Yet, sometimes, the most straightforward path forward emerges far from where one expects. A clinical field initiative unfolding in Ghana is demonstrating that with the right technology and training, frontline physicians can step into the widening gap and save lives.

AISAP, an emerging voice in AI-supported point-of-care diagnostics, announced a landmark deployment of its Food and Drug Administration-cleared cardiac diagnosis platform across Ghana. The initiative powers the country’s first nationwide program to train cardiac sonographers and is being deployed in partnership with the G-ACT Foundation. What is unfolding across this West African nation may well offer the most compelling and implementable model for tackling America’s growing cardiology deserts.

When Specialists Are Scarce, Technology Becomes the Essential Partner

Ghana’s health system faces an extraordinary shortage, with fewer than 30 cardiologists serving a population of approximately 35 million. For years, this scarcity placed extraordinary weight on general practitioners, nurses, and emergency teams who lacked the tools or training to perform early cardiac assessments. The AISAP initiative changes that.

“AISAP brings world-class AI diagnostic capability that accelerates training, safeguards quality, and ensures every scan counts,” said Alexis K. Okoh, MD, Executive Chairman of the G-ACT Foundation. “This partnership sets a new standard for accessible cardiovascular care across Ghana, empowering local clinicians to become the new frontline of heart health.”

Clinicians can now access specialist-level interpretation at the bedside. This is more than a clinical advance; it’s a rebalancing of access within care systems. When the tools of expertise reach the people closest to patients, whole nations shift from reactive care to proactive health creation.

A Proven Model for the U.S. Rural Challenge

While the headlines may focus on Ghana now, the unspoken message is aimed squarely at the United States. America’s rural hospitals increasingly rely on traveling specialists, overburdened telecardiology services, or simply do without. AISAP CEO, Adiel Am-Shalom, makes the connection:

“This project represents the heart of our mission, ensuring that access to advanced cardiac care should not depend on geographic location. We are deploying the same FDA-cleared technology trusted by major US hospitals across remote frontlines in Ghana. The model is clear – our cloud-based platform delivers specialist-grade insights to frontline physicians. This deployment is the ultimate proof of concept that AISAP can help solve the diagnostic gap for U.S. rural hospitals facing critical cardiologist shortages.”

Proof of concept is often clinical. Here, it is also a moral imperative. If a middle-income country with constrained resources can deploy expert-level diagnostic capability at scale, what excuse remains for wealthier nations struggling to bridge gaps only widened by geography and policy inertia?

Inside the Technology: When Data Becomes Diagnostic Power

The AISAP Point-of-Care Assisted Diagnosis (POCAD™) platform represents a new generation of applied AI, built not to replace clinicians, but to enable them.

Developed in collaboration with Sheba Medical Center, one of the world’s top hospitals, POCAD has been trained on more than 300,000 echocardiogram studies and 24 million video clips. The platform provides real-time, expert-grade interpretation, along with high-quality guidance for non-specialists. It also provides an Urgency Score that helps clinicians prioritize the sickest patients immediately.

The system does not require proprietary equipment. Almost any portable ultrasound device with an internet connection can transmit images to the secure, HIPAA-compliant cloud.

This accessible specialist knowledge has already made inroads in leading U.S. systems, including Mass General Brigham, Mayo Clinic, Jefferson Health, and Stanford. What makes Ghana’s deployment so compelling is the scale at which the technology is being integrated into clinical pathways, starting with training.

Building an Ecosystem of Capability: The BEAT Program

The Ghana initiative operates through the G-ACT Foundation BEAT Program (Building Echo-Capacity for Access & Triage). It is the nation’s first structured and internationally benchmarked cardiac sonographer training curriculum, developed in collaboration with Ghanaian cardiologists and global academic partners.

“The ability to deploy advanced, life-saving diagnostic capacity directly to our citizens is a monumental step forward for our healthcare system,” said Prof. Yaw A. Wiafe, Associate Professor of Clinical Ultrasound and Echocardiography at Kwame Nkrumah University of Science and Technology. “AISAP’s technology removes traditional barriers to care and offers immediate, tangible results for our population.”

Training programs tend to succeed or fail on three pillars: quality, consistency, and clinical reinforcement. By providing specialist-level diagnostic support directly to trainees, the BEAT Program bypasses traditional barriers and accelerates the development of a new cadre of cardiac professionals. It creates not only capability but confidence.

A Future Defined by Shared Solutions

Ghana’s experience is a striking reminder that innovation need not follow wealth. It follows will, collaboration, and a refusal to accept that a shortage of specialists must translate into a shortage of care.

In many ways, AISAP efforts reflect a shift taking shape across global health: solutions once designed for high-resource environments are being refined in low-resource settings and then reapplied to mature health systems that need new pathways to scale.

“The very first patient we scanned in Ghana was a 46-year-old woman, and her life was immediately changed when our platform quickly identified severe heart failure and multiple valve diseases. She was transferred for urgent care. This outcome is exactly why we built this technology,” shares Adiel Am-Shalom, AISAP co-founder and CEO of AISAP.  “We are now focused on scaling US implementations to ensure our proven, FDA-cleared technology helps even more people and provides access to critically needed care nationwide.”

For the United States, where rural communities are growing older, sicker and more medically isolated, the lesson is unmistakable. Technology that equalizes expertise is no longer optional. It is central to ensure that ZIP codes do not determine survival.

As Ghana builds its next generation of cardiac frontline clinicians, the implications stretch far beyond national borders. This initiative demonstrates what is possible when innovation and intention align, and when the goal is not just to advance diagnostics, but to advance equity.

Ghana is charting a course that others, including the U.S., can follow. AISAP deployment is not just a technology story. It serves as a reminder that health is a shared human endeavor and that the most effective ideas in medicine are those that bring care closer to those who need it most.

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SNAP is not an abstract line item. It is a lifeline for nearly 42 million Americans, one in eight citizens. In fiscal year 2024, the program distributed almost $100 billion in benefits, with the average recipient receiving approximately $187 per month. For families living paycheck to paycheck, this is the difference between nourishment and hunger, health and hardship.

War on Poverty

SNAP’s history reveals both bipartisan vision and enduring necessity. The program originated during the early 1960s as a pilot effort to stabilize farm prices and reduce hunger. In 1964, President Lyndon Johnson signed legislation making the Food Stamp Program permanent as part of his War on Poverty. His message to Congress was clear: a nation strong enough to feed the world must also be able to feed its own people.

Through the decades, the program evolved from paper coupons to electronic benefits, and in 2008, it was rebranded as the Supplemental Nutrition Assistance Program to emphasize nutrition and dignity rather than charity. That renaming symbolized an essential truth – food security is fundamental to health, not a handout. SNAP has survived political shifts and economic crises because it reflects a moral consensus: no one in America should go hungry.

Who Relies on SNAP

The faces behind SNAP are as diverse as the nation itself. Nearly 40 percent of participants are children, and another 20 percent are seniors. Millions of adults are living with disabilities, many of whom also qualify for Medicare regardless of age. For individuals managing chronic conditions, experiencing mobility limitations, or living on a fixed income, SNAP assistance serves as a proven vital lifeline for maintaining preventive health.

Often sympathetic to the Administration, a Fox News story shared the fear many are now experiencing. A cancer survivor who depends on disability benefits described how the possible halt in SNAP payments left her anxious and uncertain: “It’s scary. I really need the extra for food, because by the time I pay all the bills, there’s really nothing left.” Her story mirrors that of millions who balance medication co-pays against grocery costs, forced into trade-offs that jeopardize both health and dignity. Let’s not forget paying for housing and transportation.

Working families are also part of this equation. Many SNAP households have at least one employed adult. The wages are not enough to cover rent, childcare, transportation to work and medical bills, so food becomes the only variable expense they can afford to cut. SNAP ensures that food insecurity doesn’t become the hidden cost of low-wage work.

What SNAP Provides

SNAP benefits are issued through an EBT card and can be used to purchase fruits, vegetables, meats, fish, poultry, dairy products, bread, cereals, and even seeds and plants to grow food. They cannot be used for alcohol, tobacco, hot prepared meals or household items. The program supplements, rather than replaces, household food budgets, providing predictability that allows families to direct scarce income toward other essentials.

