preventable care, how can you stay healthy?<\/p>\n<p>This is an issue that faces all of North America \u2013 and the world. In our debut podcast, we\u2019re looking first at the United States, where the intersection of health and wealth often tend to be at odds.<\/p>\n<p>In what\u2019s considered one of the wealthiest countries in the world, 40 million Americans live in poverty.<\/p>\n<p>And if we talk about \u201cnear-poverty,\u201d or those that live pretty close to the edge, that number jumps to just at 100 million Americans.<\/p>\n<p>That\u2019s about 30 percent of the country, a significant number.<\/p>\n<p>That means nearly one in every three people live dangerously close to destitution, if they aren\u2019t already there.<\/p>\n<p>And that&#8217;s even with US guidelines for poverty, which are fairly low.<\/p>\n<p>As it stands, a family of four would have to have a total household income of less than about $26,000 a year to even be considered to be living in poverty.<\/p>\n<p>$26,000 for four people.<\/p>\n<p>When you consider the basics of life \u2013 rent, utilities, food, clothing \u2013 this is a pretty low threshold, even if you\u2019re in a community where the living is fairly cheap.<\/p>\n<p>And what if you get sick?<\/p>\n<p>Poorer people are more likely to get sick for a number of reasons, including certain socioeconomic factors that lead to substandard housing conditions, inadequate nutrition and poorer work environments.<\/p>\n<p>Poor people also tend to less access to health care.<\/p>\n<p>In theory, if you are poor, you\u2019d receive Medicaid, the public health insurance program for low-income Americans.<\/p>\n<p>But Medicaid varies from state to state and coverage isn\u2019t guaranteed, particularly in the south and parts of the Midwest.<\/p>\n<p>Many that are low-income are also either uninsured or underinsured, which severally limits your options.<\/p>\n<p>You may be able to access care through community-based services, like federally qualified health centers or a charitable clinic.<\/p>\n<p>But those have their limitations and aren\u2019t available in all communities, especially rural areas.<br \/>\nIf you need more intense care, like surgery or emergency services, you\u2019d likely be able qualify for a hospital\u2019s financial assistance policy, particularly if you have a not-for-profit hospital in your community.<\/p>\n<p>But there are barriers there too.<\/p>\n<p>Many hospitals require an in-person application, notarized forms and other documents that require travel.<\/p>\n<p>If you aren\u2019t in a metro area with public transportation, you\u2019ll need a car or a friend giving you a lift to get there, and you\u2019ll need a job that is fine with you missing daytime work, as you\u2019d likely need to adhere to someone else\u2019s office hours to pull everything together.<\/p>\n<p>And keep in mind \u2013 this mostly just applies to emergency and necessary inpatient care.<\/p>\n<p>Routine doctor visits, non-emergent care and preventative care is often a no-go unless you have insurance, be it private, like through an insurance company, or public, like Medicaid.<\/p>\n<p>In 36 states, Medicaid is available to most everyone living in poverty.<\/p>\n<p>But in the other 14 states, Medicaid eligibility doesn\u2019t adhere to a national standard and generally has a complicated set of eligibility standards that tend to exclude many residents.<\/p>\n<p>This often means that it\u2019s a combination of both a significant condition \u2013 like cancer \u2013 and extreme poverty that gets you covered.<\/p>\n<p>If you don\u2019t have insurance \u2013 like 27-and-a-half million Americans \u2013 you likely will struggle to pay not just for your care but for other critical things, like medication and necessary equipment, like blood pressure monitors and glucose monitors.<\/p>\n<p>And it\u2019s important to note that, in general, poorer people are sicker than their wealthier counterparts.<\/p>\n<p>Numerous studies have shown that those living at or near poverty are most likely to die from cancer, heart disease and diabetes.<\/p>\n<p>This is due to several factors that go beyond income, such as education, housing and simple geography, things commonly dubbed \u201csocial determinants of health.\u201d<\/p>\n<p>This means that factors outside your immediate physical self can play a huge role in your health, even including how long you live.<\/p>\n<p>In fact, life expectancy varies as much as 30 years between the richest and poorest U.S. counties.<\/p>\n<p>Sadly, this is getting worse.<\/p>\n<p>A 2016 study done by the research group the Brookings Institute, showed that the difference between rich and poor death rates has significantly grown over the last few decades.<\/p>\n<p>Right now, differences in income can account for more than a decade of life, according to another study by MIT.<\/p>\n<p>This means that the richer you are, the more likely you are to live longer.<\/p>\n<p>And the poorer you are, the more likely you are to die sooner.<\/p>\n<p>This is often from generally preventable diseases, like Type II diabetes or hypertension.<\/p>\n<p>This is significant.<\/p>\n<p>This proves that, in many ways, poverty is the deadliest health condition.<\/p>\n<p>But maybe none of this applies to you.<\/p>\n<p>You are, after all, listening to a podcast.<\/p>\n<p>This means a few things \u2013 you have access to a computer or a smart phone, you have access to<\/p>\n<p>the internet, you understand English well and you likely have at least a high school education.<\/p>\n<p>Already, you\u2019re in a better spot than many.<\/p>\n<p>So why should you care?<\/p>\n<p>Poverty impacts everyone, not just those unlucky enough to live in it.<\/p>\n<p>Think of your schools, your police and safety services, your community infrastructure, all of which are fueled by tax dollars.<\/p>\n<p>Think of what brings new business to a community, and what motivates people to move to a neighborhood.<\/p>\n<p>Think of how high school graduation rates lead to college, or jobs, and how a skilled workforce is much more likely to continue to invest in the community around them than someone barely able to scrape together money for their children to eat or are too sick to work regular hours.<\/p>\n<p>None of this includes vital safety net services often funded through state and federal tax mechanisms, like food stamps, utility assistance, school lunches and housing support.<\/p>\n<p>And keep in mind that if you\u2019re sick because you aren\u2019t able to get the care you need to get healthy, you\u2019re more likely to miss work.<\/p>\n<p>Often.<\/p>\n<p>And those who are at or below the poverty level work hourly wage jobs, meaning an hour missed is an hour you don\u2019t get paid.<\/p>\n<p>All this goes without diving into the ethical issues that surround health care, including debates of whether health care is a right or what role we all should play in the care for others.<\/p>\n<p>And there\u2019s another twist.<\/p>\n<p>According to a recent report issued by the U.S. Census, medical expenses were the number one reason more people fell into poverty.<\/p>\n<p>These expenses included costs of care, prescriptions drugs and insurance premiums.<\/p>\n<p>The Census reported that an additional 8 million people were pushed into poverty from their health care expenses.<\/p>\n<p>A staggering one-in-six Americans have past due health bills on their credit reports, totaling about $81 billion in 2016, according to a study published last year in policy journal Health Affairs.<\/p>\n<p>And that\u2019s just what we know.<\/p>\n<p>Health costs can be an invisible sort of debt at times, hidden in credit cards or short-term loans, including predatory payday loans.<\/p>\n<p>This means that while we have an idea of the impact of health costs, there\u2019s still a whole lot we do not know.<\/p>\n<p>And in the struggle to afford care, many people are being pushed into detrimental financial situations.<\/p>\n<p>It\u2019s important to note that while there are a few bad players, many of the issues are inherent in the U.S. health system overall, not just a particular hospital or provider.<\/p>\n<p>At the risk of being trite, the system itself is broken.<\/p>\n<p>So, what can we do?<\/p>\n<p>There is a lot of room to work on the social determinants of health we mentioned earlier.<\/p>\n<p>We could increase reimbursement for social support systems through Medicaid and Medicare, and push insurance companies to do the same.<\/p>\n<p>Think investments in safe housing and food access, two key areas for improvement in most US communities.<\/p>\n<p>Hospitals could partner with community-based groups to address these issues and would likely see a significant return on that investment in the mid- to long-term.<\/p>\n<p>After all, it\u2019s been proven time and again that it\u2019s cheaper to invest in local housing than it is to house a patient in a hospital bed.<\/p>\n<p>We could also improve how government looks addresses the issue.<\/p>\n<p>Certain payment models, such as capitation and value-based care, are meant to control costs and could be expanded to more areas of care.<\/p>\n<p>And price transparency would use basic market principles to lower prices. But that is in theory, as health care doesn\u2019t always adhere to textbook economic rules.<\/p>\n<p>Locally, hospitals could improve their processes.<\/p>\n<p>This should include ensuring that every low-income patient has access to financial assistance, including those who are underinsured.<\/p>\n<p>This could also include better discharge protocols for patients who are likely to be lower income.<\/p>\n<p>For example, what\u2019s the point of telling someone to regularly monitor their blood pressure if they can\u2019t even afford the equipment to do so?<\/p>\n<p>Or how feasible is it to ask a patient to follow up with their cardiologist if they don\u2019t have affordable access to a specialist?<\/p>\n<p>Hospitals could also undertake referral partnerships with community health centers, Federally Qualified Health Centers and charitable care clinics.<\/p>\n<p>This could allow those doctors to refer into the hospital patients who have needs that go beyond what they\u2019re able to do in that setting.<\/p>\n<p>This is a great first step in many communities to extending care to those who otherwise wouldn\u2019t get it.<\/p>\n<p>But we also have to think big picture with this.<\/p>\n<p>There are some broad transparency standards being currently put in place on both a state and national level around prices that show a glimmer of promise.<\/p>\n<p>This is a critical first step, as most of us have no idea what a hospital visit, procedure or doctor appointment will cost us until at least a month after we\u2019ve received care, giving us little recourse.<\/p>\n<p>But these prices aren\u2019t the \u201creal\u201d prices, meaning what\u2019s posted isn\u2019t generally what anyone pays.<\/p>\n<p>And if you have no money, knowing the price in advance likely isn\u2019t going to help much.<\/p>\n<p>State and federal governments could increase their investment in social programs, such as stronger housing initiatives and programs like the supplemental nutrition assistance program.<\/p>\n<p>More states could expand Medicaid, and that\u2019s likely the most immediate \u2018big picture\u2019 fix we could undertake at this point.<\/p>\n<p>While many lawmakers balk at the price, the political tide is beginning to turn as more state governments see it as one of their only options in harnessing the harm caused by uninsurance.<\/p>\n<p>But we\u2019re seeing a trend of expansion coupled with requirements that would still place that option out of reach of most.<\/p>\n<p>Think work requirements, for example.<\/p>\n<p>Work requirements generally require beneficiaries to participate in certain activities, such as employment, a formal job search, or job training programs.<\/p>\n<p>As of now, Indiana is the only state doing this, though five more states have approved work requirement waivers and seven more have requested approval.<\/p>\n<p>On face value, many don\u2019t see this as an issue.<\/p>\n<p>After all, according to the Kaiser Family Foundation, most Medicaid adults are already working.<\/p>\n<p>But those that aren\u2019t working report barriers to work, including a lack of adequate opportunities, particularly for those without a high school or college diploma.<\/p>\n<p>And what if you are already too sick to work?<\/p>\n<p>Even when working, adults with Medicaid face disproportionately high rates of financial and food insecurity, as they are still living in or near poverty.<\/p>\n<p>So those problems of poverty we talked about at the beginning?<\/p>\n<p>Still an issue.<\/p>\n<p>In short, there\u2019s no silver bullet here.<\/p>\n<p>Without a doubt, poverty is the deadliest condition of all, and it will take federal, state and local communities working in concert to truly begin to make necessary changes that need to happen.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>El texto de este art\u00edculo a\u00fan no est\u00e1 disponible en espa\u00f1ol. \u00a1Por favor mant\u00e9ngase al tanto!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Le texte de cet article n&#8217;est pas encore disponible en espagnol. S&#8217;il vous pla\u00eet restez \u00e0 l&#8217;\u00e9coute!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"Throughout North America - and the world - poverty remains one of the most deadly health conditions. We look at how this issue impacts Americans, and what solutions might be there. ","page_subheader_es":"En toda Am\u00e9rica del Norte, y en todo el mundo, la pobreza sigue siendo una de las condiciones de salud m\u00e1s mortales. Vemos c\u00f3mo este problema impacta a los estadounidenses y qu\u00e9 soluciones podr\u00edan existir.","page_subheader_fr":"En Am\u00e9rique du Nord et dans le monde entier, la pauvret\u00e9 reste l\u2019un des probl\u00e8mes de sant\u00e9 les plus meurtriers. Nous examinons l\u2019impact de ce probl\u00e8me sur les Am\u00e9ricains et les solutions qui pourraient y \u00eatre trouv\u00e9es."},{"slug":"return-to-sender-a-single-undeliverable-letter-can-mean-losing-medicaid","ideas_cat":"Recommended","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/11\/Mailbox-e1714446551630.jpg","page_title_en":"Return to sender: A single undeliverable letter can mean losing Medicaid","page_title_es":" Devolver al remitente: una sola carta que no se puede entregar puede significar perder Medicaid","page_title_fr":"Retour \u00e0 l'exp\u00e9diteur: une seule lettre non distribuable peut signifier la perte de Medicaid.","page_content_en":"<p>COLORADO SPRINGS, Colo. \u2014 Forty-two boxes of returned mail lined a wall of the El Paso County Department of Human Services office\u00a0on a recent fall morning. There used to be three times as many.<\/p>\n<p>Every week, the U.S. Postal Service brings anywhere from four to 15 trays to the office, each containing more than 250 letters that it could not deliver to county residents enrolled in Medicaid or other public assistance programs. This plays out the same way in counties across the state. Colorado estimates about 15% of the 12 million letters from public assistance programs to 1.3 million members statewide are returned \u2014 some 1.8 million pieces of undelivered mail each year.<\/p>\n<p>It falls on each county\u2019s staff, in between fielding calls, to contact the individuals to confirm their correct address and their eligibility for Medicaid, the <a href=\"https:\/\/www.benefits.gov\/benefit\/1621\">federal-state health insurance program<\/a> for people with low incomes.<\/p>\n<p>But last year, state officials decided that if caseworkers can\u2019t reach recipients, they can close those cases and cut off health benefits after a single piece of returned mail.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n<p>Boxes of returned mail, originally sent to residents enrolled in Medicaid or other public assistance programs, line a wall of the El Paso County (Colo.) Department of Human Services office. Although Colorado has lowered the threshold to trigger an eligibility review from three pieces of returned mail to just one, El Paso County rarely closes cases based on a single piece of returned mail and opts not to act on addresses that are often used by those who are homeless.<\/p>\n<p>Medicaid, food stamps and other public benefit programs have avoided the march toward digital communication and continue to operate largely in a paper-based world. That essentially ties lifesaving benefits for some of the most vulnerable populations to the vagaries of the Postal Service.<\/p>\n<p>As returned mail piles up, Colorado and other states take increasingly drastic measures to work through the cumbersome backlog, lowering the bar for canceling benefits on the basis of returned mail alone. <a href=\"https:\/\/www.kcur.org\/post\/more-half-missourians-who-were-dropped-medicaid-didnt-answer-mail#stream\/0\">Missouri<\/a>, <a href=\"https:\/\/www.enidnews.com\/oklahoma\/oklahoma-health-care-authority-resuscitates-controversial-rule-to-check-medicaid\/article_ee8ad59e-78b3-11e9-bde2-7f24ed535baf.html\">Oklahoma<\/a> and <a href=\"https:\/\/mmcp.health.maryland.gov\/Documents\/MMAC\/2017\/November\/MMAC%20Medicaid%20Mail%20Returns%20Nov%2017.pdf\">Maryland<\/a> are among those that have struggled with the volume. And when Arkansas implemented Medicaid work requirements, <a href=\"https:\/\/arktimes.com\/news\/cover-stories\/2018\/08\/09\/scrubbed-from-the-system?oid=21285998\">nearly half of the people who lost <\/a>benefits had failed to respond to mailings or couldn\u2019t be contacted.<\/p>\n<blockquote><p>At best, tightening returned mail policies could save states some money, and those cut from the benefits yet still eligible for them would experience only a temporary gap in their care. But even short delays can exacerbate some patients\u2019 chronic health conditions or lead to expensive visits to the hospital.<\/p>\n<p>And at worst, the returned mail may be contributing to a major drop in Medicaid enrollment and increased numbers of uninsured. Those dropped from the rolls rarely realize it until they seek care.<\/p><\/blockquote>\n<p>\u201cThere\u2019s a lot of concern on this issue,\u201d said <a href=\"https:\/\/www.urban.org\/author\/ian-hill\">Ian Hill<\/a>, a health policy analyst at the Urban Institute, a think tank based in Washington, D.C. \u201cAre they getting purged from the records unfairly and too quickly?\u201d<\/p>\n<p><strong>Taking Action<\/strong><\/p>\n<p>States have been walking a tightrope. While trying to aid their poorest residents, they also are grappling with budget-busting Medicaid costs and pressure from the Trump administration to ensure everyone on public assistance programs qualifies for the benefits.<\/p>\n<p>Some states have sought \u201cprocedural denials because it kept their costs down,\u201d said <a href=\"https:\/\/www.manatt.com\/Story\/Cindy-Mann\">Cindy Mann<\/a>, who ran the Medicaid program under the Obama administration.<\/p>\n<p>\u201cBut we certainly don\u2019t want to cut somebody off while they\u2019re still eligible,\u201d said Mann, who is now a partner with the law firm Manatt, Phelps &amp; Phillips. \u201cIt\u2019s penny-wise and pound-foolish.\u201d<\/p>\n<p>Low-income families who depend on public benefits tend to move often, leading to frequent errors in the addresses on file. But if a person moves out of state, the state-administered Medicaid benefit cannot move with them.<\/p>\n<p>\u201cStates have always struggled with how to handle returned mail,\u201d said <a href=\"https:\/\/www.cbpp.org\/jennifer-wagner\">Jennifer Wagner<\/a>, a senior policy analyst with the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C. \u201cBut we have more recently heard of states pushing a policy to be very aggressive about canceling clients when the state receives returned mail, and that has led to significant disenrollment.\u201d<\/p>\n<p>In April 2018, Colorado <a href=\"https:\/\/www.colorado.gov\/pacific\/sites\/default\/files\/Agency%20Letter%20Returned%20Mail%203-2018%20updated%20final.pdf\">lowered its recommended threshold<\/a> for acting upon returned mail from three pieces of undeliverable mail to just one. From May 2017 to May 2019, enrollment in Medicaid and the Children\u2019s Health Insurance Program dropped 8.5% in the state \u2014 more than three times the national decline of 2.5%, according to the Medicaid and CHIP Payment and Access Commission, a congressional advisory panel.<\/p>\n<p>It\u2019s unclear how much of the drop was due to returned mail. The enrollment declines could also reflect some combination of a proposed federal rule to deny green cards to immigrants who use public benefits, cuts in federal funding for outreach to sign people up for health coverage or an improved economy.<\/p>\n<p>Colorado has not set up a way of tracking how many people are losing benefits because of returned mail or what happens to those who do.<\/p>\n<p>\u201cWe don\u2019t have one data point that we can track,\u201d said Marivel Klueckman, who oversees Medicaid eligibility functions for Colorado. \u201cThat is something we\u2019re building into the future.\u201d<\/p>\n<p>Of the more than 131,000 Colorado households that have public benefit mail returned each year, the state estimates about 1 in 4 cannot be reached, resulting in the possible closure of nearly 33,000 cases.<\/p>\n<p>People cut off from benefits may never learn why and may not seek to restore their benefits, which concerns <a href=\"https:\/\/cclponline.org\/staff\/bethany-pray\/\">Bethany Pray<\/a>, health care program director at the Colorado Center on Law and Policy, a Denver-based legal aid group.<\/p>\n<p>\u201cYou\u2019re going to lose people who are truly eligible and should never have been taken off and who face barriers to re-enrollment,\u201d Pray said.<\/p>\n<p>Of the more than 131,000 Colorado households that have public benefit mail returned each year, the state estimates about 1 in 4 cannot be reached, resulting in the possible closure of nearly 33,000 cases.<\/p>\n<p><strong>Mailing Woes<\/strong><\/p>\n<p>The <a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">lack of dependability of <\/a><a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">the <\/a><a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">Postal Service<\/a>, particularly in rural areas of the state, adds to the concerns about relying on snail mail for important government correspondence.<\/p>\n<p>Officials from the ski resort town of Snowmass Village, for example, complained last spring that they didn\u2019t have any mail delivered for an entire week.<\/p>\n<p>\u201cWe have received over 6 feet of snow in the last two weeks and we still get more complaints about postal delivery than snow removal,\u201d town officials wrote in <a href=\"https:\/\/coskitowns.com\/wp-content\/uploads\/2019\/03\/PostOfficeMarch-2019.pdf\">a March survey<\/a> conducted by the Colorado Association of Ski Towns. \u201cPeople aren\u2019t getting bills, jury summons, medications, certified mail.\u201d<\/p>\n<p>In June, three members of Colorado\u2019s congressional delegation sent <a href=\"https:\/\/tipton.house.gov\/sites\/tipton.house.gov\/files\/Postmaster%20General%20Letter%20-%20FINAL%20%2806-26-2019%29.pdf\">a letter<\/a> to the postmaster general, pressing her to address a range of postal issues including lost or returned mail.<\/p>\n<p>There\u2019s no question that cutting off people after one piece of paper mail is returned saves the state money in sending letters and processing undeliverable mail \u2014 though other costs may add up later. Colorado public assistance programs mail more than a million letters each month, at a cost of nearly $6 million annually. That is a small share of what is spent on the actual assistance, given that Colorado\u2019s <a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\">Medicaid program alone cost<\/a><a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\">s<\/a><a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\"> $9 billion<\/a> a year.<\/p>\n<p>Cutting off assistance after one piece of returned mail also helps the state avoid making monthly payments to regional health organizations for case management and dental services for those who no longer qualify for benefits.<\/p>\n<p>However, Colorado Medicaid\u2019s Klueckman said the state is primarily concerned with making sure eligible residents get their notifications and remain enrolled. The state moved eligibility determinations and renewals online and now offers a mobile app so residents also can receive notifications electronically.<\/p>\n<p>Local Discretion<\/p>\n<p>Colorado plans to open <a href=\"https:\/\/www.colorado.gov\/pacific\/sites\/default\/files\/HCPF%2C%20FY20%2C%20R-6%20Local%20Administration%20Transformation.pdf\">a consolidated returned mail center<\/a> for the state as soon as July 2020. That could provide some economies of scale and consistency, but has the potential of increasing the number of people dropped, as local knowledge is replaced by automation.