Bouncing along a narrow dirt path through the rain forest, I held on for dear life on a motorcycle driven by Markson Farley, a supervisor for Last Mile Health. We were on the way to Buwey, Liberia, to observe Patience, the community health care worker in the village. Last Mile Health is implementing a community health care worker program in remote areas to provide primary care, implement preventive medical practices and give health education to the villagers.
At the end of the visit, Patience – with downcast eyes – quietly told us that her 17-year-old brother, recently married, had died Sunday. He had a history of epilepsy since childhood. Until last July, his seizures had been well controlled on medications. When Ebola erupted last year, supplies were disrupted, and his medications ran out. Since that time, he had had one to two seizures every week. During a prolonged, uncontrolled seizure, he died.
On the bumpy ride back to our office, this tragic story drove me to reflect on North Carolina and the state of medical care back home.
In Liberia, you expect to hear grief-laden stories every day. The odds against Liberians are stacked high: few doctors or nurses, malnutrition, a multitude of endemic infections including malaria and childhood diarrhea, poverty, lack of clean water or electricity and non-existent paved roads. As a result, the maternal mortality rate is an overwhelming 1,072 per 100,000 live births, and the infant mortality is 54 per 1,000 live births. In North Carolina, these rates are better. Nonetheless, we rank 44th in infant mortality and 37th in maternal deaths compared with the rest of the country.
Our residents do not face the same odds as those in Liberia, but there is one other difference between North Carolina and Liberia. In Liberia, the government and agencies such as Last Mile Health are actively trying to take basic health care to all citizens. In North Carolina, our leaders are working actively to decrease access to health care for the poor and working poor by denying them health insurance, access to contraceptives and safe abortions.
Beginning in January 2014, North Carolina could have expanded Medicaid
to include the working poor through funding from the federal government, providing health insurance for close to 500,000 North Carolinians. There is ample evidence of the negative consequences of not expanding Medicaid. The uninsured are less likely to seek preventive care. In North Carolina in 2007, 33 percent of the uninsured did not have access to diabetes supplies, 56 percent had never had a mammogram to screen for breast cancer, 9 percent had never had a PAP smear to screen for cervical cancer and 68 percent had never had a colonoscopy or sigmoidoscopy to screen for colon cancer. The uninsured have an 8 to 15 percent increase in cancer mortality and shorter survival time.
In states where health insurance was expanded, there was a significant decrease in mortality compared to non-expansion states, a drop of 25 deaths per 100,000 population. When former Gov. Mitt Romney expanded health insurance in Massachusetts, there was a 4.5 percent decrease in mortality.
N.C. House Speaker Tim Moore, Senate President Pro Tem Phil Berger and Gov. Pat McCrory ignore facts in blocking Medicaid expansion in North Carolina. We now have a year of data from states that expanded Medicaid and so can examine the economic cost to North Carolina by not expanding. North Carolinians saw their tax money flow to Medicaid expansion states last year. We lost $2.7 billion in federal funding, $1.7 billion in state gross product, $99 million in state tax revenue and 23,500 jobs not created. Rather than costing the state, fully implementing the Affordable Care Act would have given a jolt to our still lagging economy.
Our hospitals are bearing the brunt of providing care for these uninsured patients, a hidden cost to North Carolinians. Without the ability to obtain primary care and preventive services, these working poor become ill and seek care at our hospitals. Since hospitals can’t print money and also are required by law to provide this care, they shift the costs to those of us with insurance. An estimated 60 percent of the cost of uncompensated care is borne by those of us with insurance. In 2005 that meant an additional $1,130 in premium costs or 10.7 percent higher premiums for a privately insured family in North Carolina than would have happened if we expanded Medicaid.
In Liberia, all of us are working as a team to improve the health of the population in remote villages. But that hasn’t happened in North Carolina because of the stubborn refusal of McCrory, Berger and Moore. Their intransigence in the face of the funding and opportunities made available through the Affordable Care Act is nothing short of immoral as it is leading to the death of our citizens.
Charles van der Horst, M.D., is a professor of medicine at the University of North Carolina at Chapel Hill.