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This show is presented by the Commonwealth Fund, a nonprofit foundation whose mission is to promote a high performing, equitable health care system. The Commonwealth Fund supports research to improve healthcare policy and practice and has a long history of exploring what the US can learn from the best healthcare around the world to do better here at home, especially for people of color, people with low income and those who are uninsured. To learn more, visit commonwealthfund.org work Are you looking for ways to make your everyday life happier, healthier, more productive and more creative? I'm Gretchen Rubin, the number one bestselling author of the Happiness Project, bringing you fresh insights and practical solutions in the Happier with Gretchen Rubin podcast. My co host and happiness guinea pig.
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Is my sister, Elizabeth Craft.
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That's me, Elizabeth Craft, a TV writer and producer in Hollywood. Join us as we explore ideas and hacks about cultivating happiness and good habits. Check out Happier with Gretchen Rubin from Lemonada Media Lemonade Want to listen to your favorite Lemonada shows without the ads? Subscribe to Lemonada Premium on Apple podcasts for just 5.99. You'll get ad free episodes and exclusive bonus content from shows like this one, as well as Wiser Than Me with Julia Louis Dreyfus, Fail Better with David Duchovny, and so many more. It's a great way to support the work we do and treat yourself to a smoother, uninterrupted listening experience. Just head to any Lemonada show feed on Apple Podcasts and hit subscribe Make Life Suck Less with fewer ads with Lemonada Premium.
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You know, you have all of the thoughts about Mississippi and stereotypes that you can imagine from television and movies and your parents history and your grandparents history, and you're bringing all that with you.
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Dr. Kimberly Sanford had reservations about moving to the south, especially as a black woman. She moved to Mississippi in 2016 thanks to a federal loan forgiveness program. But after spending most of her life in major cities like St. Louis and Atlanta, moving to the Delta was definitely a culture shock.
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The town that I moved to is a matter of fact the cotton capital of the world still and you see sharecropping shacks and you know, as you get to town you see, you know, older homes, but then it changes. Then you go to the other side of town where you have all of the very large antebellum homes. So it was a dichotomy.
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But it wasn't just the southern landscape that stood out to her. When Dr. Sanford started working in the labor and Delivery unit as an OB GYN at Greenwood lafleur Hospital she found herself treating a different patient population than she was used to.
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Once you move here, you start to see the disparities of just being in a rural place and having access to healthcare. It's just what people are used to, right? We live an hour away from the hospital and we only go if we absolutely have to.
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An hour drive to the ER for a life or death situation. Having to travel to the next town over because your local hospital has closed its labor and delivery unit. Missing your doctor's appointment because you don't have any means of transportation. These aren't hypotheticals. This is the reality for Americans living in rural communities across the country. About a third of all community hospitals are rural. I was surprised to learn this, and you might be too. But millions of Americans rely on these hospitals for care, and the access they provide, which is already limited, is on the line. Rural health care is in crisis. Nearly half of rural hospitals are operating in the red. So when Medicaid cuts hit and they're coming, the situation will only get more dire. Today we're focusing on Mississippi, a state that never expanded Medicaid under the Affordable Care Act. It's also got high uninsured rates and some of the deepest health care gaps in the country. In fact, according to the Commonwealth Fund, Mississippi's health system ranks last in the nation. We have two guests today who are right in the thick of it. Dr. Kimberly Sanford, an OB GYN passionate about caring for her rural patients, and Dr. Daniel Edney, MS's state health officer.
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I just look at my mother and father who never had health insurance, and my father died at 56 of colon cancer, preventable disease. And I just, I just know how it would have changed their world to have had health insurance. And they were working two and three jobs. They didn't have health insurance. So, you know, the opportunity to give low income, hard working Mississippians a hand up is I think, just really important. And it fits the character of Mississippians who are very generous.
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Dr. Daniel Edney has been Mississippi's state health officer since August 2022. In the lobby of his office hangs a framed poster that reads, Change can't wait. Moving Mississippi out of last Place. That pretty much sums up his mission. Since taking the post, Dr. Edney has been working to move Mississippi out of last place as the worst health system in the country. And with over half of Mississippi's population living in rural areas, that's the region he's focused on.