<\/p>\n<p>Counties currently receive guidance from the state on how to process returned mail, but they have leeway to set their own procedures. El Paso County, for example, rarely closes cases based on a single piece of returned mail and opts not to act on addresses that are often used by those who are homeless, such as a shelter or post office.<\/p>\n<p>\u201cThey\u2019re the least likely for us to be able to have a phone number to call them,\u201d said <a href=\"https:\/\/humanservices.elpasoco.com\/dhs-contact-us\/\">Karen Logan<\/a>, economic and administrative services director for the county.<\/p>\n<p>The county, Colorado\u2019s second-largest, used grant money this year to pay staff overtime to whittle down its backlog of returned mail. That has helped the county process more than 48,000 pieces of returned mail in the past year, with more than a third prompting database changes. But officials could not say how many of those resulted in people losing benefits.<\/p>\n<p>\u201cWe have some other things that are a little bit higher on the priority scale, so we don\u2019t close as many cases as we probably could,\u201d Logan said. \u201cBut I can tell you this: Closing a case and having a person have to reapply two months later takes significantly more work.\u201d<\/p>\n","page_content_es":"<p>COLORADO SPRINGS, Colo. \u2014 Forty-two boxes of returned mail lined a wall of the El Paso County Department of Human Services office\u00a0on a recent fall morning. There used to be three times as many.<\/p>\n<p>Every week, the U.S. Postal Service brings anywhere from four to 15 trays to the office, each containing more than 250 letters that it could not deliver to county residents enrolled in Medicaid or other public assistance programs. This plays out the same way in counties across the state. Colorado estimates about 15% of the 12 million letters from public assistance programs to 1.3 million members statewide are returned \u2014 some 1.8 million pieces of undelivered mail each year.<\/p>\n<p>It falls on each county\u2019s staff, in between fielding calls, to contact the individuals to confirm their correct address and their eligibility for Medicaid, the <a href=\"https:\/\/www.benefits.gov\/benefit\/1621\">federal-state health insurance program<\/a> for people with low incomes.<\/p>\n<p>But last year, state officials decided that if caseworkers can\u2019t reach recipients, they can close those cases and cut off health benefits after a single piece of returned mail.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n<p>Boxes of returned mail, originally sent to residents enrolled in Medicaid or other public assistance programs, line a wall of the El Paso County (Colo.) Department of Human Services office. Although Colorado has lowered the threshold to trigger an eligibility review from three pieces of returned mail to just one, El Paso County rarely closes cases based on a single piece of returned mail and opts not to act on addresses that are often used by those who are homeless.<\/p>\n<p>Medicaid, food stamps and other public benefit programs have avoided the march toward digital communication and continue to operate largely in a paper-based world. That essentially ties lifesaving benefits for some of the most vulnerable populations to the vagaries of the Postal Service.<\/p>\n<p>As returned mail piles up, Colorado and other states take increasingly drastic measures to work through the cumbersome backlog, lowering the bar for canceling benefits on the basis of returned mail alone. <a href=\"https:\/\/www.kcur.org\/post\/more-half-missourians-who-were-dropped-medicaid-didnt-answer-mail#stream\/0\">Missouri<\/a>, <a href=\"https:\/\/www.enidnews.com\/oklahoma\/oklahoma-health-care-authority-resuscitates-controversial-rule-to-check-medicaid\/article_ee8ad59e-78b3-11e9-bde2-7f24ed535baf.html\">Oklahoma<\/a> and <a href=\"https:\/\/mmcp.health.maryland.gov\/Documents\/MMAC\/2017\/November\/MMAC%20Medicaid%20Mail%20Returns%20Nov%2017.pdf\">Maryland<\/a> are among those that have struggled with the volume. And when Arkansas implemented Medicaid work requirements, <a href=\"https:\/\/arktimes.com\/news\/cover-stories\/2018\/08\/09\/scrubbed-from-the-system?oid=21285998\">nearly half of the people who lost <\/a>benefits had failed to respond to mailings or couldn\u2019t be contacted.<\/p>\n<blockquote><p>At best, tightening returned mail policies could save states some money, and those cut from the benefits yet still eligible for them would experience only a temporary gap in their care. But even short delays can exacerbate some patients\u2019 chronic health conditions or lead to expensive visits to the hospital.<\/p>\n<p>And at worst, the returned mail may be contributing to a major drop in Medicaid enrollment and increased numbers of uninsured. Those dropped from the rolls rarely realize it until they seek care.<\/p><\/blockquote>\n<p>\u201cThere\u2019s a lot of concern on this issue,\u201d said <a href=\"https:\/\/www.urban.org\/author\/ian-hill\">Ian Hill<\/a>, a health policy analyst at the Urban Institute, a think tank based in Washington, D.C. \u201cAre they getting purged from the records unfairly and too quickly?\u201d<\/p>\n<p><strong>Taking Action<\/strong><\/p>\n<p>States have been walking a tightrope. While trying to aid their poorest residents, they also are grappling with budget-busting Medicaid costs and pressure from the Trump administration to ensure everyone on public assistance programs qualifies for the benefits.<\/p>\n<p>Some states have sought \u201cprocedural denials because it kept their costs down,\u201d said <a href=\"https:\/\/www.manatt.com\/Story\/Cindy-Mann\">Cindy Mann<\/a>, who ran the Medicaid program under the Obama administration.<\/p>\n<p>\u201cBut we certainly don\u2019t want to cut somebody off while they\u2019re still eligible,\u201d said Mann, who is now a partner with the law firm Manatt, Phelps &amp; Phillips. \u201cIt\u2019s penny-wise and pound-foolish.\u201d<\/p>\n<p>Low-income families who depend on public benefits tend to move often, leading to frequent errors in the addresses on file. But if a person moves out of state, the state-administered Medicaid benefit cannot move with them.<\/p>\n<p>\u201cStates have always struggled with how to handle returned mail,\u201d said <a href=\"https:\/\/www.cbpp.org\/jennifer-wagner\">Jennifer Wagner<\/a>, a senior policy analyst with the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C. \u201cBut we have more recently heard of states pushing a policy to be very aggressive about canceling clients when the state receives returned mail, and that has led to significant disenrollment.\u201d<\/p>\n<p>In April 2018, Colorado <a href=\"https:\/\/www.colorado.gov\/pacific\/sites\/default\/files\/Agency%20Letter%20Returned%20Mail%203-2018%20updated%20final.pdf\">lowered its recommended threshold<\/a> for acting upon returned mail from three pieces of undeliverable mail to just one. From May 2017 to May 2019, enrollment in Medicaid and the Children\u2019s Health Insurance Program dropped 8.5% in the state \u2014 more than three times the national decline of 2.5%, according to the Medicaid and CHIP Payment and Access Commission, a congressional advisory panel.<\/p>\n<p>It\u2019s unclear how much of the drop was due to returned mail. The enrollment declines could also reflect some combination of a proposed federal rule to deny green cards to immigrants who use public benefits, cuts in federal funding for outreach to sign people up for health coverage or an improved economy.<\/p>\n<p>Colorado has not set up a way of tracking how many people are losing benefits because of returned mail or what happens to those who do.<\/p>\n<p>\u201cWe don\u2019t have one data point that we can track,\u201d said Marivel Klueckman, who oversees Medicaid eligibility functions for Colorado. \u201cThat is something we\u2019re building into the future.\u201d<\/p>\n<p>Of the more than 131,000 Colorado households that have public benefit mail returned each year, the state estimates about 1 in 4 cannot be reached, resulting in the possible closure of nearly 33,000 cases.<\/p>\n<p>People cut off from benefits may never learn why and may not seek to restore their benefits, which concerns <a href=\"https:\/\/cclponline.org\/staff\/bethany-pray\/\">Bethany Pray<\/a>, health care program director at the Colorado Center on Law and Policy, a Denver-based legal aid group.<\/p>\n<p>\u201cYou\u2019re going to lose people who are truly eligible and should never have been taken off and who face barriers to re-enrollment,\u201d Pray said.<\/p>\n<p>Of the more than 131,000 Colorado households that have public benefit mail returned each year, the state estimates about 1 in 4 cannot be reached, resulting in the possible closure of nearly 33,000 cases.<\/p>\n<p><strong>Mailing Woes<\/strong><\/p>\n<p>The <a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">lack of dependability of <\/a><a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">the <\/a><a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">Postal Service<\/a>, particularly in rural areas of the state, adds to the concerns about relying on snail mail for important government correspondence.<\/p>\n<p>Officials from the ski resort town of Snowmass Village, for example, complained last spring that they didn\u2019t have any mail delivered for an entire week.<\/p>\n<p>\u201cWe have received over 6 feet of snow in the last two weeks and we still get more complaints about postal delivery than snow removal,\u201d town officials wrote in <a href=\"https:\/\/coskitowns.com\/wp-content\/uploads\/2019\/03\/PostOfficeMarch-2019.pdf\">a March survey<\/a> conducted by the Colorado Association of Ski Towns. \u201cPeople aren\u2019t getting bills, jury summons, medications, certified mail.\u201d<\/p>\n<p>In June, three members of Colorado\u2019s congressional delegation sent <a href=\"https:\/\/tipton.house.gov\/sites\/tipton.house.gov\/files\/Postmaster%20General%20Letter%20-%20FINAL%20%2806-26-2019%29.pdf\">a letter<\/a> to the postmaster general, pressing her to address a range of postal issues including lost or returned mail.<\/p>\n<p>There\u2019s no question that cutting off people after one piece of paper mail is returned saves the state money in sending letters and processing undeliverable mail \u2014 though other costs may add up later. Colorado public assistance programs mail more than a million letters each month, at a cost of nearly $6 million annually. That is a small share of what is spent on the actual assistance, given that Colorado\u2019s <a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\">Medicaid program alone cost<\/a><a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\">s<\/a><a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\"> $9 billion<\/a> a year.<\/p>\n<p>Cutting off assistance after one piece of returned mail also helps the state avoid making monthly payments to regional health organizations for case management and dental services for those who no longer qualify for benefits.<\/p>\n<p>However, Colorado Medicaid\u2019s Klueckman said the state is primarily concerned with making sure eligible residents get their notifications and remain enrolled. The state moved eligibility determinations and renewals online and now offers a mobile app so residents also can receive notifications electronically.<\/p>\n<p>Local Discretion<\/p>\n<p>Colorado plans to open <a href=\"https:\/\/www.colorado.gov\/pacific\/sites\/default\/files\/HCPF%2C%20FY20%2C%20R-6%20Local%20Administration%20Transformation.pdf\">a consolidated returned mail center<\/a> for the state as soon as July 2020. That could provide some economies of scale and consistency, but has the potential of increasing the number of people dropped, as local knowledge is replaced by automation.<\/p>\n<p>Counties currently receive guidance from the state on how to process returned mail, but they have leeway to set their own procedures. El Paso County, for example, rarely closes cases based on a single piece of returned mail and opts not to act on addresses that are often used by those who are homeless, such as a shelter or post office.<\/p>\n<p>\u201cThey\u2019re the least likely for us to be able to have a phone number to call them,\u201d said <a href=\"https:\/\/humanservices.elpasoco.com\/dhs-contact-us\/\">Karen Logan<\/a>, economic and administrative services director for the county.<\/p>\n<p>The county, Colorado\u2019s second-largest, used grant money this year to pay staff overtime to whittle down its backlog of returned mail. That has helped the county process more than 48,000 pieces of returned mail in the past year, with more than a third prompting database changes. But officials could not say how many of those resulted in people losing benefits.<\/p>\n<p>\u201cWe have some other things that are a little bit higher on the priority scale, so we don\u2019t close as many cases as we probably could,\u201d Logan said. \u201cBut I can tell you this: Closing a case and having a person have to reapply two months later takes significantly more work.\u201d<\/p>\n","page_content_fr":"<p>COLORADO SPRINGS, Colo. \u2014 Forty-two boxes of returned mail lined a wall of the El Paso County Department of Human Services office\u00a0on a recent fall morning. There used to be three times as many.<\/p>\n<p>Every week, the U.S. Postal Service brings anywhere from four to 15 trays to the office, each containing more than 250 letters that it could not deliver to county residents enrolled in Medicaid or other public assistance programs. This plays out the same way in counties across the state. Colorado estimates about 15% of the 12 million letters from public assistance programs to 1.3 million members statewide are returned \u2014 some 1.8 million pieces of undelivered mail each year.<\/p>\n<p>It falls on each county\u2019s staff, in between fielding calls, to contact the individuals to confirm their correct address and their eligibility for Medicaid, the <a href=\"https:\/\/www.benefits.gov\/benefit\/1621\">federal-state health insurance program<\/a> for people with low incomes.<\/p>\n<p>But last year, state officials decided that if caseworkers can\u2019t reach recipients, they can close those cases and cut off health benefits after a single piece of returned mail.<\/p>\n<p>Boxes of returned mail, originally sent to residents enrolled in Medicaid or other public assistance programs, line a wall of the El Paso County (Colo.) Department of Human Services office. Although Colorado has lowered the threshold to trigger an eligibility review from three pieces of returned mail to just one, El Paso County rarely closes cases based on a single piece of returned mail and opts not to act on addresses that are often used by those who are homeless.<\/p>\n<p>Medicaid, food stamps and other public benefit programs have avoided the march toward digital communication and continue to operate largely in a paper-based world. That essentially ties lifesaving benefits for some of the most vulnerable populations to the vagaries of the Postal Service.<\/p>\n<p>As returned mail piles up, Colorado and other states take increasingly drastic measures to work through the cumbersome backlog, lowering the bar for canceling benefits on the basis of returned mail alone. <a href=\"https:\/\/www.kcur.org\/post\/more-half-missourians-who-were-dropped-medicaid-didnt-answer-mail#stream\/0\">Missouri<\/a>, <a href=\"https:\/\/www.enidnews.com\/oklahoma\/oklahoma-health-care-authority-resuscitates-controversial-rule-to-check-medicaid\/article_ee8ad59e-78b3-11e9-bde2-7f24ed535baf.html\">Oklahoma<\/a> and <a href=\"https:\/\/mmcp.health.maryland.gov\/Documents\/MMAC\/2017\/November\/MMAC%20Medicaid%20Mail%20Returns%20Nov%2017.pdf\">Maryland<\/a> are among those that have struggled with the volume. And when Arkansas implemented Medicaid work requirements, <a href=\"https:\/\/arktimes.com\/news\/cover-stories\/2018\/08\/09\/scrubbed-from-the-system?oid=21285998\">nearly half of the people who lost <\/a>benefits had failed to respond to mailings or couldn\u2019t be contacted.<\/p>\n<blockquote><p>At best, tightening returned mail policies could save states some money, and those cut from the benefits yet still eligible for them would experience only a temporary gap in their care. But even short delays can exacerbate some patients\u2019 chronic health conditions or lead to expensive visits to the hospital.<\/p>\n<p>And at worst, the returned mail may be contributing to a major drop in Medicaid enrollment and increased numbers of uninsured. Those dropped from the rolls rarely realize it until they seek care.<\/p><\/blockquote>\n<p>\u201cThere\u2019s a lot of concern on this issue,\u201d said <a href=\"https:\/\/www.urban.org\/author\/ian-hill\">Ian Hill<\/a>, a health policy analyst at the Urban Institute, a think tank based in Washington, D.C. \u201cAre they getting purged from the records unfairly and too quickly?\u201d<\/p>\n<p><strong>Taking Action<\/strong><\/p>\n<p>States have been walking a tightrope. While trying to aid their poorest residents, they also are grappling with budget-busting Medicaid costs and pressure from the Trump administration to ensure everyone on public assistance programs qualifies for the benefits.<\/p>\n<p>Some states have sought \u201cprocedural denials because it kept their costs down,\u201d said <a href=\"https:\/\/www.manatt.com\/Story\/Cindy-Mann\">Cindy Mann<\/a>, who ran the Medicaid program under the Obama administration.<\/p>\n<p>\u201cBut we certainly don\u2019t want to cut somebody off while they\u2019re still eligible,\u201d said Mann, who is now a partner with the law firm Manatt, Phelps &amp; Phillips. \u201cIt\u2019s penny-wise and pound-foolish.\u201d<\/p>\n<p>Low-income families who depend on public benefits tend to move often, leading to frequent errors in the addresses on file. But if a person moves out of state, the state-administered Medicaid benefit cannot move with them.<\/p>\n<p>\u201cStates have always struggled with how to handle returned mail,\u201d said <a href=\"https:\/\/www.cbpp.org\/jennifer-wagner\">Jennifer Wagner<\/a>, a senior policy analyst with the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C. \u201cBut we have more recently heard of states pushing a policy to be very aggressive about canceling clients when the state receives returned mail, and that has led to significant disenrollment.\u201d<\/p>\n<p>In April 2018, Colorado <a href=\"https:\/\/www.colorado.gov\/pacific\/sites\/default\/files\/Agency%20Letter%20Returned%20Mail%203-2018%20updated%20final.pdf\">lowered its recommended threshold<\/a> for acting upon returned mail from three pieces of undeliverable mail to just one. From May 2017 to May 2019, enrollment in Medicaid and the Children\u2019s Health Insurance Program dropped 8.5% in the state \u2014 more than three times the national decline of 2.5%, according to the Medicaid and CHIP Payment and Access Commission, a congressional advisory panel.<\/p>\n<p>It\u2019s unclear how much of the drop was due to returned mail. The enrollment declines could also reflect some combination of a proposed federal rule to deny green cards to immigrants who use public benefits, cuts in federal funding for outreach to sign people up for health coverage or an improved economy.<\/p>\n<p>Colorado has not set up a way of tracking how many people are losing benefits because of returned mail or what happens to those who do.<\/p>\n<p>\u201cWe don\u2019t have one data point that we can track,\u201d said Marivel Klueckman, who oversees Medicaid eligibility functions for Colorado. \u201cThat is something we\u2019re building into the future.\u201d<\/p>\n<p>Of the more than 131,000 Colorado households that have public benefit mail returned each year, the state estimates about 1 in 4 cannot be reached, resulting in the possible closure of nearly 33,000 cases.<\/p>\n<p>People cut off from benefits may never learn why and may not seek to restore their benefits, which concerns <a href=\"https:\/\/cclponline.org\/staff\/bethany-pray\/\">Bethany Pray<\/a>, health care program director at the Colorado Center on Law and Policy, a Denver-based legal aid group.<\/p>\n<p>\u201cYou\u2019re going to lose people who are truly eligible and should never have been taken off and who face barriers to re-enrollment,\u201d Pray said.<\/p>\n<p>Of the more than 131,000 Colorado households that have public benefit mail returned each year, the state estimates about 1 in 4 cannot be reached, resulting in the possible closure of nearly 33,000 cases.<\/p>\n<p><strong>Mailing Woes<\/strong><\/p>\n<p>The <a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">lack of dependability of <\/a><a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">the <\/a><a href=\"https:\/\/coloradosun.com\/2019\/06\/18\/colorado-mountain-town-post-office-problems\/\">Postal Service<\/a>, particularly in rural areas of the state, adds to the concerns about relying on snail mail for important government correspondence.<\/p>\n<p>Officials from the ski resort town of Snowmass Village, for example, complained last spring that they didn\u2019t have any mail delivered for an entire week.<\/p>\n<p>\u201cWe have received over 6 feet of snow in the last two weeks and we still get more complaints about postal delivery than snow removal,\u201d town officials wrote in <a href=\"https:\/\/coskitowns.com\/wp-content\/uploads\/2019\/03\/PostOfficeMarch-2019.pdf\">a March survey<\/a> conducted by the Colorado Association of Ski Towns. \u201cPeople aren\u2019t getting bills, jury summons, medications, certified mail.\u201d<\/p>\n<p>In June, three members of Colorado\u2019s congressional delegation sent <a href=\"https:\/\/tipton.house.gov\/sites\/tipton.house.gov\/files\/Postmaster%20General%20Letter%20-%20FINAL%20%2806-26-2019%29.pdf\">a letter<\/a> to the postmaster general, pressing her to address a range of postal issues including lost or returned mail.<\/p>\n<p>There\u2019s no question that cutting off people after one piece of paper mail is returned saves the state money in sending letters and processing undeliverable mail \u2014 though other costs may add up later. Colorado public assistance programs mail more than a million letters each month, at a cost of nearly $6 million annually. That is a small share of what is spent on the actual assistance, given that Colorado\u2019s <a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\">Medicaid program alone cost<\/a><a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\">s<\/a><a href=\"http:\/\/files.kff.org\/attachment\/fact-sheet-medicaid-state-CO\"> $9 billion<\/a> a year.<\/p>\n<p>Cutting off assistance after one piece of returned mail also helps the state avoid making monthly payments to regional health organizations for case management and dental services for those who no longer qualify for benefits.<\/p>\n<p>However, Colorado Medicaid\u2019s Klueckman said the state is primarily concerned with making sure eligible residents get their notifications and remain enrolled. The state moved eligibility determinations and renewals online and now offers a mobile app so residents also can receive notifications electronically.<\/p>\n<p>Local Discretion<\/p>\n<p>Colorado plans to open <a href=\"https:\/\/www.colorado.gov\/pacific\/sites\/default\/files\/HCPF%2C%20FY20%2C%20R-6%20Local%20Administration%20Transformation.pdf\">a consolidated returned mail center<\/a> for the state as soon as July 2020. That could provide some economies of scale and consistency, but has the potential of increasing the number of people dropped, as local knowledge is replaced by automation.<\/p>\n<p>Counties currently receive guidance from the state on how to process returned mail, but they have leeway to set their own procedures. El Paso County, for example, rarely closes cases based on a single piece of returned mail and opts not to act on addresses that are often used by those who are homeless, such as a shelter or post office.<\/p>\n<p>\u201cThey\u2019re the least likely for us to be able to have a phone number to call them,\u201d said <a href=\"https:\/\/humanservices.elpasoco.com\/dhs-contact-us\/\">Karen Logan<\/a>, economic and administrative services director for the county.<\/p>\n<p>The county, Colorado\u2019s second-largest, used grant money this year to pay staff overtime to whittle down its backlog of returned mail. That has helped the county process more than 48,000 pieces of returned mail in the past year, with more than a third prompting database changes. But officials could not say how many of those resulted in people losing benefits.<\/p>\n<p>\u201cWe have some other things that are a little bit higher on the priority scale, so we don\u2019t close as many cases as we probably could,\u201d Logan said. \u201cBut I can tell you this: Closing a case and having a person have to reapply two months later takes significantly more work.