“The first wealth is health.” – Ralph Waldo Emerson
Good health is fundamental to our general welfare. Without it, we may not be able to work, care for others and contribute to our community. We may feel stressed, anxious and unhappy if we are in poor health or worried about what will happen if we become ill and don’t have insurance. Or we may feel we cannot afford to seek treatment even if we are insured. Children are particularly vulnerable, and their ability to learn is affected if they are ill and can’t get treatment.
Likewise, the entire community is affected when families are destabilized by poor health, people are unable to work and participate in the daily activities of life. The financial burden of care is born by families, employers, hospitals and government. Those who are uninsured delay seeking care, do not obtain preventative services and require more costly care. Chronic and severe illness may mean people require public assistance to survive.
Those in the South are affected disproportionately by poor health. Moreover, those in rural areas tend to have worse health still. Georgia and North Carolina rank in the lowest quarter percentile for state health rankings, according to the Commonwealth Fund.
A recent phone survey of almost 3,000 residents in Clay County and western North Carolina provides a look inside what matters most to people, their experiences and their health from 2012 to 2018. For example, about 36 percent experienced emotional abuse and household substance abuse. Over 50 percent said their life had been affected by substance abuse. There was a high incidence of heart disease and asthma (compared to the rest of the country) There is also evidence of poor diets, less leisure time, and being overweight. On a positive note, there were fewer smokers. The number of people unable to get medical care increased.
Are people in the region in good health?
How do people in my county and state fair on key health outcomes, i.e., length of life and quality of life? What factors influence their health, such as their behavior, clinical care, social and economic factors and the environment?
- Cherokee County, NC
- The county has high rates of rates of premature death, smoking, obesity, uninsured, unemployment, children in poverty and injury related deaths. Strengths are adequate preventable hospital stays and access to exercise opportunities.
- Clay County, NC
- The county has high rates of rates of premature death, smoking, obesity, uninsured, children in poverty and injury related deaths. Strengths are adequate number of primary physicians, preventable hospital stays, low rates of income inequity, low air pollution and access to exercise opportunities.
- Towns County, GA
- The county has high rates of rates of premature death, smoking, obesity, unemployed and injury related deaths. Strengths are an adequate number of primary physicians, preventable hospital stays, low rates of income inequity, low air pollution and access to exercise opportunities.
- Union County, GA
- Union County is similar to Towns in in strengths and weaknesses, though lower in the rates of smoking.
The common theme running through the data for all four counties are high rates of premature death and lack of insurance.
One topic not addressed in this data but an important one is drugs. Our region, along with the rest of the country, is experiencing high rates of drug use and many deaths due to overdoses. The CDC reports that opioids (prescription and illicit) were involved in 33,091 deaths in the U.S. in 2015, and opioid overdoses have quadrupled since 1999.
The Harvard Business Review reports that 100 Americans a day a dying and it has been declared an epidemic. While opioid addiction is closely related to poverty, unemployment and lack of health insurance, it cuts across income levels.
How many opioid deaths are occurring in my state? Have there been increases?
Those using drugs experience physical and mental health problems, families may breakup and jobs are lost. There is a severe shortage of mental health providers and drug rehabilitation resources in our area. Those who have been convicted of a drug related crime find it difficult to obtain employment.
To learn about the degree to which drug poisoning and deaths are affecting the state and the four counties represented by PPN, view the downloadable charts below. Not only are adults dying, but infants are being born as drug addicted. A booklet of community resources has been prepared so families, individuals suffering with drug addiction and professionals can easily locate community services and supportive organizations.
What are the challenges of providing care in rural areas?
At the same time, rural residents are older, more likely to be poor and uninsured, and generally less healthy than their urban counterparts. Additionally, rural residents face challenges in accessing care due to provider shortages, transportation issues, and geographic isolation.” Two of the most prominent challenges are described here.
