Hospitals in the United States continue to close at an alarming rate, with 183 hospitals in rural areas alone shuttered since 2005. City hospitals have also suffered, perhaps most notably with the closing of Hahnemann Hospital in Philadelphia, Pennsylvania, in 2019. This troublesome trend has worsened the already poor healthcare access for many Americans, with disproportionate effects on poor and working class communities. A primary factor leading to hospital closures is a high burden of uncompensated care. This explains why a disproportionate number of hospital closures are in states that have yet to expand Medicaid and thus have higher uninsurance rates among low-income individuals.1 Despite many of these hospitals serving as vital public goods, health care in America shamelessly invites the prioritization of profits over patient needs, an issue exacerbated by the rising involvement of private equity throughout health care.

It is in this national context that Wellstar Atlanta Medical Center (AMC) in Georgia recently closed its doors. AMC was a 460-bed hospital, one of two remaining level one trauma centers in Atlanta, Georgia, the other being Grady Memorial Hospital, the largest safety net hospital in the state and fifth largest in the United States. There was little time to prepare for the fallout from this crisis, which has already shown signs of further limiting access to trauma, inpatient, and outpatient care for many Atlanta residents.

According to Wellstar, the closure was economically necessary, as the site lost tens of millions of dollars annually due to uncompensated care. These uninsured patients will now turn primarily to Grady, a short 1.2 mile walk away, increasing the burden on the safety net hospitals’ already over-taxed workforce. Grady, a 953-bed hospital, operates at full capacity daily with emergency room wait times frequently exceeding the average wait time of other emergency departments. Grady Hospital, with roughly one in four patients uninsured, was previously itself on the verge of closure in 2007 due to financial pressures. Incredibly, despite AMC’s closure, Fulton county leadership, where Grady is located, continues to express concerns of Grady’s short-term viability reaffirming that access to health care is far from a right in this country.

In Atlanta, Grady has seen an early jump in trauma arrivals by more than 25% while other local hospitals’ emergency rooms have seen visits increase by 15-30%. In all, it is estimated more than 10,000 patients will be affected by the hospital and surrounding ambulatory centers closing. Hospital closures are particularly concerning in Georgia given the states last place rank in provision of health care across all states in 2021. Unfortunately, the shuttering of these public goods is not new in Georgia, where eight rural hospitals have closed in the last 10 years. Georgia’s high rate of uninsured patients at more than 15 percent, almost twice the U.S. state average, is largely a result of Georgia’s lack of Medicaid expansion under the Affordable Care Act (ACA).2 Georgia remains one of only 12 states yet to do so despite additional financial incentives included in the American Rescue Plan Act of 2021, on top of federal funding for 90% of annual expansion costs at baseline. Expansion would increase coverage eligibility to those making less than 138% of the federal poverty level, $18,754 for an individual in 2022. This would make insurance available to an estimated 450,000 Georgians, including many low-income adults who cannot afford to purchase insurance and do not currently meet Georgia’s narrow Medicaid eligibility criteria.

Notably, the data demonstrate that expansion drives improved health and economic outcomes. An analysis of 404 studies looking at Medicaid expansion found overwhelming evidence that expansion improved healthcare access, financial security, health outcomes, and was a positive economic stimulus for states.3 It is estimated that more than 15,000 people, thousands in Georgia, aged 55-64, died prematurely due to lack of coverage in just a four-year period in non-expansion states. Additionally, Medicaid expansion has been shown to reduce arrests for drug, low-level, and violent crime by more than 20% when compared to counties in non-expansion states.

The current crisis surrounding AMC is tragic yet unsurprising, and it is no mistake that those who will bear the costs of AMC’s closure will be poor and working class Black patients in Atlanta—the same patients who come from neighborhoods where life expectancy is 10-15 years shorter than more affluent and whiter neighborhoods. Atlanta is the most unequal city in the most unequal country amongst so-called peer nations in the world. Neglect and divestment unfortunately are too often the norm for Black Americans, seen in the concurrent crisis of crumbling water infrastructure in Jackson, Mississippi. The closing of AMC is the latest example of structural violence manifest, or as Dr. Paul Farmer explained, “…social arrangements that put individuals and populations in harm’s way … The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people.” There was nothing inevitable about AMC’s closing and nothing abstract about the fact that with worse health access comes worse health outcomes.

