Navajo story

Alex Kacik: Healthcare is inextricably tied to your zip code. Where you live often determines what services you have access to and how good the care is. Providers often direct more resources to more affluent neighborhoods where care for the commercially insured is reimbursed at higher levels and services for Medicare and Medicaid beneficiaries. What does care look like for those who disproportionately bear the brunt of health care inequity and our providers trying to bridge these care gaps? Welcome to Beyond the Byline where we tried to give more context to our reporting. My name is Alex Kacik, senior operations reporter and I’m joined by Kara Hartnett, our health equity reporter. Thanks for coming on, Kara.

Kara Hartnett: Thanks for having me, Alex.

Kacik: All right. You were selected to participate in the fellowship from the USC Annenberg School for Communication and Journalism to study health inequity. And you use the Centers for Disease Control and Prevention, social vulnerability index, and Health Resources and Services Administration access scores, to map the regions with the poorest access to health care. Take us through why you chose to highlight Evangeline Parish, Louisiana; the Bronx, New York; and Navajo County, Arizona and what your analysis showed,

Hartnett: Each area ranked within the 99th percentile for social vulnerability, which is a measure of about 14 census metrics, tracking income, access to food, water, transportation, you know, etc. And each was designated medically underserved by HERSA, which essentially means that there aren’t enough providers or services there to meet demand.

Reporting from the perspective of these communities came from this underlying thought process that those who face a lot of social barriers are often the people who need healthcare the most. Yet there’s a lot of overlap between vulnerability and a lack of access to care, which means that healthcare organizations as a whole are not positioning themselves to serve those needs. And nationally speaking, I think our health, and quite frankly, our budgets suffer because of it.

The US has the lowest life expectancy among wealthy industrialized nations, and the worst rate of avoidable deaths yet spends the most per capita on health care services. Infant and maternal morbidity rates are the highest and death rates from diabetes, hypertension, and certain cancers have actually been rising since 2015. And so that is in part because of the disparities that are forged by this misalignment of capital. And Alex, I know you’ve done a lot of reporting on sort of consolidation in hospitals cutting services, most recently in maternity and cancer care. What have you found?

Kacik: The maternity and cancer care services are typically the first to go when a hospital is struggling financially. I looked at rural hospitals in particular, and the number of those types of hospitals discontinuing obstetric services, for instance, increased 9% from 2019 to 2020, leaving nearly 220 communities without access to maternity care. That’s according to data from the Chartis Center for Rural Health.

I took a look at Community Medical Center, which had been delivering babies in Falls City, Nebraska for more than a century until it shut down its obstetrics units in November 2019. The problem there was annual delivery volumes had steadily declined at the critical access hospital making it hard and attract to attract and retain anesthesiologist specialized nurses and surgeons. So that meant administrators had to pay high rates for on-call physicians and practitioners who are already stretched.

This scenario is happening across the country, widening long-standing healthcare inequities, and I know that’s an area you focus on daily. I was curious to learn more about what you learned for this project when you spoke with the largest provider in the Bronx, Montefiore, which closed a family practice clinic in Grand Concourse and directed patients to nearby alternate sides because the old one was, quote, unquote, suboptimal? Why did the clinic close? And what impact did it have?

Hartnett: Montefiore consolidated a group of clinics in the Bronx last year, and they said, it’s because the facility that they ultimately shut down was falling apart and generally not a great place to provide care. It’s important to note that Montefiore didn’t technically cut services, they just diverted them to two other clinics in the Bronx. One was, you know, within a 10-minute walk of the clinic that was shut down, and another a few miles down the road. When I spoke to leadership about this decision, they said that the two other clinics were state-of-the-art and they had plenty of capacity to take on the patients from this other clinic. They said that they were working with patients on transitioning them to the new locations, and they talked about it in a way that made it feel like it would be pretty seamless.

But when I talked to nurses about it, they were not so convinced. They said that the move is going to be a big disruption for patients that received care there and that many will simply stop going to the doctor and perhaps risk losing control of their chronic health condition or whatever else they may be facing. Aside from the direct patient impact, a group of nurses I talked to who were just involved in a major labor action against the hospital. They really saw this consolidation as part of a broader trend of disinvestment in low-income areas in the city.

The cuts were made while Montefiore was undergoing a $500 million initiative to cut costs because currently, the organization is operating at a loss. But at the same time, they opened a massive new medical center in the suburbs, sort of north of the city. The nurses that I talked to live in the Bronx, and most of them have their entire lives. They’re calling that out because they see the need that is going unfilled in their community. They don’t understand why their leaders would expand elsewhere, when there’s so much work left to do locally.

That was really the rallying cry for the strike in general. I think more than anything, what this story really describes is a healthcare system that does not incentivize businesses to provide care for low-income communities. That work ends up getting put back on government safety-net and community-based organizations, which are oftentimes overwhelmed and underfunded in these areas, and in general have limited capabilities. The question really comes down to that, Alex, is who should be picking up the slack.

Kacik: I’m excited to delve into that more in a story that you and I are working on right now. We’re looking at safety-net hospitals and their financial situation and how when they close or cut services, how that affects these broader markets. When services are cut and hospitals closed, they have to drive further for care, which as you can imagine, can be critical in emergency situations. A lot of times, transport is hard to come by too. There’s like one EMS ambulance in a certain area. Outcomes inevitably decline. academic medical centers and larger systems often have to pick up the slack. But there’s a limit to how much they can do. Many of the operators are already full with very sick patients, their tertiary and quaternary facilities that are outfitted to do that type of care. So the patients usually face higher costs either in the form of higher cost sharing and higher premiums. We’ve seen this situation play out in 2019, when Hanuman Hospital in Philadelphia closed. Atlanta Medical Center closed last year, and that left the area without a safety net provider that treated many low-income patients.

