At Debate, Clinton Defends Support For Universal Coverage, Sanders Praises Cuba’s Health System

Hillary Clinton and Bernie Sanders jabbed at each other over health care and immigration in the eighth Democratic debate, which came a day after Clinton's surprising loss in Michigan.

Hospital Closures Rattle Small Towns

RICHLAND, Georgia — For years, Sybil Ammons was the director of nursing at Stewart County’s only hospital. Now, she’s the county coroner.

Since the hospital here closed three years ago, Ammons says more than a dozen local residents were unable to get medical care quickly enough and were either harmed or died because of the delays. “We’ve had a stroke, several heart attacks,” she said, standing along Richland’s main street in this small town about 150 miles south of Atlanta. “We’ve had traumas out on the four-lane.”

This KHN story also ran on PBS Newshour. It can be republished for free (details).

Across the country, more than 50 rural hospitals have closed over the last six years, and another 283 are in fragile financial condition, according to the National Rural Health Association. With rural populations long in decline in the United States, small-town hospitals have lost customers and struggled to keep pace with the striking advancements in medical technology.

But the pace of closures has escalated in recent years, hastened by a series of budget control measures passed by Congress that reduced Medicare payments and by the Affordable Care Act, which is slowly restructuring the health care industry. The law rewards scale and connectivity — difficult goals for rural hospitals that are, by their geographic nature, low-volume and remote.

Compounding their financial troubles, 19 states have not taken advantage of a key provision in the health law to expand their Medicaid programs. That’s left many rural hospitals with uninsured patients just as federal subsidies for taking care of the uninsured are being reduced.

‘It’s Hurting A Lot’

As hospitals have closed in Georgia, hundreds of people have lost their jobs, and many small towns have been left reeling.

When the Lower Oconee Community Hospital in Glenwood, two and a half hours southeast of Atlanta, abruptly laid off its workers, transferred its remaining patients and locked the front door nearly two years ago, it was yet another blow to a rural town accustomed to hardship. The hospital was the town’s largest employer and without the daily traffic from its 100 employees and families and friends of its patients, the town’s only restaurant closed, followed soon by its only bank.

“After the hospital closed, we dropped about 30 percent sales,” said D.K. Patel, owner of the local grocery store that sits on the edge of Glenwood’s town square. “All I can say is it’s been hurting a lot.”

The town’s mayor, G.M. Joiner, who has held his elected post for three decades, and whose father was mayor before him, laments the hospital’s decision to close. “It was our lifeblood,” he said. “It’s not overemphasizing or trying to be a doomsday prophet, but it’s devastating.”

Joiner has been courting suitors for the shuttered hospital, but with little success. The building sits eerily abandoned. At a nurses’ station, antiquated security cameras flicker between images of empty hallways and patient rooms with the beds still crisply made; dead cockroaches litter the floors; vials of patient blood sit in refrigerators, long ago unplugged, in the hospital laboratory.

For many residents, the disruption in medical care caused by the hospital closures has been deeply unsettling and, for some, life threatening.

It only takes one tragedy to realize how detrimental losing this facility is.

Dawn Malin

At her home in Folkston, near the Okefenokee Swamp, Pam Renshaw had to bypass her town’s closed hospital when she needed it most. After a day of yard work, Renshaw accidentally overturned her four-wheeler and spilled into a fire pit used to burn trash. Her then boyfriend, Billy Chavis, pulled Renshaw from the fire and patted down the flames on her body with his bare hands. Chavis got her into his truck and started driving down the long dirt road for help.

“And the whole time I’m driving to town, I said, ‘Where do I go? Where do I go?’”

The hospital in Folkston had closed just months before Renshaw’s accident, and Chavis scrambled to find help. He first tried the EMT office but when he didn’t find anyone, he ran to the police station and a dispatcher summoned an ambulance. Renshaw was driven to a nearby landing strip and airlifted to a hospital 100 miles away in Gainesville, Florida. Doctors finally tended to the burns, which covered 45 percent of her body, an hour and a half after the initial accident.

She spent weeks in in a medically induced coma and nearly eight months in the hospital.