Poverty and Lack of Insurance
One quarter of Georgians live in poverty (2.2 million nonelderly citizens). Poverty is defined as incomes at or below 138% of the federal poverty level (FPL: $33,500 for a family of four). Of these, 600,000 report no insurance at any time (2014/15 average) according to the GHPC.
Georgia has the fifth highest uninsured rate in the country, with 1.2 million being uninsured. The rate is projected to skyrocket to 25 percent by 2026 according to the Georgia Chamber of Commerce.
The poverty rates for residents in the four counties represented by PPN are displayed here (2015 data).
To learn more about poverty, visit http://www.povertyusa.org/the-state-of-poverty/poverty-map-county/
The population of our region is older and uninsured. The last U.S. Census (2010) found that a large proportion of the population is ages 60 and older in the counties represented by PPN.
As you can see, the population is older in the counties represented by PPN than surrounding counties.
The NC Justice Center has information on poverty in the state and detailed profiles describing poverty in Clay and Cherokee counties. http://www.ncjustice.org/?q=budget-and-tax/btc-brief-county-economic-snapshots-2017
What services are available to the uninsured or underinsured in our region?
Community Health Centers and Clinics
- The only community health center in the four-county PPN region is the Peachtree Community Health Center in Murphy, NC. There is, however, a community health center in Rabun (Med link Georgia) and one near Blue Ridge; Georgia Mountain Health Services. The only free clinic serving the area, which is currently open two days a week and provides very limited services, is the Healing Hands Community Clinic in Blairsville, GA.
- The only free clinic serving the area, which is currently open two days a week and provides very limited services, is the Healing Hands Community Clinic in Blairsville, GA.
- Chatuge Family Practice in Hayesville offers services on a sliding scale and does not refuse services based on ability to pay.
- There is a Veterans Administration (VA) clinic in Blairsville, and an outpatient VA clinic in Franklin, NC. The websites describe what services are offered.
- Local health departments in the area provide a variety of basic care and preventive services. Georgia’s health departments do not have web sites, but North Carolina does;
- There are few mental health providers in the area. For example, in Clay County there was only one provider per 1,189 people in 2016.
- Those eligible for Medicaid and Medicare may receive services for those providers accepting it, plus hospitals are required to provide care to those without the ability to pay.
- Those who receive Medicaid must meet strict criteria to enroll and you must be very poor to qualify. For example, in Georgia, a family of three can make no more than $6,600 a year. Eligibility is tied to the Federal Poverty Guidelines (FPG).
- Medicaid provides a good return on investment for Georgia. For every one dollar the state invests, the federal government matches with more than two dollars.
- Given the high percentage of seniors in the area, who require more care as they age, Medicaid provides a critical safety net. It pays for in-home care, to prevent people from needing nursing home care. It is also the primary payer of nursing home care for low-income seniors who need it. Learn More
- Georgia and North Carolina are among the states that spend the least Medicaid dollars per enrollee for seniors and those with disabilities. Learn More
- Medicaid is key to covering the health needs of Veterans in our area. Learn More
- This region has a high number of personal injuries, and Medicaid plays a role in serving those people through trauma care. Learn More
- Medicaid also plays a role in supporting the individuals and families affected by the opioid epidemic. Learn More
- In NC, 2,037,941 citizens are covered by Medicaid and CHIP. In Georgia, 1.98 million are covered, including 1.3 million children.
- In 2015, a significant portion of the citizens were covered by Medicaid in Towns County; 1,055 or 10% of the population and 2,667 or 13% of population in Union County.
Patient and Affordable Care Act (or ACA)
The goal of the Patient and Affordable Care Act (or ACA) is to reduce number of uninsured, the number of bankruptcies and slow the rate of health insurance costs. It does this by providing subsidies for care for low income individuals through private for-profit insurance companies and distributing the cost across the general population. It has been successful in reducing the rate of uninsured people to a historic low of 8 percent nationally in 2017.
Due to availability of the ACA, the percentage of uninsured dropped significantly in this area. From 2013-2015 the uninsured dropped 5 percent in Clay County, 3 percent in Cherokee, and 6 percent in Towns and Union Counties.
