As rural hospitals close and low-income South Carolinians struggle to find and afford medical care, one candidate for governor says the solution lies in taking more federal dollars. The other says that solution would cost too much and come with too many strings.
Republican Gov. Henry McMaster has resisted calls from Democrats to accept federal money to expand Medicaid, the joint federal-state insurance program for the poor and disabled, despite South Carolina sitting near the bottom in national rankings that measure health care cost, access and outcomes.
Meanwhile, state Rep. James Smith, McMaster’s Democratic challenger for governor, says the first stroke of his pen if elected governor will be to expand Medicaid to cover more uninsured South Carolinians and boost the state’s economy.
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The issue of health care — and who will pay for it — is important in South Carolina, one of the nation’s poorest states and one of its unhealthiest — plagued by high levels of obesity, diabetes and other ailments.
“We are not a healthy state,” said health-care economist Lynn Bailey of Columbia. “We have problems in care for aging South Carolinians. ... We don’t have enough providers, physicians or nurse practitioners. We have critical shortages … hindering” the state’s economic growth.
“If you don’t have healthy, educated people, where is your workforce going to come from?”
Rural hospitals closings
Three rural S.C. hospitals have closed since 2010 in Bamberg, Barnwell and Marlboro counties. Another, Fairfield Memorial in Winnsboro, will close later this year, leaving only a stand-alone emergency room that will open in its place.
In 2014, state lawmakers created a $40 million hospital transformation fund to try to ensure that health-care facilities continue to operate in poor, rural areas. That fund makes one-time money available if a non-rural hospital makes at least a 10-year commitment to serving a rural area.
Bailey said rural hospitals were hurt by South Carolina’s decision not to expand Medicaid as part of the federal Affordable Care Act.
But hospitals also need customers to stay open, and rural flight makes that difficult, Bailey said. She said a hospital needs at least 30,000 residents in a county to succeed. The counties that have seen hospitals close have less than 30,000 residents each.
However, Medicaid expansion would help keep some rural hospitals open, Bailey argues, by providing health-care insurance to the mostly poorer residents that they serve.
“If we don’t do it soon, it will be too late,” she said.
Too few doctors
McMaster has said expanding Medicaid would cost S.C. taxpayers $1 billion, arguing there are better alternatives. Those include promoting the use of telemedicine and loosening the restrictions on nurse practitioners so they can do more to improve the health of rural South Carolinians.
The state needs those nurses to do more, in part, because it has too few doctors.
South Carolina, with its estimated 4,000 active primary-care physicians, ranks 37th in the nation in the number of doctors. The state has 80.1 physicians per 100,000 residents, compared to a state median of 90.8 doctors per 100,000 residents nationally, according to the Association of American Medical Colleges.
This summer, McMaster signed a law — supported by Democrat Smith and his lieutenant governor-running mate Mandy Powers Norrell of Lancaster — to remove limits on advanced-practice registered nurses. One limit previously said those nurses could not provide care outside a 45-mile radius of a supervising physician. The new law also allows the nurses to practice via telemedicine.
Cutting red tape that prevented nurses from providing care they are qualified to give will provide better access to health care at a lower cost, McMaster argues.
“The opens the door to nurse practitioners going all over the state,” McMaster said. “You’ve seen the minute clinics and things of that nature. Those work.”
He added, “We need to get to a point where anyone can call a physician or nurse practitioner on their cellphone and get answers to their health problems.
“When we take medicine to the people, instead of taking people to the medicine, that’s where we’ll be happy and healthy in South Carolina.”
Under the Affordable Care Act, the federal government agreed to cover the cost of expanding Medicaid to cover previously uninsured S.C. residents from 2014 to 2016. That would have poured about $2 billion a year in federal money into South Carolina and extended insurance coverage to hundreds of thousands of residents, according to estimates at the time.
After 2016, however, South Carolina would have had to start picking up part of that cost. That state match would phase in until 2020 but would not increase past 10 percent of the cost.
State officials estimated that expanding Medicaid would have cost the state between $1.1 billion and $2.3 billion during the first six years of the program — or from $183 million to $383 million a year.
“Yes, health care is a problem,” McMaster, 71, said during a June 20 televised GOP primary runoff debate. “We don’t need the centralization that came from Obamacare. We have to get the free enterprise involved in it. We will be better off.”
McMaster added: “The health care system can be very much better in this country without a huge monolithic bureaucracy like that strangling everything.”
Smith, 51, says the state is leaving money on the table by turning down federal dollars. Those dollars, the Democrat argues, would yield economic benefits for the state, and improve access to medical care, its affordability and health outcomes.
“Too many South Carolinians, when they get sick, they don’t have coverage. There’s no way to pay for it,” Smith said. “It doesn’t cost South Carolinians one cent in additional taxes to bring their money ... back to South Carolina to serve us.”
