Category Archives: Health care

Kudos: U.S.-China Climate Pact

Shanghai: Soot City

Shanghai: Soot City

By Peter Galuszka

President Barack Obama’s trailblazing pact with Chinese leader Xi Jinping to limit greenhouse gas emissions through 2025 is welcome news and could do much to reduce carbon dioxide emissions since the two countries are responsible for about 40 percent of the globe’s total.

China is an economic powerhouse so energy hungry it builds a new coal-fired generating plant about every eight to 10 days. Its leaders have pledged to cap  carbon emissions by 2030 or earlier.

Obama announced a plan to cut U.S. emissions by 26 to 28 percent below 2005 levels by 2025. This is a bigger cut than the 17 percent reduction by 2020 that he had announced earlier.

The agreement, reached in Beijing, is most welcome for the obvious reason that it would make a huge contribution to reducing greenhouse gases. It also undercuts the arguments by the fossil fuel industry, some utilities and their drum beaters that any steps the U.S. takes in cutting carbon pollution are pointless since China (or other Asian countries) will keep polluting anyway.

The arguments are crucial since Virginia’s Big Energy industry and the staff of the State Corporation Commission are attacking plans by the EPA to greatly reduce carbon.

Consider this gem of wisdom from another correspondent on this blog: “Virginia could revert to stone-age levels of zero greenhouse gas emissions tomorrow, and the savings would offset the increase in CO2 from coal-fired power plants built in India and China in a year! (OK, maybe not a year, but over a very short period of time.)”

Sadly, this kind of mentality is regressive and, with the new Washington-Beijing pact, is becoming increasingly irrelevant.

One thing many American commentators don’t seem to realize is that China isn’t necessarily a primitive business juggernaut stomping on any rational plan to check pollution. Beijing and Shanghai have some of the highest rates of air pollution in the world and its leadership, especially engineers and policy makers capable of understanding how technology can help them, knows they just can’t continue as before.

Three years ago, I visited both cities to research a book on the coal industry (newly out in an updated paperback, by the way, see below). I also went to Ulanbatour, the capital of coal-driven Mongolia where the air was so bad, I felt delirious within hours after arrival and by the next morning I showed signs of pulmonary illness.

The promise for changing things seems to money and the system.

In the U.S., we have a regulatory oversight apparatus over energy generation. This is reasonable because it prevents electric utilities from using their monopoly power to stick customers with high rates. But the system is flawed because: (1) it too often favors big utilities over average consumers and; (2) it is rigged to prevent new, experimental and possibly transformative technologies that very well could allow the use of dirty and dangerous but still cheap coal.

In the latter case, the thinking seems to be to go for ephemeral cost benefits (like using natural gas) without having any long-term strategy that actually might save lots more money through better health and more efficient, less-polluting energy.

In several cases, regulators nixed pilot plants that burn coal but use special new ways of doing so that capture a lot of carbon either in a chemical process involving ammonia or by stripping off the carbon emission from the pollution stream and sequestering them safely away. The plants cost big money. They are much cheaper to do as greenfield sites but regulators are more inclined to prevent them in favor with the soup d’jour of power that happens to be cheapest at the moment, in our current case, natural gas. Continue reading

Takeaways From the GOP’s Big Win

gillespie warnerBy Peter Galuszka

The night of Tuesday, Nov. 4 was an ugly one for the Democrats and a big win for Republicans. Here are my takeaways from it:

  • U.S. Sen.Mark Warner clings to a tiny lead that seems to grow slightly, still making it uncertain if opponent Ed Gillespie will ask for a recount. The surprisingly tight race is an embarrassment for Warner. It likely takes him out of consideration to be Hillary Clinton’s running mate in 2016 although Democrats Tim Kaine and Jim Webb are still possibilities.
  • Ed Gillespie ran a smart campaign and came off as a solid candidate. Of course, we are comparing him against Kenneth Cuccinelli and that’s a very low bar but Gillespie’s projection of being relaxed and confident helped him. Gillespie did very well despite being dissed by the national Republican money machine. Look for him in the gubernatorial race of 2017.
  • Barack Obama takes his lumps — again. The country’s on the mend and things are going fairly well (despite what you may watch on Fox), but Obama is incapable of cashing in on that. His cool, detached style is a big minus and makes him seem careless and incompetent, especially when crisis like ebola come up that are not of his making.
  • The Republican wins on Capitol Hill are more significant than the Tea Party inspired once during the 2010 midterms.But the earlier races brought in a kind of mindless negativity and gridlock by both parties that truly hurt the country. Will that happen again? Or will older, wise heads prevail?
  • Increase in coverage my Obamacare The New York Times