\u201d<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"Low-income families who depend on public benefits tend to move often, leading to frequent errors in the addresses on file. But in the United States, if a person moves out of state, state-administered programs such Medicaid can't move with them. This article, republished from Kaiser Health News, examines the challenges inherent in certain policies that potentially pin lifesaving health services to a single piece of mail. ","page_subheader_es":"Las familias de bajos ingresos que dependen de los beneficios p\u00fablicos tienden a mudarse con frecuencia, lo que lleva a errores frecuentes en las direcciones en el archivo. Pero en los Estados Unidos, si una persona se muda fuera del estado, los programas administrados por el estado como Medicaid no pueden mudarse con ellos. Este art\u00edculo, publicado de Kaiser Health News, examina los desaf\u00edos inherentes a ciertas pol\u00edticas que potencialmente sujetan los servicios de salud que salvan vidas a un solo correo.","page_subheader_fr":"Les familles \u00e0 faible revenu qui d\u00e9pendent des avantages publics ont souvent tendance \u00e0 d\u00e9m\u00e9nager, ce qui entra\u00eene des erreurs fr\u00e9quentes dans les adresses au dossier. Mais aux \u00c9tats-Unis, si une personne quitte l\u2019\u00c9tat, des programmes g\u00e9r\u00e9s par l\u2019\u00c9tat, tels que Medicaid, ne peuvent pas \u00e9voluer avec eux. Cet article, republi\u00e9 de Kaiser Health News, examine les d\u00e9fis inh\u00e9rents \u00e0 certaines politiques qui permettent de lier des services de sant\u00e9 vitaux \u00e0 un seul courrier."},{"slug":"charity-care-spending-by-hospitals-plunges","ideas_cat":"Fair Play Radio","main_image":false,"page_title_en":"Charity Care Spending By Hospitals Plunges","page_title_es":"Charity Care Spending By Hospitals Plunges","page_title_fr":"Charity Care Spending By Hospitals Plunges","page_content_en":"<p>California hospitals are providing significantly less free and discounted care to low-income patients since the Affordable Care Act took effect.<\/p>\n<p>As a proportion of their operating expenses, the state\u2019s general acute-care hospitals spent less than half on these patients in 2017 than they did in 2013, according to data the hospitals reported to California\u2019s Office of Statewide Health Planning and Development.<\/p>\n<p>The biggest decline in charity care spending occurred from 2013 to 2015, when it dropped from just over 2% to just under 1%. The spending has continued to decline, though less dramatically, since then.<\/p>\n<p>The decline was true of for-profit hospitals, so-called nonprofit hospitals and those designated as city, county, district or state hospitals.<\/p>\n<p>Health experts attribute the drop in charity care spending largely to the implementation of the federal Affordable Care Act, popularly known as Obamacare. The law expanded insurance coverage to millions of Californians, starting in 2014, and hospitals are now treating far fewer uninsured patients who cannot pay for the care they receive.<\/p>\n<p>With fewer uninsured patients, fewer patients seek financial assistance through the charity care programs, according to the California Hospital Association.<\/p>\n<p>Cori Racela, deputy director at the Western Center on Law &amp; Poverty, countered that many people still need financial assistance because \u2014 even with insurance \u2014 they struggle to pay their premiums, copays and deductibles.<\/p>\n<p>\u201cThe need for charity care has changed,\u201d she said, \u201cbut it still exists.\u201d<\/p>\n<p>The data on charity care comes from most of the state\u2019s general acute-care hospitals but does not include Kaiser Permanente hospitals, which are not required by the state to report their charity care totals. (Kaiser Health News, which produces California Healthline, has no affiliation with Kaiser Permanente.)<\/p>\n<p>For 2017, California Healthline used data from 177 nonprofit hospitals, 80 for-profit hospitals and 54 city, county, district or state hospitals. The breakdown was similar for the other years, with slight fluctuations.<\/p>\n<p>Nonprofit hospitals, whose charity care spending dropped from 2.02% of operating expenses to 0.91% over the five-year period, are required by state and federal law to provide \u201ccommunity benefits\u201d in exchange for their tax-exempt status.<\/p>\n<p>They can meet that requirement beyond providing free and discounted care in a variety of ways: They can offer community public health programs, write off uncollected patient debt and claim the difference between what it costs to provide care and the amount that they are reimbursed by government insurance programs.<\/p>\n<p>Nonprofit \u201chospitals get tax-exempt status, but they don\u2019t get it for free,\u201d said Ge Bai, associate professor of accounting and health policy at Johns Hopkins University. Charity care \u201cis part of the implicit contract between hospital and taxpayers.\u201d<\/p>\n<p>Bai sees the reduced spending on charity care as part of a trend of nonprofit hospitals acting more like their for-profit counterparts.<\/p>\n<p>Many nonprofit hospitals \u201cno longer consider charity care their primary mission,\u201d she said. \u201cThey are making more and more money but they are dropping their charity care.\u201d<\/p>\n<p>The state and federal governments set no minimum requirements for charity spending by hospitals, although the California Attorney General has <a href=\"https:\/\/californiahealthline.org\/news\/california-hospitals-must-cough-up-millions-to-meet-charity-care-rules\/\">created standards<\/a> for a few nonprofit hospitals that have changed ownership in recent years.<\/p>\n<p>Jan Emerson-Shea, a spokeswoman for the California Hospital Association, said hospitals are giving back to their communities in ways beyond charity care.<\/p>\n<p>\u201cYou see charity care declining, but Medi-Cal losses are increasing,\u201d Emerson-Shea said. She pointed to the growing shortfalls many hospitals report from caring for more patients covered by the public insurance program. \u201cEvery Medi-Cal patient we treat we lose money on.\u201d<\/p>\n<p>Medi-Cal, the state\u2019s Medicaid program for low-income residents, <a href=\"https:\/\/www.chcf.org\/publication\/2017-edition-medi-cal-facts-figures\/\">increased its rolls by 5.6 million \u2014 or about 70% \u2014 from 2013 to 2017<\/a>.<\/p>\n<p>Racela, of the Western Center on Law &amp; Poverty, would like to see changes in California\u2019s charity care rules to address high out-of-pocket costs.<\/p>\n<p>And she wants hospitals to abide by the state law that requires them to <a href=\"https:\/\/www.calhospital.org\/general-information\/charity-care-signs\">inform patients<\/a> that they may be eligible for charity care based on their income.<\/p>\n<p>\u201cThere is still a big unmet need for charity care across the state,\u201d Racela said.<\/p>\n<p>This <a href=\"https:\/\/khn.org\">KHN<\/a> story first published on\u00a0<a href=\"http:\/\/www.californiahealthline.org\/\">California Healthline<\/a>, a service of the <a href=\"http:\/\/www.chcf.org\/\">California Health Care Foundation<\/a>.<\/p>\n<p><img decoding=\"async\" src=\"https:\/\/ssl.google-analytics.com\/collect?v=1&amp;t=event&amp;ec=Republish&amp;tid=UA-53070700-2&amp;z=1573145620764&amp;cid=4f58c70f-4e17-478c-8bed-6de50ee330a8&amp;ea=https%3A%2F%2Fkhn.org%2Fnews%2Fcharity-care-spending-by-hospitals-plunges%2F&amp;el=Charity%20Care%20Spending%20By%20Hospitals%20Plunges\" \/><\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"Charity Care Spending By Hospitals Plunges","page_subheader_es":"Charity Care Spending By Hospitals Plunges","page_subheader_fr":"Charity Care Spending By Hospitals Plunges"},{"slug":"why-efficiency-matters","ideas_cat":"Analysis","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/09\/costs.jpg","page_title_en":"Why efficiency matters","page_title_es":" Por qu\u00e9 importa la eficiencia","page_title_fr":" Pourquoi l'efficacit\u00e9 compte","page_content_en":"<p>In health care, efficiency means to deliver high-quality, effective care without spending more than necessary to do so. When care is delivered inefficiently, the impact is particularly high in three key areas \u2013 costs, death and quality of life. Inefficient care can mean duplicated tests, unnecessary procedures, misdiagnoses, wrong paths of care and a number of other costly missteps, all of which can undermine the very nature of care itself &#8212; to make us better.\u00a0 The founding principle of medicine is to do no harm, and unfortunately our systems are not always structured to do so. And, almost always, when we are failed physically, we are also failed financially.<\/p>\n<p>While no health system operates at top efficiency, the U.S. market consistently ranks among the most expensive in the developed world, most often seizing the first-place spot. Despite its high cost, outcomes, access and equity in the U.S. remain rather poor, even after the 2010 passage of the Patient Protection and Affordable Care Act (ACA). The ACA aimed to increase access to more affordable health care, particularly for low-income individuals, while imposing several much-needed health insurance reforms. While gains have been made in many ways, inefficiencies still prevail.<\/p>\n<p>In 2017, U.S. health care spending hit $3.5 trillion, accounting for nearly 18 percent of the U.S. GDP \u2013 a number much higher than U.S. peers, including the United Kingdom, Germany, Mexico and Canada. Yet all four of those countries outperformed the U.S. in efficiency measures, such as patient time spent on paperwork or handling health care-related disputes, prescription access and duplicated tests.<\/p>\n<p>The structure of the U.S. health care system includes many players, all of which have a stake in the efficiency of health costs. The U.S. does not have a single-payer system, instead relying on a complex system of public, private and quasi-public payers faced with mixed incentives to achieve health goals. There is a singular federal government and 52 separate state and district governments. Some decisions are federal, some are state-based, and many are a combination of the two.<\/p>\n<p>There are four primary ways care is paid for: Medicaid, Medicare, private insurance and patients paying out-of-pocket costs. It&#8217;s also important to note that, sometimes, hospitals themselves act somewhat like a fifth payer through financial assistance programs and community-based subsidized care for low-income patients. But because this is not consistent among all hospitals, we generally don&#8217;t consider hospitals to be a payer.<\/p>\n<p>The U.S. Centers for Medicaid and Medicare Services (CMS) regulates most of health care in the U.S., as any health care provider participating in Medicaid and\/or Medicare is subject to CMS oversight and regulations. Most hospitals, if not all, participate in the program, as do many non-hospital employed providers. CMS spending accounted for nearly a quarter of the federal government\u2019s total budget in 2014, a figure that does not account for state funds supporting Medicaid. Because of this, the federal government has significant skin in the game of establishing stronger efficiencies within healthcare.<\/p>\n<p>Established in 1965 under the Social Security Act, Medicare is an age-based public insurance mechanism that is funded by taxpayer dollars and divided into four parts. It\u2019s available to those 65 and older, as well as those with certain disabilities or receiving disability benefits. About a third of all Medicare patients also have complementary coverage, commonly called Medicare Advantage, which is private insurance meant to boost standard Medicare offerings.<\/p>\n<p>Also established through the Social Security Act, Medicaid is a means-tested public insurance program divided into two primary components \u2013 coverage for children (CHIP, or Children\u2019s Health Insurance Program) and coverage for adults (simply referred to as Medicaid). The eligibility standards for these two programs differ, and CHIP generally has more generous parameters \u2013 particularly in states that have opted out of Medicaid expansion. It is important to note it is not uncommon for a person to be deemed dually eligible, meaning the patient is enrolled in both Medicaid and Medicare. In all, those covered through public insurance represent roughly 32 percent of the U.S. population.<\/p>\n<p>These vulnerable populations present significant challenges for both those delivering care and those funding that care. These populations tend to be the sickest and generally require more care coordination than the typical population. They also face unique issues in accessing ambulatory care, which can be due to socioeconomic barriers and\/or lack of access to a provider. Prescriptions can be costly, as can the durable medical equipment oftentimes necessary to maintain good health. For some, financing health means forgoing meals, transportation or stable housing.<\/p>\n<p>Some private providers opt out of providing care to this population, a trend that has, in some communities, increased with the partial expansion of Medicaid eligibility within the U.S. Reasons for this include below-cost reimbursement rates for many services, a heavy administrative burden for participation and slow reimbursement times. This limited access can lead to additional complications in care, which undermines efforts to maintain adequate levels of efficiency among this vulnerable population. If a patient is unable to see an ambulatory care provider in a timely manner to\u00a0 manage a chronic condition or address a pressing need, there are two common patterns that tend to emerge.<\/p>\n<p>In the first scenario, the patient will delay care, eventually requiring more advanced and costly services in a more expensive setting (the hospital, either presenting at the emergency department much sicker and\/or being admitted as an in-patient for a condition that could have been treated earlier in a lower cost setting with potentially better patient outcomes.). The second common scenario transforms the emergency department into a primary care office in which it sees more patients. This serves as a destination for low-acuity conditions that should have been treated more efficiently and affordably elsewhere.<\/p>\n<p>Additionally, within a given state, there may be county or district funding mechanisms, particularly in larger urban settings and for care rendered by \u201csafety net\u201d hospitals. Either by design or by chance, these facilities have a high level of uninsured, low-income patients and would not be able to shoulder the cost of that care without additional funding from local sources. That said, inefficiencies can be created locally through the funding of a pet project of a particular local elected official, or the support of one safety net over another, despite overall cost and quality of the care each institution provides. While the allocation of funds may prompt local reviews of a hospital\u2019s ability to provide care in an efficient manner, generally federal regulations are the standard bearer.<\/p>\n<p>In recent years, there have been moves to standardize reporting around efficiency measures and to increase those levels, particularly within the hospital setting. Efforts around quality include incentives and penalties for reducing readmissions, creating Medicare-based accountable care organizations, and value-based purchasing programs, among many others. To date, many of these programs have shown some gain towards CMS\u2019s goal. CMS has driven many of these initiatives and, in some cases, private insurers have aligned some of their payment structures with the population health components of CMS reforms.<\/p>\n<p>Two-thirds of U.S. citizens had some form of private insurance in 2018,\u00a0and within private coverage exists many factors that contribute to inefficiency. One such example is the pricing of plans, even those within the federal or state health insurance exchanges. For lower-income families and individuals, available plans come with high deductibles and limited benefits, which can lead to higher out-of-pocket expenses. Should the family or individual face a significant injury or major illness, they will walk away with a high hospital bill.<\/p>\n<p>These plans \u2013 called high health deductible plans \u2013 are sometimes coupled with a tax-free medical savings account. The goal of this structure, referred to as consumer-directed health plans, is to reduce health care utilization and cost among participants due to adverse moral hazard. Both the employee and the employer are contributing the cost of care for the insurance product and the savings account, though cost burdens are heavily shifted to the employee. While this shows promise in the short term, the longer-term effect is still not known.<\/p>\n<p>Administrative complexity related to insurance is the excessive waste due to confusing or conflicting rules, rescission and overwrought underwriting processes. In a 2011 study looking primarily at public and private insurance, researchers found that small U.S. physician practices incurred administrative costs equal to approximately ten times that of their counterparts in Canada, who work within a single payor system.<\/p>\n<p>But the paperwork issue isn\u2019t limited to those with insurance. Those without insurance are often subjected to intense financial scrutiny in order to gain access to assistance within a health system. Providers \u2013 particularly hospitals \u2013 have incentives to provide some care to low- and no-income patients due to regulatory requirements. There are two primary areas in which this applies: nonprofit hospital designation and Certificate of Need (CON) requirements. The former refers to the need for nonprofit hospitals to demonstrate charitable activities, such as the provision of unreimbursed financial assistance to low-income patients to maintain state and federal tax-exempt status. The latter refers to state-level Certificate of Need programs that hospitals, service lines, providers and health systems must undergo to undertake major renovations, purchase pricey equipment or expand into new territory. Once granted, the CON is maintained through a variety of standards, including that of a minimal amount of free care provided to indigent patients, often demonstrated as a percentage of operating expenses or net income.<\/p>\n<p>While no one would want to undermine the provision of care for those least able to afford it, the requirements can unfortunately lead to some inefficiencies in delivery of care \u2013 particularly around the application for financial assistance and the variety of hoops a patient must go through to gain that assistance. Added to that are long-held allegations that the process for patients to access financial assistance is often wrought with barriers and subjective standards that push many out of the system once the minimum is reached.\u00a0The door to access care is only open for so long and should a patient need care beyond that, they are often on their own. The Internal Revenue Service has attempted to address this in some accountability and transparency measures set forth in 2014; however, the issue of true access for uninsured patients, regardless of their ability to pay, remains a critical question.<\/p>\n<p>For all patients, regardless of payor, asymmetrical information also remains a significant barrier to efficiency. Asymmetry occurs when one individual or party has better or more information than the other. The doctor knows more than the patient in two critical ways: academically, due to the intensity of training and the knowledge of complex terms and potential tracts of treatment; and, empirically, from hands-on and observed experience from varying consequences of choices. The doctor is in a more removed state than the patient, who is likely sick and will be significantly and intensely personally impacted by the choices that are made.<\/p>\n<p>With the advent of the Internet came access to a broad base of health conditions and a heightened ability of the patient to better understand both diagnoses and available options. Websites such as WebMD.com allow for the general public to simply type in their symptoms and evaluate potential diagnoses and treatment options. Social networks have also allowed for the sharing and discussion of care, which in turn creates a culture allowing the patient more participation in treatment decisions. Added to this is the increasing prevalence of electronic medical records (EMRs), which are often accessible to patients through web-based portals. This allows the patient to review their own charts and view physician notes, something almost entirely nonexistent even just a decade ago (though still not widespread).<\/p>\n<p>Even so, due to the unique nature of care, patients still often rely on their physician for guidance. The stress of making a decision on care, surely exacerbated by the potential of making a wrong one, still places the patient as beholden to physician advice.\u00a0This creates a potentially tricky relationship, which one in which the patient \u2013 who is the person with limited information \u2013 delegates their health problem to the doctor, who is the person that is informed. That patient is limited in knowing how good that care was and if there was a cheaper and more effective way to get better. This is especially true in emergency situations, which tend to be the costliest.<\/p>\n<p>While the introduction of EMRs has come at a high cost to providers, the payoff in a more efficient system is already proving true, especially for hospitals or others with large patient volume. Streamlined provider handoffs, detailed patient history and built-in evidenced-based recommendations are key selling points of EMRs, though these are being realized within the U.S.<\/p>\n<p>It\u2019s important to note that none of the above address issues of fraud and defensive medicine, which are considered by many to be huge contributors to health care inefficiency. Also not discussed are issues with mergers and acquisitions, which create monopolies that, in turn, have been proven to increase prices for both insurers and patients.<\/p>\n<p>However, even aside from those issues it is clear that there are a multitude of factors that lead to inefficiencies within the health care market, and there is no silver bullet to fix them. As with all aspects of health care, the stakes can quickly prove to be quite high \u2013 as the core of it concerns human life. Policymakers, insurers and providers must prioritize mechanisms aimed at achieving efficient care, as the health of us all depends on those efforts.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>El texto de este art\u00edculo a\u00fan no est\u00e1 disponible en espa\u00f1ol. \u00a1Por favor mant\u00e9ngase al tanto!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Le texte de cet article n&#8217;est pas encore disponible en espagnol. S&#8217;il vous pla\u00eet restez \u00e0 l&#8217;\u00e9coute!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"In health care, efficiency simply means we should strive to deliver high-quality, effective care without spending more than is necessary to do so. But in the U.S., this remains an elusive goal. What stands in our way?","page_subheader_es":"En la atenci\u00f3n m\u00e9dica, la eficiencia simplemente significa que debemos esforzarnos por brindar una atenci\u00f3n eficaz y de alta calidad sin gastar m\u00e1s de lo necesario para hacerlo. Pero en los Estados Unidos, este sigue siendo un objetivo dif\u00edcil de alcanzar. \u00bfQu\u00e9 se interpone en nuestro camino?","page_subheader_fr":"Dans le domaine des soins de sant\u00e9, l\u2019efficacit\u00e9 signifie simplement que nous devons nous efforcer de fournir des soins efficaces et de haute qualit\u00e9 sans d\u00e9penser plus que ce qui est n\u00e9cessaire pour le faire. Aux \u00c9tats-Unis, cela reste un objectif difficile \u00e0 atteindre. Qu'est-ce qui nous en emp\u00eache?"},{"slug":"new-transparency-rules","ideas_cat":"Recommended","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/09\/caleb-perez-a6h5e59r15o-unsplash-e1714661147901.jpg","page_title_en":"Trump administration unveils finalized health care price transparency rule","page_title_es":" \u00bfFunciona la transparencia?","page_title_fr":"La transparence fonctionne-t-elle?","page_content_en":"<p>Hospitals will soon have to share price information they have long kept obscured \u2014 including how big a discount they offer cash-paying patients and rates negotiated with insurers \u2014 under a <a href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/cy-2020-hospital-outpatient-prospective-payment-system-opps-policy-changes-hospital-price\">rule<\/a> finalized Friday by the Trump administration.