For the health system, SNAP is prevention in action. Food insecurity fuels chronic disease and poor health outcomes. According to the Centers for Disease Control and Prevention, adults experiencing food insecurity are 2 to 3 times more likely to develop diabetes and more than twice as likely to suffer from depression. Children in food-insecure households face 19% higher odds of hospitalization before age three and significantly higher risks of anemia, asthma, and behavioral problems.

A study published in JAMA Internal Medicine found that SNAP participation was associated with a 14% reduction in emergency department visits and lower overall healthcare expenditures. When families can afford healthy food, chronic illness becomes more manageable, adherence to medications improves, and children achieve better developmental outcomes. Conversely, disruptions in SNAP benefits correlate with spikes in hospitalizations for malnutrition, hypoglycemia and mental-health crises.

SNAP functions as one of this nation’s most effective public-health interventions, less visible than vaccines or prescription drugs, and essential to community well-being.

The Big Apple, Empire State and the Nation

The human impact of this shutdown can be seen most vividly on the streets of New York City, where nearly 1.73 million residents, about one in five New Yorkers, depend on SNAP to make it through the month. Grocery stores in the Bronx, Queens, and across the five boroughs see the direct connection between Federal stability and neighborhood well-being. When SNAP dollars are delayed, the effects ripple far beyond individual households: local grocers lose revenue, food pantries face longer lines, and families already budgeting every dollar must make painful trade-offs between groceries, rent and medicine. Child care for working parents is already an out-of-reach luxury.

At the state level, the scale becomes even more striking. As of January 2025, nearly three million New Yorkers –from Buffalo to Brooklyn – received a combined $655.9 million in SNAP benefits that month. These benefits circulate quickly through communities, sustaining small businesses and providing a stabilizing force in counties where economic opportunity fluctuates with the seasons. The State Comptroller’s office estimates that more than $7 billion flowed to New York households in the last fiscal year through SNAP. This Federal investment fuels local economies while preventing hunger from escalating into a public-health emergency.

Nationally, these numbers paint a powerful and painful picture of need and vulnerability. Across the United States, roughly 42 million people, one in eight Americans, rely on SNAP each month. The Federal government must provide approximately $9 billion monthly to sustain those benefits; however, contingency funds currently fall billions of dollars short of that requirement. That gap is not theoretical. Food banks and community kitchens from California to Kentucky are already bracing for the overflow, warning that their shelves and volunteers cannot absorb the loss of a Federal program that moves food on a national scale.

From a New York City food pantry to a rural supermarket in upstate counties, the story reverberates: SNAP keeps families fed, children nourished and local businesses viable. When the Federal system stumbles, the consequences cascade, turning this government shutdown into a community crisis.

A few days ago, a Federal judge ordered the government to use all available contingency funds to sustain SNAP. Still, those dollars fall short of the roughly $9 billion needed for November benefits. The result is confusion, fear and logistical strain. Governors and mayors across the country are scrambling to respond to the crisis. In New York City, Mayor Eric Adams announced $15 million in emergency funding to bolster food pantries and community kitchens. State agencies are urging residents to call 311 in the city and 211 statewide to find food resources.

Still, no local initiative can replace the Federal infrastructure that delivers food assistance on a national scale. Charity can fill temporary gaps; however, it cannot replace the efficiency, reach and consistency of a program built to prevent hunger in the first place.

Health and Economic Stakes

SNAP is among the most cost-effective anti-poverty and public-health tools the nation has ever introduced. Every dollar in benefits generates approximately $1.50 to $1.80 in economic activity, circulating through local farmers, grocers and supply chains. When benefits are delayed or reduced, families face impossible choices between food and heat, or groceries and prescriptions. Hospitals see higher emergency visits; schools see lower attendance and test scores; local economies contract.

A CNN analysis broadcast this week underscores the link between nutrition and resilience. The report notes that food insecurity not only increases health costs but also reduces life expectancy. People living in food-insecure households have a 32% higher risk of premature mortality from preventable disease. Supporting food banks helps in the short term, but it cannot replace a Federal program designed to prevent hunger on a larger scale.

Without SNAP, the nation’s social safety net frays, leaving millions exposed to physical and psychological harm and the country’s public-health foundation weakened.

The Social Impact

Food assistance is not a partisan favorite; it is a measure of a vibrant society caring for its most vulnerable. SNAP’s durability across administrations reflects a shared American understanding: no child should be hungry because adults can’t agree. The current shutdown tests the consensus and the moral fiber of the nation’s leadership.

From the individual with a disability counting on SNAP to stay fed, to the child trying to learn on an empty stomach, to the local grocer whose shelves depend on steady EBT purchases, the stakes are not political. They are human. As winter approaches, this must not become the season when America’s nutrition safety net blinks and citizens are left in the cold.

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By leveraging local knowledge and fostering active community participation, these initiatives ensure that interventions are effective, culturally relevant, and sustainable. It’s about empowering the community to take control of their health destinies, making sure every step taken is a step that resonates with their unique way of life. When communities are at the helm, the improvements in health outcomes are not just significant; they are monumental, lasting, and deeply personal. This is the true power of community-driven public health: a collaborative effort that transforms lives, one initiative at a time.

Community-driven initiatives are crucial for several reasons. First, they promote higher levels of engagement and ownership among community members, leading to more sustainable health outcomes. Second, when communities are directly involved in identifying problems and implementing solutions, the interventions are more likely to be culturally relevant and accepted.

Moreover, these initiatives often leverage local knowledge and resources, making them cost-effective and adaptable to specific local contexts. Community participation also helps in building trust and accountability, which are essential for the success of any public health intervention. Finally, community-driven initiatives can bridge gaps in formal health systems by providing tailored solutions to underserved populations.

Successful community initiatives

Engaging community members in every step of the process ensures ownership and sustainability. Moreover, strong local leaders can drive change and motivate others to participate. Focusing on long-term solutions, such as sustainable agriculture or sanitation facilities, ensures lasting benefits. Collaboration with government agencies can also provide additional resources and legitimacy to the initiatives.

In India, the Swachh Bharat Abhiyan, or Clean India Mission, is a nationwide campaign launched by the government to improve sanitation and hygiene. Communities across urban and rural areas have been mobilized to build toilets, promote handwashing, and eliminate open defecation.i Similarly, the Self-Employed Women’s Association (SEWA) has also implemented various health initiatives to empower women and improve family health. Its approach integrates health education with economic empowerment.ii

The Aaraku Coffee Project in Andhra Pradesh is another unique initiative combining sustainable agriculture and health improvement. Alongside agricultural training, the project includes health education and the provision of basic healthcare services to tribal communities. The holistic approach of integrating economic development with health interventions has proven to be highly effective in enhancing the well-being of the community.iii

The Mae Fah Luang Foundation in Thailand is a prime example of how sustainable agricultural practices, such as organic farming, can drive public health improvements. Established to improve the livelihoods of hill tribe communities, the foundation has integrated health initiatives with economic development.iv By promoting sustainable agriculture, the foundation has enhanced food security and reduced malnutrition and health issues related to poverty.

Similarly, in the Philippines, community-led health and nutrition programs such as the Integrated Community Food Production initiative have empowered local communities to produce their own food through sustainable methods, thereby reducing the rates of malnutrition, especially in children.v

Another example is how Indonesia has implemented numerous community-driven projects aimed at improving water quality and sanitation, which are critical for preventing waterborne diseases. One notable initiative is the Community-Based Total Sanitation (CBTS) programme, which encourages communities to build and maintain their own sanitation facilities, thereby reducing open defecation and improving overall hygiene.vi

However, it’s important to acknowledge that these community-level initiatives often face formidable challenges such as limited resources and resistance to change. Overcoming these hurdles demands not just flexibility and persistent community engagement but also an unwavering commitment to adapt interventions based on real-time feedback.

What have we learned from these efforts? First and foremost, building trust within the community is paramount as it is the foundation upon which all successful interventions are built. Continuous education and training are equally essential, ensuring that community members are well-equipped to sustain these initiatives. Moreover, integrating economic development with health interventions has proven to be a game-changer, demonstrating that health and prosperity go hand in hand.

Community initiatives are not just a piece of the puzzle but the driving force behind sustainable public health changes. By actively engaging local populations, tapping into cultural wisdom, and emphasizing sustainable practices, these initiatives have significantly improved health outcomes across the Asia-Pacific region. These stories are powerful testaments to the potential of community-driven efforts to create lasting public health improvements. They serve as valuable blueprints for future initiatives, illustrating that we can overcome any challenge and build healthier, more resilient communities with trust, education, and economic integration.