    Increase in coverage by Obamacare
    The New York Times

    You might get some bipartisan action on taxes and the budget, but deadlock remains for Affordable Care and immigration. The fact is that Obamacare is too far along to change much and people actually like it, despite what you hear in the right-wing echo chamber. This chart from the New York Times shows that the ACA has boosted health coverage in some of the poorest parts of the country, such as the Appalachian coal country, the African-American belts of the Deep South; and poor parts of the Southwest like New Mexico and parts of Arizona. This alone is a big success.

  • Immigration. Look for Obama to use executive authority to come up with an immigration plan. It is an emotional, hot button issue that reveals lots of ugly attitudes. But something needs to be done fast. The GOP has no plan, except for George W. Bush who actually pushed a workable solution that was compassionate. That got soaked by the Tea Party, but then Republican Mitt Romney came up with a health care plan for Massachusetts that looks remarkable like Obamacare and was a precursor. If the GOP can get back to those helpful ideals, there may be hope.
  • Warner lots big swaths of voters who had been with him, like Loudoun County and parts of rural Virginia. This is alarming for the Dems and shows they need to project their messages a lot better. Warner’s poor performance in debates didn’t help either.

It is a big win for the GOP, but somehow I don’t feel as bitter as I was in 2010.

Brat’s Strange Immigrant-Bashing

BratBy Peter Galuszka

It must have been an interesting scene. Congressional candidate David Brat had been invited to a meeting of the Virginia Hispanic Chamber of Commerce along with his Democratic rival Jack Trammell to outline his views on immigration and undocumented aliens.

Brat, an obscure economics professor who nailed powerhouse Eric Cantor in a Republican primary for the 7th Congressional District in June, danced around the topic, according to a news account.

It took several attempts to get him off his spiel on just how wonderful free market capitalism is to actually address the issue at hand. Before him were a couple dozen business executives, many of them Hispanic.

They, naturally, were interested in Brat’s views because of his over-the-top Latino-baiting during the primary campaign. One of Brat’s ads trumpeted: “There are 20 million Americans who can’t find a full time job. But Eric Cantor wants to give corporations another 20 million foreign workers to hire instead.”

Finally, Brat claimed, “I have never said I’m against legal immigration.” He later said, “nations that function under the rule of law do well.” Brat also said he wants to “secure” the U.S. border with Mexico. Trammell said he supports the DREAM Act that could provide a path to U.S. citizenship for some of the 11 million undocumented aliens in this country.

Brat’s immigrant-baiting and his “rule of law” smacks of a lot of ugliness in American history. “Know–Nothings” of white Anglo Saxons beat and harassed Catholic immigrants, primarily from Ireland. Chinese were harassed on the West Coast and Japanese-Americans were locked up in concentration camps during World War II. Jewish newcomers were met with restrictive covenants and college quotas.

In Richmond during the 1920s, efforts by Catholic Italian-Americans to build a monument to Christopher Columbus were fought by the Ku Klux Klan, which insisted that any such statue not dirty-up Monument Avenue and its parade of Confederate generals. Columbus had to go elsewhere in the city.

There’s a new twist and judging from Brat’s behavior on Tuesday. He seems uneasy by getting so out front on immigrant-bashing. He’s not the only Republican to take such strident stands. Look at New Hampshire, where Scott P. Brown, a Republican, faces Jeanne Shaheen, a Democrat, in a closely-watched race for the U.S. Senate.

