♪ ♪ ♪ ♪ WERE WHETHER YOU THINK THAT HEALTHCARE IS A RIGHT, A PRIVILEGE OR SOMETHING THAT MUST BE EARNED, I THINK THAT WE CAN ALL AGREE THAT IT SHOULD BE GOOD AND AVAILABLE.

PLEASE STAY WITH US AS WE DISCUSS SOME OF THE PROBLEMS FACING THE DELIVERY OF QUALITY HEALTHCARE IN RURAL AREAS NEXT ON KENTUCKY HEALTH.

WE OFTEN BRAG THAT THE UNITED STATES HAS THE HIGHEST STANDARD OF HEALTHCARE IN THE WORLD.

WHILE THIS IS TRUE, UNFORTUNATELY NOT EVERYONE HAS CONSISTENT ACCESS TO THIS HIGH QUALITY CARE.

TOO MANY OF US RECEIVE EITHER NO HEALTHCARE OR AMOUNTS INSUFFICIENT TO ADDRESS THE PROBLEMS THAT WE HAVE.

TWO SEEMINGLY DISPARATE GROUPS, USUAL URBAN AND RURAL CORE EXPERIENCE THE SAME ISSUES WITH THE QUALITY AND THE ABILITY TO ACCESS THE SERVICES.

MANY OF US MAY BE AFFECTED BY ONE OF THESE.

BUT TOO MANY OF US ARE AFFECTED BY EITHER A COMBINATION OR ALL OF THESE OBSTACLES.

THE NET EFFECT IS THAT THESE POPULATIONS EXPERIENCE POOR HEALTH OUTCOMES COMPARED TO THE MORE AFFLUENT OF US IN THE UNITED STATES THIS IS ESPECIALLY TRUE HERE IN KENTUCKY.

TO DISCUSS THE PROBLEMS FACING RURAL HEALTHCARE AND MOST IMPORTANTLY, HOW WE CAN LEVEL THE PLAYING FIELD WE HAVE AS OUR GUEST TODAY Dr. EUGENE SHIVELY AT THE UNIVERSITY OF LOUISVILLE, A GRADUATE FROM THE UNIVERSITY OF LOUISVILLE SCHOOL OF MEDICINE AND COMPLETED HIS RESIDENCY IN GENERAL SURGERY AT THE UNIVERSITY OF LOUISVILLE.

AFTER OVER 51 YEARS IF PRACTICE AT CAMPBELLSVILLE KENTUCKY, HE HE HAS NOW RETIRED FROM THE PRACTICE OF SURGERY BUT REMAINS ACTIVE WITH CACTIANS FOR SINGLE-PAYER HEALTHCARE AND HOSTS THE RADIO SHOW SINGLE-PAYER RADIO.

I'M SURE YOU DON'T GET ON THERE AND SING.

BUT THAT MIGHT BE INTERESTING IF YOU DID.

WHAT GOT YOU PRACTICING IN MEDICINE IN CAMPBELLSVILLE, KENTUCKY.

WHAT GOT YOU TO COME BACK THERE?

>> I'M FROM THERE AND DURING MY RESIDENCY, I DECIDED THAT I WANTED TO GO BACK THERE.

I KNOW I FIGURED IF I WAS GOING TO STAY IN LOUISVILLE, I WOULD BE SPENDING MOST OF MY TIME IN A CAR.

IN THOSE DAYS, EVERYBODY WAS GOING TO EVERY HOSPITAL IN TOWN.

AND OF COURSE THAT IS DIFFERENT NOW.

AND I WANTED TO GO BACK HOME AND PROVIDE CARE IN CAMPBELLSVILLE.

>> WHEN WE TALK ABOUT A RURAL AREA, WHAT DOES THAT REALLY MEAN?

>> THAT'S AN INTERESTING SUBJECT.

THE DEPARTMENT OF AGRICULTURE HAS ABOUT 11 DIFFERENT DEFINITIONS BUT THE ONE WE ARE GOING TO USE TODAY IS AN AREA OF A COUNTY THAT IS LESS THAN 50,000, THAT IS NOT SURROUNDED BY URBAN AREA; FOR EXAMPLE, TAYLOR COUNTY IS SURROUNDED BY COUNTIES LESS THAN 50,000 AND BULL IT COUNTY BULLITT COUNTY IS SURROUNDED BY URBAN AREA SO THEY WOULDN'T BE CLASSIFIED AS RURAL BUT TAYLOR COUNTY AND SURROUNDING COUNTIES WOULD BE CLASSIFIED AS RURAL.