<\/p>\n<p>In a <a href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/transparency-coverage-proposed-rule-cms-9915-p\">companion proposal<\/a>, the administration announced it is also planning to require health insurers to spell out beforehand for all services just how much patients may owe in out-of-pocket costs. That measure is now open for public comment.<\/p>\n<p>\u201cWhat is more clear and sensible than Americans knowing what their care is going to cost before going to the doctor?\u201d said Joe Grogan, director of the White House Domestic Policy Council.<\/p>\n<p>The hospital rule is slated to go into effect in January 2021.\u00a0It is part of an effort by the Trump administration to increase price transparency in hopes of lowering health care costs on everything from hospital services to prescription drugs. But it is controversial and likely to face court challenges.<\/p>\n<p>When that rule was first proposed in <a href=\"https:\/\/khn.org\/news\/trump-administration-moves-to-make-health-care-costs-more-transparent\/\">July<\/a>, hospitals and insurers objected. They argued it would require them to disclose propriety information, could hamper negotiations and could backfire if some medical providers see they are underpriced compared with peers and raise their charges.<\/p>\n<p>Shortly after the final rule\u2019s release, four major hospital organizations said they would challenge it in court.<\/p>\n<p>\u201cThis rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers and stymie innovations,\u201d according a joint statement from these groups, which made clear their intent to soon \u201cfile a legal challenge to the rule on the grounds including that it exceeds the administration\u2019s authority.\u201d The statement was signed by the American Hospital Association, the Association of American Medical Colleges, the Children\u2019s Hospital Association and the Federation of American Hospitals.<\/p>\n<p>Insurers also pushed back. \u201cThe rules the administration released today will not help consumers better understand what health services will cost them and may not advance the broader goal of lowering health care costs,\u201d said Scott Serota, president and CEO of the Blue Cross Blue Shield Association, in a statement.<\/p>\n<p>Requiring disclosure of negotiated rates, he said, could lead to price increases \u201cas clinicians and medical facilities could see in the negotiated payments a roadmap to bidding up prices rather than lowering rates.\u201d The rule, he added, could confuse consumers.<\/p>\n<p>It\u2019s also a potentially crushing amount of data for a consumer to consider. However, the administration said it hopes the data will also spur researchers, employers or entrepreneurs to find additional ways of making the data accessible and useful.<\/p>\n<p>The amount of information the rule requires to be disclosed will be massive \u2014 including gross charges, negotiated rates and cash prices \u2014 for every one of the thousands of services offered by every hospital, which they will be required to update annually.<\/p>\n<p>In a nod to how hard it might be for a consumer to add up items from such an a la carte list of prices, the rule also requires each hospital to include a list of 300 \u201cshoppable\u201d services, described in plain language, with all the ancillary costs included. So, in effect, a patient could look up the total cost of a knee replacement, hernia repair or other treatment.<\/p>\n<p>Insurers, under the proposed rule, would have to disclose the rates they negotiate with providers like hospitals. They would also be required to create online tools to calculate for individual consumers the amount of their estimated out-of-pocket costs for all services, including any deductible they may owe, and make that information available before the consumer heads to the hospital or doctor.<\/p>\n<p>It would go into effect one year after it is finalized, although it is not known when that will occur.<\/p>\n<p>Although consumer advocates say price information can help patients shop for lower-cost services, they also note that <a href=\"http:\/\/www-personal.umich.edu\/~zachb\/zbrown_eqm_effects_price_transparency.pdf\">few consumers do<\/a>, even when provided such information.<\/p>\n<p>Earlier this year, the administration <a href=\"https:\/\/khn.org\/morning-breakout\/hhs-appeals-judges-decision-on-rule-requiring-drugmakers-to-include-drug-prices-in-tv-ads\/\">ordered<\/a> drugmakers to include their prices in advertisements, but the industry sued and won a court ruling blocking the measure. The administration has appealed that ruling.<\/p>\n<p>Nonetheless, Health and Human Services Secretary Alex Azar said the administration is confident.<\/p>\n<p>\u201cWe may face litigation, but we feel we are on sound legal footing for what we are asking,\u201d Azar said. \u201cWe hope hospitals respect patients\u2019 right to know the prices of services and we\u2019d hate to see them take a page out of Big Pharma\u2019s playbook and oppose transparency.\u201d<\/p>\n<p>He and other officials on a call with reporters admitted they don\u2019t have any estimates on how much the proposal would save in lowered costs because such a broad effort has never been tried in the U.S. before.<\/p>\n<p>Still, \u201cpoint me to one sector of the American economy where having pricing information actually leads to higher prices,\u201d said Azar.<\/p>\n<p>Azar cited some studies that show that when prices are disclosed, overall spending can go down because patients choose cheaper services. However, such efforts also generally require financial incentives for the patient, such as sharing in the cost savings.<\/p>\n<p>The proposed rule for insurers urges them to create such incentives, said Seema Verma, who oversees the federal government\u2019s Center for Medicare &#038; Medicaid Services.<\/p>\n<p>George Nation, a business professor at Lehigh University in Pennsylvania who studies hospital pricing, called the final rule and the insurer proposal \u201cexactly a move in the right direction.\u201d<\/p>\n<p>Among other things, he said, the price information may prove useful to employers comparing whether their insurer or administrator is doing a good job in bargaining with local providers.<\/p>\n<p>Today, \u201cthey just see a bill and a discount. But is it a good discount? This will now all be transparent,\u201d said Nation.<\/p>\n<p><a href=\"http:\/\/www.kaiserhealthnews.org\/\">Kaiser Health News<\/a> (KHN) is a national health policy news service. It is an editorially independent program of the <a href=\"http:\/\/www.kff.org\/\">Henry J. Kaiser Family Foundation<\/a> which is not affiliated with Kaiser Permanente.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<h1>White House Unveils Finalized Health Care Price Transparency Rule<\/h1>\n<p>\t<span class=\"byline\">Julie Appleby, Kaiser Health News<\/span><\/p>\n<p>Hospitals will soon have to share price information they have long kept obscured \u2014 including how big a discount they offer cash-paying patients and rates negotiated with insurers \u2014 under a <a href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/cy-2020-hospital-outpatient-prospective-payment-system-opps-policy-changes-hospital-price\">rule<\/a> finalized Friday by the Trump administration.<\/p>\n<p>In a <a href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/transparency-coverage-proposed-rule-cms-9915-p\">companion proposal<\/a>, the administration announced it is also planning to require health insurers to spell out beforehand for all services just how much patients may owe in out-of-pocket costs. That measure is now open for public comment.<\/p>\n<p>\u201cWhat is more clear and sensible than Americans knowing what their care is going to cost before going to the doctor?\u201d said Joe Grogan, director of the White House Domestic Policy Council.<\/p>\n<p>The hospital rule is slated to go into effect in January 2021.\u00a0It is part of an effort by the Trump administration to increase price transparency in hopes of lowering health care costs on everything from hospital services to prescription drugs. But it is controversial and likely to face court challenges.<\/p>\n<p>When that rule was first proposed in <a href=\"https:\/\/khn.org\/news\/trump-administration-moves-to-make-health-care-costs-more-transparent\/\">July<\/a>, hospitals and insurers objected. They argued it would require them to disclose propriety information, could hamper negotiations and could backfire if some medical providers see they are underpriced compared with peers and raise their charges.<\/p>\n<p>Shortly after the final rule\u2019s release, four major hospital organizations said they would challenge it in court.<\/p>\n<p>\u201cThis rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers and stymie innovations,\u201d according a joint statement from these groups, which made clear their intent to soon \u201cfile a legal challenge to the rule on the grounds including that it exceeds the administration\u2019s authority.\u201d The statement was signed by the American Hospital Association, the Association of American Medical Colleges, the Children\u2019s Hospital Association and the Federation of American Hospitals.<\/p>\n<p>Insurers also pushed back. \u201cThe rules the administration released today will not help consumers better understand what health services will cost them and may not advance the broader goal of lowering health care costs,\u201d said Scott Serota, president and CEO of the Blue Cross Blue Shield Association, in a statement.<\/p>\n<p>Requiring disclosure of negotiated rates, he said, could lead to price increases \u201cas clinicians and medical facilities could see in the negotiated payments a roadmap to bidding up prices rather than lowering rates.\u201d The rule, he added, could confuse consumers.<\/p>\n<p>It\u2019s also a potentially crushing amount of data for a consumer to consider. However, the administration said it hopes the data will also spur researchers, employers or entrepreneurs to find additional ways of making the data accessible and useful.<\/p>\n<p>The amount of information the rule requires to be disclosed will be massive \u2014 including gross charges, negotiated rates and cash prices \u2014 for every one of the thousands of services offered by every hospital, which they will be required to update annually.<\/p>\n<p>In a nod to how hard it might be for a consumer to add up items from such an a la carte list of prices, the rule also requires each hospital to include a list of 300 \u201cshoppable\u201d services, described in plain language, with all the ancillary costs included. So, in effect, a patient could look up the total cost of a knee replacement, hernia repair or other treatment.<\/p>\n<p>Insurers, under the proposed rule, would have to disclose the rates they negotiate with providers like hospitals. They would also be required to create online tools to calculate for individual consumers the amount of their estimated out-of-pocket costs for all services, including any deductible they may owe, and make that information available before the consumer heads to the hospital or doctor.<\/p>\n<p>It would go into effect one year after it is finalized, although it is not known when that will occur.<\/p>\n<p>Although consumer advocates say price information can help patients shop for lower-cost services, they also note that <a href=\"http:\/\/www-personal.umich.edu\/~zachb\/zbrown_eqm_effects_price_transparency.pdf\">few consumers do<\/a>, even when provided such information.<\/p>\n<p>Earlier this year, the administration <a href=\"https:\/\/khn.org\/morning-breakout\/hhs-appeals-judges-decision-on-rule-requiring-drugmakers-to-include-drug-prices-in-tv-ads\/\">ordered<\/a> drugmakers to include their prices in advertisements, but the industry sued and won a court ruling blocking the measure. The administration has appealed that ruling.<\/p>\n<p>Nonetheless, Health and Human Services Secretary Alex Azar said the administration is confident.<\/p>\n<p>\u201cWe may face litigation, but we feel we are on sound legal footing for what we are asking,\u201d Azar said. \u201cWe hope hospitals respect patients\u2019 right to know the prices of services and we\u2019d hate to see them take a page out of Big Pharma\u2019s playbook and oppose transparency.\u201d<\/p>\n<p>He and other officials on a call with reporters admitted they don\u2019t have any estimates on how much the proposal would save in lowered costs because such a broad effort has never been tried in the U.S. before.<\/p>\n<p>Still, \u201cpoint me to one sector of the American economy where having pricing information actually leads to higher prices,\u201d said Azar.<\/p>\n<p>Azar cited some studies that show that when prices are disclosed, overall spending can go down because patients choose cheaper services. However, such efforts also generally require financial incentives for the patient, such as sharing in the cost savings.<\/p>\n<p>The proposed rule for insurers urges them to create such incentives, said Seema Verma, who oversees the federal government\u2019s Center for Medicare &#038; Medicaid Services.<\/p>\n<p>George Nation, a business professor at Lehigh University in Pennsylvania who studies hospital pricing, called the final rule and the insurer proposal \u201cexactly a move in the right direction.\u201d<\/p>\n<p>Among other things, he said, the price information may prove useful to employers comparing whether their insurer or administrator is doing a good job in bargaining with local providers.<\/p>\n<p>Today, \u201cthey just see a bill and a discount. But is it a good discount? This will now all be transparent,\u201d said Nation.<\/p>\n<p><a href=\"http:\/\/www.kaiserhealthnews.org\/\">Kaiser Health News<\/a> (KHN) is a national health policy news service. It is an editorially independent program of the <a href=\"http:\/\/www.kff.org\/\">Henry J. Kaiser Family Foundation<\/a> which is not affiliated with Kaiser Permanente.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<h1>White House Unveils Finalized Health Care Price Transparency Rule<\/h1>\n<p>\t<span class=\"byline\">Julie Appleby, Kaiser Health News<\/span><\/p>\n<p>Hospitals will soon have to share price information they have long kept obscured \u2014 including how big a discount they offer cash-paying patients and rates negotiated with insurers \u2014 under a <a href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/cy-2020-hospital-outpatient-prospective-payment-system-opps-policy-changes-hospital-price\">rule<\/a> finalized Friday by the Trump administration.<\/p>\n<p>In a <a href=\"https:\/\/www.cms.gov\/newsroom\/fact-sheets\/transparency-coverage-proposed-rule-cms-9915-p\">companion proposal<\/a>, the administration announced it is also planning to require health insurers to spell out beforehand for all services just how much patients may owe in out-of-pocket costs. That measure is now open for public comment.<\/p>\n<p>\u201cWhat is more clear and sensible than Americans knowing what their care is going to cost before going to the doctor?\u201d said Joe Grogan, director of the White House Domestic Policy Council.<\/p>\n<p>The hospital rule is slated to go into effect in January 2021.\u00a0It is part of an effort by the Trump administration to increase price transparency in hopes of lowering health care costs on everything from hospital services to prescription drugs. But it is controversial and likely to face court challenges.<\/p>\n<p>When that rule was first proposed in <a href=\"https:\/\/khn.org\/news\/trump-administration-moves-to-make-health-care-costs-more-transparent\/\">July<\/a>, hospitals and insurers objected. They argued it would require them to disclose propriety information, could hamper negotiations and could backfire if some medical providers see they are underpriced compared with peers and raise their charges.<\/p>\n<p>Shortly after the final rule\u2019s release, four major hospital organizations said they would challenge it in court.<\/p>\n<p>\u201cThis rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers and stymie innovations,\u201d according a joint statement from these groups, which made clear their intent to soon \u201cfile a legal challenge to the rule on the grounds including that it exceeds the administration\u2019s authority.\u201d The statement was signed by the American Hospital Association, the Association of American Medical Colleges, the Children\u2019s Hospital Association and the Federation of American Hospitals.<\/p>\n<p>Insurers also pushed back. \u201cThe rules the administration released today will not help consumers better understand what health services will cost them and may not advance the broader goal of lowering health care costs,\u201d said Scott Serota, president and CEO of the Blue Cross Blue Shield Association, in a statement.<\/p>\n<p>Requiring disclosure of negotiated rates, he said, could lead to price increases \u201cas clinicians and medical facilities could see in the negotiated payments a roadmap to bidding up prices rather than lowering rates.\u201d The rule, he added, could confuse consumers.<\/p>\n<p>It\u2019s also a potentially crushing amount of data for a consumer to consider. However, the administration said it hopes the data will also spur researchers, employers or entrepreneurs to find additional ways of making the data accessible and useful.<\/p>\n<p>The amount of information the rule requires to be disclosed will be massive \u2014 including gross charges, negotiated rates and cash prices \u2014 for every one of the thousands of services offered by every hospital, which they will be required to update annually.<\/p>\n<p>In a nod to how hard it might be for a consumer to add up items from such an a la carte list of prices, the rule also requires each hospital to include a list of 300 \u201cshoppable\u201d services, described in plain language, with all the ancillary costs included. So, in effect, a patient could look up the total cost of a knee replacement, hernia repair or other treatment.<\/p>\n<p>Insurers, under the proposed rule, would have to disclose the rates they negotiate with providers like hospitals. They would also be required to create online tools to calculate for individual consumers the amount of their estimated out-of-pocket costs for all services, including any deductible they may owe, and make that information available before the consumer heads to the hospital or doctor.<\/p>\n<p>It would go into effect one year after it is finalized, although it is not known when that will occur.<\/p>\n<p>Although consumer advocates say price information can help patients shop for lower-cost services, they also note that <a href=\"http:\/\/www-personal.umich.edu\/~zachb\/zbrown_eqm_effects_price_transparency.pdf\">few consumers do<\/a>, even when provided such information.<\/p>\n<p>Earlier this year, the administration <a href=\"https:\/\/khn.org\/morning-breakout\/hhs-appeals-judges-decision-on-rule-requiring-drugmakers-to-include-drug-prices-in-tv-ads\/\">ordered<\/a> drugmakers to include their prices in advertisements, but the industry sued and won a court ruling blocking the measure. The administration has appealed that ruling.<\/p>\n<p>Nonetheless, Health and Human Services Secretary Alex Azar said the administration is confident.<\/p>\n<p>\u201cWe may face litigation, but we feel we are on sound legal footing for what we are asking,\u201d Azar said. \u201cWe hope hospitals respect patients\u2019 right to know the prices of services and we\u2019d hate to see them take a page out of Big Pharma\u2019s playbook and oppose transparency.\u201d<\/p>\n<p>He and other officials on a call with reporters admitted they don\u2019t have any estimates on how much the proposal would save in lowered costs because such a broad effort has never been tried in the U.S. before.<\/p>\n<p>Still, \u201cpoint me to one sector of the American economy where having pricing information actually leads to higher prices,\u201d said Azar.<\/p>\n<p>Azar cited some studies that show that when prices are disclosed, overall spending can go down because patients choose cheaper services. However, such efforts also generally require financial incentives for the patient, such as sharing in the cost savings.<\/p>\n<p>The proposed rule for insurers urges them to create such incentives, said Seema Verma, who oversees the federal government\u2019s Center for Medicare &#038; Medicaid Services.<\/p>\n<p>George Nation, a business professor at Lehigh University in Pennsylvania who studies hospital pricing, called the final rule and the insurer proposal \u201cexactly a move in the right direction.\u201d<\/p>\n<p>Among other things, he said, the price information may prove useful to employers comparing whether their insurer or administrator is doing a good job in bargaining with local providers.<\/p>\n<p>Today, \u201cthey just see a bill and a discount. But is it a good discount? This will now all be transparent,\u201d said Nation.<\/p>\n<p><a href=\"http:\/\/www.kaiserhealthnews.org\/\">Kaiser Health News<\/a> (KHN) is a national health policy news service. It is an editorially independent program of the <a href=\"http:\/\/www.kff.org\/\">Henry J. Kaiser Family Foundation<\/a> which is not affiliated with Kaiser Permanente.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"Hospitals will soon have to share price information they have long kept obscured \u2014 including how big a discount they offer cash-paying patients and rates negotiated with insurers \u2014 under a rule finalized Friday by the Trump administration. ","page_subheader_es":"Los nuevos cambios regulatorios de EE. UU. Tienen como objetivo aumentar la transparencia de los precios en los hospitales. Pero, \u00bfestos cambios realmente reducir\u00e1n los costos?","page_subheader_fr":"Les nouvelles modifications de la r\u00e9glementation am\u00e9ricaine visent \u00e0 accro\u00eetre la transparence des prix dans les h\u00f4pitaux. Mais ces changements vont-ils r\u00e9ellement r\u00e9duire les co\u00fbts?"},{"slug":"the-rise-of-not-for-profit-hospitals","ideas_cat":"How'd we get here","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/09\/hospitals-main-image.jpg","page_title_en":"The rise of not-for-profit hospitals","page_title_es":"El surgimiento de hospitales sin fines de lucro","page_title_fr":"La mont\u00e9e des h\u00f4pitaux \u00e0 but non lucratif","page_content_en":"<p>About two-thirds of all U.S. hospitals are tax-exempt,<a href=\"#_edn1\" name=\"_ednref1\">[i]<\/a> meaning these organizations have an obligation to their communities due to lost tax revenue \u2013 a formidable amount that tops an estimated $31 billion each year in local, state and federal taxes. In exchange for those exemptions, federal and some state laws require that communities receive from their hospitals certain benefits, appropriately called community benefit. These programs are generally meant as programs intended to increase access to care and boost the health of the community, with a focus on low-income populations.<\/p>\n<p>With the passage of the 2010 Patient Protection and Affordable Care Act<a href=\"#_edn2\" name=\"_ednref2\">[ii]<\/a> (ACA) came significant shifts in how lower income patients paid for care. Thirty-seven states have since expanded Medicaid, the state-federal public insurance program geared to poorer populations. Because of this, more folks in those states are insured, drastically reducing the number of uninsured patients needing hospital-sponsored financial assistance, which is generally the most significant benefit a hospital provides back to its community. For example, in California, indigent care has dropped significantly in the last three years. And even though Medicaid shortfalls \u2013 another community benefit \u2013 have increased, it\u2019s no match for what financial assistance once was.<\/p>\n<p>Because of this, many have called into consideration what these not-for-profit hospitals should do in exchange for their tax-exempt status. That\u2019s a complex question, and the answer likely varies from state to state. This is something we\u2019ll examine continually from a variety of perspectives. But first, let\u2019s understand how this structure even came to be.<\/p>\n<p><strong><u>Humble origins<\/u><\/strong><\/p>\n<p>Hospitals have been a part of the U.S. for nearly 200 years, having first emerged as almshouses to provide to the poor a place for treatment at a time when most people received care in their homes.<a href=\"#_edn3\" name=\"_ednref3\">[iii]<\/a> These hospitals then relieved what was a governmental burden by establishing a mechanism for everyone to receive care \u2013 even those unable to barter or pay for services \u2013 that subsisted largely on donations. Because of this, in 1894, hospitals received tax-exempt status.<\/p>\n<p>Over the next three decades, the care delivery model began to change. Although house calls still existed, advances in medical practices and technology helped solidify the hospital as a major source of care. Payment models evolved and were generally direct fee for service between the patient and the hospital or provider.