Groups backing Brown, such as John Bolton, the surly former U.S. Ambassador to the United Nations, have run anti-Shaheen ads showing throngs of people clambering over a border just before showing Islamic militants beheading James Foley, a journalist and New Hampshire native, according to the New York Times. The ad was pulled after the Foley family complained, the Times says.

A major coincidence is that the Times‘ description of New Hampshire almost matches that of Virginia’s 7th Congressional District. Neither seems a hot bed of immigrant strife and threats.

The Granite State has one of the smallest populations of illegal immigrants in the country, the Times says. Of the state’s 1.3 million residents, only 5 percent are foreign-born and 3 percent are Hispanic.

The Virginia district has a population of 757,917 of whom 12.7 percent are foreign born and 4.9 percent are Hispanic. Most of the residents, 74.3 percent are white.

The district runs from the largely white and well-off western Richmond suburbs in Henrico and Chesterfield Counties and scoots northwest across mostly rural farmland to east of Charlottesville and up to Madison. With only 7.6 percent of the people living below the poverty level, it isn’t exactly a barrio of Los Angeles.

It is hard to imagine hordes of brown-skinned people swarming from up Mexico or Central America displacing the managerial executives, small business people and farmers in the Seventh. People that Brat seems to be worried about are employed in other nearby areas, such as the poultry plants of the Shenandoah Valley. But those workers are there because of local labor shortages. One wonders where Brat gets his ideas that illegal immigrants are going to steal true-blue American jobs in his district.

Last June during the primary, there was plenty of news about thousands of young Hispanic children coming across the southern border from Central America. At the time, there were estimates that up to 90,000 such children might come illegally into the U.S. this year. Many are fleeing gang violence in their homelands.

This is apparently what Brat is running against – a bunch of poor, 12-year-old Nicaraguans out to steal jobs and provide cover for Islamic terrorists. Their plight is a serious issue, but it is a humanitarian one. Brat chose to make it an odd classroom lesson in economics. He says the U.S. should not put up “green lights” and “incentivizing children from other countries to come here illegally and at their own peril.”

The news from the border seems to have calmed down since June. Brat may have found that now it is likely he’s going to Washington, playing the Hispanic-baiting card may not work as well on the national scene as it apparently did in his mostly-white district. It could be why he was hemming and hawing so much before the Virginia Hispanic Chamber of Commerce.

Illegal immigrant Ayn Rand

Illegal immigrant Ayn Rand

Perhaps other Republican politicians are having the same epiphany. As the New York Times writes: “Republicans have long relied on illegal immigration to rally the conservative base, even if the threat seemed more theoretical than tangible in most of the country. But in several of this year’s midterm Senate campaigns — including Arkansas and Kansas, as well as New Hampshire — Republicans’ stance on immigration is posing difficult questions about what the party wants to be in the longer term.”

There’s another strange contradiction with Brat. He’s a former divinity student interested in probing how unfettered free market capitalism can magically make the right choices for the betterment of mankind.

He draws a lot of his thinking from Ayn Rand, the famous thinker, refugee from the Bolsheviks and backer of her own brand of anti-government capitalism.

It may interest Brat that by today’s standards, Rand would have been an illegal immigrant.

Health Insurance as Driver of Income Inequality

Road to serfdom

If you want to address increasing income inequality in the United States, a good place to start would be to bring runaway health insurance costs under control. Health care costs — not globalization, automation or corporate greed — are the biggest driver in income inequality today, argue Mark J. Warshawsky and Andrew G. Biggs in the Wall Street Journal today. Warshawsky is a visiting scholar at George Mason University’s Mercatus Center.

Here’s what the usual media analysis doesn’t tell you about the growing income gap. If you compare total compensation — wages/salaries plus benefits — low-income workers actually fared better than high-income workers between 1999 and 2006. Citing Bureau of Labor Statistics data, Warshawsky and Biggs note:

For low-income workers, total pay and benefits rose by 41% from 1999 through 2006. But those workers’ wages increased only by 28%, barely outpacing inflation.  The reason: Employer costs for those workers health costs nearly doubled. …

Total compensation for [those earning $250,000 or more a year] rose by 36% from 1999 through 2006. That’s actually less than for low-income workers. But the one-percenters’ health costs rose from just 4% of compensation in 1999 to only 4.3% in 2006.