>> HOW DO WE STAND IN KENTUCKY?

WHAT KIND OF NUMBERS ARE WE LOOKING AT AS FAR AS RURAL AREAS HERE?

>> WELL, THE UNITED STATES, 20% OF THE PEOPLE WHO LIVE IN RURAL AREAS, BUT IN KENTUCKY, IT'S 40%.

AND SO THAT'S A BIG DIFFERENCE AT THE END OF THE DAY, IS THERE REALLY A BIG DIFFERENCE BETWEEN WHAT GOES ON IN RURAL AREAS COMPARED TO WHAT GOES ON IN URBAN AREAS?

I MEAN WHY SHOULD WE HAVE THIS DISTINCTION AND CARE?

>> THE ACCESS TO CARE IN RURAL AREAS IS LESS THAN IT IS IN URBAN AREAS.

AND THERE IS A LOT OF CHRONIC ILLNESSES IN RURAL AREAS.

IT'S KIND OF LIKE THE SAME SITUATION WITH BROWN, BLACK AND LATINOS.

THE RURAL PEOPLE DON'T GET AS ADEQUATE CARE IN RURAL AREAS AS OTHER PEOPLE DO, PARTICULARLY IN URBAN AREAS.

>> BY NECESSITY, WHEN WE SAY RURAL ARE WE TALKING ABOUT AREAS THAT MAY BE LESS AFFLUENT OR ARE THERE AFFLUENT AREAS?

>> MOST RURAL AREAS HAVE LOWER INCOME.

THERE ARE OBVIOUSLY SOME AFFLUENT PEOPLE WHO LIVE IN SMALL TOWNS BUT MOST OF THEM ARE LOWER INCOME AND HAVE CHRONIC ILLNESSES.

AND IN RURAL AREAS, 18% OF THE POPULATION IS OVER AGE 65.

IN URBAN AREAS, IT'S ABOUT 14%.

DOES THAT PRESENT A PARTICULAR CHALLENGE IN ANY PARTICULAR WAY?

>> YES, BECAUSE ELDERLY PEOPLE HAVE MORE ILLNESSES AND THEY HAVE MORE DEMAND FOR CARE, AND THERE ARE LESS PHYSICIANS IN RURAL AREAS.

>> NOW WE KNOW THAT ALL HOSPITALS ARE HAVING A BATTLE WITH THE BOTTOM LINE.

IS THIS A MORE ACUTE PROBLEM IN THE RURAL AREA THAN IT IS IN OTHER AREAS?

>> YES.

SOME HOSPITALS ARE IN CRITICAL CONDITION.

IN KENTUCKY, IT'S ESTIMATED THAT APPROXIMATELY 25% OF HOSPITALS ARE IN SERIOUS PROBLEMS WITH FINANCES.

AND THE REASON FOR THAT IS MOST RURAL HOSPITALS DEPEND ON MEDICAID AND MEDICARE AND THEY ONLY PAY ABOUT 88% OF COST.

OTHER HOSPITALS, FOR EXAMPLE, AFFLUENT HOSPITALS IN URBAN AREAS, MAKE UP THAT WITH PRIVATE PAY; FOR EXAMPLE, SOME PRIVATE INSURANCES WILL PAY UP TO 140% OF COST.

WE DON'T HAVE THAT IN RURAL HCHES.

73% OF THE PATIENTS ARE MEDICAID AND MEDICARE AND SOME AREAS, FOR EXAMPLE, IN APPALACHIA, OVER 90% OF THE PATIENTS WILL BE MEDICARE OR MEDICAID AND OF COURSE, WE ALSO HELP PATIENTS WITH NO INSURANCE AND WE HAVE A LOT OF PATIENTS WHO ARE INADEQUATELY INSURED.

>> LET'S GO BACK AND LOOK AT THE TERM COST.

NOW I KNOW THAT MEDICARE, THEY LOOK AT HOW MUCH IT COSTS TO PRACTICE IN A PARTICULAR AREA, HOW MUCH ACTIVITY WE HAVE TO PUT INTO THE WORK OF DOING TAKING CARE OF THE PATIENT, AND ALSO MALPRACTICE ISSUES.

SO WHEN WE LOOK AT COSTS, ARE WE LOOKING AT REALLY HOW MUCH PEOPLE WANT TO MAKE OR ARE YOU SAYING THAT THE MEDICARE IS NOT EVEN PAYING THE MINIMUM TO MEET THE EXPENSES OF KEEPING THE DOORS OPEN?