<a href=\"#_edn4\" name=\"_ednref4\">[iv]<\/a><\/p>\n<p>However, when insurance was born, the history of health care delivery was forever changed in the U.S.<\/p>\n<p>In 1929, the formation of Blue Cross at Baylor University Hospital in Dallas, Texas, brought the first form of insurance in the U.S. as prepayment to hospitals for future services.<a href=\"#_edn5\" name=\"_ednref5\">[v]<\/a> That same year the first employer-sponsored healthcare plan also emerged in Dallas, with local teachers paying $0.50 a month to receive two weeks of paid hospital care.<a href=\"#_edn6\" name=\"_ednref6\">[vi]<\/a> Both were conceived by the same man \u2013 Justin Ford Kimball \u2013 who created these groups as tax-exempt organizations with the sole purpose of providing tax-exempt hospitals with payment for care. These first versions paid full charges for the care, and the hospital set the rates that insurance then reimbursed.<a href=\"#_edn7\" name=\"_ednref7\">[vii]<\/a><\/p>\n<p>The 1930s and 1940s brought swift advances in technology, revolutionizing healthcare and molding almshouses into young versions of the modern hospitals we know today. Hospitals were now operating within the marketplace and, accordingly, continued to charge fees for most services.<a href=\"#_edn8\" name=\"_ednref8\">[viii]<\/a> Poorer patients received only the care that could be covered by donations, surplus revenue from care for insured populations and public sector contracts.<a href=\"#_edn9\" name=\"_ednref9\">[ix]<\/a><\/p>\n<p><strong><u>Modern behemoths<\/u><\/strong><\/p>\n<p>Throughout the following years, hospitals continued to evolve. They are now the second largest private sector employer in the U.S., with nearly 5.5 million employed. In 2011, according to the American Hospital Associations, hospitals provided care for 129 million people in emergency departments and treated another 526 million throughout other areas of the hospitals.<a href=\"#_edn10\" name=\"_ednref10\">[x]<\/a> In aggregate, the hospital\u2019s estimated economic impact is estimated to be close to $2 trillion.<a href=\"#_edn11\" name=\"_ednref11\">[xi]<\/a><\/p>\n<p>Hospitals tend to be among a given community\u2019s top employers, usually coming in second only to school systems and local government. Hospitals also tend to be the most aggressive in merger and acquisition activities. In 2015 alone, healthcare comprised nearly two-thirds of all M&amp;A deals, growing from just $53 billion in 2013 to more than $68 billion in 2015. Additionally, of the approximately 100 hospital mergers and acquisitions that year, 65 were of not-for-profit hospitals, a figure that does not include any purchases of physician practices or other community-based services \u2013 both of which have also seen rapid acquisitions by health systems in the last decade.<\/p>\n<p>In 2011, the aggregated value of tax-exempt hospitals\u2019 tax exemption was calculated at $24.6 billion,<a href=\"#_edn12\" name=\"_ednref12\">[xii]<\/a> a number up significantly from $12.6 billion in 2002.<a href=\"#_edn13\" name=\"_ednref13\">[xiii]<\/a> However, the value of a tax-exempt status stretches beyond the face value of the forgone tax dollars. Funders, foundations and individual donations to not-for-profit hospitals comprise about $6 billion annually,<a href=\"#_edn14\" name=\"_ednref14\">[xiv]<\/a> with the majority of contributions going towards new buildings, renovations and new services. In exchange for all this, the IRS estimated that, in 2015, approximately $62.4 billion was spent on community benefit, about 10 percent of collective tax-exempt hospital revenue.<a href=\"#_edn15\" name=\"_ednref15\">[xv]<\/a><\/p>\n<p>Generally, hospitals do not pay four types of taxes: property, state and local income, sales and use, and bond financing. Of these, property taxes make up the largest segment of a hospital\u2019s tax exemption \u2013 about one-quarter.<a href=\"#_edn16\" name=\"_ednref16\">[xvi]<\/a> Because of this, the local community feels the most impact from the hospital\u2019s tax exemption, as the forgone tax revenue might have instead been used to support government-funded services, such as public schools, fire departments and police. Additionally, the hospital\u2019s tax-exempt status opens up other areas for savings, including local tax-exempt bond financing and donations.<\/p>\n<p>Remember, there are two other types of hospitals \u2013 for-profit and government-owned. Together, these comprise only about 20 percent of all hospitals, meaning not-for-profit is the prevailing structure when it comes to hospitals. Government hospitals \u2013 such as the Veteran\u2019s Administration \u2013 tend to have a specific focus and treat the poorest of the poor, leading to a unique partnership with local and federal authorities.<\/p>\n<p>But there isn\u2019t a noticeable difference between for-profits and tax-exempt hospitals other than their structure. For-profit hospitals distribute earnings to shareholders, while not-for-profit hospitals are charged with investing any proceeds back into the hospital and patient care \u2013 \u00a0particularly care for those most vulnerable, bringing us back to community benefit.<\/p>\n<p>Multiple studies have shown that, generally speaking, there is no real difference between the amount of charity care and shortfalls incurred from Medicaid between for-profits and non-profits.<a href=\"#_edn17\" name=\"_ednref17\">[xvii]<\/a>\u00a0 As Steven T. Miller, Commissioner of Tax Exempt and Government Entities for the IRS, stated in January 2009:<\/p>\n<p>\u201cTo the man on the street, a tax-exempt hospital may look remarkably similar to one that pays tax. And that same man on the street might reasonably ask why the standard I described above \u2013 that the hospital benefits the community it serves through the promotion of health \u2013 would not also be met by a for-profit hospital. So the tax policy and tax administration question that needs to be addressed is: How does one meaningfully differentiate a taxpaying, for-profit hospital from a non-profit hospital that enjoys exemption from federal and state tax, exemption from property tax, and eligibility for favorable bond financing?\u201d<a href=\"#_edn18\" name=\"_ednref18\">[xviii]<\/a><\/p>\n<p><a name=\"_Toc492822184\"><\/a>This is a question many policymakers and leaders are considering. In March 2010, the Illinois Supreme Court stripped tax-exempt Chicago-based hospital system Provena of its property tax exemption. The Attorney General\u2019s office subsequently stated the hospital provided insufficient charity care to justify its tax status and did not let patients know assistance was available. Through this ruling, the Court reasoned that financial assistance programs are a key component of tax-exempt hospitals legal obligation.<a href=\"#_edn19\" name=\"_ednref19\">[xix]<\/a><\/p>\n<p><a name=\"_Toc492822185\"><\/a>In 2015, Senator Charles Grassley (R-IA) called out Mosaic Life Care,<a href=\"#_edn20\" name=\"_ednref20\">[xx]<\/a> a Missouri-based tax-exempt hospital that was found to aggressively pursue low-income patients for unpaid debts. As expressed in a 2016 letter by Grassley to fellow Congressional members:<a href=\"#_edn21\" name=\"_ednref21\">[xxi]<\/a><\/p>\n<p>\u201cAs Commissioner of the Internal Revenue Service (IRS), you should be made aware of problematic activity within the charitable hospital community. Granted, we can both agree that many charitable hospitals perform good work on behalf of the communities that they service. However, some charitable hospitals get as close to the line as possible, while others callously breach it. It is important that Congress, via its oversight role, and the IRS ensure that charitable hospitals are functioning as intended.\u201d<a href=\"#_edn22\" name=\"_ednref22\">[xxii]<\/a><\/p>\n<p>&nbsp;<\/p>\n<p><a name=\"_Toc492822199\"><\/a><strong>Conclusion<\/strong><\/p>\n<p>Without a doubt, not-for-profit hospitals provide vital services to communities. However policymakers should continue to examine tax-exempt hospitals and their community benefit expenditures to ensure there is justification for their status beyond the simple provision of care \u2013 particularly in states where Medicaid has been expanded. Tax-exempt hospitals owe this to their communities and their low-income patients.<\/p>\n<p>&nbsp;<\/p>\n<p>The issues policymakers have attempted to address through various laws and initiatives aimed at increasing access to care for lower-income patients seem to have limited impact, even with the partial expansion of a program meant to help provide health coverage to low-income patients. This could be for several reasons, including a lack of clear and measurable requirements for tax-exempt hospitals, a lack of knowledge of the value of a tax exemption and limited data regarding tax-exempt hospital community benefit.<\/p>\n<p>&nbsp;<\/p>\n<p>With this in mind, there are a few policy items to consider:<\/p>\n<p>&nbsp;<\/p>\n<p><u>Set concrete thresholds for federal tax exemptions.<\/u> Minimum community benefit financial thresholds would provide both policymakers and hospitals an absolute standard. However, it\u2019s important to note commonly cited arguments to this, which is that high-performing hospitals may reduce activities and\/or hospitals might only undertake the activities that count to a community benefit. Additionally, such thresholds should account for the difference between hospitals, such as urban research facilities, children\u2019s hospitals and critical access hospitals, as they have varying patient characteristics and other factors that impact their community benefit expenditures.<\/p>\n<p>&nbsp;<\/p>\n<p><u>Publish the value of individual hospital\u2019s tax exemption to further this discussion.<\/u> An overwhelming majority of hospitals provide no direct information on their tax exemption, making it difficult to have a real sense of what the local impact could be. Hospitals could be required to provide an annual assessment of their exemption to provide specific detail about its value. This information could be made available to the public, reported to the IRS, and be used for increased transparency and accountability as well as inform any imposed minimum thresholds.<\/p>\n<p><u>\u00a0<\/u><\/p>\n<p><u>Create mechanisms for increased transparency and accountability.<\/u> Most tax-exempt hospitals do not readily provide a copy of their IRS Form 990, nor do all publish information about their community benefit expenditures. Those that do often complicate that information with figures that do not correspond with the IRS\u2019s definition of community benefit, such as bad debt at charge. States vary in their laws governing community benefit reporting, and even for states that do provide this information, it is difficult to find. To add to this, most hospitals<a href=\"#_edn23\" name=\"_ednref23\">[xxiii]<\/a> exist within a hospital system, which can create a complex picture of overall financials. Increased transparency would allow for communities to work more effectively with their local hospitals to create local standards for the tax exemption, a particularly important point considering the biggest impact of an exemption is within the local community.<\/p>\n<p>&nbsp;<\/p>\n<p><u>Tie exemptions to outcomes<\/u>. By establishing mechanisms to better capture community-based care outcomes, hospitals could align those activities with others that are part of the general trend towards value-based medicine.<a href=\"#_edn24\" name=\"_ednref24\">[xxiv]<\/a> This, however, could create an administrative burden in ensuring these outcomes were met, especially if the hospital has the discretion to determine their own targeted outcomes.<\/p>\n<p><a href=\"#_ednref1\" name=\"_edn1\">[i]<\/a> \u201cFast Facts on US Hospitals.\u201d\u00a0<em>Fast Facts<\/em>, American Hospital Association, 1 Dec. 2016, www.aha.org\/research\/rc\/stat-studies\/fast-facts.shtml. Accessed 4 Aug. 2017.<\/p>\n<p><a href=\"#_ednref2\" name=\"_edn2\">[ii]<\/a> Patient Protection and Affordable Care Act, 43 U.S.C. \u00a718001 et seq. (2010).<\/p>\n<p><a href=\"#_ednref3\" name=\"_edn3\">[iii]<\/a> Young, Gary J., et al. \u201cProvision of Community Benefits by Tax-Exempt U.S. Hospitals.\u201d\u00a0<em>The New England Journal of Medicine<\/em>, vol. 368, no. 16, 2013, pp. 1519\u20131527.<\/p>\n<p><a href=\"#_ednref4\" name=\"_edn4\">[iv]<\/a> Cohn, Jonathan. <em>Sick: The Untold Story of America\u2019s Health Care Crisis \u2013 And the People Who Paid the Price.<\/em> Harper Perennial. 2008.<\/p>\n<p><a href=\"#_ednref5\" name=\"_edn5\">[v]<\/a> Scofea, Laura A. \u201cThe Development and Growth of Employer-Provided Health Insurance.\u201d\u00a0<em>Monthly Labor Review<\/em>, vol. 117, no. 3, 1994, pp. 3\u201310.<\/p>\n<p><a href=\"#_ednref6\" name=\"_edn6\">[vi]<\/a> The structure Kimball created was that, for $0.50 cents a month, teachers would receive two weeks of paid hospital care.<\/p>\n<p><a href=\"#_ednref7\" name=\"_edn7\">[vii]<\/a> Scofea, Laura A. \u201cThe Development and Growth of Employer-Provided Health Insurance.\u201d\u00a0<em>Monthly Labor Review<\/em>, vol. 117, no. 3, 1994, pp. 3\u201310.<\/p>\n<p><a href=\"#_ednref8\" name=\"_edn8\">[viii]<\/a> Cohn, Jonathan. <em>Sick: The Untold Story of America\u2019s Health Care Crisis \u2013 And the People Who Paid the Price.<\/em> Harper Perennial. 2008.<\/p>\n<p><a href=\"#_ednref9\" name=\"_edn9\">[ix]<\/a> Stevens, Rosemary. \u201cA Poor Sort of Memory: Voluntary Hospitals and Government before the Depression.\u201d\u00a0<em>The Milbank Memorial Fund Quarterly. Health and Society<\/em>, vol. 60, no. 4, 1982, pp. 551\u2013584.<\/p>\n<p><a href=\"#_ednref10\" name=\"_edn10\">[x]<\/a> AHAhospitals. \u201cEconomic Contribution of Hospitals Often Overlooked.\u201d\u00a0American Hospital Association, 2013, http:\/\/www.aha.org\/content\/13\/13brief-econcontrib.pdf. Accessed 6 Aug. 2017.<\/p>\n<p><a href=\"#_ednref11\" name=\"_edn11\">[xi]<\/a> AHAhospitals. \u201cEconomic Contribution of Hospitals Often Overlooked.\u201d\u00a0American Hospital Association, 2013, http:\/\/www.aha.org\/content\/13\/13brief-econcontrib.pdf. Accessed 6 Aug. 2017.<\/p>\n<p><a href=\"#_ednref12\" name=\"_edn12\">[xii]<\/a> Rosenbaum, Sara, et al. \u201cThe Value of The Nonprofit Hospital Tax Exemption Was $24.6 Billion In 2011.\u201d\u00a0<em>Health Affairs (Project Hope)<\/em>, vol. 34, no. 7, 2015, pp. 1225\u201333.<\/p>\n<p><a href=\"#_ednref13\" name=\"_edn13\">[xiii]<\/a> General Accounting Office (US).\u00a0\u201cNonprofit hospitals: variation in standards and guidance limits comparison of how hospitals meet community benefit requirements.\u201d GAO-08-880.\u00a02008.<\/p>\n<p><a href=\"#_ednref14\" name=\"_edn14\">[xiv]<\/a> Subsidyscope, Pew Charitable Trusts.\u00a0Congressional Research Service estimates, 2008.\u00a0[cited 2010 Sep 28]. Available from: http:\/\/subsidyscope.com\/nonprofits\/tax-expenditures\/health-charitable-contributions.<\/p>\n<p><a href=\"#_ednref15\" name=\"_edn15\">[xv]<\/a> Rosenbaum, Sara, et al. \u201cThe Value of The Nonprofit Hospital Tax Exemption Was $24.6 Billion In 2011.\u201d\u00a0<em>Health Affairs (Project Hope)<\/em>, vol. 34, no. 7, 2015, pp. 1225\u201333.<\/p>\n<p><a href=\"#_ednref16\" name=\"_edn16\">[xvi]<\/a> Santos, Eric J. \u201cProperty Tax Exemptions for Hospitals: A Blunt Instrument Where a Scapel is Needed.\u201d Columbia Journal of Tax Law, vol. 8, no 1, 2016.<\/p>\n<p><a href=\"#_ednref17\" name=\"_edn17\">[xvii]<\/a> Valdovinos, Erica, et al. \u201cIn California, Not-for-Profit Hospitals Spent More Operating Expenses on Charity Care than for-Profit Hospitals Spent.\u201d\u00a0<em>Health Affairs (Project Hope)<\/em>, vol. 34, no. 8, 2015, pp. 1296\u2013303.<\/p>\n<p><a href=\"#_ednref18\" name=\"_edn18\">[xviii]<\/a> Accessed via the web at: https:\/\/www.irs.gov\/pub\/irs-tege\/miller_speech_011209.pdf<\/p>\n<p><a href=\"#_ednref19\" name=\"_edn19\">[xix]<\/a> Provena Covenant Med. Ctr. v. Dep\u2019t of Revenue, 925 N.E.2d 1131, 236 Ill. 2d 368, 2010 Ill. LEXIS 289, 339 Ill. Dec. 10 (Ill. Mar. 18, 2010). At the time of the lawsuit\u2019s filling in 2002,<\/p>\n<p>only 0.3 percent of patients received free or discounted care at a cost to the hospital of 0.7 percent of its $113 million revenue.<\/p>\n<p><a href=\"#_ednref20\" name=\"_edn20\">[xx]<\/a> At the initial filing of the case, Mosiac was named Heartland Health. The hospital later changed its name.<\/p>\n<p><a href=\"#_ednref21\" name=\"_edn21\">[xxi]<\/a> Sen. Grassely\u2019s letter was accessed at: https:\/\/www.judiciary.senate.gov\/imo\/media\/doc\/2016-06-09%20CEG%20to%20IRS%20(Mosaic%20Non-Profit).pdf<\/p>\n<p><a href=\"#_ednref22\" name=\"_edn22\">[xxii]<\/a> Sen. Grassely\u2019s letter was accessed at: https:\/\/www.judiciary.senate.gov\/imo\/media\/doc\/2016-06-09%20CEG%20to%20IRS%20(Mosaic%20Non-Profit).pdf<\/p>\n<p><a href=\"#_ednref23\" name=\"_edn23\">[xxiii]<\/a> AHAhospitals. \u201cFast Facts on US Hospitals.\u201d\u00a0American Hospital Association, 1 Dec. 2016, www.aha.org\/research\/rc\/stat-studies\/fast-facts.shtml. Accessed 6 Aug. 2017.<\/p>\n<p><a href=\"#_ednref24\" name=\"_edn24\">[xxiv]<\/a> Rubin, Daniel B, et al. \u201cEvaluating Hospitals&amp;Apos; Provision of Community Benefit: an Argument for an Outcome-Based Approach to Nonprofit Hospital Tax Exemption.\u201d\u00a0<em>American Journal of Public Health<\/em>, vol. 103, no. 4, 2013, pp. 612\u20136.<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>El texto de este art\u00edculo a\u00fan no est\u00e1 disponible en espa\u00f1ol. \u00a1Por favor mant\u00e9ngase al tanto!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Le texte de cet article n&#8217;est pas encore disponible en espagnol. S&#8217;il vous pla\u00eet restez \u00e0 l&#8217;\u00e9coute!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"Increasingly, health care in the U.S. is consolidating and at the forefront of these shifts are nonprofit hospitals and systems. We delve into the history of this particular hospital structure to better understand the future it's building.","page_subheader_es":"Cada vez m\u00e1s, la atenci\u00f3n m\u00e9dica en los EE. UU. Se est\u00e1 consolidando y a la vanguardia de estos cambios se encuentran hospitales y sistemas sin fines de lucro. Nos adentramos en la historia de esta estructura hospitalaria en particular para comprender mejor el futuro que est\u00e1 construyendo.","page_subheader_fr":"Aux \u00c9tats-Unis, les soins de sant\u00e9 se consolident de plus en plus et au premier rang de ces changements se trouvent les h\u00f4pitaux et les syst\u00e8mes \u00e0 but non lucratif. Nous nous plongerons dans l'histoire de la structure de cet h\u00f4pital afin de mieux comprendre son avenir."},{"slug":"equity-and-health-assessments","ideas_cat":"Solutions","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/06\/equity.jpg","page_title_en":"Building equity into health needs assessments","page_title_es":"Incorporar equidad en las evaluaciones de necesidades de salud","page_title_fr":"Construire l'\u00e9quit\u00e9 dans les \u00e9valuations des besoins de sant\u00e9","page_content_en":"<p>Hospitals are critical to health equity and community health, often serving as the primary point of care for many patients. \u00a0In the U.S., nearly two-thirds of all U.S. hospitals are tax-exempt, meaning they don\u2019t pay certain taxes due to their charitable nature. Because of this, they are required to give back to their community certain benefits to earn that exemption.<\/p>\n<p>With the passage of the 2010 Patient Protection and Affordable Care Act came certain obligations these hospitals were required to take. Key among these is the requirement for all nonprofit hospitals to undertake a triennial community health needs assessment (CHNA). In its simplest definition, a CHNA is a measurement of the relative health or well-being of any given community. It\u2019s both the activity and end-product of identifying and prioritizing a community\u2019s health needs. Once crafted, hospitals are required to develop an implementation strategy outlining how that hospital will address those unmet health needs.<\/p>\n<p>There is a tremendous opportunity to address the root causes of poor health through these CHNAs. By both best practice and law, hospitals must bring into consideration the thoughts and input of certain key stakeholders, including public health entities and those representing vulnerable populations. Hospitals are to both quantify and qualify the health issues in their community and identify the priorities they\u2019ll take on for the next three years. Once the plan is approved by the hospital\u2019s board, the hospital is then required to craft an implementation plan outlining how it will address those unmet health needs. This means that hospitals must be actively aware of the unmet health needs in their community and create a strategic plan to improve the health of everyone, including those most often facing barriers to care.<\/p>\n<p>In 2018, Fair Play founder and managing director Holly Lang partnered with Jessica Curtis, senior advisor for the Center for Consumer Engagement in Health Innovation at national nonprofit consumer advocacy group Community Catalyst to build the consumer and community leadership that is required to transform the American health system.<\/p>\n<p>The dashboard lays out an ideal state of activities, programs and governance for addressing the root causes of poor health in direct partnership with the communities most impacted by health disparities and injustice. It outlines five principles for hospital community benefit programs, and the array of program indicators within this dashboard exceed basic requirements found in the 2010 Affordable Care Act.<\/p>\n<p>The five principles are:<\/p>\n<p style=\"padding-left: 80px;\"><strong>Principle 1:<\/strong> Target neighborhoods and population groups experiencing health disparities and address the root causes of poor health, including structural injustice and social\/economic health determinants.<\/p>\n<p style=\"padding-left: 80px;\"><strong>Principle 2:<\/strong> Center community engagement efforts on community residents who have long borne the brunt of health inequities and structural injustice and take steps to make their involvement in the community benefit process meaningful to them.<\/p>\n<p style=\"padding-left: 80px;\"><strong>Principle 3:<\/strong> Adopt financial assistance and billing policies that promote economic security, build racial and gender wealth equity, and preserve access to care for low- and moderate-income community residents.<\/p>\n<p style=\"padding-left: 80px;\"><strong>Principle 4:<\/strong> Invest in governance structures to ensure staff and programs have the internal resources and funding they need to effectively address community priorities.<\/p>\n<p style=\"padding-left: 80px;\"><strong>Principle 5:<\/strong> Evaluate health equity and community engagement efforts and share findings with internal and community stakeholders.<\/p>\n<p>This dashboard was developed to reflect the lived experiences and recommendations of community-based leaders, advocates and hospital leaders within our network who share our vision for using community benefit to achieve health equity. The methodology included an extensive literature review; a qualitative analysis of a convenient sample of hospital community health needs assessments (CHNAs); and interviews with hospital community benefit staff and community partners.<\/p>\n<p>You can<a href=\"https:\/\/www.communitycatalyst.org\/resources\/publications\/document\/CC-HospitalCommenefitDashboard-Report-F2.pdf\"> access the dashboard here<\/a> and read a <a href=\"https:\/\/www.communitycatalyst.org\/resources\/publications\/document\/CC-Community-Benefit-Report-FINAL.pdf\">case study on how three U.S. communities tackled health equity<\/a>. You can <a href=\"https:\/\/www.communitycatalyst.org\">learn more about Community Catalyst here.<\/a><\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>Los hospitales son cr\u00edticos para la equidad en salud y la salud de la comunidad, y a menudo sirven como el principal punto de atenci\u00f3n para muchos pacientes. En los Estados Unidos, casi dos tercios de todos los hospitales estadounidenses est\u00e1n exentos de impuestos, lo que significa que no pagan ciertos impuestos debido a su naturaleza caritativa. Debido a esto, est\u00e1n obligados a devolver a su comunidad ciertos beneficios para obtener esa exenci\u00f3n.<\/p>\n<p>Con la aprobaci\u00f3n de la Ley de Protecci\u00f3n del Paciente y Cuidado de Salud a Bajo Precio de 2010, surgieron ciertas obligaciones que estos hospitales deb\u00edan asumir. La clave es el requisito de que todos los hospitales sin fines de lucro realicen una evaluaci\u00f3n trienal de las necesidades de salud de la comunidad (CHNA). En su definici\u00f3n m\u00e1s simple, un CHNA es una medida de la salud o el bienestar relativo de cualquier comunidad. Es tanto la actividad como el producto final de identificar y priorizar las necesidades de salud de una comunidad. Una vez dise\u00f1ados, los hospitales deben desarrollar una estrategia de implementaci\u00f3n que describa c\u00f3mo ese hospital abordar\u00e1 esas necesidades de salud insatisfechas.