The authors do not explain why they cite data only through 2006 when data is available through June 2014. Whatever the reason, it appears that the cost of benefits continues to outpace wages/salaries. According to the BLS, for the quarter ending June 2014, “wages and salaries (which make up about 70 percent of compensation costs) increased 0.6%, and benefits (which make up the remaining 30 percent of compensation) increased 1.0 percent.

In other words, much if not most of the perceived increase in income inequality in recent years is an artifact of the tax code. Employer-paid health insurance is not taxable, thus not reported as income, while wages/salaries are taxable and reported as income. Eliminate the tax break for employer insurance and the growth in the wage gap disappears.

If we are sincere about wanting to reduce income inequality, the first place we should be looking is at inflation in health care costs. Here’s a real irony that Warshawsky and Biggs do not explore: Insofar as Obamacare shifts the cost of health care to employer-sponsored health insurance plans — I have a friend, a small business owner, whose health insurance is scheduled to go up 35% next year — it doesn’t just destroy job creation, it shifts compensation from taxable income to non-taxable health insurance, thus aggravating the reported income gap.

Meanwhile, the low interest rate policy of the Federal Reserve Board rewards the Top 1% by pushing up the price of stocks and bonds and punishes small savers by depressing interest rates. It is no accident that income inequality is worse under Obama than Bush. Perhaps Obama acolytes can cite the Warshawsky-Biggs research as evidence that the administration’s policies haven’t been as unfair to the poor as they seem to be.

– JAB

Tobacco Commission Needs Huge Makeover

tobacco leafBy Peter Galuszka

One more glaring example of mass corruption in Virginia is the grandly named Virginia Tobacco Indemnification and Community Revitalization Commission formed 14 years ago to dole out Virginia’s share of a $206 billion settlement among 45 other states with cigarette makers.

I’ve been writing for years about how millions of dollars are doled out with little oversight to economic development projects supposedly helpful to the former tobacco-growing parts of the state from the bright leaf belt around Dinwiddie out west to the burley leaf land of the mountains.

There have been no-strings giveaways to absentee tobacco quota holders, a board member sent to prison for siphoning off grant money and the shenanigans of the extended Kilgore family which is very politically powerful in those parts. The commission even figured in the McDonnell corruption trial starring the former and now convicted governor and back-slapping witnesses for the prosecution, entrepreneur and tobacco-believer Jonnie R. Williams Sr.

I revisit the issue in Sunday’s Washington Post and I ask the obvious question of why no one seems to watching the commission. I raise broader ones, too, such as why the commission  serves only people in the tobacco belt. That doesn’t seem fair since the Attorney General’s office represented all of the state in the 1998 Master Settlement Agreement against four major tobacco firms. People in Hampton Roads, Arlington, Onancock and Winchester should be benefit but get nothing from the settlement. They didn’t  because tobacco road legislators pulled a fast one back in 1999 when they set things up.

There needs to be a thorough disassembling of the commission’s current governance structure with many more people far from Tobacco Road included. There’s far too much family and friend back-scratching as it is. It is like watching a vintage episode of the Andy Griffith show but it really isn’t funny.

(Hat tip to James A. Bacon Jr. who spotted the commission as a great story back in the year 2000 when he was publisher of Virginia Business).

So, please read on.

In the “If Your Like Your Health Care Plan, You Can Keep It” Department…

then-i-saidFrom the Times-Dispatch: “After a year’s reprieve, up to 250,000 Virginians will receive notice by the end of November that their health insurance plans will be canceled because the plans do not comply with the Affordable Care Act and accompanying state law.”

Now those Virginians will have to buy new, Obamacare-compliant plans, which means they will have more benefits they may or may not want… and will cost more.

The Virginia Association of Health Plans, which has become a wholly owned subsidiary of the Obama administration, defended the forced switch. Said Executive Director Doug Gray: “I don’t call that cancellation – I call that an adjustment to the new law.”