>> MEDICARE IS NOT PAYING THE MINIMUM EXPENSES TO KEEP THE DOORS OPEN.

NOW OF COURSE THAT'S A VERY CONTROVERSIAL SUBJECT.

WHAT IS THE REAL COST OF HOSPITALS?

AND TO BE HONEST WITH YOU, I DON'T THINK ANYBODY KNOWS.

YOU TALK TO DIFFERENT HOSPITAL ADMINISTRATORS OR FINANCIAL OFFICERS, YOU ARE PROBABLY GOING TO GET DIFFERENT ANSWERS.

BUT THESE ARE MEDICARE NUMBERS THAT THEY HAVE CALCULATED.

>> MEDICARE IS THE STANDARD, THOUGH.

THAT'S WHAT, EVEN THE PRIVATE INSURERS BASE THEIR PAYMENT SCHEDULES ON.

AND I'VE OFTEN WONDERED WHETHER OR NOT WE ARE, WHEN WE LOOK AT EVEN PHYSICIAN FEES OR HOSPITAL FEES, WHETHER OR NOT WE HAVE INFLATED THAT NUMBER A BIT MORE-- I HOPE I'M NOT GETTING IN TROUBLE WITH MY MEDICAL COLLEAGUES, BUT WORRIED WE HAVE INFLATED THAT ABOUT WHAT IS A REASONABLE PROFIT AND WHO DETERMINES WHAT A REASONABLE PROFIT IS, FOR THE WORK THAT WE ARE DOING.

>> THERE IS NO QUESTION THAT HAS BEEN INFLATED.

IT HAS BEEN GOING ON FOR SEVERAL YEARS.

AND EVERY YEAR HOSPITALS INCREASE THEIR CHARGES.

IT'S ACTUALLY TO THE BENEFIT FOR THE INSURANCE COMPANIES THAT THEY INCREASE THEIR CHARGES BECAUSE UNDER A.C.A., THEY MAKE MORE MONEY IF THE CHARGES ARE MORE.

THEY CAN ONLY MAKE 20%.

THE REST HAS TO PAY FOR MEDICAL EXPENSE.

BUT 20% OF $2 BILLION IS MORE THAN 20% OF $1 BILLION.

SO IF THEY CAN PROVE THAT THEIR CHARGES, WHAT THE CHARGES ARE OR MORE, THEY CAN INCREASE THEIR PROFIT.

>> WE ARE GOING TO COME BACK AND TALK ABOUT THE AFFORDABLE CARE ACT OR CONNECT AS CAN I KNECHT AS IT IS CALLED IN KENTUCKY.

MEDICAID COVERS THOSE IN POVERTY VERSUS MEDICARE FOR THOSE BROADLY WHO ARE OVER 65 IS MEDICAID AT A LOWER RATE?

>> YES, ONE OF THE THINGS THAT HAPPENED UNDER THE A.C.A.

IS THE FEDERAL GOVERNMENT GAVE STATES THE OPPORTUNITY TO GIVE MEDICAID EXPANSION.

KENTUCKY DID THAT AND THAT REALLY HELPED RURAL HOSPITALS.

BUT THE STATES THAT DID NOT DO THAT, FOR EXAMPLE, TENNESSEE AND TEXAS, THEY HAVE HAD A LOT OF PROBLEMS WITH RURAL HOSPITALS.

FOR EXAMPLE, TEXAS, IN THE LAST FEW YEARS, HAS HAD APPROXIMATELY 20 HOSPITALS THAT HAVE CLOSED.

AND THERE IS A BIG GAP BETWEEN COUNTY SEATS IN TEXAS, YOU KNOW.

I EVEN KNOW OF A CHILD WHO DIED BECAUSE OF LACK OF ACCESS.

IF YOU ARE TALKING ABOUT 50 OR 60 MILES TO GET CARE, THAT'S A BIG PROBLEM.

>> BUT IF YOU SAID THAT MEDICAID IS PAYING US AND HOSPITALS AT A RATE THAT IS BELOW COST, WHICH WE'VE ALREADY DETERMINED IS A MOVING TARGET, WHAT IS THE ADVANTAGE OF INCREASING THE NUMBER OF PEOPLE WHO GET MEDICAID?

>> WE HAD A LOT OF PATIENTS WHO DIDN'T HAVE ANY INSURANCE OR WERE INADEQUATELY INSURED.