Studies have shown that expanding Medicaid actually saves money for many states, even after a state pays its share of the added cost. Those states — including Arkansas, Kentucky, Louisiana and New Jersey — saw big drops in the number of low-income and vulnerable residents who did not have insurance, according to a Kaiser Family Foundation summary of findings from 202 studies of Medicaid expansions beginning in January 2014.
A 2016 study also found that Medicaid spending grew more slowly in states that expanded Medicaid than in states — including South Carolina — that did not. But an uptick was predicted for 2017 as, in part, the federal government cut its share of the cost of expanding Medicaid. However, several states that expanded Medicaid planned to use provider taxes or fees to pay for all or part of their higher Medicaid costs.
Expanding Medicaid also lessened the burden on a patchwork of largely state-funded programs that connect people — homeless, with substance-use disorders or other serious health needs — with critical services, according to the Center on Budget and Policy Priorities, a nonpartisan research and policy institute.
Smith estimates expanding Medicaid would create 40,000 health-care jobs in South Carolina, jobs that also would bring more tax revenue to the state.
‘“It’s not just about the money,” Smith said. “It’s also about the strategy that we use. That we support preventative care. ... And, in the long term, that saves money. Other states do this and have done it successfully. And it ought to be happening here in South Carolina. It will improve health-care outcomes, save tax dollars and make for a much better state.”
Universal health care and Planned Parenthood
McMaster has slammed Smith for his response to a question about whether he would support Medicare-for-all, a proposal pushed by self-described democratic socialist Bernie Sanders, the U.S. senator from Vermont.
Smith on Friday, though, said he had changed his position and does not support Sander’s health care plan.
“I’ve always said I believe we should have universal access to health care,” Smith said. “That everyone, if they get sick, they ought to be able to go see a doctor. And they better be able to have access to preventative care. To say you’re for universal health care does not equate to a Bernie Sanders-specific plan. While I appreciate what he’s done ... I don’t necessarily agree that is the way to go.”
Sanders’ proposal, also known as single-payer health care, would boost government health-care spending by $32.6 trillion over 10 years, according to a study from a university-based libertarian policy center affiliated with the conservative Koch brothers.
Sanders puts the price tag at $13.8 trillion over a decade. But, he argues, Medicare-for-all also would save U.S. residents and businesses more than $6 trillion over the next decade..
Democrats, meanwhile, have criticized McMaster’s pursuit of a federal waiver to require able-bodied, working-age adults on Medicaid to get a job or volunteer if they want to keep their health coverage.
The governor’s office has said McMaster thinks government assistance is meant to be a stop-gap during difficult times. The best way for families to live happy, healthy lives is through gainful employment and giving back to their community.
Critics note most Medicaid recipients either are children or the elderly. They also say the jobs mandate would hurt mothers and adults living in rural areas, where access to jobs and transportation is slim.
Smith, too, has bashed McMaster for rejecting $14 million in federal money for health care services as part of an effort to defund Planned Parenthood’s Columbia and Charleston clinics.
Just a fraction of that money — $82,000 last year — went to Planned Parenthood, all for non-abortion services, including birth control, gynecology exams and testing for sexually transmitted diseases.
Smith has accused McMaster of playing politics with health care to score political points. McMaster contends S.C. tax dollars should not help subsidize the operations of an abortion provider.
Opioids and medical marijuana
The candidates are closer in their prescription on how to handle the opiod-abuse epidemic.
In June, McMaster signed a series of bills into law aimed at combating that epidemic. The legislation set a seven-day limit, with some exceptions, on initial prescription of opioids. The measures also made an overdose-reversal drug more readily available and called for better prescription monitoring.
Smith and Norrell, who was on the S.C. House’s Opioid Abuse Prevention Study Committee, back the measures.
Smith also says he will push to improve access to medication-assisted treatment and recovery resources if elected.
The Democrats also support medical cannabis, arguing South Carolinians need an alternative to help with chronic pain and ease opioid abuse.
Smith, an Afghanistan war combat veteran, co-sponsored legislation in the House to provide patients access to medicinal cannabis as a means for treating veterans suffering from PTSD and certain debilitating medical conditions.
McMaster said he is working with law enforcement on the issue but has concerns the proposed state legislation would bypass federal regulation. The governor said he wants to ease the suffering of patients, but “we have to be very, very careful.”
If cannabis has medicinal benefits, “it should be treated and regulated in the same manner” as other drugs, through research and oversight by the Federal Drug Administration, said Jarrod Bruder, executive director of the S.C. Sheriffs’ Association.
To date, the FDA has not approved marijuana as a safe and effective drug.
“If law enforcement is satisfied that the ingredients, the chemicals and whatever it is that is so dangerous to our people and what that would cause, if we can be satisfied, if I can be satisfied by them, then I’d be happy to sign it,” McMaster said at the GOP primary debate. “But, until that day, I will not.”