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Kevin Stansbury, the CEO of Lincoln Community Hospital in the 800-person town of Hugo, Colorado, is facing a classic Catch-22: He could boost his rural hospital’s revenues by offering hip replacements and shoulder surgeries, but the 64-year-old hospital needs more money to be able to expand its operating room to do those procedures.

“I’ve got a surgeon that’s willing to do it. My facility isn’t big enough,” Stansbury said. “And urgent services like obstetrics I can’t do in my hospital, because my facility won’t meet code.”

Besides securing additional revenue for the hospital, such an expansion could keep locals from having to drive the 100 miles to Denver for orthopedic surgeries or to deliver babies.

Rural hospitals throughout the nation are facing a similar conundrum. An increase in costs amid lower payments from insurance plans makes it harder for small hospitals to fund large capital improvement projects. And high inflation and rising interest rates coming out of the pandemic are making it tougher for aging facilities to qualify for loans or other types of financing to upgrade their facilities to meet the ever-changing standards of medical care.

“Most of us are operating at very low margins, if any margin at all,” Stansbury said. “So, we’re struggling to find the money.”

Aging hospital infrastructure, particularly in rural areas, is a growing concern. Data on the age of hospitals is hard to come by, because hospitals expand, upgrade, and refurbish different parts of their facilities over time. A 2017 analysis by the American Society for Health Care Engineering, a part of the American Hospital Association, found that the average age of hospitals in the U.S. increased from 8.6 years in 1994 to 11.5 years in 2015. That number has likely grown, industry insiders say, as many hospitals delayed capital improvement projects, particularly during the pandemic.

Research published in 2021 by the capital planning firm Facility Health Inc., now called Brightly, found that U.S. health care facilities had deferred about 41% of their maintenance and would need $243 billion to complete the backlog.

Rural hospitals don’t have the resources of larger hospitals, particularly those in hospital chains, to fund billion-dollar expansions.

Most of today’s rural hospitals were opened with funding from the Hill-Burton Act, passed by Congress in 1946. That program was rolled into the Public Health Service Act in the 1970s and, by 1997, had funded the construction of nearly 7,000 hospitals and clinics. Now, many of those buildings, particularly those in rural areas, are in dire need of improvements.

Stansbury, who is also board chair of the Colorado Hospital Association, said at least a half-dozen rural hospitals in the state need significant capital investment.

Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a think tank in Pittsburgh, said the major problem for small rural hospitals is that private insurance is no longer covering the full cost of providing care. Medicare Advantage, a program under which Medicare pays private plans to provide coverage for seniors and people with disabilities, is a major contributor to the problem, he said.

“You’re basically taking patients away from what may be the best payer that the small hospital has, and pushing those patients onto a private insurance plan, which doesn’t pay the same way that traditional Medicare pays and ends up also using a variety of techniques to deny claims,” Miller said.

Rural hospitals also must staff their emergency rooms with physicians round-the-clock, but the hospitals get paid only if someone comes in.

Meanwhile, labor costs coming out of the pandemic have increased, and inflation has driven up the cost of supplies. Those financial headwinds will likely push more rural hospitals out of business. Hospital closures dropped during the pandemic, from a record 18 closures in 2020 to a combined eight closures in 2021 and 2022, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill, as emergency relief funds kept them open. But that life support has ended, and at least nine more closed in 2023. Miller said closures are reverting to pre-pandemic rates.

That raises concerns that some hospitals might invest in new facilities and end up shutting down anyway. Miller said only a small portion of rural hospitals might be able to make a meaningful difference to their bottom lines by adding new services.

Lawmakers have tried to help. California, for example, has loan programs charging low to no interest that rural hospitals can participate in, and hospital representatives are urging Colorado legislators to approve similar support.

At the federal level, Rep. Yadira Caraveo, a Colorado Democrat, has introduced the bipartisan Rural Health Care Facilities Revitalization Act, which would help rural hospitals get more funding for capital projects through the U.S. Department of Agriculture. The USDA has been one of the largest funders of rural development through its Community Facilities Programs, providing over $3 billion in loans a year. In 2019, half of the more than $10 billion in outstanding loans through the program helped health care facilities.

“Otherwise, facilities would have to go to private lenders,” said Carrie Cochran-McClain, chief policy officer for the National Rural Health Association.

Rural hospitals might not be very attractive to private lenders because of their financial constraints, and thus may have to pay higher interest rates or meet additional requirements to get those loans, she said.

Caraveo’s bill would also allow hospitals that already have loans to refinance at lower interest rates, and would cover more categories of medical equipment, such as devices and technology used for telehealth.

“We need to keep these places open, even not just for emergencies, but to deliver babies, to have your cardiology appointment,” said Caraveo, who is also a pediatrician. “You shouldn’t have to drive two, three hours to get it.”

Kristin Juliar, a capital resources consultant for the National Organization of State Offices of Rural Health, has been studying the challenges rural hospitals face in borrowing money and planning big projects.

“They’re trying to do this while they’re doing their regular jobs running a hospital,” Juliar said. “A lot of times when there are funding opportunities, for example, the timing may be just too tight for them to put together a project.”

Some funding is contingent on the hospital raising matching funds, which may be difficult in distressed rural communities. And most projects require hospitals to cobble together funding from multiple sources, adding complexity. And since these projects often take a long time to put together, rural hospital CEOs or board members sometimes leave before they come to fruition.

“You get going at something and then key people disappear, and then you feel like you’re starting all over again,” she said.

The hospital in Hugo opened in 1959 after soldiers coming back from World War II decided that Lincoln County on the eastern Colorado plains needed a hospital. They donated money, materials, land, and labor to build it. The hospital has added four family practice clinics, an attached skilled nursing facility, and an off-site assisted living center. It brings in specialists from Denver and Colorado Springs.

Stansbury would like to build a new hospital roughly double the size of the current 45,000-square-foot facility. With inflation easing and interest rates likely to go down this year, Stansbury hopes to get financing lined up in 2024 and to break ground in 2025.

“The problem is, every day I wake up, it gets more expensive,” Stansbury said.

When hospital officials first contemplated building a new hospital three years ago, they estimated a total project cost of about $65 million. But inflation skyrocketed and now interest rates have gone up, pushing the total cost to $75 million.

“If we have to wait another couple of years, we may be pushing up closer to $80 million,” Stansbury said. “But we’ve got to do it. I can’t wait five years and think the costs of construction are going to go down.”

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While American balladeer Woody Guthrie called out, “The Land Was Made for You and Me,” Rural Americans increasingly find themselves left out of possibilities for future prosperity. While more than 46 million Americans live in rural communities, rural locales lag behind non-rural communities in almost every measure of prosperity, from poverty rates to employment opportunities.

Though Guthrie’s famed lyrics, amber grain and spacious skies suggested unlimited possibilities, rural Americans often live hours away from primary medical care, emergency services, and specialist care providers. Their well-being — indeed, their survival — often relies on a tenuous broadband connection. What’s more, the systems put in place that are intended to address their needs are usually based on urban and suburban expectations.

Recently, more than 20 top leaders from academia, associations, corporations, and government met in Washington, DC, in a candid conversation to discuss these challenges — but more importantly — the solutions they both believe and know firsthand can make a difference in the lives of rural Americans. What made these conversations compelling was that they sat around the table — without slides or prepared statements — and talked about what they were doing and what was working. They united around a shared commitment to champion solutions. [Read the eBook Heartbreak in the Heartland here.]

According to one of the gathering’s moderators, Sarah Dash, CEO of the Alliance for Health Policy: “We must continue to change the narrative about how rural America is viewed and overcome the stereotypes that continue to perpetuate. Rural communities are far more diverse, innovative, and vibrant than they’re given credit for. We must educate ourselves about the people we seek to serve and work with them to create the kind of programs that will move the needle in a meaningful way.”

Expanding Broadband to Connect the Nation

One of rural communities’ more significant challenges is high-speed internet access. The digital divide hinders education, economic growth, and access to vital health services. To address this issue, initiatives like the Federal Communications Commission’s (FCC) Rural Digital Opportunity Fund have been launched to provide funds for broadband infrastructure in underserved areas. Public-private partnerships are also crucial in expanding broadband access, with companies collaborating to build networks in rural regions.