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C
When we talk about rural health care, we're really talking about statewide care. Even in our More urban areas, because we truly don't have an urban area. You know, Jackson, Mississippi, has. Is our largest city. It has a population of less than 150,000. And then we have rural. And then we have, sure enough, rural. You're talking about extremely rural counties. We have one county whose population is 900 people. It's one big cotton field. But that, you know, those 900 people. The only health care in Esquina county is a Dallas unit.
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Dr. Edney knows this landscape well. Before becoming state health officer, he was a primary care physician in Mississippi for over 30. So he's seen firsthand again and again the barriers patients face trying to get care.
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It was very common that I would be caring for diabetics coming out of the Mississippi Delta that didn't realize they were diabetic until they were finally able to come to a doctor, be seen and identify that their A1C was 24. Now, that is horribly high. And. And even though they had Medicaid and had access to gain their medicine, they didn't have good access to dietitians, nutritionist. They certainly didn't have access to healthy food where they lived. They did. You know, their closest true grocery store was 45 minutes away from where they lived, and they didn't have a car. You know, I would order their colonoscopy that was needed, and it would be three visits trying to help them make that happen. You know, getting mammograms done. Just the things that many folks around the country just take for granted. Oh, I've got a mammogram today. I'll just break away from work, run down, get it done, get back to work. Well, if you work on the farm, you don't break away from work. You know, if you work in a chicken plant, it's hard to break away from work.
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Dr. Edney puts it like the people who were able to see him were the lucky ones. They've been able to overcome barriers to get care. Plenty of others didn't have that opportunity. Access is an issue that's worsened over time. Over the past two decades, nearly 200 rural hospitals across the country have closed, leaving gaps in health care access that have communities scrambling for care. Dr. Edney says a couple of factors accelerated the issue in Mississippi. The pandemic and the fact that the state did not elect to expand Medicaid under the Affordable Care act. So when Dr. Edney stepped into his current role, the crisis was already in full swing.
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When I first took over in 2022, it was just one hospital after another, notifying us that they were shutting down services. And the major hospital in the Delta that closed its ICU shut down its labor and delivery unit, in the Delta hospital on the coast shut down its labor and delivery unit. And we had had three hospitals that had closed before I came home. And then we had five hospitals that were preparing to convert to rural emergency hospital status, which means you shut down your inpatient units and keep your ER open and your outpatient services going. So that's basically a hospital closure. They're able to keep going, but they're not, you know, the hospitals, everybody understands it anymore.
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When rural hospitals close or even shut down some of their units, the impact goes way beyond just health care.
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When you look at rural communities, usually the largest employer in all those communities is healthcare. And so when you have a county owned hospital that, you know, its payroll likely is driving the economy of that county and you know, in every physician that a community is able to recruit and have established a practice and live there, you know, that's at minimum a 3 million dollar a year boost to that economy. And when you're talking about small economies, $3 million is huge. So. And the hospitals being the largest employer, these were just, it was like banks that were too big to fail. For many rural areas of our state, these hospitals just could not fail. We just could not allow them to fail.
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When we come back, we'll take a closer look at one Mississippi hospital that has been on the brink of closure. That's after the break. Let's be real. Without the black press, who's covering how black Americans are really treated in the healthcare system? Mainstream media barely scratches the surface, but Word in Black goes deep because lives depend on it. They're reporting the truth about medical racism, black maternal mortality, breast cancer in black women, mental health stigma, all of it. Want to stay informed and empowered? Subscribe to their weekly health newsletter and get the stories that actually put black health first. Go to wordinblack.com that's wordinblack.com and sign up. Because being informed is how we protect each other. Want to listen to your favorite Lemonada shows without the ads? Subscribe to Lemonada Premium on Apple Podcasts. You'll get ad free episodes and exclusive bonus content from shows like Wiser Than Me with Julia Louis Dreyfus, Fail Better with David Duchovny, the Sarah Silverman podcast, and so many more. It's a great way to support the work we do and treat yourself to a smoother, uninterrupted listening experience. Just head to any Lemonada show Feed on Apple podcasts and hit subscribe. Make life suck less with fewer ads with Lemonada Premium. In the heart of the Delta, along the bank of the Yazoo river, you'll find the small town of Greenwood, Mississippi. It's a predominantly black community, and nearly a third of families live in poverty. The local hospital, Greenwood lafleur, is one of the biggest employers in town and of course, absolutely vital to the community for health care. Dr. Kimberly Sanford, who you heard from earlier, settled into the area in 2016, working as an OB GYN in the hospital's labor and delivery unit. I asked her to talk me through what a typical patient looked like. Tell me about some of the challenges they faced getting care, because that. I think that concept. We'll be talking about that throughout our interview over and over again because we can't stress that enough. Most people have access, some access to care, but these communities, the getting of the care is part. A huge part of the problem of being healthy.