I call it a cancellation. I’ll be that the people affected by the law call it a cancellation, too.

– JAB

A Timely Reminder: Virginia Hospitals, Even the Non-Profits, Are Very Profitable

Norfolk General Hospital, the crown jewel of the Sentara Health System, which reported annual profit of $229 million in 2013.

Norfolk General Hospital, the crown jewel of the Sentara Health System, which reported annual profit of $229 million in 2013.

One of the justifications given for expanding Virginia’s Medicaid program as part of the implementation of Obamacare is to shore up the financial condition of Virginia’s hospitals. On the assumption that Medicaid expansion would reduce the number of indigent (non-paying patients), Obamacare will cut back funds to hospitals under the established Disproportionate Share Hospital (DSH) program to help offset the cost of uncompensated care. If Virginia fails to expand Medicaid, as now seems likely, and the federal government cuts DSH funding as planned, Virginia hospitals will take a hit to the bottom line.

The debate may be academic now that Governor Terry McAuliffe has essentially punted on Medicaid expansion in the face of strong Republican opposition in the General Assembly and has proposed a scaled-down Healthy Virginia plan. But the issue still is worth revisiting. Virginia hospitals stand to lose about $386 million in payments from the DSH program between 2017 and 2022 — an average of $77 million per year. How badly will hospitals be hurt? Will cuts impair the quality of care? Do we need to worry?

Mike Thompson, president of the Thomas Jefferson Institute, a conservative think tank, has compiled the profit figures for Virginia hospitals from the Virginia Health Information Foundation. In the aggregate, in November 2013 Virginia’s hospitals had combined profits of $1.6 billion and net worth of $15 billion. The annualized DSH payments are equivalent to about 5% of 2013 profits.

One would think that hospitals should be able to absorb that hit to revenues — equivalent to a year or so of profit growth. Does the picture change when we drill into the numbers? The burden of indigent care is not apportioned equally between hospitals. Some facilities serve largely poor populations and provide extensive uncompensated care and rely more than others on the DSH funds. Also, hospital profitability varied widely from institution to institution. Several hospitals are losing money. In theory, a loss of funds could be devastating.

Thompson’s data reveals that several money-losing hospitals are part of larger health care systems; while they lose money, they feed profitable business to the tertiary care hospitals at the center of those systems, hence, they are not in danger of being shut down. Other facilities represent expansions into new markets — start-up enterprises, in effect. Their parent companies are fully prepared to bear the losses while the facilities ramp up to profitability. Then, too, there are some hospitals that appear to have serious problems. However, it’s not clear from one year’s data whether those losses are ongoing or simply the result of a one-year write-down.

It would be helpful to get a hospital-by-hospital breakdown of DSH funding and see how it compares to hospital profitability. The not-for-profit VCU Health System is reputedly the largest provider of uncompensated care in the state. But, then, it reported a profit of $130 million — a 12.8% return on equity (net worth). Would the loss of, say, $30 million a year in DSH funding be crippling? Maybe VCU could spin a tale of woe that would persuade me otherwise, but it sure doesn’t look like it.

Don’t get me wrong. Hospital profits are a good thing. Try getting your healthcare from money-losing hospitals — you won’t like it. Even not-for-profits need earnings to help fund expansions and new initiatives. But when hospitals are funded with public funds and receive special tax exemptions, the public has a right to ask tough questions.

Update: The Virginia Hospital and Healthcare Association response to Thompson’s study can be seen here. The main thrust: The data is two years old, and the financial pressure on Virginia hospitals has intensified since then.

– JAB

Richmond’s Tech Star in Kickback Scheme?

HDL LogoBy Peter Galuszka

Critics of the American healthcare system have long cited hidden charges as one reason why costs are so high and why reform is needed.

So, it is disturbing to read a report on the front page of today’s Wall Street Journal that Health Diagnostic Laboratory, arguably the most successful of the biotechnology firms to come out of a much-touted research park in Richmond, is implicated in a possible scheme to pay kickbacks to doctors who use its blood testing services.