“Poverty rates in rural communities are higher than those in urban areas, and the FCC’s Affordable Connectivity Program (ACP) helps ensure rural residents can afford the broadband they need for work, education, and healthcare,” shared Gary Lynch, a Global Practice Leader at Verizon. “At Verizon, we have health equity programs on top of the ACP that help those individuals get devices to manage their health. What will happen to the 20 million Americans using the program when federal funding runs out in mid-2024?”

Virtual Learning as a Path to Progress

Rural students often need equal access to quality education. The COVID-19 pandemic accelerated the shift toward online learning, highlighting the need for virtual education solutions. Schools and organizations have invested in virtual learning platforms and distance education programs to address this challenge. Mobile learning centers and Wi-Fi-equipped school buses have also been deployed to ensure that students in remote areas can access educational resources, but more investment is needed.

Agricultural Innovation Tapping the Great Potential of the Heartland

Farming communities are the heart of rural America. They face unique challenges, including fluctuating markets and climate change. To support rural farmers, varied solutions are underway, including training in sustainable farming practices, affordable loans and grants and promoting local food markets. Government agencies, nonprofit organizations, and agricultural extension services are working to support farmers in a changing world. But now all regions and farms are the same.

“The narrative around how rural areas are stereotyped as older, poorer, sicker, uneducated, and white must change, says Amy Elizondo, Chief Strategy Officer of the National Rural Health Association. ”If you look at one rural community, you have seen one rural community — it’s not representative of the entire spectrum of rural America. Rural communities possess a vast depth of innovation, as they often must use what little resources they have for the incredibly diverse communities they serve.”

Native American Empowerment

Native American communities face disparities across the board — in health, education, and economic opportunities. Solutions must be rooted in respecting tribal sovereignty and self-determination. Collaboration between tribal governments, Federal agencies, and nonprofits is critical to addressing these inequities. Initiatives that support tribal entrepreneurship, cultural preservation, and access to quality health are making a difference. Expanding educational opportunities for Native American youth, including scholarships and culturally sensitive curricula, is also a focus.

The Washington, D.C., gathering included one of the nation’s leading public health advocates for Native Americans — Rear Admiral (ret.) James Galloway, MD, formerly part of the Surgeon General’s leadership team and now chief medical and partnership officer at Arc Health, has dedicated most of his career as a physician and public health expert to rallying this community. According to Rear Admiral (ret.) Dr. Galloway:

“Particularly in light of the health care provider shortages, as well as for the overall improvement of patient care, the proposed and highly supported concept of the team approach to health care to include Community Health Representatives as an approach to rural health is an essential component of quality health care, especially in rural communities.”

Telehealth Brings Access to Care Closer to Home

Access to health services in rural areas has long been a concern. Telemedicine is a game-changer, enabling health professionals to diagnose and treat patients remotely. Expanding telehealth services has made it easier for rural Americans to access medical care, especially during emergencies and throughout the COVID-19 pandemic. Again, broadband technology has been vital to accessing this life-sustaining need and policies and companies are working to meet the challenge.

Rural healthcare professionals are using telehealth and tapping into electronic medical records to improve quality care delivery. At the same time, there is ample support for remote patient monitoring and digital health technologies as tools to bring physicians’ offices closer to peoples’ homes. The biggest concern among physicians on the frontlines of addressing patient needs is clinical training and financial assistance to keep community hospitals operating.

Rural Infrastructure and Remote Care

To boost economic opportunities in rural America, infrastructure investments are crucial. Initiatives like the Infrastructure Investment and Jobs Act allocate significant funding to improve roads, bridges, and public transportation in rural areas. These improvements enhance connectivity, create jobs, and stimulate economic growth.

The rise of remote work has opened up new possibilities for rural Americans. Rural communities can retain residents and attract talent while diversifying their economies by encouraging employers to offer remote work options and training programs to develop remote-friendly skills.

John Whyte, MD, chief medical officer of WebMD, has been partnering with companies like Walmart to improve quality care and make rural life sustainable: “We conducted a research survey with Walmart last year, and we surveyed actual rural physicians and compared their assessments of the quality of care for their rural patients versus urban physicians… We saw that physicians in rural communities rated the quality of care they provide lower quality than in urban communities. That really should be a wake-up call.”

Conversation and Collaboration Are Key to Making Progress

Companies like Arc Health, Exact Sciences, FINN Partners, GSK, Huma, LifePoint Health, Molecular Biologicals & PS Fertility, OffScrip Health, Verizon, Walgreens, Walmart, WebMD; and leaders from associations like AARP, Alliance for Health Policy, Asthma and Allergy Foundation of America, Biotechnology Innovation Organization (BIO), CPSI; government agencies such as Health and Human Services and National Health Institute, and Academic institutions including Ohio State University and West Virginia University, have essential roles at the table. All are in conversation and addressing rural America’s challenges. They are doing everything from expanding broadband infrastructure, investing in rural job creation, supporting local farmers, and providing affordable goods and services to underserved areas.

“Rural America knows what is best for rural America. We need to build programs and initiatives that empower individuals and their families. That leads to a sense of purpose in the community, which can stem the tide of many adverse health and social implications. Marrying purpose with economic empowerment is the real game-changer,” reflects Pritesh Gandhi, MD, Chief Community Health Officer at Walmart.

Walgreens has improved health access by expanding telemedicine, providing pharmacy services in rural communities, and working shoulder-to-shoulder with local health providers. WebMD has moved to upskill physicians and ensure they have access to breaking medical information. The private sector has the skill and scale to advance rural America’s technology, economic, and health challenges, contributing to the overall well-being of these communities.

In sharing ideas and possibilities, attendees show how to bridge the divide and ensure that rural Americans have the tools and resources to thrive. These practical solutions address problems and build a brighter future for rural America, where opportunities are abundant and quality of life is improved for all.

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FORT DODGE, Iowa — Allison Roderick has a warning and a pledge for rural residents of her county: The water from their wells could be contaminated, but the government can help make it safe.

Roderick is the environmental health officer for Webster County in north-central Iowa, where a few thousand rural residents live among sprawling corn and soybean fields. Many draw their water from private wells, which are exempt from most federal testing and purity regulations. Roderick spreads the word that they aren’t exempt from danger.

More than 43 million Americans rely on private wells, which are subject to a patchwork of state and local regulations, including standards for new construction. But in most cases, residents are free to use outdated wells without having them tested or inspected. The practice is common despite concern about runoff from farms and industrial sites, plus cancer-causing minerals that can taint groundwater.

“You’re cooking with it. You’re cleaning with it. You’re bathing in it — and, nowadays, there are so many things that can make you sick,” Roderick said.

Federal experts estimate more than a fifth of private wells have concentrations of contaminants above levels considered safe.

Like many states, Iowa offers aid to homeowners who use well water. The state provides about $50,000 a year to each of its 99 counties to cover testing and help finance well repairs or treatment. The money comes from fees paid on agricultural chemical purchases, but about half goes unused every year, according to the Iowa Department of Natural Resources.

Roderick, who started her job in 2022, aims to spend every penny allotted to her county. Last spring, she snared an extra $40,000 that other counties hadn’t used. She promotes the program online and by mailing piles of postcards. Traveling the countryside in a hand-me-down SUV from the sheriff’s department, she collects water samples from outdoor spigots and sends them to a lab.

When she finds contamination, she can offer up to $1,000 of state grant money to help with repairs, or up to $500 to cap an abandoned well.

Experts urge all users of private wells to have them tested at least annually. Even if wells meet modern construction standards and have tested clean in the past, they can become contaminated as the water table rises or falls and conditions change above them. A faulty septic system or overapplication of fertilizer or pesticide can quickly taint groundwater.

Too many residents assume everything is fine “as long as the water is coming out of the tap and it doesn’t smell funny,” said Sydney Evans, a senior science analyst for the Environmental Working Group, a national advocacy organization that studies water pollution.

The main concerns vary, depending on an area’s geology and industries.

In Midwestern farming regions, for example, primary contaminants include bacteria and nitrates, which can be present in agricultural runoff. In rural Nevada and Maine, arsenic and uranium often taint water. And, throughout the country, concerns are rising about the health effects of PFAS chemicals, widely used products also known as “forever chemicals.” A recent federal study estimated at least 45% of U.S. tap water contains them.