Kara, you reported on some ways that hospitals are trying to rectify these healthcare disparities. I know health systems often talk about how telehealth, for instance, is trying to bridge some of these gaps. But I imagine that is not feasible and communities that don’t have reliable internet connections. What what examples Did you find?

Hartnett: That’s a good example, Alex. And it’s a dynamic that I found across a lot of these solutions. Healthcare organizations pitch ways to connect to harder-to-reach communities and sort of solve these disparities.

In general, the solutions either lack uptake by consumers or they don’t target the people that would benefit from them the most. I was actually talking to David Ansel at Rush about this, and he described this cherry-picking of healthy patients and the sort of tossing aside of unhealthy patients is still kind of the norm. It’s a big issue.

In addition to the actual infrastructure for these solutions, there’s also this very critical need to employ people that will help other people navigate these systems. This is huge and, if anything else, what I hope healthcare organizations can take away from this.

As it relates to your example on telehealth, that’s another big one because a lot of people in this in this country still don’t have access to reliable broadband. When I went to Louisiana, a local health department director told me that they found out people were parking their cars at McDonald’s, just so their child could do their schoolwork at night. In Arizona, where there are several tribal communities, many of them lack access to even basic resources like running water in their home, and they definitely don’t have high-speed internet, or perhaps even the tech literacy needed to hop on to a telehealth appointment.

But there is some hope on this. Friday, when I talked to the mayor of Ville, Platte, the county seat for Evangeline parish in Louisiana, the area had just secured a $50 million grant from the federal government to expand broadband to nearly every resident in the broader Acadiana territory. And there are other levers the government is trying to pull to bring some relief to providers that practice in low-volume, low-income areas, like the $1.7 trillion spending bill that was passed last year. Alex, what other policy solutions are providers asking for?

Kacik: That bill had a couple of provisions that were important to those low-volume hospitals, one of which was a two-year extension of an add-on Medicare payment of up to 25% purchase charge for low-volume hospitals. It also staggered Medicare cuts and extended telehealth flexibilities.

There’s a lot of consternation about these Medicare cuts and sequestration and the pay go act and how that’s going to affect particularly all types of providers, but disproportionately the low-income or the ones situated in low-income areas. In addition to some of these flexibilities, small hospital operators are asking for increased state Medicaid funding for behavioral health care. They’re also asking for boosted Medicaid payments for rural providers that still offer maternity care. So ones that don’t deliver as many babies, it’s harder for them to survive. If there were somewhat of a payment boost would help. They’re also asking for relaxed requirements to participate in the critical-access hospital program.

I wanted to touch on the human interest part of this. It’s always helpful to contextualize these issues when we view them through the perspective of patients and policymakers, and you do a great job of weaving their perspectives into your stories. Kara, could you tell us about how Fern, a member of Navajo Nation in Arizona is taking it upon herself to improve some of the infrastructure in the community?

Hartnett: Yeah, absolutely. So I guess I’ll start by saying that a lot of the infrastructure problems in Navajo County run pretty deep. The northern half of the county is really remote and consists mostly of tribal lands. Navajo Nation has a visitor center that I went to when I was there that sort of tells you more about their own internal government structures and history and relationship to the Colorado Plateau, which is where they live in Arizona.

But I would say that the key takeaway from the museum was that their sovereignty as a nation is still pretty much being fought for. For example, some tribal communities are still suing the federal government for either breaking treaties from the 1800s. Or saying these agreements were signed by our ancestors under great duress and violence, they limit our autonomy as a people, and they don’t hold the United States government accountable for the promises that they’ve made to Native Americans. You know, one of those being to provide them with adequate health care. And so that’s sort of the context that local leaders are trying to work through to get these things done.

To bring this back to Fern, she’s a member of Navajo Nation, and she’s also a supervisor for the county, basically a council person. And her main priorities are updating basic infrastructure in the northern region of her county. She said that monthly she makes her rounds to different chapter houses, which are essentially the local government within tribal villages, to work on upgrading the roads. She said that they are still having to focus on building up these essential amenities because there are so many layers of bureaucracy and trying to get anything done in their tribal nations that span across several states and several counties in several jurisdictions. They have to coordinate across these various agencies for approval and funding that’s often earmarked for very specific purposes. It lacks the flexibility that they would like.

A Navajo County friend was telling me that throughout the area, they struggle to recruit new businesses to stimulate the economy, which makes it hard to attract more people to live there. A lot of locals are employed by coal-fired power plants, for example. They’re some of the highest-paying jobs in the area, but they’re getting shut down and they’re not going to be replaced. So as all of that relates back to health care, there are no private healthcare options on the reservation. There’s just the Indian Health Service and it’s notoriously underfunded and understaffed. A lot of the residents have to travel really long distances, up to three hours in some cases, to receive specialty care. And providers in the area generally really struggled to recruit and retain clinicians to live there long term because of the economic issues I talked about earlier. It’s just this cycle that people there are just really really struggling to reverse.

Kacik: All right, Kara, and thank you so much for your reporting. Check out her latest story: Unwell: Mapping inequity in American healthcare. Kara, thanks so much for explaining the process to us.

Hartnett: Thanks for having me.

Kacik: Thank you all for listening. You can subscribe to Beyond the Byline on Spotify, Apple Podcasts or wherever you choose to listen. You can support the reporting of Kara, myself and our team of reporters by subscribing to Modern Healthcare or give us a follow on Twitter and LinkedIn. Thank you for your support.