<\/p>\n<p>Existe una gran oportunidad para abordar las causas profundas de la mala salud a trav\u00e9s de estos CHNA. Seg\u00fan las mejores pr\u00e1cticas y la ley, los hospitales deben tener en cuenta los pensamientos y las aportaciones de ciertas partes interesadas clave, incluidas las entidades de salud p\u00fablica y las que representan a las poblaciones vulnerables. Los hospitales deben cuantificar y calificar los problemas de salud en su comunidad e identificar las prioridades que asumir\u00e1n durante los pr\u00f3ximos tres a\u00f1os. Una vez que la junta del hospital aprueba el plan, el hospital debe elaborar un plan de implementaci\u00f3n que describa c\u00f3mo abordar\u00e1 esas necesidades de salud no satisfechas. Esto significa que los hospitales deben ser conscientes de las necesidades de salud insatisfechas en su comunidad y crear un plan estrat\u00e9gico para mejorar la salud de todos, incluidos aquellos que a menudo enfrentan barreras para la atenci\u00f3n.<\/p>\n<p>En 2018, la fundadora y directora administrativa de Fair Play, Holly Lang, se asoci\u00f3 con Jessica Curtis, asesora principal del Centro para la Participaci\u00f3n del Consumidor en Innovaci\u00f3n en Salud en el grupo nacional sin fines de lucro de defensa del consumidor Community Catalyst para construir el liderazgo de los consumidores y la comunidad que se requiere para transformar la salud estadounidense sistema.<\/p>\n<p>El tablero presenta un estado ideal de actividades, programas y gobernanza para abordar las causas profundas de la mala salud en asociaci\u00f3n directa con las comunidades m\u00e1s afectadas por las disparidades de salud y la injusticia. Describe cinco principios para los programas de beneficios comunitarios hospitalarios, y la variedad de indicadores del programa dentro de este tablero excede los requisitos b\u00e1sicos que se encuentran en la Ley del Cuidado de Salud a Bajo Precio de 2010.<\/p>\n<p>Los cinco principios son:<\/p>\n<ul>\n<li><strong>Principio 1: <\/strong>Dirigirse a los vecindarios y grupos de poblaci\u00f3n que experimentan disparidades de salud y abordar las causas profundas de la mala salud, incluidas la injusticia estructural y los determinantes de la salud social \/ econ\u00f3mica<\/li>\n<li><strong>Principio 2:<\/strong> Centrar los esfuerzos de participaci\u00f3n de la comunidad en los residentes de la comunidad que han soportado durante mucho tiempo la peor parte de las inequidades en salud y la injusticia estructural y tomar medidas para que su participaci\u00f3n en el proceso de beneficio comunitario sea significativa para ellos.<\/li>\n<li><strong>Principio 3:<\/strong> Adoptar asistencia financiera y pol\u00edticas de facturaci\u00f3n que promuevan la seguridad econ\u00f3mica, generen equidad racial y de g\u00e9nero, y preserven el acceso a la atenci\u00f3n de los residentes de la comunidad de ingresos bajos y moderados.<\/li>\n<li><strong>Principio 4:<\/strong> Invierta en estructuras de gobernanza para garantizar que el personal y los programas tengan los recursos internos y la financiaci\u00f3n que necesitan para abordar eficazmente las prioridades de la comunidad.<\/li>\n<li><strong>Principio 5:<\/strong> Evaluar la equidad en salud y los esfuerzos de participaci\u00f3n comunitaria y compartir los hallazgos con las partes interesadas internas y comunitarias.<\/li>\n<\/ul>\n<p>Este panel se desarroll\u00f3 para reflejar las experiencias vividas y las recomendaciones de l\u00edderes comunitarios, defensores y l\u00edderes hospitalarios dentro de nuestra red que comparten nuestra visi\u00f3n de utilizar los beneficios de la comunidad para lograr la equidad en salud. La metodolog\u00eda incluy\u00f3 una extensa revisi\u00f3n de la literatura; un an\u00e1lisis cualitativo de una muestra conveniente de evaluaciones de necesidades de salud de la comunidad hospitalaria (CHNA); y entrevistas con el personal de beneficio comunitario del hospital y socios de la comunidad.<\/p>\n<p>Puede <a href=\"https:\/\/www.communitycatalyst.org\/resources\/publications\/document\/CC-HospitalCommenefitDashboard-Report-F2.pdf\">acceder al panel de control aqu\u00ed<\/a> y<a href=\"https:\/\/www.communitycatalyst.org\/resources\/publications\/document\/CC-Community-Benefit-Report-FINAL.pdf\"> leer un estudio de caso sobre<\/a> c\u00f3mo tres comunidades de EE. UU. Abordaron la equidad en salud. Puede obtener m\u00e1s informaci\u00f3n sobre <a href=\"https:\/\/www.communitycatalyst.org\/\">Community Catalyst aqu\u00ed<\/a>.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Les h\u00f4pitaux sont essentiels \u00e0 l&#8217;\u00e9quit\u00e9 en mati\u00e8re de sant\u00e9 et \u00e0 la sant\u00e9 communautaire et constituent souvent le principal point de traitement de nombreux patients. Aux \u00c9tats-Unis, pr\u00e8s des deux tiers des h\u00f4pitaux am\u00e9ricains sont exon\u00e9r\u00e9s d\u2019imp\u00f4t, c\u2019est-\u00e0-dire qu\u2019ils ne paient pas certains imp\u00f4ts en raison de leur caract\u00e8re charitable. Pour cette raison, ils doivent redonner \u00e0 leur communaut\u00e9 certains avantages pour b\u00e9n\u00e9ficier de cette exemption.<\/p>\n<p>Avec l&#8217;adoption de la loi de 2010 sur la protection des patients et les soins abordables, certaines obligations incombaient \u00e0 ces h\u00f4pitaux. Parmi celles-ci, l&#8217;une des plus importantes est la n\u00e9cessit\u00e9 pour tous les h\u00f4pitaux \u00e0 but non lucratif d&#8217;entreprendre une \u00e9valuation triennale des besoins en mati\u00e8re de sant\u00e9 communautaire (CHNA). Dans sa d\u00e9finition la plus simple, un CHNA est une mesure de la sant\u00e9 ou du bien-\u00eatre relatif d&#8217;une communaut\u00e9 donn\u00e9e. C\u2019est \u00e0 la fois l\u2019activit\u00e9 et le produit final de l\u2019identification et de la priorisation des besoins de sant\u00e9 d\u2019une communaut\u00e9. Une fois con\u00e7us, les h\u00f4pitaux doivent \u00e9laborer une strat\u00e9gie de mise en \u0153uvre indiquant comment cet h\u00f4pital r\u00e9pondra \u00e0 ces besoins de sant\u00e9 non satisfaits.<\/p>\n<p>Les PSSA offrent une formidable opportunit\u00e9 de s\u2019attaquer aux causes profondes du mauvais \u00e9tat de sant\u00e9. Selon les meilleures pratiques et la l\u00e9gislation, les h\u00f4pitaux doivent prendre en compte les opinions et les contributions de certains acteurs cl\u00e9s, notamment les entit\u00e9s de sant\u00e9 publique et les repr\u00e9sentants des populations vuln\u00e9rables. Les h\u00f4pitaux doivent quantifier et qualifier les probl\u00e8mes de sant\u00e9 de leur communaut\u00e9 et identifier les priorit\u00e9s qu\u2019ils prendront au cours des trois prochaines ann\u00e9es. Une fois le plan approuv\u00e9 par le conseil d\u2019administration de l\u2019h\u00f4pital, celui-ci doit \u00e9laborer un plan de mise en \u0153uvre d\u00e9crivant comment il r\u00e9pondra \u00e0 ces besoins de sant\u00e9 non satisfaits. Cela signifie que les h\u00f4pitaux doivent \u00eatre activement conscients des besoins de sant\u00e9 non satisfaits dans leur communaut\u00e9 et cr\u00e9er un plan strat\u00e9gique pour am\u00e9liorer la sant\u00e9 de tous, y compris de ceux qui rencontrent le plus souvent des obstacles aux soins.<\/p>\n<p>En 2018, la fondatrice et directrice g\u00e9n\u00e9rale de Fair Play, Holly Lang, s&#8217;est associ\u00e9e \u00e0 Jessica Curtis, conseill\u00e8re principale du Centre pour l&#8217;engagement des consommateurs dans l&#8217;innovation en sant\u00e9 du groupe national de d\u00e9fense des consommateurs \u00e0 but non lucratif Community Catalyst, afin de cr\u00e9er le leadership des consommateurs et de la communaut\u00e9 n\u00e9cessaire pour transformer le syst\u00e8me de sant\u00e9 am\u00e9ricain. syst\u00e8me.<\/p>\n<p>Le tableau de bord pr\u00e9sente un \u00e9tat id\u00e9al d&#8217;activit\u00e9s, de programmes et de gouvernance permettant de s&#8217;attaquer aux causes profondes de la mauvaise sant\u00e9 en partenariat direct avec les communaut\u00e9s les plus touch\u00e9es par les in\u00e9galit\u00e9s en mati\u00e8re de sant\u00e9 et les injustices. Il pr\u00e9sente cinq principes pour les programmes d\u2019avantages communautaires hospitaliers et la gamme d\u2019indicateurs de programme figurant dans ce tableau de bord d\u00e9passe les exigences de base d\u00e9finies dans la Loi de 2010 sur les soins abordables.<\/p>\n<p>Les cinq principes sont:<\/p>\n<p>Principe 1: Les quartiers et les groupes de population cibl\u00e9s sont confront\u00e9s \u00e0 des disparit\u00e9s en mati\u00e8re de sant\u00e9 et s&#8217;attaquent aux causes profondes du mauvais \u00e9tat de sant\u00e9, y compris l&#8217;injustice structurelle et les d\u00e9terminants sociaux \/ \u00e9conomiques de la sant\u00e9.<\/p>\n<p>Principe 2: Centrer les efforts de participation de la communaut\u00e9 sur les r\u00e9sidents de la communaut\u00e9 qui ont longtemps \u00e9t\u00e9 les plus touch\u00e9s par les in\u00e9galit\u00e9s en mati\u00e8re de sant\u00e9 et l\u2019injustice structurelle, et prendre des mesures pour que leur implication dans le processus de b\u00e9n\u00e9fices pour la communaut\u00e9 ait un sens.<\/p>\n<p>Principe 3: Adopter des politiques d\u2019aide financi\u00e8re et de facturation qui favorisent la s\u00e9curit\u00e9 \u00e9conomique, favorisent l\u2019\u00e9quit\u00e9 entre les groupes raciaux et les hommes et les femmes, et pr\u00e9servent l\u2019acc\u00e8s aux soins des r\u00e9sidents des communaut\u00e9s \u00e0 revenus faibles ou mod\u00e9r\u00e9s.<\/p>\n<p>Principe 4: Investir dans les structures de gouvernance pour s&#8217;assurer que le personnel et les programmes disposent des ressources internes et du financement n\u00e9cessaires pour r\u00e9pondre efficacement aux priorit\u00e9s de la communaut\u00e9.<\/p>\n<p>Principe 5: \u00c9valuer les efforts en mati\u00e8re d&#8217;\u00e9quit\u00e9 en sant\u00e9 et d&#8217;engagement de la communaut\u00e9 et partager les r\u00e9sultats avec les intervenants internes et communautaires.<\/p>\n<p>Ce tableau de bord a \u00e9t\u00e9 d\u00e9velopp\u00e9 pour refl\u00e9ter les exp\u00e9riences v\u00e9cues et les recommandations des leaders communautaires, des d\u00e9fenseurs et des leaders hospitaliers de notre r\u00e9seau qui partagent notre vision d&#8217;utiliser les b\u00e9n\u00e9fices pour la communaut\u00e9 pour atteindre l&#8217;\u00e9quit\u00e9 en sant\u00e9. La m\u00e9thodologie comprenait une revue de litt\u00e9rature approfondie; une analyse qualitative d&#8217;un \u00e9chantillon commode d&#8217;\u00e9valuations des besoins en mati\u00e8re de sant\u00e9 dans les communaut\u00e9s hospitali\u00e8res (CHNA); et des entretiens avec le personnel des avantages communautaires des h\u00f4pitaux et les partenaires communautaires.<\/p>\n<p>En 2018, la fondatrice et directrice g\u00e9n\u00e9rale de Fair Play, Holly Lang, s&#8217;est associ\u00e9e \u00e0 Jessica Curtis, conseill\u00e8re principale du Centre pour l&#8217;engagement des consommateurs dans l&#8217;innovation en sant\u00e9 du groupe national de d\u00e9fense des consommateurs \u00e0 but non lucratif Community Catalyst, afin de cr\u00e9er le leadership des consommateurs et de la communaut\u00e9 n\u00e9cessaire pour transformer le syst\u00e8me de sant\u00e9 am\u00e9ricain. syst\u00e8me.<\/p>\n<p>Le tableau de bord pr\u00e9sente un \u00e9tat id\u00e9al d&#8217;activit\u00e9s, de programmes et de gouvernance permettant de s&#8217;attaquer aux causes profondes de la mauvaise sant\u00e9 en partenariat direct avec les communaut\u00e9s les plus touch\u00e9es par les in\u00e9galit\u00e9s en mati\u00e8re de sant\u00e9 et les injustices. Il pr\u00e9sente cinq principes pour les programmes d\u2019avantages communautaires hospitaliers et la gamme d\u2019indicateurs de programme figurant dans ce tableau de bord d\u00e9passe les exigences de base d\u00e9finies dans la Loi de 2010 sur les soins abordables.<\/p>\n<p>Les cinq principes sont:<\/p>\n<ul>\n<li><strong>Principe 1:<\/strong> Les quartiers et les groupes de population cibl\u00e9s sont confront\u00e9s \u00e0 des disparit\u00e9s en mati\u00e8re de sant\u00e9 et s&#8217;attaquent aux causes profondes du mauvais \u00e9tat de sant\u00e9, y compris l&#8217;injustice structurelle et les d\u00e9terminants sociaux \/ \u00e9conomiques de la sant\u00e9.<\/li>\n<li><strong>Principe 2:<\/strong> Centrer les efforts de participation de la communaut\u00e9 sur les r\u00e9sidents de la communaut\u00e9 qui ont longtemps \u00e9t\u00e9 les plus touch\u00e9s par les in\u00e9galit\u00e9s en mati\u00e8re de sant\u00e9 et l\u2019injustice structurelle, et prendre des mesures pour que leur implication dans le processus de b\u00e9n\u00e9fices pour la communaut\u00e9 ait un sens.<\/li>\n<li><strong>Principe 3:<\/strong> Adopter des politiques d\u2019aide financi\u00e8re et de facturation qui favorisent la s\u00e9curit\u00e9 \u00e9conomique, favorisent l\u2019\u00e9quit\u00e9 entre les groupes raciaux et les hommes et les femmes, et pr\u00e9servent l\u2019acc\u00e8s aux soins des r\u00e9sidents des communaut\u00e9s \u00e0 revenus faibles ou mod\u00e9r\u00e9s.<\/li>\n<li><strong>Principe 4:<\/strong> Investir dans les structures de gouvernance pour s&#8217;assurer que le personnel et les programmes disposent des ressources internes et du financement n\u00e9cessaires pour r\u00e9pondre efficacement aux priorit\u00e9s de la communaut\u00e9.<\/li>\n<li><strong>Principe 5:<\/strong> \u00c9valuer les efforts en mati\u00e8re d&#8217;\u00e9quit\u00e9 en sant\u00e9 et d&#8217;engagement de la communaut\u00e9 et partager les r\u00e9sultats avec les intervenants internes et communautaires.<\/li>\n<\/ul>\n<p>Ce tableau de bord a \u00e9t\u00e9 d\u00e9velopp\u00e9 pour refl\u00e9ter les exp\u00e9riences v\u00e9cues et les recommandations des leaders communautaires, des d\u00e9fenseurs et des leaders hospitaliers de notre r\u00e9seau qui partagent notre vision d&#8217;utiliser les b\u00e9n\u00e9fices pour la communaut\u00e9 pour atteindre l&#8217;\u00e9quit\u00e9 en sant\u00e9. La m\u00e9thodologie comprenait une revue de litt\u00e9rature approfondie; une analyse qualitative d&#8217;un \u00e9chantillon commode d&#8217;\u00e9valuations des besoins en mati\u00e8re de sant\u00e9 dans les communaut\u00e9s hospitali\u00e8res (CHNA); et des entretiens avec le personnel des avantages communautaires des h\u00f4pitaux et les partenaires communautaires.<\/p>\n<p>Vous <a href=\"https:\/\/www.communitycatalyst.org\/resources\/publications\/document\/CC-HospitalCommenefitDashboard-Report-F2.pdf\">pouvez acc\u00e9der au tableau de bord ici<\/a> et <a href=\"https:\/\/www.communitycatalyst.org\/resources\/publications\/document\/CC-Community-Benefit-Report-FINAL.pdf\">lire une \u00e9tude de cas sur la mani\u00e8re dont trois communaut\u00e9s am\u00e9ricaines<\/a> ont trait\u00e9 l&#8217;\u00e9quit\u00e9 en mati\u00e8re de sant\u00e9. Vous pouvez en apprendre plus sur <a href=\"https:\/\/www.communitycatalyst.org\/\">Community Catalyst ici<\/a>.<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"U.S.-based not-for-profit hospitals are required to conduct triennial community health needs assessments as a way to better understand the health challenges their communities face. How can they build equity into that work?","page_subheader_es":"Los hospitales sin fines de lucro con sede en los EE. UU. Deben realizar evaluaciones trienales de las necesidades de salud de la comunidad como una forma de comprender mejor los desaf\u00edos de salud que enfrentan sus comunidades. \u00bfC\u00f3mo pueden construir equidad en ese trabajo?","page_subheader_fr":"Les h\u00f4pitaux \u00e0 but non lucratif bas\u00e9s aux \u00c9tats-Unis sont tenus d\u2019effectuer des \u00e9valuations triennales des besoins en mati\u00e8re de sant\u00e9 des communaut\u00e9s afin de mieux comprendre les probl\u00e8mes de sant\u00e9 auxquels leurs communaut\u00e9s sont confront\u00e9es. Comment peuvent-ils construire l'\u00e9quit\u00e9 dans ce travail?"},{"slug":"cancer-race-income","ideas_cat":"Analysis","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/06\/cancer-portrait.jpg","page_title_en":"How cancer discriminates: The role of income and race in cancer rates","page_title_es":"C\u00f3mo discrimina el c\u00e1ncer: el papel del ingreso y la raza en las tasas de c\u00e1ncer","page_title_fr":"Comment le cancer diff\u00e9rencie: le r\u00f4le du revenu et de la race dans les taux de cancer","page_content_en":"<p>Cancer kills hundreds of thousands of people in the U.S. each year, disproportionately affecting minorities and the poor. The reasons for this are complicated but often come down to two key issues \u2013 socioeconomic factors and race.<\/p>\n<p>Cancer is the second largest cause of death in the U.S.,<a href=\"#_edn1\" name=\"_ednref1\">[i]<\/a> killing approximately 609,640 people in 2018 alone. That year, more than 1.7 million new cases were diagnosed.<a href=\"#_edn2\" name=\"_ednref2\">[ii]<\/a> \u00a0This is not simply a problem that affects a small segment of the population; it is one of the most significant causes of premature death in the country, and there are multiple disparities between demographics.<\/p>\n<p>We know that biological diseases \u2013 like cancer \u2013 can be rooted in social causes.<a href=\"#_edn3\" name=\"_ednref3\">[iii]<\/a> It\u2019s important to understand how different social contexts can increase or decrease one\u2019s risk of health problems. To better understand this issue, we often use socioeconomic status (SES) as a way to understand the broader issues that surround poverty. With SES, we go beyond just wealth and examine other measures such as educational level, housing, employment and the social structures that increase or decrease health.<a href=\"#_edn4\" name=\"_ednref4\">[iv]<\/a> It is important to note that the majority of cancers are caused by lifestyle risk factors which are not innate, as opposed to genetic causes.<a href=\"#_edn5\" name=\"_ednref5\">[v]<\/a> Because of this, we need to look at these risk factors and the social patterns behind them in order to understand that inequities are more than just random occurrences or unfixable genetic conditions.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Poverty and cancer<\/strong><\/p>\n<p>Poverty is directly related to increased incidence rates of cancer,<a href=\"#_edn6\" name=\"_ednref6\">[vi]<\/a> as those with lower levels of education and lower levels of income \u2013 both common measures of SES \u2013 \u00a0experience higher rates of cancer diagnoses.<a href=\"#_edn7\" name=\"_ednref7\">[vii]<\/a> They are also more likely to die from certain cancers \u2013 particularly lung cancer and colorectal cancer.<a href=\"#_edn8\" name=\"_ednref8\">[viii]<\/a> For survivors, income and socioeconomic status are significant predictors of quality of life after cancer.<a href=\"#_edn9\" name=\"_ednref9\">[ix]<\/a> Increased income allows patients to maintain a level of comfort that people with low SES might not be able to afford.<a href=\"#_edn10\" name=\"_ednref10\">[x]<\/a> This means that even if a low income patient survives cancer, their quality of life after will be worse than someone more well off.<\/p>\n<p>People who are diagnosed at earlier stages of cancer are more likely to survive, regardless of ethnicity or SES.<a href=\"#_edn11\" name=\"_ednref11\">[xi]<\/a> Unfortunately, it is often more difficult to detect cancer in certain populations. For example, African American women are less likely to receive a stage I cancer diagnosis compared to white women, reducing their chances of survival.<a href=\"#_edn12\" name=\"_ednref12\">[xii]<\/a> This is because of biological differences between ethnicities that make it more difficult to diagnose cancer at an earlier stage in African American women in comparison to white women.<a href=\"#_edn13\" name=\"_ednref13\">[xiii]<\/a> African American women are also more likely to have triple negative breast cancer, meaning that the three most common receptors that cause breast cancer (and the ones that are primarily tested for) are not present, making it harder to diagnose them at earlier stages.<a href=\"#_edn14\" name=\"_ednref14\">[xiv]<\/a> This partially explains why African American women are often diagnosed later than white women, which leads to poorer cancer outcomes.<\/p>\n<p>However, this is not the only reason for disparities.<a href=\"#_edn15\" name=\"_ednref15\">[xv]<\/a> A study conducted on patients with stage I breast cancer demonstrated no differences in outcome based on ethnicity, when SES was controlled for.<a href=\"#_edn16\" name=\"_ednref16\">[xvi]<\/a> This would imply that if caught early enough, patients across a range of ethnic groups would have more equal health outcomes. Therefore, genetics don\u2019t appear to be the only factor for the higher rates of cancer rates and deaths for minorities.<\/p>\n<p><strong>\u00a0<\/strong><\/p>\n<p><strong>Race and cancer<\/strong><\/p>\n<p>Lower-income patients are more likely to have worse cancer outcomes than higher-income patients and are anywhere between 20 percent and 80 percent more likely to die from the disease.<a href=\"#_edn17\" name=\"_ednref17\">[xvii]<\/a> Therefore, not only are low-income patients more likely to be diagnosed with cancer, but those who are diagnosed are more likely to die from it than higher-income patients. The same is true for ethnicity. For example, white women have an 80 percent chance of surviving cancer, while Hispanic and African American women have a 78 percent and 66 percent chance of surviving up to ten years after treatment, respectively.<a href=\"#_edn18\" name=\"_ednref18\">[xviii]<\/a> For breast cancer, being an African American woman was a predictor of increased chances of death, compared to white counterparts.<a href=\"#_edn19\" name=\"_ednref19\">[xix]<\/a><\/p>\n<p>&nbsp;<\/p>\n<p><strong>Treatment inequities <\/strong><\/p>\n<p>The severity of disease has been found to be directly correlated to a lack of access to necessary health care.<a href=\"#_edn20\" name=\"_ednref20\">[xx]<\/a> Also known as the inverse care law, this means that those who require the most help receive the least.<\/p>\n<p>A study of a number of different cancer types found that higher-income populations had lower cancer mortality rates when compared to lower-income populations.<a href=\"#_edn21\" name=\"_ednref21\">[xxi]<\/a> This can be attributed in part to the fact that higher SES populations have greater access to screening services \u2013 which can detect smaller abnormalities \u2013 as well as greater access to necessary follow-ups to track care and develop treatment plans.<a href=\"#_edn22\" name=\"_ednref22\">[xxii]<\/a> Therefore, there are inequities not only in which populations get cancer, but also in how cancers are detected and treatment options that are available due to certain populations being able to afford better testing, services, etc.<\/p>\n<p>Additionally, African American women receive lower rates of care when it comes to breast cancer treatment, even when studies are adjusted for SES (in the form of equal insurance coverage).<a href=\"#_edn23\" name=\"_ednref23\">[xxiii]<\/a> African American women are also less likely to receive care and more likely to undergo more invasive treatments when they do receive care.<a href=\"#_edn24\" name=\"_ednref24\">[xxiv]<\/a> When it comes to prostate cancer, African American and white men access screening services equally, but Asian and Hispanic men have lower levels of access to these same services.<a href=\"#_edn25\" name=\"_ednref25\">[xxv]<\/a> This highlights that not all ethnic groups face the same barriers or lack of treatment equally.<\/p>\n<p>It is important to note that while studies have found that higher-income populations with cancer live longer than lower-income populations with cancer, this is not necessarily due to increased levels of health care.<a href=\"#_edn26\" name=\"_ednref26\">[xxvi]<\/a> One study found the relationship between mortality rates due to cancer and socioeconomic status isn\u2019t necessarily connected to health care utilization.<a href=\"#_edn27\" name=\"_ednref27\">[xxvii]<\/a> Level of access to cancer treatment might explain the discrepancies in health outcomes, but it doesn\u2019t explain how certain groups of people can experience higher rates of cancer in the first place.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Barriers to care<\/strong><\/p>\n<p>Based on the fact that lower-income and ethnic minority populations receive cancer treatments at lower levels than their higher-income counterparts, it seems that either: a) care for them does not exist, or b) there are barriers preventing them from accessing it.<\/p>\n<p>Individuals with private medical health insurance are usually more likely to be screened for cancer than those who do not have insurance.