Medicaid expansion remains an immediate necessity for those most vulnerable to premature death. Expansion would benefit struggling hospitals and uninsured patients throughout Georgia and other non-expansion states. It will not, however, fix the structural issues of a healthcare system that remains the most expensive compared to peer nations, costing twice per capita the comparable country average. Despite this, the United States has the worst health outcomes across many metrics. With more than 80% of health outcomes driven by policy decisions, by choices of who, what, and where to invest in, physicians and other healthcare providers must demand better for patients.4

We must be unambiguous in demanding a fundamentally more just universal and comprehensive publicly funded health insurance system. Medicaid expansion is the floor, not the ceiling. We must reject a system that leaves more than 60 million people uninsured or underinsured and dooms millions of Americans to bankruptcy while burdening millions more with pervasive medical debt.

To ask how we can possibly afford universal coverage is to ignore the more urgent and obvious question of how can we possibly continue this current path?

It is not and has never been for lack of money, as seen in the corporate bailouts from the financial crisis and COVID-19 pandemic. In fact, a streamlined public insurance system would remove much of the bureaucracy and inefficiencies that plague our multi-payer, profit-driven model and would significantly lower overhead costs. A system where a single company can squeeze an unconscionable 17 billion dollars in profit from patients during 2021 as they were trying to survive a pandemic is a system built for corporations, not patients. Given the vast dysfunction and exploitation in the American healthcare system, all should welcome the simplification and equity a single insurance program would bring with the ability to negotiate and lower drug prices, the elimination of deductibles, co-pays, and premiums, and the elimination of private insurance corporate profiteering. An estimated 60,000 deaths could have been prevented had the United States had universal coverage during the first years of the ongoing COVID-19 pandemic.5 If profitability continues to determine what life-affirming institutions people have access to then premature death will continue to haunt poor and working class communities, like those AMC served, and similar communities around the United States. It is well past time for patients, physicians, and other healthcare professionals to organize together in demanding health justice now, anything less risks maintaining the unsustainable tragedy that is the status quo.

References

  1. Lindrooth RC, Perraillon MC, Hardy RY, et al. Understanding the relationship between Medicaid expansions and hospital closures. Health Aff (Millwood). 2018 Jan;37(1):111-120. doi:10.1377/hlthaff.2017.0976.
  2. Buettgens M, Ramchandani U. 3.7 million people would gain health coverage in 2023 if the remaining 12 states were to expand Medicaid eligibility. Urban Institute. https://www.urban.org/research/publication/3-7-million-people-would-gain-health-coverage-2023-if-remaining-12-states-were. Published August 3, 2022. Accessed January 15, 2023.
  3. Guth M, Garfield R, Rudowitz R. The effects of Medicaid expansion under the ACA: Studies from January 2014 to January 2020. Kaiser Fam Found. https://www.kff.org/medicaid/report/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/. Published March 17, 2020. Accessed January 15, 2023.
  4. Hood CM, Gennuso KP, Swain GR, et al. County health rankings: Relationships between determinant factors and health outcomes. Am J Prev Med. 2016 Feb;50(2):129-35. doi:10.1016/j.amepre.2015.08.024. Epub 2015 Oct 31.
  5. Campbell T, Galvani AP, Friedman G, et al. Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study. Lancet Reg Health Am. 2022 Aug;12:100264. doi:10.1016/j.lana.2022.100264. Epub 2022 May 12.

Issue

Topic

Advocacy, Health Equity, Health Policy & Advocacy, Hospital-based Medicine, SGIM, Social Determinants of Health

Author Descriptions

Dr. Spencer (mark.lawrence.spencer@emory.edu) is a PGY-3 Internal Medicine Resident at the J. Willis Hurst Internal Medicine Residency Program at Emory University School of Medicine. @mspencer22. Dr. Henry (tlhenry@emory.edu) is an associate professor of medicine in the department of medicine at Emory University School of Medicine. @docwithapurpose

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