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Yeah, right. The most common patient is just, you know, these. Just the working poor. I mean, it's just the people who can't miss a paycheck. Right. And the normal folks. But then you do have these other people that live in the outlying areas that you, you know, you might only see them. You're supposed to see a patient 14 times during the pregnancy, so you might only see them six times or seven times because that's the only number of times they can get in. Or you may see them at the end. At the beginning. And at the end, you know, sometimes they do a lot of ER visits. Right. What I found initially in 2016, just, you know, a historical lesson. We had the marketplace, you know, Obamacare, affordable health care. And what I saw were people who finally had health care, they finally had insurance, and, you know, women coming in saying, yeah, I haven't had a pap smear for seven years. So, you know, just. You see the limitations of time, money, transportation. You know, these women were mostly dependent on information that their mothers had been given.
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Mississippi has one of the highest rates of both infant and maternal mortality in the nation. Black women in the state are also almost three times more likely than white women to die while expecting or within a year of their pregnancy ending. So the quality care that Dr. Sanford was providing, absolutely vital. But as much as patients across the Delta were relying on providers like Dr. Sanford for care, the hospital was struggling financially and had been for years. Things took a turn for the worse when In October of 2022, the hospital abruptly closed Dr. Sanford's unit. Labor and delivery in the community.
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There's always whispers and rumors. Right.
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A
Yeah.
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That, you know, it's getting bad over there, that they're going to close that hospital over there, you know, But I think it was kind of a surprise because it was all of a sudden.
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The closure was part of a larger trend happening across the country. Since 2010, over 500 hospitals have shuttered their labor and delivery departments, leaving most rural hospitals without obstetric care. For Dr. Sanford, the closure at Greenwood Lafleur basically happened overnight. I mean, I can just imagine how devastating that was. Do you remember the emotions you felt when you learned about what was happening? I know that it had been in decline, but there must have been a huge element of surprise or disappointment or something.
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Well, and it was a huge element of disbelief. And it was like, well, surely you're joking. We're not going to let the hospital that delivers the most babies in the Mississippi Delta, one of the most, you know, depleted areas in health in the country. Surely somebody's gonna step in and go, let's, you know, too big to fail. Right. No, that didn't happen. And what. What it did, what it said was, is. What it said was, what you don't want to hear is that these people don't matter. That's what it said.
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What happened at Greenwood lafleur isn't unique. Labor and delivery services are often cut because the cost of those services has been rising. It's all part of a larger trend of US Health care costs going up while reimbursement rates aren't keeping pace. Dr. Sanford watched this financial reality play out firsthand. She told me that Greenwood Lafleur Hospital had been delivering as many as 600 babies a year. Now, with the unit closed, the nearest hospital with labor and delivery services is at least a 45 minute drive.
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B
It's 34 miles away, which, you know, in miles does seem too bad. But what if you don't have a car? Yeah. Right.
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And what if you're working? You're. You're there on your lunch break, you got, I mean, time. Time is money. That's a resource that most people don't have.
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B
And time is real in obstetrics. Right. So if you're seeing me in the office, let's just say you're an obese, hypertensive diabetic. And I have a lot of them here.
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Yeah.