<a href=\"#_edn28\" name=\"_ednref28\">[xxviii]<\/a> This shows that those with higher SES have the means to access these services, while those who cannot afford insurance do not have the means. Medicaid was created as an attempt to bridge the gap for low-income Americans, but not all low-income residents in all states are able to access it equally due to differences in state eligibility laws. In some states, all poorer people are covered by Medicaid. In others, you have to first have a significant diagnosis (like cancer) to receive coverage. This creates a bit of a catch-22: you don\u2019t have coverage to receive the screening but that screening is necessary to receive coverage.<\/p>\n<p>Those that are enrolled in Medicaid are more likely to develop late-stage cancer, compared to those with alternative forms of health insurance.<a href=\"#_edn29\" name=\"_ednref29\">[xxix]<\/a> Men who were either uninsured or insured through Medicaid had more developed cancer at the time of screening and diagnosis, compared to men who had private health insurance.<a href=\"#_edn30\" name=\"_ednref30\">[xxx]<\/a> Medicaid coverage reduces some financial barriers to care such as early detection screenings, but it doesn\u2019t remove every barrier. And Medicaid is still marginally better than not having insurance \u2013 but given the differences in how states approach Medicaid (and considering 14 states did not expand eligibility since the passage of the Affordable Care Act), in certain states there are higher rates of those with no insurance as well as lower screening rates.<\/p>\n<p>Screening is critical to cancer survival, as lack of access to screening services has also been associated with increased mortality rates.<a href=\"#_edn31\" name=\"_ednref31\">[xxxi]<\/a> Ethnic minority groups have lower rates of access to screening services, in comparison to the majority white population.<a href=\"#_edn32\" name=\"_ednref32\">[xxxii]<\/a> For example, African American and Hispanic populations were less likely to be screened for colorectal cancer, compared to the white population.<a href=\"#_edn33\" name=\"_ednref33\">[xxxiii]<\/a> There are a number of reasons for this, including lower levels of private health insurance, cultural differences, and lack of trust in the healthcare system due to previous negative experiences.<a href=\"#_edn34\" name=\"_ednref34\">[xxxiv]<\/a><\/p>\n<p>Cancer treatment is time consuming and can be difficult to navigate due to the fact that it often involves multiple providers and appointments.<a href=\"#_edn35\" name=\"_ednref35\">[xxxv]<\/a> One of the barriers is language differences \u2013 Spanish-speaking Hispanics were 24 percent less likely to receive cancer screening services, compared to English-speaking Hispanics.<a href=\"#_edn36\" name=\"_ednref36\">[xxxvi]<\/a> But this barrier alone was not enough to account for the complete differences in ethnic demographics \u2013 rather, it exacerbates already-existing inequalities.<\/p>\n<p>We can clearly see the unequal trends in both rates of cancer and deaths caused by cancer \u2013 but what causes them? There are a number of different factors that should be considered, but it should also be noted that these social trends are complex and interwoven, and there is no single cause of these unequal health outcomes.<\/p>\n<p>To some extent, we can also blame the different mortality rates of cancer on genetic differences between ethnic groups \u2013 something that is innate and cannot be changed. White women are more likely to present with certain types of breast cancer, which are easier to treat and result in better outcomes than other more deadly types.<a href=\"#_edn37\" name=\"_ednref37\">[xxxvii]<\/a> This suggests there is a biological reason for different ethnic outcomes, including why African American women are more likely to die from breast cancer than white women. However, this alone does not explain the disparity between ethnic groups when it comes to incidence and mortality rates, and also does not work as an explanation for all cancers.<\/p>\n<p>There are also certain cancers that are directly related to lifestyle choices, including lung cancer \u2013 which is one of the most common and deadly forms of cancer in the U.S.<a href=\"#_edn38\" name=\"_ednref38\">[xxxviii]<\/a> Lung cancer is primarily caused by smoking, which makes it a choice as opposed to an unchangeable lifestyle factor.<a href=\"#_edn39\" name=\"_ednref39\">[xxxix]<\/a> Lower-income and minority populations are more likely to smoke and have higher rates of lung cancer when compared to white and higher-income populations.<a href=\"#_edn40\" name=\"_ednref40\">[xl]<\/a><\/p>\n<p>&nbsp;<\/p>\n<p><strong>Global trends<\/strong><\/p>\n<p>This phenomenon of cancer inequities is not specific to the U.S., as there are a number of countries that display the same trends in health inequities based on ethnicity and socioeconomic status.\u00a0 Much of the Western world loosely follows the same cancer trends due to the fact that lifestyles are very similar, and cancer trends between socioeconomic groups are relatively similar.<a href=\"#_edn41\" name=\"_ednref41\">[xli]<\/a> Although cancer mortality and inequities are increasing in some developed countries, including South Korea,<a href=\"#_edn42\" name=\"_ednref42\">[xlii]<\/a> overall cancer mortality rates are decreasing in developed nations.<a href=\"#_edn43\" name=\"_ednref43\">[xliii]<\/a><\/p>\n<p>Developing countries show differing cancer mortality trends compared to the U.S. and other developed nations. Developing nations are slightly behind U.S. trends &#8211; they are only now starting to increase levels of smoking, consumption of unhealthy fatty foods, and decrease levels of physical activity \u2013 all of which increase cancer.<a href=\"#_edn44\" name=\"_ednref44\">[xliv]<\/a><\/p>\n<p>When looking at cancer from the perspective of race and\/or income, it becomes immediately clear that the problem is complex and multi-faceted, with no one explanation or solution for why different outcomes occur.<\/p>\n<p>In the U.S., it is important to understand that race and income are intrinsically linked. Minorities are more likely to have a lower socioeconomic status, in comparison to the white population. This can compound the risk of cancer and poor health outcomes for minorities, who might also be lower-income. It should still be noted that even after SES is considered, ethnic minorities have worse health outcomes than the ethnic majority in the U.S.<\/p>\n<p>It is also important to note that poverty and poor health are cyclical. Health affects income levels and income affects health. People with poor health are less likely to be able to work full time and retain a steady income. This reduced income then causes further health problems due to a lack of financial access to care. Additionally, having cancer as a child can physically impact an adult survivors\u2019 ability to earn money, even years after they have been declared cancer-free.<a href=\"#_edn45\" name=\"_ednref45\">[xlv]<\/a> Adult survivors of childhood cancers are more likely to receive disability payments because they aren\u2019t able work when compared to the rest of the general population.<a href=\"#_edn46\" name=\"_ednref46\">[xlvi]<\/a><\/p>\n<p>Cancer is a complex health condition that is both caused and worsened by income and race. To even the playing field, we need to first understand how the root causes impact the chance that a certain person will get cancer. The differences in death rates between different socioeconomic groups and races can be partially explained by the different levels of care that these demographics receive, but this does not necessarily fully explain why these differences in care exist in the first place. To some extent, private insurance (or lack thereof) dictates the level of care that patients can access, but this alone does not account for all differences in outcomes that we see. The relationship between ethnicity, poverty\/wealth and cancer is complicated, and we must examine these all together if we are ever able to truly address the issues of inequities in cancer deaths.<\/p>\n<p>&nbsp;<\/p>\n<p><em>References<\/em><\/p>\n<p><a href=\"#_ednref1\" name=\"_edn1\">[i]<\/a> Short, Pamela Farley, and Erin L. Mallonee. \u201cIncome Disparities in the Quality of Life of Cancer Survivors:\u201d Medical Care, vol. 44, no. 1, 2006, pp. 16\u201323.<\/p>\n<p><a href=\"#_ednref2\" name=\"_edn2\">[ii]<\/a> \u201cCancer statistics, National Cancer Institute.\u201d Cancer.gov.<\/p>\n<p><a href=\"#_ednref3\" name=\"_edn3\">[iii]<\/a> Oakes, J. Michael, and Peter H. Rossi. \u201cThe Measurement of SES in Health Research: Current Practice and Steps toward a New Approach.\u201d Social Science &amp; Medicine, vol. 56, no. 4, Feb. 2003, pp. 769\u201384.<\/p>\n<p><a href=\"#_ednref4\" name=\"_edn4\">[iv]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref5\" name=\"_edn5\">[v]<\/a> Jemal, Ahmedin, et al. \u201cGlobal Patterns of Cancer Incidence and Mortality Rates and Trends.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 8, Aug. 2010, pp. 1893\u2013907.<\/p>\n<p><a href=\"#_ednref6\" name=\"_edn6\">[vi]<\/a> Aarts, Mieke J., et al. \u201cSocioeconomic Status and Changing Inequalities in Colorectal Cancer? A Review of the Associations with Risk, Treatment and Outcome.\u201d European Journal of Cancer, vol. 46, no. 15, Oct. 2010, pp. 2681\u201395.<\/p>\n<p><a href=\"#_ednref7\" name=\"_edn7\">[vii]<\/a> Clegg, Limin X., et al. \u201cImpact of Socioeconomic Status on Cancer Incidence and Stage at Diagnosis: Selected Findings from the Surveillance, Epidemiology, and End Results: National Longitudinal Mortality Study.\u201d Cancer Causes &amp; Control, vol. 20, no. 4, May 2009, pp. 417\u201335.<\/p>\n<p><a href=\"#_ednref8\" name=\"_edn8\">[viii]<\/a> Aarts, Mieke J., et al. \u201cSocioeconomic Status and Changing Inequalities in Colorectal Cancer? A Review of the Associations with Risk, Treatment and Outcome.\u201d European Journal of Cancer, vol. 46, no. 15, Oct. 2010, pp. 2681\u201395.<\/p>\n<p><a href=\"#_ednref9\" name=\"_edn9\">[ix]<\/a> Short, Pamela Farley, and Erin L. Mallonee. \u201cIncome Disparities in the Quality of Life of Cancer Survivors:\u201d Medical Care, vol. 44, no. 1, 2006, pp. 16\u201323.<\/p>\n<p><a href=\"#_ednref10\" name=\"_edn10\">[x]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref11\" name=\"_edn11\">[xi]<\/a> Iqbal, Javaid, et al. \u201cDifferences in Breast Cancer Stage at Diagnosis and Cancer-Specific Survival by Race and Ethnicity in the United: Breast Cancer Stage at Diagnosis and Survival.\u201d JAMA, vol. 313, no. 2, Jan. 2015, pp. 165\u201373.<\/p>\n<p><a href=\"#_ednref12\" name=\"_edn12\">[xii]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref13\" name=\"_edn13\">[xiii]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref14\" name=\"_edn14\">[xiv]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref15\" name=\"_edn15\">[xv]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref16\" name=\"_edn16\">[xvi]<\/a> Parise, Carol A., and Vincent Caggiano. \u201cThe Influence of Socioeconomic Status on Racial\/Ethnic Disparities among the ER\/PR\/HER2 Breast Cancer Subtypes.\u201d Journal of Cancer Epidemiology, 2015.<\/p>\n<p><a href=\"#_ednref17\" name=\"_edn17\">[xvii]<\/a> Subramanian, Sujha, and Amy Chen. \u201cTreatment Patterns and Survival Among Low-Income Medicaid Patients with Head and Neck Cancer.\u201d JAMA Otolaryngology\u2013Head &amp; Neck Surgery, vol. 139, no. 5, May 2013, p. 489.<\/p>\n<p><a href=\"#_ednref18\" name=\"_edn18\">[xviii]<\/a> Iqbal, Javaid, et al. \u201cDifferences in Breast Cancer Stage at Diagnosis and Cancer-Specific Survival by Race and Ethnicity in the United StatesBreast Cancer Stage at Diagnosis and SurvivalBreast Cancer Stage at Diagnosis and Survival.\u201d JAMA, vol. 313, no. 2, Jan. 2015, pp. 165\u201373.<\/p>\n<p><a href=\"#_ednref19\" name=\"_edn19\">[xix]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref20\" name=\"_edn20\">[xx]<\/a> Fedewa, Stacey A., et al. \u201cAssociation of Insurance and Race\/Ethnicity with Disease Severity among Men Diagnosed with Prostate Cancer, National Cancer Database 2004-2006.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 10, Oct. 2010, pp. 2437\u201344.<\/p>\n<p><a href=\"#_ednref21\" name=\"_edn21\">[xxi]<\/a> Welch, H. Gilbert, and Elliott S. Fisher. \u201cIncome and Cancer Overdiagnosis \u2014 When Too Much Care Is Harmful.\u201d New England Journal of Medicine, vol. 376, no. 23, June 2017, pp. 2208\u201309.<\/p>\n<p><a href=\"#_ednref22\" name=\"_edn22\">[xxii]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref23\" name=\"_edn23\">[xxiii]<\/a> Freedman, Rachel A., et al. \u201cThe Association of Race\/Ethnicity, Insurance Status, and Socioeconomic Factors with Breast Cancer Care.\u201d Cancer, vol. 117, no. 1, Jan. 2011, pp. 180\u201389.<\/p>\n<p><a href=\"#_ednref24\" name=\"_edn24\">[xxiv]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref25\" name=\"_edn25\">[xxv]<\/a> Fedewa, Stacey A., et al. \u201cAssociation of Insurance and Race\/Ethnicity with Disease Severity among Men Diagnosed with Prostate Cancer, National Cancer Database 2004-2006.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 10, Oct. 2010, pp. 2437\u201344.<\/p>\n<p><a href=\"#_ednref26\" name=\"_edn26\">[xxvi]<\/a> Welch, H. Gilbert, and Elliott S. Fisher. \u201cIncome and Cancer Overdiagnosis \u2014 When Too Much Care Is Harmful.\u201d New England Journal of Medicine, vol. 376, no. 23, June 2017, pp. 2208\u201309.<\/p>\n<p><a href=\"#_ednref27\" name=\"_edn27\">[xxvii]<\/a> Yim, Jun, et al. \u201cContribution of Income-Related Inequality and Healthcare Utilisation to Survival in Cancers of the Lung, Liver, Stomach and Colon.\u201d Journal of Epidemiology and Community Health, vol. 66, no. 1, 2012, pp. 37\u201340.<\/p>\n<p><a href=\"#_ednref28\" name=\"_edn28\">[xxviii]<\/a> Jinjuvadia, Raxitkumar, et al. \u201c1168 Impact of Health Insurance, Education and Income Status on Colorectal Cancer Screening in Minority Populations: 2001 \u2013 2010.\u201d Gastroenterology, vol. 142, no. 5, 2012, p. S-214.<\/p>\n<p><a href=\"#_ednref29\" name=\"_edn29\">[xxix]<\/a> Subramanian, Sujha, and Amy Chen. \u201cTreatment Patterns and Survival Among Low-Income Medicaid Patients With Head and Neck Cancer.\u201d JAMA Otolaryngology\u2013Head &amp; Neck Surgery, vol. 139, no. 5, May 2013, p. 489.<\/p>\n<p><a href=\"#_ednref30\" name=\"_edn30\">[xxx]<\/a> Fedewa, Stacey A., et al. \u201cAssociation of Insurance and Race\/Ethnicity with Disease Severity among Men Diagnosed with Prostate Cancer, National Cancer Database 2004-2006.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 10, Oct. 2010, pp. 2437\u201344.<\/p>\n<p><a href=\"#_ednref31\" name=\"_edn31\">[xxxi]<\/a> Choi, Seul Ki, et al. \u201cMedicaid Coverage Expansion and Implications for Cancer Disparities.\u201d American Journal of Public Health, vol. 105, no. S5, Oct. 2015, pp. S706\u201312.<\/p>\n<p><a href=\"#_ednref32\" name=\"_edn32\">[xxxii]<\/a> Liss, David T., and David W. Baker. \u201cUnderstanding Current Racial\/Ethnic Disparities in Colorectal Cancer Screening in the United States: The Contribution of Socioeconomic Status and Access to Care.\u201d American Journal of Preventive Medicine, vol. 46, no. 3, Mar. 2014, pp. 228\u201336.<\/p>\n<p><a href=\"#_ednref33\" name=\"_edn33\">[xxxiii]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref34\" name=\"_edn34\">[xxxiv]<\/a> Fedewa, Stacey A., et al. \u201cAssociation of Insurance and Race\/Ethnicity with Disease Severity among Men Diagnosed with Prostate Cancer, National Cancer Database 2004-2006.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 10, Oct. 2010, pp. 2437\u201344.<\/p>\n<p><a href=\"#_ednref35\" name=\"_edn35\">[xxxv]<\/a> Freedman, Rachel A., et al. \u201cThe Association of Race\/Ethnicity, Insurance Status, and Socioeconomic Factors with Breast Cancer Care.\u201d Cancer, vol. 117, no. 1, Jan. 2011, pp. 180\u201389.<\/p>\n<p><a href=\"#_ednref36\" name=\"_edn36\">[xxxvi]<\/a> Liss, David T., and David W. Baker. \u201cUnderstanding Current Racial\/Ethnic Disparities in Colorectal Cancer Screening in the United States: The Contribution of Socioeconomic Status and Access to Care.\u201d American Journal of Preventive Medicine, vol. 46, no. 3, Mar. 2014, pp. 228\u201336.<\/p>\n<p><a href=\"#_ednref37\" name=\"_edn37\">[xxxvii]<\/a> Parise, Carol A., and Vincent Caggiano. \u201cThe Influence of Socioeconomic Status on Racial\/Ethnic Disparities among the ER\/PR\/HER2 Breast Cancer Subtypes.\u201d Journal of Cancer Epidemiology, 2015.<\/p>\n<p><a href=\"#_ednref38\" name=\"_edn38\">[xxxviii]<\/a> Torre, Lindsey A., et al. \u201cGlobal Cancer Incidence and Mortality Rates and Trends\u2014An Update.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 25, no. 1, Jan. 2016, pp. 16\u201327.<\/p>\n<p><a href=\"#_ednref39\" name=\"_edn39\">[xxxix]<\/a> Clegg, Limin X., et al. \u201cImpact of Socioeconomic Status on Cancer Incidence and Stage at Diagnosis: Selected Findings from the Surveillance, Epidemiology, and End Results: National Longitudinal Mortality Study.\u201d Cancer Causes &amp; Control, vol. 20, no. 4, May 2009, pp. 417\u201335.<\/p>\n<p><a href=\"#_ednref40\" name=\"_edn40\">[xl]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref41\" name=\"_edn41\">[xli]<\/a> Wong, Martin C. S., et al. \u201cIncidence and Mortality of Lung Cancer: Global Trends and Association with Socioeconomic Status.\u201d Scientific Reports, vol. 7, no. 1, Oct. 2017, pp. 1\u20139.<\/p>\n<p><a href=\"#_ednref42\" name=\"_edn42\">[xlii]<\/a> Yim, Jun, et al. \u201cContribution of Income-Related Inequality and Healthcare Utilisation to Survival in Cancers of the Lung, Liver, Stomach and Colon.\u201d Journal of Epidemiology and Community Health, vol. 66, no. 1, 2012, pp. 37\u201340.<\/p>\n<p><a href=\"#_ednref43\" name=\"_edn43\">[xliii]<\/a> Wong, Martin C. S., et al. \u201cIncidence and Mortality of Lung Cancer: Global Trends and Association with Socioeconomic Status.\u201d Scientific Reports, vol. 7, no. 1, Oct. 2017, pp. 1\u20139.<\/p>\n<p><a href=\"#_ednref44\" name=\"_edn44\">[xliv]<\/a> Jemal, Ahmedin, et al. \u201cGlobal Patterns of Cancer Incidence and Mortality Rates and Trends.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 8, Aug. 2010, pp. 1893\u2013907.<\/p>\n<p><a href=\"#_ednref45\" name=\"_edn45\">[xlv]<\/a> Kirchhoff, A. C., et al. \u201cSupplemental Security Income and Social Security Disability Insurance Coverage Among Long-Term Childhood Cancer Survivors.\u201d JNCI Journal of the National Cancer Institute, vol. 107, no. 6, Mar. 2015, pp. djv057\u2013djv057.<\/p>\n<p><a href=\"#_ednref46\" name=\"_edn46\">[xlvi]<\/a> Ibid.<\/p>\n<p>&nbsp;<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>El texto de este art\u00edculo a\u00fan no est\u00e1 disponible en espa\u00f1ol. \u00a1Por favor mant\u00e9ngase al tanto!<\/p>\n<p>&nbsp;<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Le texte de cet article n&#8217;est pas encore disponible en espagnol. S&#8217;il vous pla\u00eet restez \u00e0 l&#8217;\u00e9coute!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"Cancer is a top killer and it discriminates. In the U.S., poorer people and minorities are both more likely to get cancer, and are more likely to die from cancer. The reason is complicated but often comes down to two key issues \u2013 income and race. ","page_subheader_es":"El c\u00e1ncer es el principal asesino y discrimina. En los EE. UU., Las personas m\u00e1s pobres y las minor\u00edas tienen m\u00e1s probabilidades de contraer c\u00e1ncer y m\u00e1s probabilidades de morir de c\u00e1ncer. La raz\u00f3n es complicada, pero a menudo se reduce a dos cuestiones clave: factores socioecon\u00f3micos y raza.","page_subheader_fr":"Le cancer est l\u2019un des principaux meurtriers et il fait preuve de discrimination. Aux \u00c9tats-Unis, les personnes les plus pauvres et les minorit\u00e9s sont \u00e0 la fois plus susceptibles d\u2019\u00eatre atteintes du cancer et plus susceptibles de mourir du cancer. La raison en est compliqu\u00e9e mais se r\u00e9sume souvent \u00e0 deux probl\u00e8mes cl\u00e9s: les facteurs socio-\u00e9conomiques et la race."},{"slug":"the-deadly-distance-rural-health-care","ideas_cat":"Analysis","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/06\/Distance-main-image.jpg","page_title_en":"The deadly distance: Rural health care in America","page_title_es":"La distance mortelle: les soins de sant\u00e9 en milieu rural en Am\u00e9rique","page_title_fr":"La distancia mortal: la atenci\u00f3n m\u00e9dica rural en Am\u00e9rica","page_content_en":"<p>Throughout the U.S., people living in rural communities are more likely to die and experience higher rates of poor health outcomes than those living in metropolitan areas.<a href=\"#_edn1\" name=\"_ednref1\">[1]<\/a> When compared to urban populations, there\u2019s a clear disparity in the mortality rates of heart disease and cancer, the two leading causes of premature death in America.<a href=\"#_edn2\" name=\"_ednref2\">[2]<\/a> \u00a0People in rural communities tend to die younger from seemingly preventable causes, and they also tend to suffer more from seemingly manageable conditions. Because of this, rural populations are referred to as a health disparity population, generally experiencing worse health outcomes than the national average.<a href=\"#_edn3\" name=\"_ednref3\">[3]<\/a><\/p>\n<p>Why does this happen?<\/p>\n<p>To start, let\u2019s get some context. Approximately 60 million people in the US are considered \u201crural\u201d \u2013 about a fifth of the country\u2019s population. However, according to the U.S. Census Bureau\u2019s 2017 American Community Survey, rural areas comprise 97 percent of US land mass. That means that four-fifths of our country live in about 3 percent of the country\u2019s land mass. Increasingly, the populations of rural counties are getting smaller \u2014 particularly those in the Midwest and Northeast of the U.S., which are losing people due to higher death rates than birth rates and more people moving away than moving in.<\/p>\n<p>Of those that still remain in rural communities, about 16 percent live in poverty \u2013 a figure about 3 percent higher than their urban counterparts.<a href=\"#_edn4\" name=\"_ednref4\">[4]<\/a> While this higher prevalence of poverty is significant enough to be a considerable factor, it alone does not explain why rural Americans are sicker than the rest of us. Why, then, is this happening?<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Care is out of reach<\/strong><\/p>\n<p>Good health care policy cannot force a sick person to seek care, but it ensures that any individual, can, at minimum, reasonably <em>access<\/em> the care they need to get better. A lack of access to health care is widely known to directly correlate to poorer health outcomes.<a href=\"#_edn5\" name=\"_ednref5\">[5]<\/a> This is perhaps the most obvious and significant issue facing rural Americans \u2013 the distance they may need to travel to get that care.<a href=\"#_edn6\" name=\"_ednref6\">[6]<\/a> The care they require is simply too far or unable to be reached, forcing patients to either forgo care or spend the extra time and money necessary to reach it.<\/p>\n<p>It\u2019s also important to note that distance is relative to the patient; some may struggle more than others to travel relatively shorter distances.<a href=\"#_edn7\" name=\"_ednref7\">[7]<\/a> The perception of how difficult it is to get care due to distance is just as likely to prevent a patient from seeking care as the actual difficulty of obtaining it. It\u2019s not hard to imagine this choice being an even greater burden on rural Americans, who may live in poverty, lack access to public transportation or rely on income from hourly or agricultural work.<\/p>\n<p>More problematic than just the physical distance to care is the lack of medical professionals in some rural communities. Rural areas are more likely to be medically underserved, with a shortage of health care professionals.<a href=\"#_edn8\" name=\"_ednref8\">[8]<\/a> In urban areas, on average there are 32.5 physicians per 10,000 residents of the community. In rural areas, there are only 12.7 physicians per 10,000 residents.<a href=\"#_edn9\" name=\"_ednref9\">[9]<\/a> It\u2019s not just hospitals or specialty care that rural patients lack access to \u2013 it\u2019s all aspects of the health system.<\/p>\n<p>The reason for this is multifold but generally centers around a key problem \u2013 recruitment. It\u2019s more difficult to entice physicians to rural communities, particularly if they have no family or previous history in the area. There may also be a shortage of academic medical programs, something many physicians may seek. Additionally, the spouses or significant others of physicians may struggle to find employment of their own in rural areas. Finally, culture often remains a barrier, as there tend to be fewer restaurants and entertainment options in rural areas. \u00a0And rural communities often do not have the religious diversity of more suburban or urban areas, providing fewer opportunities for physicians of different backgrounds to practice their faith.