Filters can help ensure safety, but only if they’re selected to address the specific problem affecting a home’s water supply, Evans said. The wrong filter can give a false sense of safety.

Evans said people who wonder about possible contaminants in their area can ask to see test results from wells supplying nearby community water systems. Those systems are required to test their water regularly, and the results should be public, she said: “It’s a great place to start, and it’s free and easy.”

She also said people who rely on private water wells should ask local health officials about eligibility for help paying for testing and possible repairs or filters. Subsidies are often available but not publicized, she said.

A study by Emory University researchers published in 2019 found that all states have standards for new well construction, and most states require permits for them. However, the researchers wrote, “even in states with standards for water quality testing, testing is typically infrequent or not conducted at all.”

Some longtime rural residents live in homes that have been in their families for generations. They often know little about their water source. “They’ll say, ‘This is the well my grandfather dug. We’ve used it ever since, and no one’s had an issue,’” said David Cwiertny, director of the University of Iowa’s Center for Health Effects of Environmental Contamination. They might not realize impure water can harm health over time, he said.

Some states require inspection and tests of private wells when properties are sold. Iowa doesn’t mandate such measures, although Webster County does. It’s a good idea for homebuyers anywhere to request them, said Erik Day, who oversees the private well program for the Iowa Department of Natural Resources. He also recommends asking for a technician who can run a flexible scope down the well to visually inspect the inside.

Day estimated fewer than 10% of Iowa’s private well owners have them tested annually, even though testing can be free under the state grant program.

In Webster County, Larry Jones recently took advantage of free well testing at a weathered ranch house he bought west of Fort Dodge, in a subdivision bordering a large soybean field. Jones lives next door to the 54-year-old home, and he is refurbishing it as a place for his relatives to stay.

Roderick, the county health official, sampled water from the well and found it was tainted with bacteria. She offered Jones $1,000 from the state grant to help get it fixed. He added a few thousand dollars of his own and hired a contractor.

“It’s an investment for the future,” he said. “You’re talking about your family.”

The old well was made with a 2-foot-diameter concrete casing sunk vertically in sections about 60 feet into the ground. A smaller plastic pipe ran down the middle of the casing to water at the bottom. A pump pulled water up through the smaller pipe and into the home.

Lynn Rosenquist, who owns a local well-repair business, told Jones the well probably was original to the house and likely met standards when it was built. But at least one chunk of concrete had broken off and fallen in.

Repairs took two days of heavy work by Rosenquist and his brother, Lanny, who are the third generation of their family to maintain wells. The brothers used a backhoe and small crane to remove much of the concrete casing. They replaced it with a narrower, PVC pipe, which they sealed with a cement mixture to prevent seepage from the surface. When finished, they “shocked” the system with a bleach solution, then flushed and tested again.

Such modern construction is less prone to becoming tainted, Roderick said. “If it’s not sealed airtight, bacteria can get in there and it’s just gross,” she said.

Grossness is not the only thing Roderick considers. Besides E. coli and other bacteria, she tests for nitrates and sulfates, which can exist in farm or lawn runoff or come from natural sources, and for arsenic and manganese, which can occur in rock formations. She plans to add tests for PFAS chemicals soon.

She collects the water in small plastic bottles, which she mails to a lab. She enters information about each well into a state database. If the tests turn up contaminants, she advises homeowners of their options.

Roderick said she enjoys the routine. “I’ve met so many people — and I’ve met a lot of dogs,” she said with a laugh. “I love the feeling that I’m really helping people.”

The post Millions of Rural Americans Rely on Private Wells. Few Regularly Test Their Water appeared first on Medika Life.

FALLON, Nev. — Linda Noneo turned up the heat in her van to ward off the early-morning chill that persists in northern Nevada’s high desert even in late June. As the first rays of daylight broke over a Christian cross on the top of a hill near the Fallon Paiute-Shoshone colony, she drove toward her first stop to pick up fellow tribal members waiting for transportation to their medical appointments.

Noneo is one of four community health representatives for the Fallon Paiute-Shoshone, which the tribe said includes about 1,160 enrolled members. The role primarily involves driving tribal members to their health appointments, whether in Fallon, a city of just under 10,000, or Reno, more than 60 miles west. Noneo said she and her colleagues have also taken patients as far away as Sacramento, California, and Salt Lake City, round trips of nearly 400 and 1,000 miles, respectively.

Public health experts contend the role Noneo and others like her fill is an integral part of ensuring people receive the care they need, especially for chronic illnesses, by helping close gaps in areas with medical provider shortages. Besides transporting patients to their appointments, community health representatives provide health education, patient advocacy, and more. Noneo said she and her colleagues spend a lot of time helping young mothers and elders, checking on the latter, taking them to get groceries, or delivering their medication.

Yet, most state Medicaid programs don’t recognize or pay for services offered by health workers, such as Noneo, who work on tribal lands. That’s despite their work being essentially the same as that of “community health workers” in nontribal communities, a classification many state Medicaid programs cover.

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In Nevada, that disparity recently changed when the state began allowing workers on tribal lands to qualify for Medicaid reimbursement as community health workers. Tribal leaders say the Medicaid payments supplement existing personnel funding by covering the individual services the workers provide. That in turn should allow tribes to train and hire more community health representatives, which could expand health and support services for tribal members.

Only two other states, South Dakota and Arizona, treat community health representatives serving Native American populations as eligible for the same Medicaid reimbursement as their similarly named counterparts in nontribal areas, according to Michelle Archuleta, a community health representative program consultant for the federal Indian Health Service. However, she said, the tribes the CHRs work for have not begun billing the states’ Medicaid programs.

The Community Health Representative program, established by Congress in 1968, is among the nation’s oldest community health workforces. It’s jointly funded by each tribe and the IHS, an agency within the Department of Health and Human Services responsible for providing health care to members of federally recognized tribes. As of 2019, more than 1,600 of these tribal linchpins worked in the United States, according to the IHS.

Last year, the Centers for Medicare & Medicaid Services approved Nevada’s plan to make community health workers who complete training and certification requirements eligible for Medicaid reimbursement when they assist with chronic disease management and prevention.

And in December, leaders with the Nevada Community Health Worker Association helped tribes make sure their community health representatives would receive the necessary training for certification. The association would “fully support” tribal clinics submitting their community health representative training for recognition in the state and it would not require a change to state law, said Jay Kolbet-Clausell, program director for the group. For now, community health representatives are receiving double training to be able to file for Medicaid reimbursement.

Training and certification requirements for community health workers vary widely by state and employer, as workers are often hired by hospitals, local organizations, health departments, or federally qualified health centers. But a movement has been emerging across the country to bring more uniformity to those requirements and formalize the roles, said Sweta Haldar, a policy analyst with the Racial Equity and Health Policy program at KFF.

As part of this process, states are expanding coverage for community health workers under Medicaid. According to a brief Haldar co-authored, 28 of 47 states, and Washington, D.C., reported having policies that allow Medicaid reimbursement for services provided by community health workers. Arkansas, Georgia, and Hawaii did not respond to KFF’s survey.

“There’s a really robust evidence base that is growing every day that community health worker interventions can be effective in reducing health disparities, particularly in communities of color,” Haldar said.

Studies have also shown that community health worker programs are effective in improving health outcomes for people with chronic conditions and that they reduce health care costs.

Soon after Nevada implemented its program, about 50 community health representatives completed the requirements. Another cohort of 20 finished the curriculum later, said Kolbet-Clausell. The goal is for those who have completed the recent training to help their peers through it, they said.

Even before the tribal workers were included in the community health workforce, one of its greatest strengths was its diversity, Kolbet-Clausell said. In Nevada, the 2022 student group was made up of greater shares of people who are American Indian or Alaska Native, Hawaiian or Pacific Islander, Black, Hispanic, or from rural areas than the state’s general population. They said it’s likely one of the most diverse health programs in the state.

Community health representatives such as Noneo are typically tribal or community members themselves, which, public health experts say, allows them to connect more easily with the patients they serve and better connect them to health care.

For example, the first person she picked up that June morning was her cousin, who had a 6 a.m. dialysis appointment.

Kolbet-Clausell said they’re optimistic about the growing workforce and the support it’s getting from state leaders.

“Five, six years ago, there was a lot more resistance,” they said, because lawmakers saw the efforts to expand the community health workforce as simply spending more money. “But this actually just benefits rural communities as much as it benefits underserved urban communities. It serves everyone.”