Renshaw’s accident spooked this small town of 5,000 people, where dangerous, industrial jobs drive the local economy, and made clear just how vulnerable residents could be during a crisis at home or at work.

“When you have a timber industry, you’re dealing with saws, you’re dealing with heavy equipment,” said Dawn Malin, executive director of the Folkston Chamber of Commerce. “It only takes one tragedy to realize how detrimental losing this facility is.” The hospital’s closure has caused worries about workplace accidents at a local paper plant, Malin said, and hampered her group’s effort to attract new businesses.

Difficulties For Seniors

For many elderly residents of small towns, the price of the hospital closures has been steep. When the hospital closed in Glenwood, the remaining doctors moved out of the county, and residents like Joe and Sue Connell now must drive two hours round trip for medical care.

“I’m seeing about four different doctors in Dublin. This week, we’re making three trips,” said Joe Connell, 77. “Ninety percent of the miles put on our cars is going to the doctor in Dublin. It costs us, costs a bunch of money to go back and to.”

For pregnant women in rural Georgia, the hospital closures can mean dwindling access to prenatal care and longer trips when labor begins. In Waynesboro, Georgia, Dr. Frank Carter, a prenatal specialist, said after the troubled local hospital there closed its labor and delivery unit, his patients — largely poor women with little money for transportation — face an hour’s drive to deliver their babies.

“They’re going to have to be prepared and willing to travel,” Carter said. “And that’s the reality.”

It’s not overemphasizing or trying to be a doomsday prophet, but it’s devastating.

G.M. Joiner

Adjusting to that new reality is difficult for many rural residents. Hospitals are often a vital part of small-town life, said Chuck Adams, vice president of the Georgia Hospital Association.

“Towns like Glenwood have always had a hospital. When that hospital closed, then these residents immediately lost access without an opportunity to figure out what that next access model was,” said Adams. “When you have time to figure it out, I think there are models out there that could work.”

Effect On Health Unclear

But while hospital closures in rural areas can unsettle residents’ nerves and force them to travel farther distances, the effect on health outcomes remains unclear. Researchers have found that closing down a rural hospital does not increase the chance of death, and, an investigation by the Wall Street Journal found surgeries at many rural hospitals carried a greater risk of complications. Indeed, for some emergencies, patients can receive better quality care at larger hospitals that treat more cases.

“There has to be sort of a critical mass to be able to make any business viable, and especially a community hospital,” said Alan Kent, chief executive officer of Meadows Regional Medical Center, a bustling modern hospital in Vidalia, Georgia, that has taken in patients from neighboring towns like Glenwood. While rural residents need access to primary and urgent care, not every town can sustain a hospital with costly medical equipment and a roster of specialists.

“We have to be more efficient in hospitals if we are going to be sustainable, and I think that’s one of the things that you’re seeing that’s driving the consolidation in the industry,” Kent said.

But for elderly residents like the Connells, the closures have forced them to reconsider their retirement plans. Sitting on the porch of his house in Glenwood with his wife, Sue, age 75, Joe said, “I don’t know what we’re going to when she gets where she can’t drive.”

This story was reported in collaboration with PBS Newshour producer Jason Kane.

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Managing Depression A Challenge In Primary Care Settings, Study Finds

Often referred to as the “common cold of mental health,” depression causes about 8 million doctors’ appointments a year. More than half are with primary care physicians. A new study suggests those doctors may not be the best to treat the condition due to insurance issues, time constraints and other factors.

The paper, published Monday in the March issue of Health Affairs, examines how primary care doctors treat depression. More often than not, according to the study, primary care practices fall short in teaching patients about managing their care and following up regularly to track their progress. That approach is considered most effective for treating chronic illnesses.

That’s important. Most people with depression seek help from their primary care doctors, the study notes. Why? Patients often face “shortages and limitations of access to psychiatrists,” the authors write. For example, patients sometimes have difficulty locating psychiatrists nearby or those who are covered by their insurance plans. Plus, there’s stigma: Patients sometimes feel nervous or ashamed to see a mental health specialist, according to the authors.