Before the ACA, insurers were allowed to sell plans that did not cover important services, such as prescription drugs, mental health and maternity care. Plans through the ACA have to cover essential health benefits, such as emergency services, hospitalization, laboratory tests, maternity and newborn care, management of chronic diseases such as diabetes, mental health and substance abuse treatment, outpatient care, pediatric services, vision and dental care, prescription drugs, preventative services such as immunizations, mammograms, colonoscopies, and rehabilitation services.
The ACA was intended to include expansion of Medicaid in the South, but the courts ruled states had the option of doing this and southern states have not taken advantage of federal funds to do so. Thus, fewer people are uninsured. Most of these people are the working poor, employed but still falling below the poverty line.
The Kaiser Family Foundation estimates that there are 244,000 people in NC who would have qualified for Medicaid if it was expanded.
A Harvard University study estimates 455 to 1,145 deaths result due to lack of adequate health care in NC each year. It also concluded that would Medicaid expansion there would be:
- 45,571 fewer cases of untreated depression
- 27,044 more diabetics using diabetes medications.
- 12,051 more women ages 50-64 having had a mammogram in the past 12 months
- 27,840 more women ages 21-64 having had a pap smear in the past 12 months
- 14,776 fewer persons facing catastrophic medical expenditures
The Centers for Medicare and Medicaid Services (CMS) report that North Carolina’s enrollment for the ACA in 2018 was the third highest in the nation at 539,989 people. In Georgia it was 493,880 people, coming in fourth behind NC. This was in spite of having funds for advertising and outreach cut (from $100 million to $10 million) and the time period to enroll being reduced significantly.
People may still be able to enroll if they have changes in life circumstances, as described here:
Medicare is an important form of health insurance for all seniors ages 65 and older, regardless of income, medical history or health status. In Georgia, 1,408,400 people have Medicare coverage, while in NC, 1,725,600 have it, according to the Kaiser Foundation for 2017.
Read more about the characteristics of those in Medicare program, what it services it covers and doesn’t, and out of pocket spending for beneficiaries at: https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/
The ACA significantly improved Medicare’s finances by reducing the shortfall in the Hospital Insurance Trust Fund as a percentage of taxable payroll tax. In other words, it boosted its revenues and solvency for current and future generations of seniors. For more on this, visit the AARP Public Policy Institute at https://www.aarp.org/ppi/.
When people don’t have health coverage, they go to the emergency room. Nonprofit hospitals pick up the tab for uncompensated care and fill in a gap in the safety net. They make up 70 percent of hospitals and are expected to provide “community benefit” in exchange for tax relief.
The spillover occurs because the Emergency Medical Treatment and Labor Act, passed in 1985, requires that hospitals treat all individuals in need of emergency care regardless of their insurance status. Medicaid provides compensation for low-income patients in the form of the Disproportionate Share Hospital (DSH) payments, which, according to federal law, are owed to any qualified hospital that serves a large number of Medicaid, uninsured and indigent patients. Research shows it is not enough to offset hospital costs.
Research by the Kellogg School at Northwestern University found that hospitals do not pass this cost on to other insured patients, but instead absorb two thirds of the cost of uncompensated care. Understandably then, hospitals lobbied for expansion of Medicaid to reduce the number of uninsured.
If the government does not provide coverage, the burden of uncompensated care may cause hospitals to close. When hospitals close, communities die. Seven rural hospitals have closed in Georgia since 2013 and five more are at risk.
To learn more about the crisis of southern rural hospitals go to:
The health care committee of PPN has studied the most promising ways to reduce the number of uninsured and improve health care for those residing in this area. It is a complex area and challenging endeavor, one that requires continuous research and exploration. However, there are two approaches that have demonstrated success and are worthy of support:
Continuation of the Patient and Affordable Care Act (ACA)
The ACA has reduced the number of uninsured in the area and stabilized hospitals financial viability. The committee supports continuation of the Act and especially those provisions of the ACA that:
- Require pre-existing conditions to be covered by insurers and prevent discrimination (denying coverage) or charging higher premiums.