Back in Fallon, Noneo reflected on her 27 years as a community health representative for her tribe as she prepares to retire in September. She has been there with her fellow tribal members through important and hard times in their lives — like driving an expectant mother to Reno to deliver a baby, taking people to receive treatment for mental health crises and addiction, and bringing patients to their dialysis treatments on her week off around Christmas so they wouldn’t miss their appointments.

The most challenging part of the job, she said, is experiencing the loss of someone she has regularly seen and provided years of services for.

“We all have compassion,” she said. “In this kind of job, you have to have that.”

After decades of shuttling patients, Noneo has the work down to a steady and familiar rhythm. Four hours after dropping off her cousin for dialysis, Noneo picked her up at the clinic as she dropped off the next dialysis patient. On a clipboard, she logged the hours and mileage for each appointment.

The post Tribal Health Workers Aren’t Paid Like Their Peers. See Why Nevada Changed That appeared first on Medika Life.

With its barebones layout and shockingly inexpensive merchandise, these dollar store retail powerhouses have emerged as an American cultural icon, and more importantly, an absolute necessity for lower-income shoppers. They serve as a convenient nearby option for suburban and rural communities and have historically remained resistant to inflation. The one-dollar price tags have sheltered consumers from economic ups and downs and persistent price climbs; for over 70 years, prices have barely budged (barring recent COVID-related modifications). Some 88% of Americans flock to these discount retailers yearly in search of a range of products, and in response, dollar stores’ footprint across America continues to expand.

Unsurprisingly, rural America holds the largest percentage of regular dollar store shoppers. The establishments are disproportionately concentrated in the Sun Belt and Midwest, catering to consumers with limited options. These discount stores are some families’ local grocer, convenience market, and health store all rolled into one — a rural American’s means of survival.

With the dollar store as the only convenient possibility, Dollar General’s new health clinic rollout can be a revolutionary move in rural health, providing accessible treatment options to those who might not be able to even see a clinician otherwise. Proposed clinics will provide urgent care and lab testing within easy reach when hospitals may be many miles and in some cases many hours away.

Yet two questions remain: Are dollar stores harming or helping rural America? And how much can we really trust dollar stores to administer treatment?

How Dollar Stores Work

Having more locations than Starbucks, Walmart, and McDonald’s combined is no easy feat, yet the dollar stores of America seem to be one of the most resilient establishments in our economy. During COVID-19, similar-sized stores crumbled and declared bankruptcy. Dollar stores, on the other hand, flourished.

What makes the dollar store such a successful model, even in a time of crisis? Most of these discount retailers operate the same way — selling a small selection of cheap wholesale goods to a smaller consumer pool. In many rural areas, the dollar store is the only source of food, health, home, and other vital items for miles. Accordingly, they received an ‘essential’ classification during COVID-19 and enjoyed 16% growth in the year 2020. Dollar stores have historically thrived against similar recessionary backdrops and financial downturns, including the 2008 economic recession, drawing in customers forced to turn away from more expensive establishments in search of cheaper options.

These discount chains employ many tactics to generate profit. First off, some goods aren’t worth a dollar. Dollar stores profit off eighty and ninety cent products; when looking at a Dollar Tree laundry detergent brand, there is a high proportion of water compared to cleaning liquid. Dollar stores also shrink package sizes. The Dollar Tree aluminum foil offering, priced at $1, was only 15 square feet long, while Walmart sold a 75 square foot roll for $4.06, the equivalent of more than 18 square feet per dollar. That’s not to say dollar stores do not offer discounted items; some dollar store merchandise may just be deceptively more expensive per unit. All businesses need to make a profit to survive, after all.

Dollar stores manage to cut venue-related costs by leasing their properties rather than buying them, and having relatively few employees. Their physical layout is also precisely manufactured. Dollar store aisles, particularly in the larger chains, are incredibly tiny, with an overload of merchandise surrounding customers from all angles. Towers of potato chips and party straws jut out into the aisle, so that you must make a point to move around them, and perhaps you’ll make an impulse buy you otherwise wouldn’t if those potato chips look particularly enticing.

Perhaps shoppers do score granola bars for one dollar instead of five, but dollar stores know they most likely won’t leave without a basket full of other things.

The Dollar Store Distribution

Dollar stores are now opening at a rate of 3 a day, and larger chains currently have a whopping 35,421 locations nationwide.

Targeting retail and food deserts, locations are typically situated on remote roads away from downtowns and more populated town centers. However, the selection system is more complex for America’s three dollar store titans: Dollar General, Family Dollar, and Dollar Tree.

The big three employ strikingly similar practices when searching for new sites to occupy, targeting devastated, lower-income areas, areas where no supercenter would dare go for fear of a too-small customer base. In distressed urban and suburban cities and towns, it is common to see three, four, or even five of these dollar stores within a few block radius, choking out smaller chains and grocery stores.

Rural America has seen a disproportionate share of the dollar store frenzy. Three-quarters of Dollar Generals serve communities of less than 20,000 residents, and dollar store giants favor locations that share a proximity with landmarks like a post office or a church, typically situated together in rural towns. These towns also have plenty of customers within the dollar retailer demographic — the “typical” shopper is an older, rural worker with a high school education, and a yearly salary of $40,000. An overwhelmingly high proportion of racial minorities in rural households also shop at dollar stores.

These trends are worrying. Dollar store regulars are not getting high-quality essentials they need and have no way to access them in the first place; these seemingly small sacrifices add up and contribute to a larger issue of health and consumer inequity.

The Rural Food Crisis

Though dollar stores claim they are not a grocery store, many rural Americans still utilize it as one. According to a Tufts University study, They are one of the fastest-growing food retailers in the country.

To increase store revenue, dollar stores do their best to offer the least amount of perishable items; they have lower profit margins and a shorter shelf life. As a result, any fresh produce, meats, and typically nutrient-dense foods are hard to come by, while artificial, packaged, and highly processed options are abundant. Boxes of macaroni and cheese and sour gummies line the aisles, and why not? They’re shelf stable, more visually appealing choices. It’s not hard to understand why rural consumers naturally reach for more convenient and cheaper foods, as outside of the odd farm stand or farmer’s market, the next package of strawberries or fresh green beans may be miles away.

Unsurprisingly, independent grocers struggle in the face of discount giants. A 30% decline in produce shopping is observed in areas with multiple nearby dollar stores, which is enough to harm the fresh food market. To make a problem even worse, soda, snacks, candy, and crackers account for the largest share of consumer spending at dollar stores, only incentivizing more stock of these goods, and making healthy food completely inaccessible to rural Americans.

As regions already plagued with high rates of obesity and food insecurity with no nearby health clinics or hospitals, it appears that rural Americans are doomed to increased risk of heart disease and diabetes. They are deprived of essential food options and adequate health literacy and experience increased rates of poverty due to rising healthcare bills.

Of all potential mediators, Dollar General has emerged as a paradoxical savior with its new healthcare clinics — both contributing to the problem, and helping to fix it.

DG Wellbeing — A Rural Health Lifeline? Or A Disaster?

75% of Americans live within 5 miles of a dollar store. Only 60% are that distance from a hospital.

Dollar General is the first of the discount stores to dip its toes in medical care, outpacing other retail giants in their quest to “retail-ize the healthcare system”. This has been met with some thinly veiled alarm from the media — how can a company known for constantly cutting corners and its discount model adequately take on an entire rural population’s healthcare challenges?

The new initiative, DG Wellbeing, plans to attach health clinics to select Dollar General locations and expand in-store health merchandise, seeking to fill the gaps of rural healthcare deserts. As it stands, the initiative is in its infancy — large vans are positioned outside three Dollar General locations in Clarksville, Tennessee, providing “basic, preventative, urgent care and chronic condition-management services along with lab testing”. Next in the rollout process, Dollar General plans to expand its stock of healthcare products by 30% in its more than 18,000 stores.

Dollar General may be ill-prepared to tackle an entirely new to them $808 billion dollar health sector, and is providing potentially inadequate health treatment to a struggling population a risk worth taking? The company is currently battling employee protests about worker safety violations, claims of provoking neighborhood increases of violent crime, and a disproportionate amount of robberies and customer complaints. The same problems may travel to Dollar General’s healthcare clinics, raising concern about the staffing of underpaid, underqualified workers and low-quality care, effectively shortchanging the already budget-tight rural American population.

