The High Cost Of Living Rural: A Q&A With A Journalist Covering Healthcare In Appalachia


Rural hospitals across the country are closing in large numbers, making emergency and speciality services harder and harder to come by for Americans who don’t live in urban centers. One hundred and thirteen rural hospitals have closed since 2010, and about a third of the remaining, some 670, were at risk of closing in 2016.

Mason Adams, who is based in Floyd County, Virginia, detailed the impacts of those closures on rural Appalachians in his latest report for In These Times. That includes the increased travel times that many older, poorer Appalachians now face to reach the medical services they need, sometimes requiring helicopter rides in emergency situations that can cost upwards of more than $44,000, more than the average annual income in many of the communities directly effected. 

Adams also details the difficulty communities face in finding adequate services after their local facilities downgrade the services they offer after consolidations in rural healthcare systems, such as trauma care and neonatal intensive care units (NICUs), all of which contribute to the growing cost of rural health care.

Adams spoke with 100 Days in Appalachia’s Kristen Uppercue about his reporting. 

KU: Your report details, the challenges rural Americans, especially those that are older than 65 face when trying to access health care services. Some of the biggest challenges you write about include the impact of hospital closures. But that’s not necessarily a new issue. Outlets throughout the region have been covering this issue. Was there anything you found in your reporting for this article that was new to you or that you thought was surprising?

MA: Well, first, I agree. You’re right. A lot of these issues have been around for a little while. I’ve reported on some of them myself. What I hadn’t done before this report was to really see them stacked up in one state in one story, all these different layers from access to cost to transportation, and a lot of these stacked up and so seeing that in a complex, layered way was something new to me.

I hadn’t gotten into too much before, I had thought about the emergency transportation side of it. I hadn’t thought about birth services so much. One of the interviews and the first person I quoted in the story had quadruplets that came three months early and she had to drive an hour to get to neonatal intensive care unit, which is where you need to go if you have a high-risk pregnancy or your babies need to stay over, as hers did for the next six to eight weeks after she gave birth. I think today with some of the changes that have been made to the hospital systems, she’d have been driving an hour and a half, which boggles my mind. But something else that came up in this was just the prevalence of these issues. You know, I kind of got started on it because I heard stories about these $44,000 helicopter bills, and I had trouble finding people who had had that experience and were willing to talk about it, I think in part because they signed nondisclosure agreements when they settled but it seemed like everybody I talked to had a story about it.

KU: I agree. That was one of the anecdotes that really stuck with me from your piece. You write that the cost of those helicopter rides are more than the average annual salary in the area you are or you were looking at. 

MA: Right. Well, air ambulances are, you know, that’s the term where an emergency helicopter comes in to pick up somebody and take them to a hospital. But now there’s a number of private companies running systems like that. These are out of network services for many patients and so that out of network price is you know, people will get a bill. I spoke to one lady in Rogersville, Tennessee, who’d been transported and she received a bill for more than $44,000. I will say just to qualify that, I think it’s hard to find stories of people who’ve got stuck with that whole bill. In some cases, Medicare will more or less cover it. In other cases, there’s an insurance that people purchase. I think all of the rescue squads and public safety officials in Lee County are covered by that, for instance. And they market it to people in the area because so many folks are having to be flown out. So a lot of people have that insurance that helps cover the cost. And then I think in other cases, people end up settling with the company for maybe a few thousand dollars.

KU: So your story is centered around a nonprofit healthcare provider that bought up services in a rural community, consolidated into one organization and then downgraded those services because there really isn’t any competition in the area anymore. You write that this is a trend that we’re seeing in the region. Can you explain in a little bit more detail what exactly is happening?

MA: Essentially, in northeast Tennessee and southwestern Virginia, there were two competing health care providers, Wellmont and Mountain States. And by 2014, both of them had, just covering a rural area that is increasingly losing population and the population’s older, poorer, it tends to be, you know, sick, they’re dealing with things like black lung and not to mention chronic, you know, illnesses like diabetes and heart conditions. So, they emerged under a process called a Certificate of Public Advantage, or cooperative agreement that’s in Virginia and Tennessee. And so the resulting entity, Ballad Health, basically had all of Mountain States’ and Wellmont’s assets and some of it, you know, like I said, these had been two competing healthcare systems, so they ended up with things like two hospitals in Norton, which is a city in southwestern Virginia of about 4000 people. 

And so, you know, as you’d expect, they’re looking at that larger system and looking for ways to make it more efficient. Now, some of the changes that they’ve made have really upset people who are in that coverage area. Probably the one that’s fired up people the most is they had two level-one trauma center hospitals in Kingsport and Johnson City, which are pretty close together. Kingsport, I think, is within range of more population than Johnson City. But Ballad chose to downgrade Kingsport from a level-one to a level-three trauma center, and as part of that closed the neonatal intensive care unit. They’ve essentially converted one of the hospitals in Norton into a long-term facility and they’ve moved its services to hospital and the other hospital in Norton, and then a different one in Big Stone Gap. And they’ve made changes around the edges and, you know, some people are worked up. You know, Ballad will say this makes for a more effective healthcare and they’re doing things by the book and the numbers, but at the same time, you know, the Robert Wood Johnson Foundation has done a study that found that basically hospital consolidation and these monopolies see price increases. 

