Only four days after the Pungo District Hospital in Belhaven closed its doors for good on July 1, Portia Gibbs suffered a heart attack in neighboring Hyde County, which has no doctors or hospitals.
Residents of Hyde, a sprawling, rural county in Eastern North Carolina, had long relied on Pungo for emergency medical care. Now the nearest emergency room was 75 miles away.
More than an hour after a Medevac helicopter was called, Gibbs, 48, died just as the chopper arrived to airlift her to a hospital.
“Before, she would have been given nitroglycerin, put in the back of an ambulance and been to a hospital in about 25 minutes,” said Belhaven Mayor Adam O’Neal. “In that hour that she lived, she would have received 35 minutes of emergency room care, and she very well could have survived.”
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The memory of Portia Gibbs was alive and well for O’Neal on Monday as he completed a grueling 273-mile walk from his hometown to the U.S. Capitol, where he met with reporters to share his town’s story of losing its only hospital.
O’Neal’s two-week trek was equal parts politics and public relations. In a long-shot bid to reopen Pungo, he was hoping that his shoe-leather odyssey and Gibbs’ compelling story would help him get a meeting with, and assistance from, the Obama administration. The White House did contact O’Neal, but no meeting has been scheduled.
“I’m just praying and hoping that there will be some government official that has the power to stop this,” he said.
To help trumpet his cause, O’Neal used his “march” to highlight the growing problem of rural hospital closures across America and to make the case for Medicaid expansion, which North Carolina and 23 other states have refused to implement.
Medicaid expansion blocked
Medicaid, the federal-state health insurance plan for low-income Americans, would be open to adults who earn up to 138 percent of the federal poverty level under the expansion offered by the Affordable Care Act.
Since last year, 22 rural hospitals in the U.S. have closed, according to the National Rural Health Association. Twenty were in states that blocked Medicaid expansion because of strong opposition from Republican governors or Republican-controlled legislatures.
In Georgia, where four rural hospitals have closed since 2012, Republican state Rep. Jason Shaw said the state simply couldn’t afford the long-term costs of covering higher-income people through Medicaid.
“Obviously, it’s a tough decision,” said Shaw, who chairs Georgia’s legislative rural caucus. “But I think it’s the right thing to do as far as protecting the state and the taxpayers.”
O’Neal, a conservative Republican, disagrees. He strongly supports expanding Medicaid and said Pungo hospital would probably still be open if North Carolina had done so.
That would have sent more insured patients to the hospital and cut its uncompensated charity care, which helped fuel a $1.8 million operating loss last year.
But expanding Medicaid in North Carolina isn’t an option right now, especially since the program has faced a $1.8 billion shortfall over the last four years, said Kirsti Clifford, a spokeswoman for the North Carolina Department of Health and Human Services.
“The Medicaid budget must first be stabilized,” she said in a statement. “Once we fix the current system, North Carolina can then consider expanding Medicaid eligibility.”
O’Neal plans to meet with Sen. Kay Hagan, a Democrat, to discuss the hospital closure.
He’s hoping legislation will be introduced that would require the U.S. Health and Human Services secretary to sign off on all closures of rural critical-access hospitals, such as Pungo, that are at least 35 miles from other hospitals. O’Neal also wants to require critical-access hospitals to provide a year’s notice before closing their doors.
His unorthodox campaign hasn’t won many friends in his party. His letter seeking help from Gov. Pat McCrory, a Republican, went unanswered. But Virginia Gov. Terry McAuliffe, a Democrat who’s trying to expand Medicaid in his state, met with O’Neal for 40 minutes recently.
That’s what happens when a conservative Republican pushes for a prized Democratic policy initiative.
“But this is something that’s above politics,” O’Neal told a group of supporters Friday in Fredericksburg, Va., as he passed around Portia Gibbs’ photo. “This is not about Republican or Democrat. We’ve got to leave that behind. We’ve got to make sure that people like Portia don’t die.”
Evolving health care market
America’s rural hospitals were struggling long before expanding Medicaid became an issue. But the changing health care environment has made things tougher, said Brock Slabach, a senior vice president at the National Rural Health Association.
Because they treat higher rates of poor, uninsured and under-insured patients, rural hospitals typically provide large amounts of charity care without compensation. It’s a big reason that the average rural hospital operates at an 8.3 percent loss, Slabach said.
Advances in health care delivery that cut patient volumes and shorten hospital stays have also hurt rural facilities, which already serve a smaller pool of patients, limiting their revenue potential.
Throw in funding cuts because of federal budget reductions, increased costs for new technology and reimbursement cuts for Medicaid and Medicare, which typically account for 60 percent to 80 percent of rural hospital revenues, and it’s easy to see why rural hospitals are struggling.
Medicaid expansion would go a long way toward easing the financial burden, said Paul Taylor, the CEO of Ozarks Community Hospital in Springfield, Mo., which is cutting 60 employees because of financial problems. The reductions will mean fewer beds for the hospital’s growing number of psychiatric patients.
“Had they expanded Medicaid, we would have increased bed capacity to deal with that population,” Taylor said. “But they didn’t, so I’ve got to go in a different direction.”
One-third of Ozarks’ emergency room patients are uninsured, resulting in about $3 million a year in uncompensated care, Taylor said. Nearly all the uninsured patients would qualify for Medicaid under the expansion, but he said state lawmakers wouldn’t budge.
“I call it political posturing,” Taylor said, “because, honestly, when I go to these guys and I say, ‘Let’s talk about Medicaid expansion,’ they just say ‘Aww, it’s Obamacare. We’re not going to talk about it.’ Well, at least talk about it. Come on, let’s take a serious look at it. But because it’s Obamacare, it’s just off the list. It can’t be discussed.”
In Georgia, Gov. Nathan Deal, a staunch opponent of Medicaid expansion, has formed a Rural Hospital Stabilization Committee to try to help. The committee won’t consider expanding Medicaid, because a new state law requires legislative approval for any expansion.
Through a change in hospital licensing rules, Deal has offered Georgia’s struggling rural hospitals the opportunity to offer downsized services, including an emergency department.
“It’s not the answer for everything, but I think we’ll find that some of the hospitals that have closed, at least now we’ve allowed a way for them to scale down some services and keep some emergency care available,” said Rep. Shaw.
But Slabach said that without a definitive funding stream, these “freestanding emergency departments” would also struggle.
“Emergency departments are typically the most expensive and (unprofitable) department of any rural hospital,” he said, “so it’s hard to understand how they would sustain this program.”