Dollar stores began as a budget-friendly, easy way to get crafts, toys, and the occasional snack. They were never intended to dominate the pantry and medicine cabinets of the American public. Growing the dollar store’s foray into the healthcare market only expands its reach into territory where it shouldn’t belong, and risks diverting focus away from longer-lasting, more effective treatment options for vulnerable populations like rural Americans.

While Dollar General’s entry point into the healthcare system is financially advantageous, what if improving existing locations took precedent over endless expansion and experimentation? Offering higher quality goods and accommodating nearby local grocery stores would likely be worlds more beneficial than instituting perfunctory healthcare clinics that may leave rural Americans with unsatisfactory medical treatment. The rural healthcare system is a far more complex, overwhelmed organization that the simple dollar store model is unlikely to successfully combat — perhaps dollar stores should first work on putting fewer cola bottles on their shelves.

The post Rural Healthcare’s Dollar Store Invasion appeared first on Medika Life.

For most of last year, St. Agnes Medical Center, based in Fresno, California, looked like a white knight poised to rescue smaller Madera Community Hospital from financial ruin.

Now, with the nonprofit Madera, California, hospital bankrupt and shuttered, St. Agnes looms as a dark knight, pushing to liquidate the hospital to get a loan it made to Madera paid back — even if that means dashing the hopes of the community activists, political leaders, and health care officials that the hospital can still reopen.

A pivotal moment in the case could come July 25, when a bankruptcy judge in Fresno will hear arguments on whether the Madera hospital should be allowed to spend its dwindling cash reserves on things such as building maintenance, security, utilities, and the salaries of its three top executives.

The hospital wants to run a skeletal operation while it seeks a buyer and develops a reopening plan. But the federal bankruptcy court in Fresno has authorized it to spend money only through July 29. If the judge doesn’t think the hospital has a viable plan, he may refuse an extension, which would likely mean liquidation.

Problems like Madera’s are common among other small, financially challenged hospitals in California and nationwide. They typically have low patient volumes and rely disproportionately on payments from Medicaid and Medicare, which constrains revenue and makes it difficult to attract talent or invest in cutting-edge equipment. Add to the mix a crushing surge in expenses stemming from the covid-19 pandemic, and dozens of such facilities are struggling to survive. Two others, both in California, have filed for bankruptcy this year.

Yet Madera had problems that were all of its own making. The hospital made money on patients insured by Medi-Cal, the state safety-net insurance program that pays notoriously low rates, according to financial data filed with state regulators. But it lost money on its commercially insured patients due to low volume and bad deals with insurance providers. It also failed to seek covid relief funds in a timely manner. A state hospital bailout fund came too late.

Plus, Madera had no backup plan when St. Agnes and its parent company, the hospital chain Trinity Health, walked away from a proposed merger with the troubled hospital late last year, giving virtually no notice and scant explanation. Their move shocked and infuriated officials, former employees, and community advocates in Madera and Sacramento.

In a brief December press release, St. Agnes and Trinity blamed their decision on “complex circumstances” and “additional conditions” imposed by state Attorney General Rob Bonta. But industry experts said Bonta had agreed to most of what St. Agnes asked for and were baffled as to why they walked away from the deal.

The spectacle of St. Agnes and Trinity now pushing in court for the liquidation of tiny Madera has drawn Bonta’s ire.

“For Trinity, it was always about profit, not the health of the Madera community,” Bonta told KFF Health News in a statement. “They are now attempting to use their position as Madera’s biggest creditor to extract every dollar possible, instead of keeping the community’s interests at heart.”

Bonta said his office had “offered maximum flexibility to Trinity in recognition of Madera’s financial circumstances.”

An agricultural area of 2,150 square miles and home to nearly 160,000 people, Madera County is 60% Hispanic, and more than one-fifth of its residents live below the poverty line, according to census data.

A Community Left in the Lurch

Jennifer Lara, a former Madera Community Hospital nursing assistant, said she and colleagues had been looking forward to positive change after the anticipated merger with St. Agnes. “We were floored when we found out the hospital was closing,” she said. “We didn’t think anything other than the hospital continuing on was going to happen.”

St. Agnes and Trinity declined to comment. The longtime CEO of St. Agnes, Nancy Hollingsworth, retired in May amid a reorganization that made the hospital part of a regional group based in Idaho. It’s unclear whether her departure was related to the collapse of the Madera deal. Hollingsworth could not be reached for comment.

St. Agnes’ considerable leverage in the bankruptcy case is the result of a $15.4 million loan it extended to Madera during merger talks last year. Madera has since repaid $8 million, leaving a debt of over $7 million, which still makes St. Agnes its largest creditor.

St. Agnes, one of 88 hospitals belonging to Trinity, a multistate, Catholic, nonprofit health system headquartered in Livonia, Michigan, argued in a recent bankruptcy court filing that Madera still has made no significant progress finding a buyer, more than four months after filing for Chapter 11 bankruptcy protection on March 10, and should not be allowed to continue spending money “without a serious path forward to either sell or mothball the hospital.”

The hospital has been talking to three potential partners, “one of whom is late to the game,” said Riley Walter, Madera’s bankruptcy lawyer.

Mohammad Ashraf, a cardiologist and member of the executive committee of Madera’s medical staff, said the first two entities in question, whom he declined to identify, are management service organizations, not hospital groups. “They don’t want to spend any money to buy it. They just want to run it,” he said.

Without a convincing strategy for the future of Madera Community Hospital, the end of the bankruptcy case could come quickly.

Ranjit S. Rajpal, a Madera cardiologist for over 40 years, said the closure of the hospital is bad news for patients who need time-sensitive care, such as for heart attacks, strokes, or other traumas, and who now must travel greater distances to get it.

And the closure will exacerbate existing health inequities for people who face challenges getting care because of immigration status, language barriers, lack of transportation, or other socioeconomic factors, he said. “Those disparities will be compounded as time goes by.”

Community leaders and the hospital’s leadership hold out hope for reopening. The hospital has applied for $80 million from California’s new, $300 million loan fund for distressed hospitals. Hospital leaders must produce a reopening plan by July 31, but even if it does, it’s unlikely to get the full requested amount: Sixteen hospitals have already applied for loans totaling over $385 million, said Joe DeAnda, spokesperson for the California State Treasurer’s Office.

“They’re not going to give a quarter of their total fund to one hospital that doesn’t even have a partner,” said Glenn Melnick, a health economist at the University of Southern California who authored an analysis commissioned by the AG’s office of the proposed St. Agnes-Madera merger. “Eighteen months ago, the ask would have been a lot smaller.”

Even if Madera Community Hospital finds a viable partner and gets the funding it needs, reopening would be daunting and expensive. The hospital would need to hire hundreds of nurses, technicians, and other staffers in a tight and expensive health care labor market and find a way to avoid the financial problems that landed it in bankruptcy.

“Some things an acute care hospital offers are profitable, and others are not,” said Jay Varney, Madera County’s administrative officer, whose role is akin to a CEO. “It doesn’t make much sense to have it reopen like it was and have it go bankrupt again.”

‘Running Out of Time’

Reopening the facility with all the services it provided before is not the only option. Baldwin Moy, an attorney for California Rural Legal Assistance, a community advocacy group, said he and colleagues have been arguing for the court to allow Madera additional time either to find a buyer or for the county “to put together a package that can reopen the emergency room with some stripped-down clinical operation.” But, Moy said, they are “running out of time.”

Karen Paolinelli, the hospital’s CEO, said the current suitors are interested in reopening it as an acute care facility that “may or may not have all services that were previously offered by Madera Hospital on day one.”

If the hospital can hold out for a few more months, it says, it can collect $23.5 million owed by the state for “provider fees,” and possibly an additional $10 million from the Federal Emergency Management Agency. Those payments would more than cover the hospital’s entire debt of $30 million. But the amount and timing of payments are unclear.

Paolinelli, voicing a common industry complaint, said the hospital has a disproportionately high number of Medi-Cal patients and Medi-Cal rates do not cover the cost of providing care. But state data shows that Madera received enough supplemental payments to earn nearly $15 million from Medi-Cal in 2021, though it lost over $11 million treating Medicare patients. Madera also lost about $6.8 million on commercially insured patients in 2021, the state data shows. Commercial insurance payments covered only 59.5% of what it cost to care for those patients. That compares with a statewide average of 156%, according to Melnick.