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High risk pregnancies. And these people blow a gasket real fast.
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Yeah.
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So towards the end of pregnancy, let's say she's, you know, going nuclear and becoming Pre clamped it.
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Yeah.
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Before I could send her across the street. She's got an IV in her arm, two IVs, and she's got antihypertensive of meds in within minutes.
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Yeah.
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Now I gotta send that sick lady.
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Yeah. If she's even able to.
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If. If she doesn't have a car, I gotta wait around for an ambulance. Right. See the. See the salad just. It just compounds. It just makes you. It makes your heart pound, makes it chest heavy. So it's not just the people who are. Well, it's, you know, those. Those acutely ill that then had a facility that I could kick them to across the street. Now you've got to travel.
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These aren't typical, you know, checkups and exams. These are high risk. I mean, we're talking life and death situations.
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Life and death situations.
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And not to mention on your guys's end, trying to figure out, okay, where does this woman who is in a medical emergency go for this? Have you seen patients avoid care altogether just because they can't access that? It's. It's. It's not possible for them to receive, you know, good care, regular care.
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Yeah. So what they end up doing, again, is they end up in the ER a lot because most of these towns will have an emergency room. Yeah. So what you see is multiple ER visits. They know they'll get, you know, evaluated. They know somebody will listen to their baby, and they know they'll get an ultrasound. So they end up, you know, it ends up being obstetric care by er. Er.
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We can't ignore what's been happening at Greenwood lafleur. It's been described as the canary in the coal mine for other rural hospitals in Mississippi. As Dr. Sanford has shared, those impacts of labor and delivery closing have been serious for her patients. And it's worth noting that the hospital shut down other departments, too. The icu, neurosurgery, inpatient dialysis, and urology. When we come back, how Greenwood LaFleur Hospital found an unexpected lifeline and what Dr. Sanford thinks policymakers need to understand before it's too late for communities and like hers.
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Hello, I'm Joelle Brevel, medical mythbuster and host of the Dose, a health policy podcast from the Commonwealth Fund. Each season, I sit down with a leading health policy expert and medical professionals to have real conversations about the issues that keep them up at night. We talk about breakthroughs in their research and their new ideas to make our healthcare system work better for all Americans. This idea of equity needs to be taken up by everyone. And wherever you are in your work, whatever sector that you're in, we need to have conversations about what tomorrow looks like. I hope you'll check out the Dose and enjoy listening to our interviews. You can find us at thedose show or by searching your podcast app for the Dose from the Commonwealth Fund. Hi everyone, I'm David Duchovny. Join me on my podcast Fail Better, where we use failure as a lens.
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To reflect on the past and analyze the current moment.
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B
I speak with makers and performers like.
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Rob Lowe, Rosie o' Donnell and Kenya Barris, as well as thinkers like Kara Swisher and Nate Silver to understand how both personal setbacks and larger forces impact our world.
- [22:13]
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Listen to Fail Better wherever you get your podcasts.
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Right around the time its labor and delivery unit closed, there was a lot more happening behind the scenes at Greenwood lafleur Hospital. It was on the brink of collapse. That's the reality Dr. Edney, Mississippi state health officer, was confronting. In the fall of 2022, he took a trip to Greenwood to see for himself.
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What I saw was not good, and what I saw was a system that was about to implode and we dominoes were about to fall. The first one was going to be Greenwood LaFleur.
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The hospital received about $1 million in grant money from the state, but Dr. Edney remembers telling hospital leadership that it wasn't enough to sustain it long term.
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C
I can tell you we're about to lose Greenwood Lafloor, and that will be catastrophic for lafleur County. And then, you know, I'm very worried about these other hospitals in the Delta. And I know it's not just the Delta. So we we're about to have a health care crisis in this state.
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A
But after a very close call with closing, the hospital got some good news. This year it was selected to participate in the Rural Community Hospital Demonstration Program, a federal initiative aimed at supporting healthcare access and sustainability in rural communities. This designation means Medicaid or Medicare will pay the hospital the actual amount it costs to provide the services to patients instead of paying a set fee for service. So better reimbursement rates overall.
