The 2018 Presidents & Executive Politics Presidential Greatness Survey was summarized in Politico as “Barack Obama and Ronald Reagan are up, Bill Clinton is down and Donald Trump is off to a historically bad start — and the greats, meanwhile, remain the greats.”
President Obama went from 18th place, which was an impressive start for a newcomer, to eighth which is very impressive when you know you’ve got no chance against Lincoln, Washington and FDR. Meanwhile, President Trump occupies a place at the very bottom of the list. If he had any competition, it would have to be from King Aethelred II the Unready. Laurie Garrett, a Pulitzer Prize winner for science writing, wrote a very well documented report in Foreign Policy magazine (Jan. 20) “ Trump Has Sabotaged America’s Coronavirus Response: As it improvises its way through a public health crisis, the United States has never been less prepared for a pandemic.”
This is hardly new or even news. Just about every reliable news source has a report on the lack of preparedness of the United States to cope with a pandemic. Perhaps worse, the focus of the pandemic is moving from the major coastal cities to the rural areas, which have fewer resources for improvising a response.
In recent weeks the attention has been drawn to New York City, which was reasonably predictable. New York City is the most populous city in the United States, and probably the most densely populated, at least during rush hour, when it draws on suburban commuters who arrive from New Jersey and Connecticut. Anybody who has seen the #6 subway train at 8:30 a.m. would recognize the risk of viral spread. But New York, with its collection of medical schools, could give students early graduation to care for patients, and with the army corps of engineers could convert a convention center into a 1,700 bed hospital. The US Navy could send 1,000 bed hospital ships to New York and Los Angeles.
In spite of these resources these cities and states are still badly stressed and in need of ventilators and protective clothing for hospital staff, but they have some options. A headline in Market Watch read “Nurses are wearing garbage bags as they battle coronavirus: ‘It’s like something out of the Twilight Zone’.” But NPR reported, “Small-Town Hospitals Are Closing Just As Coronavirus Arrives In Rural America.” Decatur County General Hospital in Tennessee is scheduled to close on April 15, just as coronavirus patients start to arrive. Towns that have lost their only hospital have no options, no room for expansion.
The ability of a hospital to stay open often depends on its location and the population it serves. Hospitals that can get a high percentage of patients with commercial insurance do the best financially. Even hospitals in large metropolitan centers, such as Philadelphia’s Hahnemann University Hospital or New York’s St. Vincent’s Hospital, may fail if they serve a large percentage of uninsured or even Medicaid patients. Rural hospitals commonly depend on whether their state has expanded Medicaid under the Affordable Care Act.
The Kaiser Family Foundation has reported on the status of Medicaid expansion. The states which did not expand Medicaid are primarily red states, and as the KFF report states “… because the ACA envisioned low-income people receiving coverage through Medicaid, it does not provide financial assistance to people below poverty for other coverage options. As a result, in states that do not expand Medicaid, many adults, including all childless adults, fall into a “coverage gap” of having incomes above Medicaid eligibility limits but below the poverty level, which is the lower limit for Marketplace premium tax credits.”
According to the North Carolina Rural Health Research Program, 128 rural hospitals have closed in the past 10 years, the majority in the southeastern states. One point which has been frequently made is that the closing of a small local hospital may leave a ghost town behind. Physicians, with no access to a hospital, may leave town, and without prescribers, pharmacies may close. Also, in small towns, hospitals may be among the largest employers. Tax receipts will decline, and the town will eventually shut down. According to one estimate, the cost of treating a COVID-19 patient can run to $40,000, more if they are severely ill or have serious co-morbidities. This will only accelerate the decline of rural health care, and winter is coming.
Sam Uretsky is a writer and pharmacist living in Louisville, Ky. Email sdu01@outlook.com.
From The Progressive Populist, May 15, 2020
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