AND SO THAT INCREASED THE NUMBER OF PATIENTS HOT HOSPITAL COULD GET SOME INCOME.

>> YOU ARE SUGGESTING THAT A LOT OF THOSE PATIENTS WOULD HAVE STILL SHOWED UP AT THE HOSPITAL FOR CARE BUT THAT CARE WOULD HAVE BEEN UNCOMPENSATED.

>> CORRECT.

>> HOW DOES THAT WORK THAT SOMEONE CAN TUM INTO A FACILITY AND NOT BE ABLE TO PAY BUT STILL GET TREATED.

>> WE ARE A PROFESSION, YOU KNOW.

MAYBE I'M OLD FASHIONS BUT MEDICINE HAS BECOME AN INDUSTRY, BUT WE ARE OBLIGATED TO TAKE CARE OF PATIENTS REGARDLESS OF THEIR ABILITY TO PAY.

>> HOSPITALS, BECAUSE OF WHAT, THE E.M.L.S.A.

EMERGENCY MEDICAL LABOR-- AND I FORGOT THE OTHER TWO ON THAT ONE, ARE OBLIGATED THAT IF SOMEONE COMES IN THE DOOR, THEY HAVE TO TREAT THOSE INDIVIDUALS WHICH MEANS THE HOSPITALS ARE EATING THE COST OF THAT.

>> THAT'S CORRECT.

>> SO THIS IS A WAY IN WHICH SOME HOSPITALS AT LEAST ARE GETTING SOME OF THOSE RESOURCES BACK, THE FINANCIAL RESOURCES BACK.

>> THAT'S CORRECT.

>> DID WE SEE HOSPITALS IN KENTUCKY GO OUT OF BUSINESS OR ARE WE SEEING THAT HAPPEN?

>> WE HAD ONE THIS YEAR AND WITH THE COVID, WE MAY SEE MORE.

IN THE LAST 10 YEARS, WE HAVE HAD ABOUT FIVE HOSPITALS TO CLOSE.

NOW CLOSING A HOSPITAL IS MORE THAN JUST LOSING MEDICAL CARE.

IN MANY SMALL TOWNS, THE HOSPITAL IS THE LARGEST EMPLOYER.

IF YOU CLOSE THAT HAPPEN, YOU HAVE A LARGE NUMBER OF PEOPLE THAT HAVE LOST THEIR JOBS.

YOU'VE GOT DECREASED TAX BASE, ET CETERA, ET CETERA, FOR THE INCOME.

ANOTHER IMPORTANT PROBLEM IS INDUSTRY WILL NOT GO INTO A RURAL COUNTY UNLESS THERE IS A HOSPITAL.

>> IS THAT BECAUSE OF THE VERY REASON YOU STATED AND THE PERSON DOWN IN TEXAS, THE TIME IT TAKES TO GET BACK AND FORTH.

>> THE INDUSTRY WANTS TO HAVE THE PEOPLE WHO WORK FOR THEM TO HAVE MEDICAL CARE AND EMERGENCY CARE.

I'VE BEEN FASCINATED WITH PIKEVILLE REGIONAL MEDICAL CENTER DOWN IN PIKEVILLE, HOW ONCE I HAD A CHANCE TO TALK TO THE THEN PRESIDENT DOWN THERE, TALKING ABOUT HOW HE HATED TO SEE AMBULANCES TAKING TRAUMA AND EMERGENCY CASES TO LEXINGTON, HE WANTED TO TAKE CARE OF THEM THERE BECAUSE IF YOU CAN TAKE CARE OF PEOPLE WHERE THEY LIVE, IT'S BETTER FOR EVERYBODY.

>> IT'S MUCH BETTER.

AS A MATTER OF FACT, THERE IS VERY GOOD EVIDENCE THAT IF YOU TAKE CARE OF PATIENTS IN THEIR LOCAL COMMUNITY, THEY DO BETTER.

AND UNIVERSITY OF KENTUCKY AND UNIVERSITY OF LOUISVILLE, ONE PAPER WAS PRESENTED AT SOUTHERN SURGICAL AND 2019 AND ONE 2018 STUDY, ONE STUDY MAMMOGRAMS AND BREAST CANCER AND ONE STUDIED COLONOSCOPY AND COLON CANCER AND FOUND OUT THAT AFTER WE HAD MEDICAID EXTENSION, THAT THEY FOUND CANCERS EARLIER.

PEOPLE WERE GETTING MORE MAMMOGRAMS.