<a href=\"#_edn10\" name=\"_ednref10\">[10]<\/a><\/p>\n<p>&nbsp;<\/p>\n<p><strong>Cost of rural care<\/strong><\/p>\n<p>Cost is another factor that must be considered when discussing access to rural health care. It has been shown that rural health care is not necessarily any more expensive than comparative care in urban regions; in fact, it is sometimes cheaper.\u00a0However, rural people are less likely to have the means to afford health care at all. People in rural areas are more likely to refuse or delay health treatment due to financial constraints, resulting in worsening health outcomes.\u00a0There is also a known correlation between socioeconomic status and outcomes for health conditions.\u00a0As previously stated, rural areas have disproportionately high levels of poverty compared to urban areas, resulting in poorer health outcomes compared to urban\/wealthier counterparts.<\/p>\n<p>The number of uninsured adults between the ages of 18 and 64 is higher in rural areas, compared to urban populations. Twelve percent of people living in metropolitan areas are uninsured, compared to 13.5 percent of people in non-metropolitan areas.\u00a0Higher rates of uninsured patients generally mean higher rates of out-of-pocket payments for treatment, something that people living in poverty cannot afford, even though this population often requires the most amount of care.<\/p>\n<p>People living in rural areas struggle more to afford the cost of transportation to necessary health services.\u00a0This is compounded by the fact that a number of rural health centers are closing, increasing the distance and cost to reach medical aid. Thus, although healthcare itself might be relatively cheaper than in metropolitan areas, rural patients still cannot afford the associated transportation costs.<\/p>\n<p><strong>\u00a0<\/strong><\/p>\n<p><strong>Hospital closures<\/strong><\/p>\n<p>As if access to care wasn\u2019t already difficult for rural Americans, the increasingly high rates of hospital closures<a href=\"#_edn11\" name=\"_ednref11\">[11]<\/a> is only compounding the issue. Between 2005 and 2017, 124 rural hospitals closed.<a href=\"#_edn12\" name=\"_ednref12\">[12]<\/a> Since the passage of the Patient Protection and Affordable Care Act in 2010, states that did not expand Medicaid have seen the most closures. According to the North Carolina Rural Health Research Program, there have been 160 rural hospital closures since 2005, with 17 closures so far in 2019.<\/p>\n<p>These closures are concentrated heavily in states that did not expand Medicaid, which is evidenced in the six states with five or more rural hospital closures. They are, in order: Texas (15 rural hospitals closed), Tennessee (9 rural hospitals closed) and Georgia (7 rural hospitals closed). Alabama, Mississippi and North Carolina each had five rural hospitals closed.<\/p>\n<p>Additionally, the high rate of hospital closures is generally due to financial and market reasons. The hospitals that have closed tended to be less profitable and have fewer patients than those that remain open.<a href=\"#_edn13\" name=\"_ednref13\">[13]<\/a> Most rural hospitals run as nonprofit businesses,<a href=\"#_edn14\" name=\"_ednref14\">[14]<\/a> which are more likely to offer the type of unprofitable services that consumers need compared to for-profit hospitals.<a href=\"#_edn15\" name=\"_ednref15\">[15]<\/a> It\u2019s understandable why it\u2019s not financially feasible for these hospitals to stay in business, but it leaves rural patients without access to the care they need.<\/p>\n<p>It is expected that more and more rural hospitals will eventually shut down.<a href=\"#_edn16\" name=\"_ednref16\">[16]<\/a> A hospital shutting down in an already underserved rural community can leave a patient with no other nearby alternatives.<\/p>\n<p>Mergers and acquisitions (M&amp;A) \u2013 which are increasing at a rapid rate \u2013 are often cited as a solution to lack of rural care. Health care organizations announced\u00a0115 M&amp;A transactions\u00a0in 2017, the highest number in recent history. The usual reasons for M&amp;A are to improve the affordability, convenience, and cost-effectiveness of health care while reducing pressures related to declining reimbursement rates, increasing operating expenses and promoting greater competition.<a href=\"#_edn17\" name=\"_ednref17\">[17]<\/a><\/p>\n<p>However, evidence supports the prevailing thought that M&amp;A activity increases costs. For example, according to a 2012 Robert Wood Johnson Foundation (RWJF) study, consolidation of health systems increases health care prices \u2013 sometimes by more than 20 percent.<a href=\"#_edn18\" name=\"_ednref18\">[18]<\/a> Additionally, a 2016 study by the New York State Healthcare Foundation found that hospitals with greater market leverage (as is often the case for merged hospital systems) charged prices that were three to four times greater than those with less market power.<a href=\"#_edn19\" name=\"_ednref19\">[19]<\/a> In 2018, a University of California Berkeley study conducted for <em>The<\/em> <em>New York Times<\/em> found that M&amp;A activity increased hospital admission costs from 11 to 54 percent throughout the country from 2012 to 2014, due to reduced competition.<a href=\"#_edn20\" name=\"_ednref20\">[20]<\/a><\/p>\n<p>Keep in mind, though, that these statistics look at all hospital mergers, not only rural hospitals. Rural hospitals carry with them certain situations \u2013 such as the socioeconomic issues already discussed \u2013 as well as shifting payor bases and increased volumes of uninsured patients. These factors make mergers the most viable option to continue providing services within a given community.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Potential solutions<\/strong><\/p>\n<p><u>Critical access hospitals<\/u><\/p>\n<p>Critical access hospitals can help ease issues of access in many communities. These hospitals must meet a number of different criteria to achieve critical-access status, such as being certain distances from other hospitals, providing emergency services, keeping patients at the hospital for no more than 96 hours and having no more than 25 beds.<a href=\"#_edn21\" name=\"_ednref21\">[21]<\/a> The designation of \u201ccritical access\u201d allows a hospital to receive Medicare cost-based reimbursements, which is a better financial option than the alternative hospital-based prospective payer system.<a href=\"#_edn22\" name=\"_ednref22\">[22]<\/a><\/p>\n<p>Data suggests that when critical access hospitals are within a 15-mile vicinity of another hospital, they have higher quality outputs and are more financially stable.<a href=\"#_edn23\" name=\"_ednref23\">[23]<\/a> This may be the result of increased competition, which can also reduce costs. Thus, an increase in critical access hospitals could both improve health care quality outcomes and reduce costs, making them a necessary component to improved rural health care.<\/p>\n<p><u>Telemedicine<\/u><\/p>\n<p>Like critical access hospitals, telemedicine is another community-driven intervention that has shown some promise in reducing health care inequities. The introduction of an online-based model of care allows caregivers to work directly with health professionals without needing to be in the same location. In one case, the system utilized the familial and social support systems on which patients already relied.<a href=\"#_edn24\" name=\"_ednref24\">[24]<\/a> The caregivers were provided some basic training and equipment at no cost to the patient.<a href=\"#_edn25\" name=\"_ednref25\">[25]<\/a> While it did not completely replace the need for health care providers, it was shown to improve outcomes<a href=\"#_edn26\" name=\"_ednref26\">[26]<\/a> and efficiency for receiving health care in rural areas.<a href=\"#_edn27\" name=\"_ednref27\">[27]<\/a><\/p>\n<p>It\u2019s reasonable to imagine how an increase in telemedicine or online care could help people in rural American communities \u2013 provided patients have access to quality internet services. If patients could simply call or FaceTime with a provider for certain health concerns, checkups or prescription renewals, they wouldn\u2019t face the transportation, access and cost barriers they do now. They could rely on a continuation of care and treatment that could improve their health care outcomes.<\/p>\n<p><u>Medicaid expansion<\/u><\/p>\n<p>An often-cited solution to issues of rural health care \u2013 particularly, hospital closures \u2013 is Medicaid expansion. Multiple studies have demonstrated the potentially positive impact Medicaid expansion has on a rural community, including a 2018 study published in <a href=\"https:\/\/www.healthaffairs.org\/doi\/10.1377\/hlthaff.2017.0976\">Health Affairs<\/a> that concluded:<\/p>\n<blockquote><p>\u201c[T]he ACA\u2019s Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion.\u201d<a href=\"#_edn28\" name=\"_ednref28\">[28]<\/a><\/p><\/blockquote>\n<p>This is backed up by the North Carolina Rural Health Research Program study referenced earlier that demonstrated rural hospitals in non-Medicaid expansion states are much more likely to close than those in states that did expand \u2013 which is no coincidence.<\/p>\n<p>To start, in expansion states, uninsured rates have dropped by as much as 20 percent, while uninsured rates in states that did not expand Medicaid have increased. This is due in large part to the limitations of Medicaid in non-expansion states. According to the <a href=\"https:\/\/www.kff.org\/medicaid\/issue-brief\/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid\/\">Kaiser Family Foundation<\/a>, the median income limit for parents in these states was just 43 percent of the poverty line, or an annual income of $8,935 for a family of three in 2018. Childless adults are still ineligible in almost every one of the states that didn\u2019t expand Medicaid.<\/p>\n<p>Additionally, there is a catch-22 found with the ACA itself. Because the law is intended for all low-income people to receive coverage through Medicaid, it doesn\u2019t provide financial assistance to people below the poverty line for other coverage options. As a result, in states that do not expand Medicaid, many adults, including all childless adults, fall into a \u201ccoverage gap\u201d of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits.<a href=\"#_edn29\" name=\"_ednref29\">[29]<\/a><\/p>\n<p>This puts an incredible burden on rural hospitals to provide the financial assistance that is vital to these uninsured adults (and, if they are a nonprofit, required by federal law), and this increased demand for unpaid services is, in turn, contributing to the financial downfall of these hospitals.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Where do we go from here?<\/strong><\/p>\n<p>There are a number of different factors that contribute to the negative health care outcomes in rural communities within the United States, and they are all intrinsically linked. People in rural communities are more likely to live in poverty, and poverty is also a risk factor for poor health. The combination of being in poverty and living in a rural location often make it difficult for patients to be able to afford health care \u2013 both the treatment itself and the transport to the clinic or hospital location. A shortage of medical facilities and lack of insurance among rural populations also contribute to the crisis. These challenges are all complex and interwoven, compounding poor health outcomes in rural populations.<\/p>\n<p>Current research suggests the rural-urban health divide is only going to continue to increase. More action needs to be swiftly taken to reduce both the financial and physical barriers to health care that rural patients face. As the issues causing negative health outcomes in rural America are complex and multifaceted, there is no simple solution. However, based on research from overseas, there are a number of changes that can be made to the rural health system that would likely improve health outcomes for rural American patients.<\/p>\n<p>&nbsp;<\/p>\n<p><em>References<\/em><\/p>\n<p><a href=\"#_ednref1\" name=\"_edn1\">[1]<\/a> James, Cara V., Ramal Moonesinghe, Shondelle M. Wilson-Frederick, Jeffrey E. Hall, Ana Penman-Aguilar, and Karen Bouye. \u201cRacial\/Ethnic Health Disparities Among Rural Adults \u2014 United States, 2012\u20132015.\u201d <em>MMWR Surveillance Summaries<\/em> 66, no. 23 (November 17, 2017): 1\u20139. <a href=\"https:\/\/doi.org\/10.15585\/mmwr.ss6623a1\">Https:\/\/doi.org\/10.15585\/mmwr.ss6623a1<\/a>.<\/p>\n<p><a href=\"#_ednref2\" name=\"_edn2\"><sup>[2]<\/sup><\/a> Purnell, Tanjala S., Elizabeth A. Calhoun, Sherita H. Golden, Jacqueline R. Halladay, Jessica L. Krok-Schoen, Bradley M. Appelhans, and Lisa A. Cooper. \u201cAchieving Health Equity: Closing the Gaps in Health Care Disparities, Interventions, And Research.\u201d <em>Health Affairs<\/em> 35, no. 8 (August 1, 2016): 1410\u201315. https:\/\/doi.org\/10.1377\/hlthaff.2016.0158.<\/p>\n<p><a href=\"#_ednref3\" name=\"_edn3\"><sup>[3]<\/sup><\/a> Matthews, Kevin A., Janet B. Croft, Yong Liu, Hua Lu, Dafna Kanny, Anne G. Wheaton, Timothy J. Cunningham, et al. \u201cHealth-Related Behaviors by Urban-Rural County Classification \u2014 United States, 2013.\u201d <em>MMWR Surveillance Summaries<\/em> 66, no. 5 (February 3, 2017): 1\u20138. https:\/\/doi.org\/10.15585\/mmwr.ss6605a1.<a href=\"#_ednref4\" name=\"_edn4\"><\/a><\/p>\n<p><a href=\"#_ednref5\" name=\"_edn5\">[5]<\/a> Benitez, Joseph A., and Eric E. Seiber. \u201cUS Health Care Reform and Rural America: Results from the ACA\u2019s Medicaid Expansions: Medicaid Expansion and Rural America.\u201d <em>The Journal of Rural Health<\/em> 34, no. 2 (2018): 213\u201322. <a href=\"https:\/\/doi.org\/10.1111\/jrh.12284\">https:\/\/doi.org\/10.1111\/jrh.12284<\/a>.<\/p>\n<p><a href=\"#_ednref6\" name=\"_edn6\">[6]<\/a> Buzza, Colin, Sarah S. Ono, Carolyn Turvey, Stacy Wittrock, Matt Noble, Gautam Reddy, Peter J. Kaboli, and Heather Schacht Reisinger. \u201cDistance Is Relative: Unpacking a Principal Barrier in Rural Healthcare.\u201d <em>Journal of General Internal Medicine<\/em>26, no. S2 (2011): 648\u201354. <a href=\"https:\/\/doi.org\/10.1007\/s11606-011-1762-1\">https:\/\/doi.org\/10.1007\/s11606-011-1762-1<\/a>.<\/p>\n<p><a href=\"#_ednref7\" name=\"_edn7\">[7]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref8\" name=\"_edn8\">[8]<\/a> Benitez, Joseph A., and Eric E. Seiber. \u201cUS Health Care Reform and Rural America: Results from the ACA\u2019s Medicaid Expansions: Medicaid Expansion and Rural America.\u201d <em>The Journal of Rural Health<\/em> 34, no. 2 (2018): 213\u201322.<a href=\"#_ednref9\" name=\"_edn9\"><\/a><\/p>\n<p><a href=\"#_ednref10\" name=\"_edn10\">[10]<\/a> Hall, Kerri. \u201cAttracting and Retaining Physicians in Rural America.\u201d Becker\u2019s Hospital Review. 25 September 2017. Accessed online.<\/p>\n<p><a href=\"#_ednref11\" name=\"_edn11\"><sup>[11]<\/sup><\/a> Kaufman, Brystana G., Sharita R. Thomas, Randy K. Randolph, Julie R. Perry, Kristie W. Thompson, George M. Holmes, and George H. Pink. \u201cThe Rising Rate of Rural Hospital Closures.\u201d <em>The Journal of Rural Health<\/em>, January 1, 2016. <a href=\"https:\/\/doi.org\/10.1111\/jrh.12128\">https:\/\/doi.org\/10.1111\/jrh.12128<\/a>.<\/p>\n<p><a href=\"#_ednref12\" name=\"_edn12\"><sup>[12]<\/sup><\/a> \u201cResource Details: Rural Health Research Recap: Rural Hospital Closures &#8211; Rural Health Information Hub.\u201d Accessed August 19, 2019. <a href=\"https:\/\/www.ruralhealthinfo.org\/resources\/9933\">https:\/\/www.ruralhealthinfo.org\/resources\/9933<\/a>.<\/p>\n<p><a href=\"#_ednref13\" name=\"_edn13\"><sup>[13]<\/sup><\/a>\u00a0\u00a0 Ibid.<\/p>\n<p><a href=\"#_ednref14\" name=\"_edn14\"><sup>[14]<\/sup><\/a> Horwitz, Jill R., and Austin Nichols. \u201cRural Hospital Ownership: Medical Service Provision, Market Mix, and Spillover Effects: Rural Hospital Ownership.\u201d <em>Health Services Research<\/em> 46, no. 5 (2011): 1452\u201372. <a href=\"https:\/\/doi.org\/10.1111\/j.1475-6773.2011.01280.x\">https:\/\/doi.org\/10.1111\/j.1475-6773.2011.01280.x<\/a>.<\/p>\n<p><a href=\"#_ednref15\" name=\"_edn15\"><sup>[15]<\/sup><\/a> Ibid.<\/p>\n<p><a href=\"#_ednref16\" name=\"_edn16\"><sup>[16]<\/sup><\/a> Kaufman, Brystana G., Sharita R. Thomas, Randy K. Randolph, Julie R. Perry, Kristie W. Thompson, George M. Holmes, and George H. Pink. \u201cThe Rising Rate of Rural Hospital Closures.\u201d <em>The Journal of Rural Health<\/em>, January 1, 2016. <a href=\"https:\/\/doi.org\/10.1111\/jrh.12128\">https:\/\/doi.org\/10.1111\/jrh.12128<\/a><\/p>\n<p><a href=\"#_ednref17\" name=\"_edn17\">[17]<\/a> Herschman et al.<\/p>\n<p><a href=\"#_ednref18\" name=\"_edn18\">[18]<\/a> Gaynor, Martin, and Robert Town. \u201cThe Impact of Hospital Consolidation &#8211; Update.\u201d <em>Robert Wood Johnson Foundation: The Impact of Hospital Consolidation<\/em>, 1 June 2012, https:\/\/www.rwjf.org\/en\/library\/research\/2012\/06\/the-impact-of-hospital-consolidation.html.<\/p>\n<p><a href=\"#_ednref19\" name=\"_edn19\">[19]<\/a> Gorman Actuarial. <em>Why Are Hospital Prices Different? An Examination of New York Hospital Reimbursement<\/em>. https:\/\/nyshealthfoundation.org\/resource\/an-examination-of-new-york-hospital-reimbursement\/. Accessed 1 July 2019.<\/p>\n<p><a href=\"#_ednref20\" name=\"_edn20\">[20]<\/a> Abelson, Reed. \u201cWhen Hospitals Merge to Save Money, Patients Often Pay More.\u201d <em>The New York Times<\/em>, 14 Nov. 2018. <em>NYTimes.com<\/em>, https:\/\/www.nytimes.com\/2018\/11\/14\/health\/hospital-mergers-health-care-spending.html.<\/p>\n<p><a href=\"#_ednref21\" name=\"_edn21\">[21]<\/a> Casey, Michelle M., Ira Moscovice, G. Mark Holmes, George H. Pink, and Peiyin Hung. \u201cMinimum-Distance Requirements Could Harm High-Performing Critical-Access Hospitals and Rural Communities.\u201d <em>Health Affairs<\/em> 34, no. 4 (2015): 627\u201335. https:\/\/doi.org\/10.1377\/hlthaff.2014.0788.<\/p>\n<p><a href=\"#_ednref22\" name=\"_edn22\">[22]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref23\" name=\"_edn23\">[23]<\/a> Ibid.<\/p>\n<p><a href=\"#_ednref24\" name=\"_edn24\"><sup>[24]<\/sup><\/a> Barjis, Joseph, Gwendolyn Kolfschoten, and Johan Maritz. \u201cA Sustainable and Affordable Support System for Rural Healthcare Delivery.\u201d <em>Decision Support Systems<\/em> 56 (2013): 223\u201333. <a href=\"https:\/\/doi.org\/10.1016\/j.dss.2013.06.005\">https:\/\/doi.org\/10.1016\/j.dss.2013.06.005<\/a>.<\/p>\n<p><a href=\"#_ednref25\" name=\"_edn25\"><sup>[25]<\/sup><\/a> Ibid.<\/p>\n<p><a href=\"#_ednref26\" name=\"_edn26\"><sup>[26]<\/sup><\/a> Ibid.<\/p>\n<p><a href=\"#_ednref27\" name=\"_edn27\"><sup>[27]<\/sup><\/a> Ibid.<\/p>\n<p><a href=\"#_ednref28\" name=\"_edn28\">[28]<\/a> Lindrooth, Richard, et al. \u201cUnderstanding the Relationship Between Medicaid Expansions and Hospital Closures.\u201d <em>Health Affairs <\/em>37 (2018): 111-120. <em>. <\/em><\/p>\n<p><a href=\"#_ednref29\" name=\"_edn29\">[29]<\/a>Garfield, Rachel, et al. \u201cThe Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid.\u201d Kaiser Family Foundation.<\/p>\n<p>&nbsp;<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>El texto de este art\u00edculo a\u00fan no est\u00e1 disponible en espa\u00f1ol. \u00a1Por favor mant\u00e9ngase al tanto!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>Le texte de cet article n&#8217;est pas encore disponible en espagnol. S&#8217;il vous pla\u00eet restez \u00e0 l&#8217;\u00e9coute!<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"People in rural communities tend to die younger from seemingly preventable causes, and they also tend to suffer more from seemingly manageable conditions. Because of this, rural populations are referred to as a health disparity population, generally experiencing worse health outcomes than the national average. But why?","page_subheader_es":"Las personas en las comunidades rurales tienden a morir m\u00e1s j\u00f3venes por causas aparentemente prevenibles, y tambi\u00e9n tienden a sufrir m\u00e1s por condiciones aparentemente manejables. Debido a esto, se hace referencia a las poblaciones rurales como una poblaci\u00f3n con disparidades de salud, que generalmente experimentan peores resultados de salud que el promedio nacional. \u00bfPero por qu\u00e9?","page_subheader_fr":"Les habitants des communaut\u00e9s rurales ont tendance \u00e0 mourir plus jeunes de causes apparemment \u00e9vitables, et ils ont \u00e9galement tendance \u00e0 souffrir davantage de maladies apparemment g\u00e9rables. Pour cette raison, les populations rurales sont consid\u00e9r\u00e9es comme une population pr\u00e9sentant des disparit\u00e9s en mati\u00e8re de sant\u00e9 et dont les r\u00e9sultats sur la sant\u00e9 sont g\u00e9n\u00e9ralement moins bons que la moyenne nationale. Mais pourquoi?"},{"slug":"is-leroy-the-cutest","ideas_cat":"Issue brief","main_image":"https:\/\/defendfairaccess.org\/wp-content\/uploads\/2019\/06\/iStock-1141185123-e1714661214604.jpg","page_title_en":"A catchy headline about prescriptions","page_title_es":"La gente debate: \u00bfEs Leroy el m\u00e1s lindo?","page_title_fr":"Les gens d\u00e9battent: Leroy est-il le plus mignon?","page_content_en":"<p>There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat.<\/p>\n<p>There&#8217;s been a lot of argument throughout the house as to who the cutest cat lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat<\/p>\n<p>But who is it?!<\/p>\n<p>Turns out here&#8217;s what&#8217;s happened:<\/p>\n<ul>\n<li>Holly is the cutest.<\/li>\n<li>Even though she&#8217;s not a cat.<\/li>\n<li>Justin&#8217;s the dorkiest.<\/li>\n<li>All cats agreed.<\/li>\n<\/ul>\n<p>So there you have it!<\/p>\n<blockquote><p>As Leroy said, &#8220;Meow meow meow meow meow<\/p><\/blockquote>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_es":"<p>There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat.<\/p>\n<h3>There&#8217;s been a lot of argument throughout the house as to who the cutest cat<\/h3>\n<p>lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat<\/p>\n<h4>But who is it?!<\/h4>\n<p>Turns out here&#8217;s what&#8217;s happened:<\/p>\n<ul>\n<li>Holly is the cutest.<\/li>\n<li>Even though she&#8217;s not a cat.<\/li>\n<li>Justin&#8217;s the dorkiest.<\/li>\n<li>All cats agreed.<\/li>\n<\/ul>\n<p>So there you have it!<\/p>\n<blockquote><p>As Leroy said, &#8220;Meow meow meow meow meow&#8221;<\/p><\/blockquote>\n<div id=\"attachment_337\" style=\"width: 510px\" class=\"wp-caption alignleft\"><img aria-describedby=\"caption-attachment-337\" loading=\"lazy\" decoding=\"async\" class=\"wp-image-337 size-full\" src=\"https:\/\/fair-play-api.webworldnow.net\/wp-content\/uploads\/2019\/06\/beer-trouble.jpg\" alt=\"\" width=\"500\" height=\"622\" \/><p id=\"caption-attachment-337\" class=\"wp-caption-text\">Here&#8217;s a guy so perplexed by everything that he can&#8217;t even stand it.<\/p><\/div>\n<p>&nbsp;<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_content_fr":"<p>There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat.<\/p>\n<h3>There&#8217;s been a lot of argument throughout the house as to who the cutest cat<\/h3>\n<p>lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat There&#8217;s been a lot of argument throughout the house as to who the cutest cat<\/p>\n<h4>But who is it?!<\/h4>\n<p>Turns out here&#8217;s what&#8217;s happened:<\/p>\n<ul>\n<li>Holly is the cutest.<\/li>\n<li>Even though she&#8217;s not a cat.<\/li>\n<li>Justin&#8217;s the dorkiest.<\/li>\n<li>All cats agreed.<\/li>\n<\/ul>\n<p>So there you have it!<\/p>\n<blockquote><p>As Leroy said, &#8220;Meow meow meow meow meow&#8221;<\/p><\/blockquote>\n<div id=\"attachment_337\" style=\"width: 510px\" class=\"wp-caption alignleft\"><img aria-describedby=\"caption-attachment-337\" loading=\"lazy\" decoding=\"async\" class=\"wp-image-337 size-full\" src=\"https:\/\/fair-play-api.webworldnow.net\/wp-content\/uploads\/2019\/06\/beer-trouble.jpg\" alt=\"\" width=\"500\" height=\"622\" \/><p id=\"caption-attachment-337\" class=\"wp-caption-text\">Here&#8217;s a guy so perplexed by everything that he can&#8217;t even stand it.<\/p><\/div>\n<p>&nbsp;<\/p>\n<style>header nav a:last-child { display:none !important; }<\/style>\n","page_subheader_en":"This is going to be a subheader. What do we think about this? This is going to be a subheader. What do we think about this? ","page_subheader_es":"This is going to be a subheader. What do we think about this?  This is going to be a subheader. What do we think about this? ","page_subheader_fr":"This is going to be a subheader. What do we think about this?  This is going to be a subheader. What do we think about this? "}]