The Journal reports:

Until late June, HDL paid $20 per blood sample to most doctors ordering its tests — more than other labs paid. For some physician practices, payments totaled several thousand dollars a week, says a former company employee.

HDL says it stopped those payments after a Special Fraud Alert on June 25 from the Department of Health and Human Services, which warned that such remittances presented “substantial risk of fraud and abuse under the anti-kickback statute.

HDL Chief Executive Tonya Mallory told the Journal that her firm “rejects any assertion” that the company grew as fast as it did “as a result of anything other than proper business practices.”

Meanwhile, HDL has sent Bacon Rebellion this updated response.

Others say that paying doctors fees sets up the chances for fraud, especially in Medicare, one of HDL’s biggest markets, the Journal reports. Other testing firms, the Journal reports, pay doctors nothing for using their services.

This is bad news for what was Richmond’s Poster Child of successful high tech startups after years of flops at the Virginia Biotechnology Research Park. Founded in 2008 under Mallory’s leadership, HDL zipped up to $383 million in revenues with 41 percent of that coming from Medicare,” the Journal says.

Much of the issue seems to be related to how accurately and fairly to define what is merely drawing a patient’s blood and how much goes for “P&H” or processing and handling. A problem is that Medicare doesn’t pay any more than $3 for merely drawing blood. HDL has estimated that the “P&H” part is worth about $17. The firm claims it has special proprietary methods that give it an edge.

According to Virginia Business magazine, which named Mallory its person of the year last year:

Mallory, 48, founded HDL in the summer of 2009. Since then, it has grown from a kitchen-table business plan to a corporation earning more than $420 million in annual revenue, employing 750 people, processing 4,000 lab samples and running more than 60,000 lab tests each day. HDL has driven near constant construction at its home in downtown Richmond’s Virginia BioTechnology Research Park, where a $68.5 million expansion soon will triple the company’s footprint to 280,000 square feet.

Last year Mallory received the Ernst & Young National Entrepreneur of the Year award in the Emerging Company category. One of the country’s most prestigious business awards for entrepreneurs, it recognizes leaders who demonstrate innovation, financial success and personal commitment as they build their businesses.

The Journal, however, quotes several disgruntled employees and notes that Mallory had worked for a California firm called “Berkeley Heart Lab Inc,.” which began using tests called “biomarkers” which can predict future health problems by analyzing blood.

Mallory, who was raised in Hanover County and attended Virginia Commonwealth University, was senior lab-operations manager at Berkeley until she left for Richmond in 2008, the Journal says. Two Berkeley sales executives went with her and formed a company that ended up marketing HDL’s products.
Berkeley sued HDL, accusing it of stealing its business. HDL denied the allegations. HDL settled one case for $7 million, the Journal says, but other cases are pending.

Diet Denier

Perhaps you could call Nina Teicholz a “diet denier.” The journalist and author of “The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Health Diet,” is part of the growing backlash against a half century-long orthodoxy that aimed to limit fat and cholesterol in the American diet. That orthodoxy, which ruled the medical establishment and the federal health apparatus, unwittingly engineered a society-wide shift to the sugar-heavy diet now deemed responsible for the surge in obesity and heart disease that afflicts the country.

In her book, Teicholz delved into the history of how fats, trans-fats and cholesterol came to be demonized and how public policy strove to drive fats out of the American diet. The movement began in the 1950s with a famous study by Ancel Keys, which postulated a link between cholesterol and heart health. The American Heart Association jumped on the bandwagon in 1961, the United States Department of Agriculture issued new dietary guidelines in 1978, and momentum built from there. Food companies rolled out low-fat, low-cholesterol food products, typically substituting sugar and salt for fat. Pharmaceutical companies introduced anti-cholesterol drugs. Schools and media brainwashed generations of Americans to change their behavior.

How could things have gone so wrong? As Teicholz explains in her TED talk above:

The same group of people were on all the expert panels. They all reviewed each others’ papers. These groups controlled all of the funding, so if you didn’t get on this cholesterol bandwagon, you couldn’t get funding, you couldn’t do research, you couldn’t be a scientist. Over the course of 25 years, this diet-heart hypothesis became ingrained in the institutions. There became an institutional bias. There was a bias in the media. And everybody lined up behind this hypothesis. You couldn’t be a scientist if you didn’t get on board.