PEOPLE WERE GETTING MORE COLONOSCOPIES AND SO WE WERE ACTUALLY SAVING LIVES BECAUSE WE WERE GIVING PEOPLE THE OPPORTUNITY TO GET THOSE PROCEDURES DONE.

A LOT OF PEOPLE-- I HAVE PATIENTS ALL THE TIME, WHO DON'T HAVE $20 TO TRAVEL 20 MILES TO GET CARE.

AND IF THOSE PATIENTS ARE REQUIRED TO GO 70 OR 80 MILES TO LOUISVILLE OR LEXINGTON, THEY JUST WON'T GO.

>> I'M GOING TO GUESS THAT YOU WERE A FAN OF THE FIRST GOVERNOR BESHEAR'S EXPANSION OF MEDICAID.

>> YES.

>> SO WHY SHOULD I BE IN FAVOR OF A PROGRAM WHERE WE ARE GOING TO INCREASE THE AMOUNT OF MONEY OUT OF THE COFFERS OF THE COMMONWEALTH TO COVER PEOPLE WHO DON'T HAVE HEALTHCARE INSURANCE?

>> WELL, FIRST I THINK IT'S BECAUSE WE NEED TO HELP PEOPLE.

AND WE ARE NOW AT THE POINT, IF YOU DON'T HAVE HEALTH INSURANCE, YOU ARE EITHER GOING TO BE BANKRUPT OR YOU ARE NOT GOING TO GET CARE.

AND YOU KNOW, IF YOU, 50 YEARS AGO, IF YOU DIDN'T HAVE INSURANCE, AND YOU WENT TO EMERGENCY ROOM, PROBABLY MOST PEOPLE COULD PAY 100 OR SO, BUT NOW IF YOU HAVE A HEART ATTACK, AND YOU GO TO OUR HOSPITAL AND THEN YOU GET TRANSFERRED TO SOMEWHERE ELSE, YOU ARE TALKING ABOUT $100,000.

SO WE'VE GOT TO COVER PEOPLE.

>> WHAT IS THE RETURN ON INVESTMENT OF US EXPANDING MEDICAID OR THAT WE, THAT YOU CAN SEE WHEN MEDICAID WAS EXPANDED HERE?

IN OTHER WORDS, YOU MENTIONED ABOUT THE MAMMOGRAMS AND FINDING SOME OF THESE CANCERS EARLIER.

ARE THERE OTHER THINGS THAT YOU SAW THAT WAS BENEFICIAL TO PATIENTS, THAT WOULD SAVE US MONEY DOWN THE ROAD?

>> YES, BECAUSE WE ARE TAKING CARE OF MORE PATIENTS WITH CHRONIC ILLNESSES.

THERE IS A HIGHER INS INCIDENCE OF C.O.P.D., DIABETES, LACK OF EXERCISE, METABOLIC SYNDROME, ALL THESE PATIENTS IF THEY'RE NOT ADEQUATELY TAKEN CARE OF, INCREASE THE COST OF HEALTHCARE AND THEN ANOTHER PROBLEM IS WE DON'T HAVE PHYSICIANS IN THE LOCAL AREA THAT TAKE CARE OF THOSE PATIENTS.

THEY GET EPISODIC CARE, WHICH COSTS MORE.

FOR EXAMPLE, IF YOU ARE DIABETIC AND YOU'VE GOT HEART DISEASE, AND YOU DON'T SEE YOUR DOCTOR AND GET IT TAKEN CARE OF AND THEN YOU SHOW UP IN THE EMERGENCY ROOM EVERY MONTH AND THEN YOU DON'T GO BACK TO YOUR DOCTOR, THAT DRAMATICALLY INCREASES THE COST TO THE HOSPITAL AND ALL THE CITIZENS INVOLVED.

>> WHEN YOU WERE PRACTICING, WHAT DID YOUR PATIENTS SAY TO YOU WHO WEREN'T ABLE TO PAY?

I KNOW THAT YOU WERE SEEING THEM NO MATTER WHAT.

BUT WAS THERE A RELUCTANCE ON THEIR PART TO COME IN FOR CARE?

>> WELL, I WAS IN A LITTLE DIFFERENT SITUATION IN THAT MOST-- A LOT OF THE PATIENTS I SAW LIKE THAT WERE IN EMERGENCY SITUATIONS.

AND HAD TO HAVE CARE.

BUT THERE IS RELUCTANCE, SOMETIMES TO COME BACK FOR FOLLOW-UP VISITS AND THERE IS RELUCTANCE TO SEE THEIR PRIMARY CARE PHYSICIAN.