This KHN story also ran on NPR. It can be republished for free (details).

Meanwhile, physicians and health experts have increasingly been calling for mental health conditions — such as depression and anxiety — to be treated like physical illnesses. Historically, those have been handled separately and, experts say, without the same attention and care as things like high blood pressure and heart disease.

The researchers compared strategies for treating depression with those used for asthma, diabetes and congestive heart failure. They surveyed more than 1,000 primary care practices across the country to determine how often doctors’ offices used five specific steps — considered “best practices” — to manage patients’ chronic conditions. They include employing nurse care managers, keeping a registry of all patients with a condition that requires regular follow-up, reminding patients to comply with their treatment regimens, teaching them about their illnesses and giving doctors feedback. Those approaches track with recommendations from the Department of Health and Human Services Agency for Healthcare Research and Quality.

On average, the practices surveyed were least likely to follow those protocols when treating depression. About a third kept registries of patients with depression, and the other steps were less commonly used. Less than 10 percent of practices, for instance, reminded patients about their treatments or taught them about the condition.

Doctors were most likely to use those best practices for treating diabetes. Most practices followed at least one of the strategies for managing chronic illness.

“The approach to depression should be like that of other chronic diseases,” said Dr. Harold Pincus, vice chair of psychiatry at Columbia University’s College of Physicians and Surgeons and one of the study’s co-authors. But “by and large, primary care practices don’t have the infrastructure or haven’t chosen to implement those practices for depression.” Pincus is also director of quality and outcomes research at New York Presbyterian Hospital.

That’s a problem, said Dr. Tara Bishop, an associate professor of healthcare policy and research at Weill Cornell Medical College, the study’s main author. Effectively treating any chronic illness requires working with patients beyond single visits. For depression, that means things like following up to see if medication is working, or if a dose should be adjusted.

“When we treat high blood pressure, the blood pressure may start at 150 over 95, and then it’s monitored over time until it gets to a level that’s being aimed for,” said Dr. Jeffrey Borenstein, president of the Brain and Behavior Research Foundation. The foundation funds mental health research but was not involved with this study. “If somebody has depression, their symptoms need to be monitored until it gets to a level that the depression is lifted.”

Depression can contribute to other health problems, like pulmonary disease or diabetes, Bishop said. It can make people less productive at work or less able to have healthy relationships. Unchecked, it can result in suicide.

“If we actually treat depression as a chronic illness and use the level of tools we’re using for diabetes, then we’ll be able to better treat patients — and help them live healthier lives and more productive lives,” she said.

The study didn’t delve into why the gap exists between depression and other medical conditions. But the authors pointed to potential explanations. One is that there’s been a decades-long push to improve how doctors treat diabetes — an effort that has almost been “the poster child” for how to monitor and treat a long-term illness, Pincus said.

And there are time pressures. Diagnosing a patient with depression — and following up regularly — can take more time than a diabetes blood test or insulin check. Cramming that into a 15-minute visit can get difficult, Bishop said, especially as doctors are increasingly asked to do more with less time.

Plus, she said, while there’s been an effort nationally for the medical profession to better address mental wellness, individual physicians may still struggle.

“It’s almost like a subconscious divide of mental health issues versus physical health issues,” she said. That may also contribute to why the treatment of depression sometimes falls short.

Some cited money as a key obstacle. Dr. Wanda Filer, president of the American Academy of Family Physicians, noted that, despite federal law, it’s still difficult to get insurers to pay for mental health care. That circumstance, she said, could discourage or impede primary care doctors from taking a comprehensive approach to treating it.

“Most depression cases we can manage quite easily — family physicians are well-trained to manage this particular condition,” said Filer, also a practicing family doctor in York, Pennsylvania. The problem is that “there are all these barriers to improving mental health.”

But Bishop said that, as doctors and policymakers take a broader interest in the issue, those barriers could come down and change how doctors practice.

“We’re starting to realize that mental health care, and depression in particular, are very important illnesses. They affect a large part of our population, and they have a lot of repercussions for patients and society,” she said.

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