Paolinelli said Madera tried to negotiate better rates with commercial health plans but “does not have much leverage with the payors.” She added that many residents of Madera who get commercial insurance through their employers choose Kaiser Permanente, whose nearest acute care hospital is in Fresno, 20 miles away.

State Democratic Sen. Anna Caballero, whose district includes parts of Madera, Merced, and Fresno counties, said that if Madera Community Hospital were to successfully reopen, more people with commercial insurance would have to choose it over other hospitals outside the county, which they had not been doing frequently.

“The county and the city may need to say, ‘If you need hospitalization, you need to go to Madera, and there will be no copay, but if you go out of the county, there’s a copay you have to pay,’” Caballero said.

But with no clear path to reopening yet in sight, Caballero said, that discussion is premature.

Melissa Montalvo covers Latino communities for The Fresno Bee as part of the Central Valley News Collaborative, a partnership that includes The Fresno Bee, Vida en el Valle, Valley Public Radio, and Radio Bilingüe. This article is part of the Central Valley News Collaborative, which is supported by the Central Valley Community Foundation with technology and training support from Microsoft Corp.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

The post Giant Health System Almost Saved a Community Hospital. Now, It Wants to ‘Extract Every Dollar’ appeared first on Medika Life.

DANDRIDGE, Tenn. — Rachel Solomon and judges hadn’t been on the best of terms. Then Judge O. Duane Slone “dumbfounded” her.

Solomon was given her first Percocet at age 12 by a family member with a medicine cabinet full. It made her feel numb, she said. “Nothing hurt.” By 17, she was taking 80-milligram OxyContins. A decade later, she was introduced to heroin.

During those years, Solomon was in and out of trouble with the law.

Then, five years ago, at 32, she arrived in Slone’s courtroom, pregnant, fearing the worst. But the state circuit court judge saw promise. He ruled that Solomon would serve jail time for an outstanding warrant for aggravated burglary and then would be placed in a program for pregnant or parenting women recovering from addiction. She would retain custody of her son, Brantley, now 4.

Slone also offered an option that many judges, particularly in rural jurisdictions, at that time were averse to extending: medication for opioid use disorder, or MOUD.

A study conducted a decade ago found that barely half of drug treatment courts offered medication treatment. Those that didn’t cited uncertainty about its efficacy and noted political, judicial, and administrative opposition. But research in the years since has persuaded many of the most insistent abstinence-only advocates.

According to Monica Christofferson, director of treatment court programs at the Center for Justice Innovation, amid an accelerating opioid crisis there has been a “huge shift” among judges, prosecutors, and law enforcement agencies away from the stigma associated with medication treatment. Simply put, “MOUD works,” Christofferson asserted.

By 2022, more than 90% of drug courts located in communities with high opioid mortality rates that responded to a survey said they allow buprenorphine and/or methadone, the medications most commonly used to treat addiction. The study also found that 65% of drug court program staffers have received training in medication for treatment, and a similar share have arranged for clients to continue receiving medications while serving jail time for program violations. Still, almost 1 in 4 programs told researchers they overrule medication decisions.

Federal legislation has lowered the barriers to it. And Bureau of Justice Assistance funding for treatment-court programs now mandates that medication for substance use disorder be provided.

Solomon experienced that shift in real time in Slone’s courtroom as the judge allowed her access to medication to treat her addiction to opioids.

As a young prosecutor in the 1990s in mostly rural eastern Tennessee, Slone was embedded with a drug task force and was well versed in efforts to counteract the supply side of the opioid crisis. Then, as a circuit court judge, he’d put his share of people behind bars on drug-related convictions.

As the crisis deepened, he started to wonder if addressing the demand side would be more effective.

Like so many other prosecutors and judges, Slone believed abstinence was the only path to recovery. But in 2013, after consulting with substance use disorder experts, he relented, introducing medication as an alternative to incarceration for pregnant women. By 2016, he had fully embraced it throughout his recovery courts — even as most judges, he said, “still believed that it was substituting one drug for another.”

Building from evidence-based research, Slone has launched programs that show how a judge, and a region, can trade an abstinence-only, lock-’em-up approach for one that offers a full range of paths to recovery.

Before witnessing medication treatment’s efficacy, Slone said, he would tell a defendant charged with a drug offense, “‘This is your second chance. If you violate the conditions of your probation, I’m going to put you in jail.’”

Often, six months later they’d be back in his courtroom, charged with a low-level crime and having tested positive for drugs. “They’re 19, maybe 20 years old, and I’m executing a five-year sentence. It makes me sick to my stomach now.”

Slone was sure there must be a better way.

A drug recovery court, which he co-founded in his 4th Judicial District in 2009, was a first step. It allows defendants with nonviolent drug-related charges to avoid jail time by entering treatment and counseling. They’re closely monitored by a team that includes a judge, case manager, public defender, prosecutor, and probation officer. If the participant violates the terms of the agreement, the first step is a reassessment of treatment needs. Multiple violations may result in incarceration.

Because this form of drug court is resource-intensive, relatively few people can be enrolled. So in 2013, Slone introduced the Tennessee Recovery Oriented Compliance Strategy, or TN-ROCS, an alternative to jail for those who aren’t considered at high risk of recidivism but are deemed in urgent need of treatment. Many are pregnant women or mothers of young children.

Given the reduced need for supervision, the program can accommodate more participants. So far, more than 1,000 people have been on the district’s TN-ROCS docket.

Both the recovery court and TN-ROCS offer three medication options: buprenorphine, methadone, and naltrexone.

Since TN-ROCS’ launch, Slone said, his community has seen a decrease in property crimes and its jail population. Over its first five years, all 34 pregnant women in the program gave birth to healthy babies and 30 kept custody of their children. TN-ROCS is now being replicated across the state.

One barrier to broader acceptance of medication treatment in both rural and urban communities, Christofferson said, is a lack of education.

Corey Williams agrees. He advocates for educating criminal justice system officials. Williams is an officer with the Lubbock, Texas, Police Department and is a consultant with the Law Enforcement Action Partnership, which promotes drug policy and criminal justice reform. He believes that if more criminal justice officials had personal experience with medication to treat substance use disorder, they’d view it differently.

Williams’ wife, Brianne Williams, became addicted to opioids in medical school. She participated in a series of abstinence-only programs and was free of the drugs for seven years, then relapsed. She was arrested for writing herself a prescription for opioids and placed on probation.

She had entered a Suboxone treatment program, but her probation officer incorrectly informed her she couldn’t remain on Suboxone on probation. Williams relapsed, failed a drug test, and served 30 months in federal prison. After her release, she went back on Suboxone — a brand-name combination of buprenorphine and naloxone — and has maintained her sobriety. “It improved my life drastically,” she said. She now hopes to regain her medical license and specialize in addiction treatment.

The relative unavailability in rural areas of medication treatment is certainly a problem. A shortage, Christofferson noted, is not only an issue in itself, but also a barrier to overcoming stigma. More openings available, more success stories. More success stories, less stigma. Fewer provider options also means one bad actor — a provider who overprescribes or is otherwise negligent — perpetuates the stigma. Strict oversight is essential.

Physician Stephen Loyd influenced Slone’s decision to embrace medication treatment and is now a member of Slone’s recovery court team. Loyd was practicing internal medicine in eastern Tennessee when he developed a 100-pill-a-day addiction to prescription opioids. He was the inspiration for the character Michael Keaton portrayed in the Hulu series “Dopesick.” Loyd overcame his addiction and served as the state’s “opioid czar” under Gov. Bill Haslam from 2016 to 2018.

While in state government, Loyd helped plant the seed for TN-ROCS. He told Slone the first judge to take such an initiative would “be on the cover of Time magazine, because your success rates are gonna go up dramatically; you’re gonna save a bunch of lives.”

“He didn’t get on the cover of Time,” Loyd allowed, “but he did win the William H. Rehnquist Award.” The William H. Rehnquist Award for Judicial Excellence is among the country’s highest judicial honors.

Rachel Solomon contends one of those lives saved was hers.

Today she and her son are together; she’s employed. She remains on Suboxone. She feels good. And she feels fortunate she arrived in Slone’s courtroom when she did.

“He’s the reason I am where I am today,” she said. “He really is.”

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