ONE OF THE OTHER PROBLEMS THAT I SAW WAS THAT IF WE HAD A PATIENT WHO WAS MEDICAID, AND SAY I HAD DONE SURGERY ON THEM, AND THEN I HAD SEEN THEM IN FOLLOW-UP AND THEY WERE DOING OKAY, AND WE WANTED THEM TO HAVE A PRIMARY CARE PHYSICIAN, IT WAS DIFFICULT FOR US TO GET THEM INTO PRIMARY CARE PHYSICIAN BECAUSE PRIMARY CARE PHYSICIAN HAD TO PAY HIS OVERHEAD AND MEDICAID WAS AT SUCH A LOW RATE, THAT IT MADE IT DIFFICULT.

SO THEY WOULD LIMIT THE NUMBER OF MEDICAID PATIENTS THEY SAW.

>> SO THIS IS A PROBLEM, AGAIN, THE ACCESS ISSUE FOR SOME OF THESE PATIENTS.

>> RIGHT.

>> WE HEAR A LOT OF TERMS NOWADAYS, BUT WHAT DOES IT MEAN WHEN YOU SAY SINGLE-PAYER?

>> THAT'S A TERM THAT IS USED FOR INSTEAD OF HAVING MULTIPLE INSURANCE COMPANIES, WE WOULD JUST HAVE ONE ENTITY THAT WOULD PAY.

ONE OF THE CONCEPTS WOULD BE THAT EVERYONE WOULD BE ON MEDICARE, FOR EXAMPLE.

AND THERE WOULD ONLY BE ONE PAYER.

NOW IN ORDER TO HAVE A SYSTEM WHERE EVERYBODY IS COVERED, YOU DON'T HAVE TO GO TO STATE FAIR OR SINGLE-PAYER OR YOU CAN GO LIKE IN GERMANY WHERE THERE ARE MULTIPLE INSURANCE COMPANIES, BUT THERE IS A STANDARD.

YOU KNOW, YOU KNOW AS WELL AS I DO, IF YOU HAVE A PATIENT COME IN WITH ONE INSURANCE COMPANY, THERE IS A DIFFERENT REQUIREMENT THAN FOR THE NEXT INSURANCE COMPANY AND CANADA, THAT'S ALL STANDARDIZED.

A PATIENT COMES IN FOR A COLONOSCOPY, YOU FILL OUT A FORM, SEND IT INTO ONE ENTITY AND THEY PAY YOU BACK.

YOU DON'T HAVE TO SEND IT TO THREE OR FOUR DIFFERENT ENTITIES, YOU DON'T HAVE TO GET ON THE PHONE, GET IT PREAUTHORIZED.

YOU DON'T HAVE TO TALK TO A MEDICAL DIRECTOR SAYING I THINK THIS PATIENT NEEDS A PET SCAN BECAUSE I'M AFRAID HE'S GOT METASTATIC DISEASE.

THEY JUST TAKE CARE OF IT.

>> I MUST ADMIT, I REMEMBER WHEN A LOT OF DISCUSSIONS WITH THE AFFORDABLE CARE ACT WERE BEING ROLLED OUT, PEOPLE WERE SAYING THEY DIDN'T WANT THE GOVERNMENT MAKING A DECISION ON THEIR HEALTHCARE.

AND I ALWAYS FELT THAT MOST PEOPLE HAD NO IDEA THE EXTENT OF THE PRIVATE INSURERS WHAT THEIR ROLE WAS IN DETERMINING.

I FOUND THEM HARDER TO WORK WITH THAN EVEN MEDICARE.

BUT HAVING SAID THAT, AREN'T PEOPLE A LITTLE FRAYED THAT YOU ARE TAKING AWAY THEIR CHOICE IF YOU START TALKING ABOUT SINGLE-PAYER?

AND AGAIN, PEOPLE USE THE EXAMPLE OF CANADA, WELL, THIS RESTRICTS MY ACCESS AND HOW TIMELY I CAN GET SERVICES DONE.

>> WELL, THE CONCEPT OF SINGLE-PAYER RIGHT NOW IS THAT EVERYONE WOULD HAVE A CHOICE WHICH DOCTORS YOU SEE.

A LOT OF THE PRIVATE INSURANCE, PARTICULARLY ADVANTAGE CARES, THEY RESTRICT WHO YOU CAN SEE AND WHAT SPECIALISTS YOU CAN SEE.