- Charge the same fo premiums for both genders.
- Prohibit establishment of an annual spending cap of dollar amounts on essential health benefits.
- Require insurers to include all 10 essential health benefits.
- Mental health parity.
- Insurers must spend 85% of their premium dollars on health care (80 percent for private group plans.)
The ACA can certainly be improved but should not be discontinued.
Here are some different proposals on how that might be accomplished:
The ACA was designed to include expansion of Medicaid. The counties in which PPN supporters reside could benefit greatly from expansion of Medicaid. It is the most cost effective way to reduce the number of uninsured.
If Medicaid expanded in North Carolina, an additional 1,853 people would be insured in Cherokee County and 782 additional people would be insured in Clay County.
The NC Justice Center reports: In Cherokee County, between 2020 and 2024, Medicaid expansion would create 75 jobs, $10.7 million more in economic growth and bring in $142.5 million in new tax revenue. In neighboring Clay County, between 2020 and 2022, Medicaid expansion would create 15 jobs, $2.3 million in economic growth and $46.2 million in new tax revenue.
The Cone Foundation has also done an analysis of the impact of not expanding Medicaid in North Carolina. In Clay County, for example, from 2016 to 2020 it represents $4.1 million less growth in the economy, $6 million less in business activity and $62.2 thousand less in tax revenue. For the full report visit: https://www.conehealthfoundation.com/foundation/initiatives/nc-medicaid-expansion/
If Medicaid were expanded it would represent a $3 billion-dollar investment of federal dollars in to Georgia and have similar benefits for Towns and Union Counties. Yet the political will does not exist for this to happen.
Explore Midlife Medicare
This approach opens up the highly popular and successful Medicare program to Americans starting at age 50 rather than 65. The proposal allow Americans to by in to Medicare at age 50 if they were not offered coverage through their jobs. Many people in their 50s and early 60s struggle to find affordable health care coverage.
Expanding Medicare may make more sense than expanding Medicaid because the Supreme Court made it into a patchwork program that varies by state. It also makes more sense than enlarging the markets under the ACA, given the repeated attempts by conservatives to undermine those markets.
Another advantage is that Medicare is on more stable political ground and it holds down medical costs more than any other part of the health care system. The main reason that medical costs are so much higher here than anywhere else, is the price, rather than the volume of treatments.
For more information on health care costs, read “It’s the Prices, Stupid” by Sarah Kliff.
To learn about the Midlife Medicare proposal read an article by eminent scholar, Paul Starr, at http://prospect.org/article/new-strategy-health-care
Examine Viability of Single Payer System
States and other countries have implemented a single health care system successfully and reduced the number of uninsured, the number of bankruptcies due to medical costs, premature deaths and health care costs.
To learn more about this approach and its variations, visit:
PPN will be working this year to explore the ways health care can be expanded to citizens in this area. Stay tuned!
Resources to learn more about health care:
Federally-funded agencies and organizations serving citizens in the area
- Appalachian Regional Commission (ARC) *
The ARC has identified the economies of Towns and Union counties as being “at risk” due to its unemployment rate, per capital market income and poverty rates. They give grants to localities to further their goals of improving access to health care for workers and their families, establishing clinical services to address health conditions that affect the local economy and competitiveness and developing programs that reduce barriers to working.
Centers for Disease Control (CDC) *
CDC aims to prevent death and disease, and recommend interventions to reduce them. To this end, staff collects data and information on the local, state and national levels to assist in this effort.
To learn more about their many functions, visit https://www.cdc.gov/about/organization/mission.htm.
To learn more about health problems affecting our area, such as those included in the dashboard of this web site, visit https://www.cdc.gov/DataStatistics/
Department of Health and Human Services
HHS administers state programs including Medicaid, Medicare, Community Health Centers, Temporary Assistance for Needy Families (TANF), the Supplemental Nutritional Assistance Program (SNAP), Head Start, programs for persons with disabilities, home visiting, programs for seniors and military families. Here are links to its largest programs:
Refer to some of the nonprofit organizations starred below (*) below for excellent information on how these programs and services benefit the counties PPN represents.