And so we’re still in the early years of this Ballad procedure or this Ballad entity, so there’s still a lot to learn, but a lot of people are pretty worried about it. You know, there have been protests going on in front of that Kingsport hospital that was downgraded, Holston Valley Medical Center. They’ve been, there’s protesters there who’ve been out front 24/7 continuously for more than 200 days and are involved in, you know, some battles with Ballad just not only protesting the service changes but even kind of fighting to hold their ground now Kingsport town councils looked at some ordinances that might push those protesters out and so that’s like one ongoing front with Ballad. 

But, to its credit, you know Ballad is also reopening the hospital in the county that closed in 2013. The hospital there in Pennington Gap was one of two in Virginia that closed. Folks there have been really trying to reopen that hospital and, you know, this fall, six years after that hospital closed, its doors reopen, not as a full critical access hospital or even an ER but as an urgent care center and Ballad says they’re going to reopen it as a critical access hospital next year. And that’s met with some extra spots, but I think a lot of people in Lee County are glad it’s going to be reopening again that even if it’s not providing the services of a level one or even level two trauma center, it’s still, you know, a place where there’ll be an emergency room and in case of a trauma or other situation like a heart attack or stroke.

KU: We know that Appalachia is a region that’s struggling with many health issues. The rates of diabetes, of heart disease, of cancer, they’re all high here. After doing this reporting, and this might be an obvious question, but do you feel like you can say that the financial climate of rural healthcare is impacting the health of the people here?

MA: Yeah, absolutely. And I think that’s true, not just in Appalachia, but across America, especially rural America. I mean, that’s just speaking from firsthand experience, you know? I’m one of the many, many Americans who’s basically one healthcare crisis away from financial disaster. Like, we’re doing okay, but if we were to, you know, suffer an unexpected issue, you know, I think I think we’d be in financial trouble and I think a lot of people are that way, you know, and will let small things go just because they know it’s going to come with a bill, and often when they can’t afford. I mean even co-pays, you know. You can see that play out if you look at the local courts were Ballad is certainly not the only company, they’re one of many healthcare providers that will pursue patients for bills in court, you know. They go after them to enable them to chase the debt more aggressively and then they start to garnish wages. And in all the cases I checked, I could not find one case where somebody had come to court with a lawyer. Yeah, it’s, it’s, I think it’s a challenge for a lot of Americans and Appalachians. 

KU: So with those challenges and the challenges that you’ve reported on before, are there any solutions out there? Are there ways to make healthcare more accessible and more affordable in Appalachia? 

MA: That’s a good question. A lot of folks are trying different things. There are clinics that have gone out and really made a difference, like a few people made a point to me that you know, just having a registered nurse or a nurse practitioner who can see people at a spot and help them maintain their long term chronic conditions like diabetes or heart issues, that’s, that’s super important. Ballad itself is focused on a lot of community health issues, you know, helping support Parks and Rec and things that get people outside to exercise, helping support healthy eating patterns. I certainly saw Ballad trying to engage on that level and that’s something we don’t always think about, but it does make a difference in community health. 

And then you have more, I guess, more political solutions or looking at changing the healthcare…healthcare system in more fundamental ways, you know, that I talked to some people for this story that made a case that moving to a single-payer system for healthcare will take the profit motive out of it. And if you can do that, then maybe you can kind of make a more level playing field, both for providers, but also patients across the U.S. instead of into this system of winners and losers of have and have not healthcare providers that we currently have now.

KU: What can rural Appalachians who view this report, learn from you, especially those who want to push back against this divide in health care?

MA: I’m not sure they’d want to look to me to learn but I do think they can look to people in the story. There are voices in the story like Danny Cook who decided to take action against the closure of the NICU in Kingsport. Now, you know, you can argue whether or not she has been successful. Ballad still closed the NICU and downgraded the trauma center level at that hospital, but she’s certainly drawn a lot of attention to the topic, not just from me but from other reporters as well and I think probably from lawmakers. I’m sure there are a lot of elected officials who may not otherwise be thinking about this story but are thinking about it and how to handle it due to her. 

I think one thing is that did come through from this is just the sturdiness of Appalachian people. I think, most everybody I talked to, had a very stoic attitude toward it, which can cut both ways, but I do think and surviving day to day, it makes a difference and it’s a quality I’ve seen in people in the mountains throughout my career.

This article was originally published by 100 Days in Appalachia.