EDEN — For now, UNC Rockingham Healthcare has a strong pulse and a healthy commitment from the UNC Health Care system to fortify the facility for years to come.
Over the past 18 months, the Chapel Hill-based system has sunk $10 million into capital improvements to the former Morehead Memorial Hospital — half of the $20 million it pledged to spend over its first three years of ownership, according to Dana Weston, the hospital’s chief administrator.
UNC bought the 700-employee rural hospital’s assets in January 2018 for $11.5 million after the facility declared Chapter 11 bankruptcy.
Positioned on a 22-acre campus, the not-for-profit hospital is licensed for 108 acute care beds and 134 long-term care beds.
With the North Carolina General Assembly’s recent vote against expansion of Medicaid, for the fifth year running, proponents say some 500,000 citizens who need health insurance coverage are left out in the cold.
And expansion advocates forecast hospitals in Rockingham County and the state’s 79 other rural counties will feel acutely the burden of debt from those uninsured.
Close to 4,400 Rockingham Countians would become eligible for Medicaid if expansion were green lighted, cutting nearly by half the county’s number of uninsured, expansion advocates at the N.C. Justice Center estimate.
The majority of those would-be eligibles are working poor — folks unable to make a living wage and afford private insurance.
Even with full-time employment, such individuals cannot afford private health insurance premiums, according to the NCJC and Reidsville physicians Dr. William S. Luking and Dr. Sandi Fields, who have publicly advocated for Medicaid expansion this year.
In many cases, such individuals work blue collar jobs without health benefits. Lacking insurance, they are blocked from preventive health care and access to vital prescription medications, Luking and Reid stressed during last week’s Eden vigil to call for closure of the state’s coverage gap.
Like Rural North Carolina,
Rockingham County struggles
Rockingham County residents are among the 40 percent of North Carolinians who dwell in one of the state’s 80 rural counties.
Statistics show that while mortality rates have improved statewide, death rates in rural counties have remained higher than in metropolitan areas over the past decade.
And rural counties like Rockingham continue to struggle with provider shortages, higher incidences of preventable hospitalizations and teen births, substance abuse and suicide, data from UNC Chapel Hill’s Cecil G. Sheps Center for Health Services shows.
Ranked as one of 11 most rural states in the nation, the Tar Heel state is among eight such rural states that have not expanded Medicaid, according to the North Carolina Rural Health Institute.
When illness strikes, though, the uninsured have to see doctors and visit hospitals like UNC Rockingham and Cone Health’s Annie Penn Hospital in Reidsville. And those facilities have a legal obligation to provide service regardless of a patient’s ability to pay.
In turn, the county’s hospitals end up absorbing unpaid bills for inpatient and emergency room services in an era when nearly one-third of North Carolina’s rural hospitals are operating in the red.
Nationwide, 106 rural hospitals, including five in North Carolina, have closed since 2010, according to the Sheps Center.
While N.C. has the sixth highest number of uninsured residents nationwide, state legislators continue to reject expansion that would mean an estimated $19 million in savings from uncompensated care for Rockingham’s health care providers and hospitals alone, according to the NCJC.
Uninsured ED visitors
At UNC Rockingham, between 28,000 and 30,000 patients visited the emergency department annually over the past eight years, while 20-21% did not have health insurance, Weston explained during a Monday interview.
That amounts to about 6,000 patients per year who may not have the means to “self pay’’ in a market where average ED visits can cost between $1,200-$1,900, consumer reports show.
Weston estimates the emergency department census is comparable at Annie Penn, bringing the combined number of annual county ED visits to roughly 60,000, compared with the county population of about 91,000, Weston said.
“We see those high numbers because of lack of primary care access, lack of mental health resources, as well as lack of coverage,’’ Weston said of the county with an 18.5 % poverty rate.
In order to deal with the debt, Weston uses every saving measure at her disposal.
“UNC Rockingham does everything it can to continue operations, despite the costs, including expense reduction and operational efficiencies,’’ Weston said.
“However, without ongoing support, rural hospitals will continue to face financial challenges,’’ Weston said. Officials at Annie Penn were not available for comment.
Expansion may help, but no “Silver Bullet”
Weston said she sees a critical need to “close the coverage gap” as swiftly as possible in North Carolina. Indeed, Medicaid expansion could certainly help narrow that breach, but it is not a “Silver Bullet” solution guaranteed to save rural hospitals, she said.
Instead, the issue of sustainability for rural hospitals like hers is much more complicated, Weston said.
To close the coverage gap, “We need to come together as a state and solve what is a health care issue, an economic development issue and an ethical issue,’’ Weston said. “At some point we have to end the debate about the coverage gap and end the coverage gap.”
Other current threats to rural hospitals pose “real challenges to our long-term viability,’’ Weston said.
“What keeps me up at night? The proposed changes to the State Health Plan, the potential repeal of CON (Certificate of Need) laws, the upcoming Medicaid Transformation,’’ Weston said.
“Rural Health Care is in a position of death by a thousand cuts.’’ Weston said, itemizing myriad threats.
For instance, rural hospitals like UNC Rockingham could suffer due to increasing regulatory requirements, aging facilities, high rural unemployment, an aging county population, expanding technology needs and dwindling numbers of providers as many longtime doctors approach retirement age, Weston explained.
Moves by the legislature to redraw the State Health Plan, insurance for state employees, could take business away from rural hospitals.
A push in Raleigh to do away with the CON system by which hospitals are regulated could shift care away from smaller multi-service facilities like rural hospitals and boost more specialized facilities, such as outpatient surgical centers in more urban areas.
Is UNC system committed
for the long haul?
When UNC Health Care bought the hospital in 2018, the terms of the purchase included a pledge by the system to operate the facility as a hospital for no less than five years, Weston explained.
Such language is a show of good faith by a buyer to protect communities from predatory buyers seeking to acquire a facility purely for profitable land, for example.
But as a physician to more than 5,000 patients, Luking says without Medicaid expansion, the hospital could languish and UNC Health Care could potentially lose interest in its investment after the five year mark.
Luking cautioned that an unforeseen economic downturn, such as the Great Recession of 2008, could make it difficult for UNC to remain committed to its investment in a rural hospital.
Weston though, feels secure, and itemized capital investments UNC has made since January. They include: a new CT scanner for low dose lung screening, new stretchers and a new telemetry monitoring system. In the coming year, the hospital will add a new linear accelerator for its radiation oncology program, new 3D mammography technology and make needed facility upgrades.
The economic strain rural hospitals statewide will face in the absence of Medicaid expansion is troubling in the short-and long-term, though, said Carla Obiel, vice-president of programs for the Foundation for Health Leadership and Innovation in Raleigh. The non-profit promotes affordable, quality health care policies and holistic strategies toward care.
“We are concerned that without expansion, more and more rural hospitals are going to have a hard time keeping their doors open.’’