- Department of Veterans Affairs (VA)
The VA administers its own health care system for those in the military and who have completed their service. There is an office located in Blairsville, GA and Franklin, NC. https://www.va.gov/health/
- National Institutes of Health (NIH)
NIH’s mission is to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability. The NIH conducts and funds research to prevent and cure disease. To learn more about their work, visit https://www.nih.gov/about-nih/what-we-do/mission-goals
State Specific Information
- Federally Qualified Community Health Centers in Georgia*
- Free Clinics in Georgia
- Georgia Health Policy Center
- Georgia Medicaid Office
- Georgia Budget and Policy Institute*
- Georgia Department of Health Statistics
- Georgia Primary Care Association
- Georgia Watch
- Georgians for a Healthy Future*
- Healing Hands Clinic
- Voices for Georgia’s Children
- USDA GA
- Carolina Press
- NC Budget and Management Office
- North Carolina Community Health Center Association
Large web site that covers many services and programs provided by health centers,access, clinical services, policy and advocacy.
- North Carolina Division of Public Health
- NC Justice Center has prepared county profiles that include demographic information on Clay and Cherokee counties, which affect health and access to health care.
- North Carolina Health News
- Cherokee Health Department
- Clay County Health Department
- North Carolina Medical Assistance – Health and Human Services
State Medicaid office uses resources and partnerships of Medicaid to improve health care for all North Carolinians.
- North Carolina State Center for Health Statistics
Includes statistics and reports and interactive health data.
- NC School of Law, Poverty Research Fund
Non Profit Organizations
- American Association of Retired Persons (AARP)*
They provide information on Medicare and other health programs, as well as advocating for health care services for those aged 55 and older. They have state offices and offer health insurance of their own,
- AARP Public Policy Institute
The Institute promotes the development of sound, creative policies to address our common need for economic security, health care, and quality of life.
- Agency for Health Care Quality
The Agency provides data and information on the quality of health care and measures for evaluating it. They provide data on how each state is doing on key indicators of the health care system.
- For example, here is how Georgia rates on health access, quality and diseases and conditions:
- Here is where the state is strong and needs improvement:
- Here is the state profile for North Carolina:
- American Hospital Association
- American Medical Association
- Association of State and Territorial Health Officials
- Bipartisan Policy Center.
Congressional center committed to developing bipartisan policy recommendations that will improve health care quality, lower costs, and enhance health care coverage and delivery. The project focuses on coverage and access to care, delivery system reform and cost containment, and long-term care.
- Brooking Institute
The Brookings Institution is a nonprofit public policy organization based in Washington, DC. Our mission is to conduct in-depth research that leads to new ideas for solving problems facing society at the local, national and global level.
- Center for Connected Health Policy
The National Telehealth Policy Resource Center. Includes tabs for state laws and reimbursement policies, Medicare, Medicaid, legal barriers, health information Technology, HIPPA, FTA, and professional licensure boards.
- Community Catalyst
The Community Catalyst mission is to organize and sustain a powerful consumer voice to ensure that all individuals and communities can influence the local, state and national decisions that affect their health
- The Commonwealth Fund*
The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. They have excellent data, including state-specific health data.
- Families USA
Families USA aims to achieve high-quality, comprehensive, and affordable health care.
- Kaiser Family Foundation
Kaiser has good data on many aspects of health care in Georgia and North Carolina:
- National Alliance for the Mentally Ill
- National Association of County and City Health Officials
- National Governors Association
- National Network of Public Health Institutes
- Patient and Affordable Care Act (ACA)
- Pew Charitable Trust
- Poverty USA
- Robert Wood Johnson Foundation – Rural Health
- What Works? Strategies to Improve Rural Health
- United States Department of Agriculture (USDA)