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C
They're not fully healthy yet, but they're getting healthier every day. And I do fully expect them to stabilize and get strong and thrive again, but only because of the demonstration opportunity. You know, all the hospitals, it's going to worry me a lot. Even the rural hospital demonstration hospitals, if that supplemental payment opportunity is really cut back, it's going to be a negative impact for our hospitals.
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Dr. Edney knows that the hospital, even with the new designation, hangs in the balance. And then there's the issue of Medicaid cuts. The Trump administration passed the biggest Medicaid cut in history this summer, a trillion dollar cut over the next decade as part of the Big Beautiful Bill Act. These cuts will lead to even more hospital closures.
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C
Medicaid benefits every Mississippian. It benefits the economy. No two ways about it. But every hospital in this state benefits by what Medicaid pays towards their infrastructure. So even though I have never been on Medicaid and never will be on Medicaid, when I go to the hospital, I have benefited from the Medicaid program because my hospital benefited from the Medicaid program. And, you know, I need all Mississippians to understand that you cut Medicaid, you hurt everybody.
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A
What Dr. Edney is saying is that even if you're not on Medicaid yourself, Medicaid cuts will impact you because they lead to more hospital closures. These cuts will affect everyone in rural communities. Dr. Sanford has already seen the impact of rural hospitals not having enough funding. After the closure of her entire department, the labor and delivery unit, she left Greenwood LaFleur Hospital. She now practices in Granada, Mississippi, 45 minutes away from Greenwood. And even though she's still able to see many of her same patients, the closure of Greenwood's labor and delivery unit has changed what healthcare access looks like for people in the Delta. What do you think as a physician kind of impact this has, especially on preventable health issues? Because like you said, I mean, you're going to the ER because something, it feels really off. But what do you think, as a physician, the impact this has, you know, on preventable health issues? Because that almost becomes a luxury when you don't have.
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B
Right? So one of the major preventable things that we practice is, you know, the annual exam, right. With a Pap smear, mammogram, all of those things, pre cancerous cells that, you know, if we manage it within a year or two or three, we can definitely prevent cancer. But pre cancerous cells unattended over six to 10 years can become carcinoma or cancer. And so that's what you see. You start to see women who are coming in now because they found somebody they trust. Okay, I like you. I'll get a Pap smear with you. Yeah, right. Some of them will come in with a friend who's pregnant, listen to my conversation with their friend and say, I'm going to make an appointment with you. I like you. Right. So, you know, it's it's the searching is and not really understanding the urgency and the importance of that annual year to year examine what you're preventing. And so again, that's part of my goal too, is to sit down with every woman. Here's an interesting story. So you talk about rural stories. I had a 74 year old lady who came in and you're familiar with what an intrauterine device is? We use it for contraception.
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A
Okay. Yes, an iud.
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B
So an iud, right. So I get a call from one of my colleagues that says I have a 74 year old that needs an intrauterine device removed. And so I peeked my head around the table and I said, how long has this IUD been in? And she turned and looked at her 46 year old daughter and she said, well, we put it in when, After I delivered her. So hers had been placed for the purposes of contraception and she is now 71. Somewhere between 71 and 74. So that says things.
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A
Wait, and she didn't get that out because she didn't have access to care?
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B
No, she had access, she just didn't go. Right. So access also. Also would talk about the importance of it, like you said. So if I don't really know the importance of this preventive care. Right. Then I don't go. Right. I had this iudna. It served the purpose of not getting me pregnant.
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Yeah.
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Then that doctor did a CT scan and saw the iud, found that this IUD was there, but he found it, guess what? In the middle of a cancer mass. Wow. Right. Because that's really why she was coming.
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A
It's just compounding.
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B
It's compounded. So she'd lost 30 plus pounds over the last three or four months. Got the daughter's attention, made her go to the doctor, she said, yeah, I am a little uncomfortable. Got the scan. You see the iud, the IUD is embedded into a cervical tumor because she had not also gotten a PAP smear in 46 years.
- [29:41]
A
So that, I mean that story.
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It.
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Just, it stops you in your tracks.
