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Friday, December 30, 2016

More than loss of a hospital

Yesterday a hospital was demolished in Belhaven, North Carolina after years of controversy. I don't know whether demolition of this hospital was the best decision, but the affair does bring to mind several points.

Belhaven is tiny, population 1600. Like many areas in North Carolina between I-95 and the Atlantic coast, it is depopulating, it is majority African-American, and it is far from prosperous. Unfortunately, it is also geographically isolated. The nearest hospital emergency room (for my British readers, "ER" in the U.S. means "A&E" where you live) is an hour away. Carrie Fisher's life slipped away in less time than that, despite intervention.

Hospitals like the former one in Belhaven that serve a high proportion of Medicare and Medicaid patients face a very difficult financial problem because the allowable reimbursements in those programs are so low. Even WakeMed in Raleigh struggles with this — one reason why WakeMed competes so vigorously against UNC-Rex and Duke for high-spending cardiac patients who are privately insured. I am not a fan of employer-paid healthcare, and there is something to be said for the single-payer model. However, if every hospital in the nation were to have its income restricted to Medicare and Medicaid reimbursements, nearly all of them would quickly go bankrupt. I am not surprised that the hospital in Belhaven was impossible to keep open.

Aside from the beach communities, much of eastern NC has entered a death spiral. The tax base in many counties cannot sustain quality schools. Jobs paying more than minimum wage are scarce. Internet access is slow. Shopping for anything besides gasoline, bread, and milk is difficult. Health care is increasingly centralized, with many residents facing a long drive just to reach a dentist or an OB/GYN (much less an ER). These factors encourage more people to move out and discourage others from moving in, even though real estate prices are cheap.

The British have a useful word to describe this: deprivation. The word is rarely used here, perhaps because Americans in better circumstances prefer to believe that there is little or no deprivation in America and that people who find themselves in deprivation have only themselves to blame.

State government's response to this scenario is minimal. NCDOT proposes road improvements to make the areas more attractive to large businesses, but I question whether that will work by itself. State funding for schools isn't sufficient in the absence of substantial county funding, and the state's community college system that could help these people is consistently under-funded while the state's university system (largely inaccessible to the Belhavens) gets billions of dollars.

Not a happy situation. The question is, can our deeply divided state and national governments — which reflect our deeply divided citizenry — do anything constructive to help these areas… or do we simply let them rot.