Thankfully, a new generation of scientists questioned the orthodoxy. Now researchers are focusing on the excess consumption of sugar as the main culprit responsible for our dietary woes.

Fortunately, we’ve learned from our mistakes. Our scientific, media and government officials would never enforce another orthodoxy on the grounds that “97 percent of all scientists” in a given field agree that “the science is settled.”  We’d never rig the peer-review process to suppress unpopular scientific viewpoints. We’d never channel billions of dollars of federal funding into supporting one particular point of view of a massively complex phenomenon while de-funding dissenters. We’d never demonize skeptics as “anti-science,” tools of evil, self-interested corporations and moral analogues of holocaust deniers. We’re far too enlightened in the United States to ever let that happen.

Or are we?

– JAB

RAM, Coal and Massive Hypocrisy

The Pikesville RAM clinic in 2011. Photo by Scott Elmquist

The Pikesville RAM clinic in 2011. Photo by Scott Elmquist

By Peter Galuszka

Sure it’s a photo op but more power to him.

Gov. Terry McAuliffe is freshly arrived from the cocktail and canape circuit in Europe on a trade mission and is quickly heading out to the rugged and impoverished coal country of Wise County.

There, he, Attorney General Mark Herring and Health and Human Resources Secretary William A. Hazel will participate in a free clinic to help the mountain poor get free health care. The political opportunity is simple: Many of the 1,000 or more who will be attending the Remote Area Medical clinic are exactly the kind of people getting screwed over by the General Assembly’s failure to expand Medicaid to 400,000 low income Virginians.

RAM makes its Wise run every summer and people line up often in the wee morning hours to get a free medical and dental checkup. For many, it’s the only health care they get all year unless it’s an emergency. Another problem: Distances are great in the remote mountains and hospitals can be an hour away.

Mind you, this is Coal Country, the supposedly rich area upon which Barack Obama is waging war and harming local people by not going along with coal executives’ demands on environmental disasters such as mountaintop removal, keeping deep mine safety standards light and avoiding carbon dioxide rules.

The big question, of course,  is why if the land is so rich in fossil fuel, are the people so poor and in need of free medical care? It’s been this way for 150 years. And now, coal’s demise got underway in Southwest Virginia in 1991 when employment peaked at about 11,000. It is now at 4,000 or less. It’s getting worse, not better.

In June 2011, by coincidence, I happened along a RAM free clinic in Pikesville, Ky., not that far from Wise when I was researching my book, “Thunder on the Mountain: Death at Massey and the Dirty Secrets Behind Big Coal.” My photographer Scott Elmquist and I spotted the clinic at a high school. There must have been hundreds of people there —  some of whom told me they had been waiting since 1:30 a.m. It was about 8:30 a.m.

Attending them were 120 medical and dental personnel from the U.S. Public Health Service. They were dressed in U.S. Navy black, grey and blue colored fatigues. The University of Louisville had sent in about 80 dental chairs.

Poverty in Pike County had been running about 27 percent, despite the much-touted riches of coal. Pike is Kentucky’s biggest coal producer.

One man I spoke with said he had a job as a security guard, but he doesn’t qualify for regular Medicaid and can’t afford a commercial plan. In other words, had I interviewed him more recently and had he been a Virginian, he would have been lost through the cracks of Medicaid expansion. Alas, he’s in luck. In 2013, Kentucky opted for a “marketplace” expansion system where federal funds would be used to help lower income buy health plans through private carriers.

Lucky the man isn’t from here. The marketplace plan is exactly the kind that McAuliffe has proposed and exactly the one that stubborn Republicans such as Bill Howell in the General Assembly are throttling. The feds would pick up the bill for expanding Medicaid to 400,000 needy Virginians, at least initially.

Yet another irony. Expanded medical benefits are available just across an invisible border in two states whose coalfield residents somehow never got the great benefits of King Coal.