By James C. Sherlock
The RTD today published an article “Petersburg is Virginia’s least healthy locality, and money is a big reason why” about one of my favorite subjects – the stubborn health problems in Petersburg and other poor urban areas of Virginia.
The story references the latest annual study from the University of Wisconsin Population Health Institute that ranks localities in Virginia from 1 to 133 in both health outcomes and health factors.
Residents of Petersburg, where the median household income is among the lowest in the state, face a life expectancy of only 66.2 years, the lowest in the state and 10 years worse than the national average, according to a study from the University of Wisconsin Population Health Institute that was circulated by the Virginia Department of Health.
It has ranked as the state’s least healthy locality in eight of the past 10 years.
The RTD headline attibutes those results to lack of money. But the headline is nonsense.
We can and should do far better with the government assets and funded programs already in place to help Petersburg.
Certainly the citizens of Petersburg have personal agency and they and their community leaders bear that level of responsibility. But what of the government programs that are supposed to prevent the kind of third-world health outcomes that we see in that city?
The federal government has three public health clinics in Petersburg. They should be part of the solution. But federal efforts there are dwarfed by those of the state.
Given these results, what has been done in Petersburg with all of the money Virginians have poured into our state health and Medicaid agencies for decades?
Do public schools in Petersburg try to help with the problem? Does the syllabus pay sufficient attention to health? What of school nurses? VDOE should check.
And how will we do better in the future? First, we must assign accountability. Then we need a plan.
Accountability starts at the state level by determining the current levels of coordination, integration and oversight of state efforts.
Start with the office of the Secretary of Health and Human Resources and its subordinate agencies, the Virginia Department of Health (VDH) and the Virginia Department of Medical Assistance Services (DMAS), Virginia’s Medicaid agency.
We need to know the responsibility attributable to DMAS managed care contractors, who are supposed to guide patients through the health care system and match beneficiaries with primary medical and dental care providers to improve community health.
How is Bon Secours, which as a pure act of charity took over Petersburg’s Southside Regional Medical Center a couple of years ago, handling its new responsibilities as a non-profit for Petersburg community health? From what I know of Bon Secours, they will prove a net positive.
Background. Most of the data shows Petersburg to be a city that is poor, but also a population that is demonstrably self-destructive, with state agencies, churches, and non-profits that have failed in their missions.
- It has high child and infant mortality rates, and a prevalence of diabetes, smoking and obesity;
- Petersburg’s rate of chlamydia is the highest in the state; its HIV rate is twice the Virginia average; and its teen birth rate is the worst;
- Its drug overdose mortality rate is the highest in the state, though not all localities reported figures. Petersburg’s White residents die of drug overdoses at twice the rate of its Black residents. The city is 76% Black, 15% White and 5% Latino;
- The homicide rate and firearm fatality rate are among the highest of localities that reported a figure, and the violent crime rate is the worst in the state. The injury death rate — which counts fatal car crashes and accidental drug overdoses — is worse than every other locality;
- Petersburg’s severe housing problems — such as overcrowding, a high cost of facilities and a lack of access to kitchens or plumbing — is also worse than in the rest of Virginia.
Health factors measured by the survey include include education, employment, income, safety, tobacco and alcohol use, diet, access to care, clean air and water, and access to housing and transit.
Some of that is partially attributable to poverty, but poverty need not be as thoroughly dispositive as it has proven to be in Petersburg.
Virginians have reason to expect VDH and DMAS to work together on public health, but I saw little evidence of that in previous administrations.
DMAS retains full authority for the administration of the Medicaid and Family Access to Medical Insurance Security (FAMIS) programs in accordance with the requirements of federal and state laws and regulations. DMAS places 90% of Virginia’s 2 million Medicaid patients under managed care.
An obvious question, unexplored in the RTD article, is whether DMAS has cracked down on its managed care contractors.
Contractor profits are guaranteed by DMAS, but they have not succeeded in the core responsibilities of “managed” care. Yet they have failed to link Petersburg patients to a sufficient density of primary care providers in sufficient numbers to improve population health and (not inconsequentially) keep them out of the emergency rooms in order to keep Medicaid costs down.
The contractors will respond that they have a hard task in Petersburg. Answer: do it better.
Plenty of available assets. Preventive services have failed in Petersburg despite a wealth of resources. It is useful to review what public health services are available to Petersburg residents.
Insurance and primary care providers. The same study shows that Petersburg’s number of uninsured residents is low. The insurance is heavily Medicaid. Petersburg also has more primary care providers per 10,000 persons than the average Virginia locality.
Federal clinics. There are three Federally Qualified Health Centers funded by the Health Resources and Services Administration (HRSA) in Petersburg and another in Hopewell. Those clinics are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas regardless of ability to pay.
Virginia Department of Health. The various clinics of the VDH-run Petersburg Health Department include Family Planning, HealthSpace Teen Clinic, Immunizations, Maternity Care, Pregnancy Testing, Sexually Transmitted Infections (STI) testing, Tuberculosis Screening & Skin Testing, and Women, Infants, and Children (WIC) programs.
Medicaid. Ninety percent of Medicaid recipients are under managed care by DMAS contractors. Medicaid managed care programs in Virginia include CCC Plus and Medallion 4.0
CCC Plus, a Medicaid-managed long-term services and support program, serves over 260,000 Virginians. CCC Plus includes Medicaid members who:
- Are 65 or older;
- Are children or adults with disabilities (ABD Medicaid coverage groups);
- Receive Medicare benefits and full Medicaid benefits (dual eligible);
- Receive Medicaid long-term services and supports (LTSS) in a facility or through one of the home and community-based (HCBS) waivers. Individuals enrolled in the Community Living, the Family and Individual Support, and Building Independence waivers, known as the Developmental Disabilities (DD) waivers, are enrolled for their non-waiver services only. DD waiver services are covered through Medicaid fee-for-service;
- Are medically complex (have a medical or behavioral health condition and a functional impairment).
Medallion 4.0 is Virginia’s Medicaid program for infants, children, pregnant women and adults in low-income families with children. Medallion has been in place since the 1990s and provides acute and primary healthcare services, prescription drug coverage and behavioral health services. It covers 75% of Virginia’s Medicaid population, 1,510,327 enrolled members as of January 2022.
FAMIS, Virginia’s health insurance program for children, and Medicaid for Children cover these services:
- Dental care
- Doctor visits
- Emergency care
- Hospital visits
- Mental health care
- Prescription medicine
- Tests and X-rays
- Vision care
- Well-baby check-ups
- Well-child check-ups
There are no enrollment costs or monthly premiums for either program. At this time, there are no co-pays for any FAMIS covered services. Children may qualify if they:
- Live in Virginia
- Are uninsured
- Are under age 19
- Are United States citizens or lawfully residing immigrants
- Live in families that meet income rules
FAMIS and Medicaid for Children cover the majority of the children in Petersburg and have for a long time.
There are only 33,458 people in Petersburg. So this problem is not one of scale. The Commonwealth, in coordination with Bon Secours, the federal clinics, local primary providers and community leaders must do a better job with the assets at its disposal.
We look forward to a joint Virginia plan to actively and in a coordinated manner address the until-now-inscrutable problem of public health in that city. The plan must include signatories that include:
- the Virginia Secretary of Health and Human Resources and his subordinate agencies including VDH, the Petersburg Health Department and DMAS;
- Bon Secours;
- the Virginia Department of Education;
- Petersburg City Public Schools; and
- the Petersburg City Council
Money is not the problem. The will to succeed and to manage to success have been.
Find out what has been wrong and fix it.