SO, FOR MOST OF THE IDEAS ON SINGLE-PAYER, I THINK THAT YOU WILL HAVE FREE CHOICE AND IT WILL COVER ALL PATIENTS WHO WITH PREEXISTING CONDITIONS.

I DON'T THINK WE ARE GOING TO GO TO SINGLE-PAYER ANYWAY UNDER THE CURRENT POLITICAL SITUATION.

WE ARE PROBABLY GOING TO HAVE PUBLIC OPTION.

THAT'S WHAT JOE BIDEN WANTS TO DO.

>> WHAT IS YOUR IDEAL WORLD LOOK LIKE?

>> MY IDEAL WORLD WOULD BE THAT EVERYONE IS COVERED; THAT THERE IS NO SUCH THING AS PREEXISTING CONDITION, AND THAT WE WOULD HAVE A SITUATION SIMILAR TO SWITZERLAND OR GERMANY, WHERE THE GOVERNMENT HAS STRICT CRITERIA THAT YOU'VE GOT TO BE COVERED BUT THEY DON'T TELL YOU WHICH INSURANCE COMPANY HAVE YOU TO HAVE; FOR EXAMPLE, IN GERMANY, I THINK IT'S AROUND 7.5% OF YOUR INCOME GOES TO PAY FOR YOUR INSURANCE.

YOU HAVE TO PAY IT.

IF YOU DON'T PAY IT, THEN YOU COULD BE FINED.

BUT THE PATIENT CAN SELECT WHICH INSURANCE COMPANY THEY WANT TO DEAL WITH AND THEY CAN ALSO DECIDE WHICH SPECIALISTS THEY WANT TO SEE.

YOU CAN ALSO, IF YOU ARE ABOVE A CERTAIN INCOME LEVEL, BUY PRIVATE INSURANCE.

SO THERE IS LOTS OF FREEDOM BUT EVERYONE IS COVERED.

>> THERE IS A GREAT COST TO THE GOVERNMENT IN MAKING SURE EVERYBODY GETS COVERED.

WITH DOLLARS BEING TIGHT NOW, ESPECIALLY WITH COVID-19, IS THAT AN UNFAIR BURDEN TO PUT UPON TAXPAYERS TO PAY FOR SOMEONE WHO IS NOT PAYING TAXES INTO THE SYSTEM?

>> WELL THAT'S AN INTERESTING QUESTION.

WHAT WE HAVE TO LOOK AT IS WAS WE ARE DOING RIGHT NOW.

18% OF OUR NGP IS GOING TO HEALTHCARE.

THAT'S TWICE AS MUCH AS ANY OTHER FIRST WORLD COUNTRY IN THE WORLD.

AND ABOUT A THIRD OF THAT MONEY IS WASTED.

IT HAS NOTHING TO DO WITH HEALTHCARE.

AND, FOR EXAMPLE, WE ARE PAYING TWICE THIS MONTH FOR-- TWICE AS MUCH FOR PHARMACEUTICAL AS ANY COUNTRY IN THE WORLD.

WE ONLY REPRESENT ABOUT 4% OF THE POPULATION OF THE WORLD AND YET WE ARE PAYING MOST OF THE DRUG COSTS.

WE CAN'T CONTINUE TO DO THAT.

SO MY ARGUMENT IS THAT IF WE DECREASE ALL THE UNNECESSARY EXPENSE AND THEN WE GO TO SOME OTHER SYSTEM, THEN WE MAY END UP SAVING MONEY.

YOU KNOW, THERE ARE A LOT OF GOOD DOCS DURING RURAL HEALTHCARE SUCH AS YOURSELF AND MANY THAT WE HAVE HAD ON THE SHOW HERE.

BUT HAVE I TO ASK YOU.

DO YOU FEEL THAT THERE IS A DIFFERENCE IN THE CARE THAT SOMEONE MAY RECEIVE AND SOME OF OUR RURAL AREAS VERSUS IN SOME OF THE URBAN AREAS?

>> WELL, THERE MAY BE A PROBLEM WITH ACCESS TO CARE.

THAT'S ONE OF THE BIGGEST PROBLEMS.

I THINK YOU HAVE TO BE TRAINED A LITTLE DIFFERENT IN RURAL AREAS, PARTICULAR WILL I IN RURAL AREAS WHERE YOU DON'T HAVE A LARGE GROUP OF PHYSICIANS.

