Rural hospital closures impact healthcare of Tennessee’s most vulnerable children

BY KATE COIL
TML Communications Specialist

With one of the highest rates of rural hospital closures in the nation, communities across Tennessee are struggling to ensure their most vulnerable residents have access to needed care.
The Tennessee Commission on Children and Youth’s recent “Kids Count” report found that, for the first time in a decade, the number of uninsured children increased in 2018. Furthermore, there are more than 45,000 Tennessee children who qualify for TennCare of CoverKids who still lack health insurance.
The Tennessee Justice Center (TJC) was founded in 1996 as a nonprofit, nonpartisan public policy advocacy organization that works across the state of Tennessee to provide advocacy, research, and legal aid to low-income families across the state of Tennessee. The organization works with families to secure health care, assistance, and food aid as well as to help them navigate programs like TennCare, Medicaid, Medicare, SNAP, and LIHEAP.
Kinika Young, director of children’s health for TJC, said health care touches more aspects of people’s lives than many realize.
“Health is really at the core of people being able to live and thrive, specifically for children,” she said. “If they are not healthy, they are more likely to miss days of school. We have seen studies that find kids who have comprehensive health coverage tend to miss fewer days of school, have better grades, are more likely to finish high school, more likely to go to and graduate from college, and more likely to earn more money. It is also essential for developmental reasons for children to have this access so any issues can be identified and addressed early on. With this care, children can grow up to be healthy adults who then work and are able to earn more money as adults and contribute more to the community. The lack of access to healthcare has impacts on education, the economy and filling jobs, and also the criminal justice system.”
With 12 closures, Tennessee has lost the second-highest number of rural hospitals among all states since 2010. Several more remain at risk, meaning many more rural children could lose healthcare access. Young said her organization has seen a lot of impact on families in rural communities where hospitals have closed.
“A lot of communities depend on these hospitals as a primary employer, and once that hospital is lost, it can be hard to attract other employers to the area,” Young said. “A lot of the officials we have talked to in rural communities are concerned about being able to attract new companies and new people to their area if they no longer have a hospital to provide for those healthcare needs.”
Unfortunately, the fact that a lot of these hospitals provide care for those who are uninsured or underinsured is also one of the reasons so many are struggling to stay afloat financially.
“A lot of these rural hospitals are nonprofits; they aren’t part of these larger hospital corporations,” Young said. “Therefore, they have been more likely to treat patients who maybe can’t afford to pay. These rural hospitals are often struggling to keep the lights on and rely on programs like Medicaid to stay viable for their patients. A lot of hospitals that are closing are seeing patients who could be covered if Medicaid were expanded and are still coming to these facilities for treatment but without any insurance. Covering them through Medicaid expansion would benefit hospitals because they would have that source of revenue to offset the loss these hospitals are seeing.”
Of course, even those with insurance are still struggling to pay their medical bills.
A new study by the Commonwealth Fund found that more middle-class workers are spending their income on health care rather than other necessities because of rising insurance costs.
In Tennessee, the average, middle-income resident loses 13.5% of their income to health insurance with the average premium contribution and deductible increasing from $4,090 to $7,966 in the past decade. Sara Collins, lead author of the study, said these rising costs could put healthcare out of the reach of even middle-income families and cause more and more people to defer healthcare treatment.
The closure of a hospital may also lead to a domino effect of closures of other medical facilities or put a strain on the area’s medical community at large.
“Doctor’s offices often need to have access to a facility so they can send their patients if they need inpatient care,” she said. “Sometimes, hospitals will have physicians who are employees that also have outpatient offices. If the main employer is the hospital and the hospital leaves, that means the doctor loses out on that employer. Those doctors may then not be able to sustain themselves on those outpatient practices.”
Beyond that, the loss of rural health care facilities can further reduce the access residents have to healthcare. Young said many are beginning to realize the important role transportation plays in healthcare.
“There are a lot of people who are also concerned about where they will get their healthcare when these facilities close,” Young said. “People worry about having an emergency situation, like a heart attack, and then having to go to the next county over to be treated. A lack of local healthcare resources means that a parent may have to take more time off work and then take their child out of school for longer to see a doctor in another area. It really adds a lot of time and stress to a working parent’s day if they have to travel somewhere else just to see a doctor. Transportation is also a big issue for low-income people, particularly since public transport isn’t available in a lot of places. If they don’t have a car or money for gas, then they are really stuck.”
While rural areas have a lower percentage of the population under the age of 18, Tennessee children in rural areas are more likely to live in poverty than their urban counterparts. An estimated 21% of the state’s children live in poverty or roughly one-in-five children. Food insecurity, afterschool care, and healthcare are all issues that can impact families in poverty.
Beyond primary care, Tennesseans living in rural areas often have a harder time accessing other types of healthcare. A smaller percentage of rural Tennessee children receive dental care than the national average, according to the Kids Count survey.
Rural populations with lower dental care utilization also tend to have less water fluoridation, fewer dentists per population, and children in these areas are three times as likely to miss school because of an oral health problem. For every $1 spent on preventative dental care, it is estimated that between $8 and $50 is saved on restorative and emergency dental treatments.
Pregnant women and new mothers are also being impacted by a lack of comprehensive care, Young said.
“We had 52 women die in 2017 from preventable deaths in Tennessee because their post-partum coverage ended,” she said. “Presently, the state only provides two months of post-partum coverage. Moms really need comprehensive coverage before, during, and after birth.”
The ongoing opioid crisis is also another healthcare need that is pressing rural communities.
“Medicaid is the largest insurer or provider for substance abuse disorder treatment,” Young said. “If people don’t have that coverage, they aren’t able to afford to get treatment for these issues. In terms of children born with neonatal abstinence syndrome (NAS), moms really need treatment and need coverage to get that treatment to avoid issues during pregnancy and to deliver a healthy baby. Especially those with substance abuse disorders, the time after birth is critical. If a woman goes off a substance to have a baby and then relapses after birth, her likelihood of overdose is very high. Having coverage and access to ongoing treatment is important.”
Furthermore, Young said that a lot of those who have turned to abusing illicit substances have done so because they were already not getting the healthcare they needed.
“Studies have shown that a lot of people who are incarcerated have significant illnesses, especially mental health issues and drug addiction,” she said. “Substance-use disorders are often times a side affect of not having access to healthcare at an early age. In a lot of instances, people start to self-medicate or develop a drug addiction to cope with mental illness or the fact that they haven’t been able to reach their full potential.”
Young said people with disabilities have the highest need of anyone in rural areas.
“They have chronic needs that require consistent care,” she said. “Particularly for kids who have special equipment or may rely on a ventilator or breathing tubes in their home, if that equipment needs to be replaced that can be the difference between life or death for those kids. Provider capacity is an issue across the state. We don’t have enough providers for therapies and different interventions that kids with disabilities need. ”
The expansion of Medicaid is one of the main solutions to all of the state’s healthcare issues.
“The best thing leaders can do is to speak out about Medicaid expansion,” Young said. “That is really the thing that separates Tennessee from other states. The states that expanded Medicaid are six times less likely to have a rural hospital close. Expanding Medicaid is the best thing we can do to stop this tide of hospital closures.”