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B
Yeah.
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When you go through each step by step and you're losing doctors and you're losing hospitals and then you don't have the education, then you don't have the resources and then. And it all makes sense by the way. Yeah.
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B
In the point I really try to make is, yes, these rural areas are at risk and Green Willow Floor Hospital is the poster child for that. One of the things that, that the CEO said about us, he says is that we're not the Only we're just the first. And it's true. The thing that most people don't realize in the United States is that most people in the United states in this 370 million of us, live in rural communities. The most of us live in rural communities. So it's not this small smattering of people. We are a microcosm of the United States.
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A
Yeah.
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Of a bigger problem.
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A
What would you want Mississippi's leaders, policymakers to know about rural health care.
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B
Here? Don't make me scoff. They know about rural health care. They know best. They live here. They take care of these people. The policymakers grew up with these folks because that's the way this state works.
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A
Right.
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B
What I would want them to know or what I would want to say to them is to, for once, don't take politics first. For once, actually put the people first, like you say you do in every campaign, in every speech. If you just gave me enough money that I know they have, you could build three or four really nice medical centers within this state that would better serve these 2 million people.
- [32:10]
A
So with all of the challenges that you face practicing medicine in rural Mississippi and you've seen, you know, the confluence of all of this, what keeps you personally going, what are the reasons that you've stayed?
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B
Those patients that I mentioned, you know, when. When you could change the way a lady or woman feels and she didn't even know she felt that, you know, man, that's rewarding.
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A
Yeah.
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B
And then I realized one day I'm the first person to touch everybody's baby.
- [32:49]
A
Yeah.
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B
That's like, I touched you first. Put my mitts on you first. Right.
- [33:02]
A
In a struggling system, Dr. Sanford is still there as the first person to touch newborn babies. That kind of care for her patients is exactly what's on the line. What you've heard today from Dr. Sanford and Dr. Edney isn't just about Greenwood, LaFleur Hospital or even Mississippi. It's a preview of what's coming for rural America. A health care system under assault from every direction. Medicaid pays for nearly half of all births in rural communities. And when those dollars disappear, so does access to that crucial care. The communities that will be hit hardest are the ones that can least be afforded. Places where poverty is already limiting health care options and where a 45 minute drive to the hospital isn't just inconvenient, it's sometimes impossible. That's why it's on all of us to call on our elected officials and let them know just how important this issue is. Because our rural healthcare systems can't truly serve their communities without proper funding. Every closure, every department cut, and every mile added to a patient's journey takes a toll on the health of rural America. There's more Uncared for with Lemonada Premium if you haven't subscribed to Lemonada Premium yet, now's the perfect time. Because guess what? You can listen completely ad free. Plus you'll unlock exclusive bonus content like tips from health experts and caregivers that you won't hear anywhere else. Subscribe now on Apple Podcasts or head to lemonadapremium.com to subscribe on any other app or listen ad free on Amazon Music with your prime membership. That's lemonadapremium.com Uncared for is a production of Lemonada Media. I'm your host. Sujinpath Muna Danish is our senior producer. Lisa Fu and Hannah Boomershein are our producers. Our mix is by Ivan Kuraev. Music is by Andrea Christensdotter. Jackie Danziger is our VP of Partnerships and Production executive. Producers are Jessica Cordova Kramer and Stephanie Wittleswax. This season of Uncared for is presented by the Commonwealth Fund, a nonprofit foundation working toward a healthy care system where everyone, no matter who they are, where they live or how much money they make, can get the health care they need. Help others find our show by leaving us a rating and writing a review. You can follow me on Instagram at sujinpak and Lemonada Lemonada Media across all social platforms. Thanks so much for listening. See you next week. This show is presented by the Commonwealth Fund, a nonprofit foundation whose mission is to promote a high performing, equitable health care system. The Commonwealth Fund supports research to improve healthcare policy and practice and has a long history of exploring what the US can learn from the best healthcare around the world to do better here at home, especially for people of color, people with low income and those who are uninsured. To learn more, visit commonwealthfund.org.
- [36:30]
B
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