AND OUR HOSPITAL, WE HAVE A LOT OF SPECIALISTS AND A LOT OF PHYSICIANS, BUT AT SOME HOSPITALS THEY DON'T HAVE THAT.

SO IF YOU ARE GOING TO BE A PRIMARY CARE PHYSICIAN, YOU HAVE GOT TO BE A LITTLE DIFFERENT THAN YOU ARE HERE IN LOUISVILLE.

IN LOUISVILLE YOU MAY JUST DO OUTPATIENT PRIMARY CARE, BUT IN A RURAL AREA, YOU MAY HAVE TO TALK CARE OF MORE SERIOUSLY ILL PATIENTS AND YOU NEED TO TAKE CARE OF HOSPITAL PATIENTS.

YOU MAY HAVE TO DO SOME CRITICAL CARE, ET CETERA.

GENERAL SURGEONS EXTREMELY IMPORTANT IN SMALL HOSPITALS AND HE HAS TO BE TRAINED TO DO CRITICAL CARE ENDOSCOPY, TRAUMA, LOTS MORE THINGS THAN MOST GENERAL SURGEONS HERE IN LOUISVILLE DO.

>> SO WHAT IS IT THAT YOU THINK THAT WE ARE NOT DOING RIGHT TO ATTRACT THAT WOMAN TO GO INTO A RURAL AREA TO PRACTICE SURGERY OR TO DO PRIMARY CARE?

OR ARE WE DOING ENOUGH?

>> WELL, THERE ARE A LOT OF DIFFERENT THINGS.

THERE ARE A LOT OF THINGS THAT WE ARE NOT DOING RIGHT.

WE ARE NOT MAKING IT ATTRACTIVE MOST MEDICAL STUDENTS DON'T UNDERSTAND HOW NICE IT IS TO BE ABLE TO PRACTICE IN RURAL AREAS.

ONE OF THE THINGS THAT WE'VE DONE IS THAT WE HAVE HAD MEDICAL STUDENTS, SENIOR STUDENTS ROTATE WITH US AND WE HAVE ATTRACTED SURGEONS AND PRIMARY CARE PHYSICIANS TO COME TO RURAL AREAS AND THEN THEY ATTRACTED THEIR FRIENDS.

ONE OF THE OTHER THINGS WE'VE DONE IS, WHICH IS REALLY QUITE UNIQUE.

WE INTRODUCE JUNIOR AND SENIOR MEDICAL-- I MEAN HIGH SCHOOL STUDENTS TO MEDICINE.

IT'S CALLED MEDICAL EXPLORERS.

IT'S ACTUALLY PART OF THE BOY SCOUTS OF AMERICA.

THEY'VE ALWAYS INCLUDED WOMEN, TOO, OF COURSE.

AND WE HAVE MEETINGS ONCE OR TWICE A MONTH AND WE ALLOW THEM TO SHADOW DIFFERENT DOCTORS.

THEY CAN DO E.M.T.S, THEY CAN SHADOW VETERINARIANS, DENTISTS, ET CETERA, AND WE HAVE ACTUALLY GOTTEN A LOT OF PEOPLE INVOLVED IN MEDICINE AND NURSING, ET CETERA.

>> IT'S INTERESTING BECAUSE I KNOW WE HAVE HAD REPRESENTATIVES IN PIKEVILLE WITH ONCOLOGY MEDICINE BEFORE AND ONE OF THEIR THINGS IS GETTING PEOPLE TO LIVE IN THE AREA TO STAY THERE.

IT HAS BEEN FUN TALKING WITH YOU AND I WOULD LIKE TO THANK YOU FOR BEING WITH US TODAY, TOO.

I HOPE THAT YOU HAVE A BETTER UNDERSTANDING OF THE PROBLEMS AND OPPORTUNITIES FACING US PROVIDING HEALTHCARE IN RURAL AREAS.

THIS IS A COMPLEX PROBLEM.

BUT THERE ARE SOLUTIONS AND WE MUST ADDRESS THEM.

IF YOU WISH TO WATCH THIS SHOW AGAIN OR WATCH AN ARCHIVED VERSION OF PAST SHOWS, PLEASE GO TO ket.org/HEALTH.

IF YOU HAVE A QUESTION OR COMMENT ABOUT THIS OR OTHER SHOWS, WE CAN BE REACHED AT KYHEALTH@ket.org OF I LOOK FORWARD TO SEEING YOU ON THE NEXT KENTUCKY HEALTH.

PLEASE BE SAFE AND WEAR YOUR MASK.