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[Cross-posted from the Rio Arriba Community Health Council Blog.]

Recently, after months of silence, New Mexico Governor Susana Martinez became one of several Republicans to blur the Right's anti-socialist line in the sand by adopting Medicaid expansion. As New Mexico is surpassed only by Texas in its ranks of uninsured, and leads almost every list of scary medical conditions known to humanity, adding 170,000 insured out of a population of 2,000,000 is obviously good for our statewide health.

But health wasn't the primary reason Martinez bucked her party. Her decision is rooted in New Mexico's economy.

 photo 350px-Truchas-NM-May05.jpgI live and work in Rio Arriba County. Like most of New Mexico, it is rural. Forty-one thousand people inhabit a County that is larger than Connecticut and Rhode Island combined, often in remote mountain villages.

New Mexico leads the US in drug overdose deaths, while Rio Arriba's death rate surpasses New Mexico by 2.5 to 1.

 photo url_zps7a889b96.gifSeveral years ago, in an attempt to understand the causes of the epidemic, I compared demographically similar northern New Mexico villages.

Contrary to popular belief, overdose deaths in these communities did not correlate with poverty: Taos and Tierra Amarilla experience lower death rates than nearby Chimayo and Española despite lower median incomes.

The communities with higher overdose death rates shared two important  but unexpected distinctions. These towns bordered New Mexico's wealthiest counties; a large percentage of adults thus commuted more than 30 minutes to work in Los Alamos or Santa Fe (or even Albuquerque),  often as much as 60 to 90 minutes one way.

 photo url_zpsf1efe808.jpegIf an adult commutes more than 30 minutes one way, the commute exceeds the lunch hour making him or her unavailable to social networks during working hours. If a high enough percentage of adults are traveling more than 30 minutes one way to a job in a given community, then there is nobody left behind to care for children, bring soup to a sick neighbor, or retrieve forgotten homework assignments.

We are emptying southern Rio Arriba County of healthy adults during daytime hours for relatively low-paying jobs. Because we lack monetary resources, we have very little public or private afterschool programming. Gangs are targeting middle school age children, offering them drugs and alcohol to act as mules.

It appears that the best community-wide resolution to the drug epidemic in Rio Arriba may be the the return of good jobs to the County.

 photo 0217744d-188a-4c4c-98a0-7739d0bc7e93_zps8737b8e5.jpgHealth Care is the fastest growing sector of New Mexico's economy, and its largest source of local wages. Twenty-five percent of all Rio Arriba wages can be attributed to healthcare-related jobs. These are also the best-paying jobs, and tend to include benefit packages. In our most remote villages, often, the local clinic is the largest, or even the only employer. Northern New Mexico College, located in Española, offers several health care degrees and certificates. The local hospital and clinics are among the best in the state. Rio Arriba is perfectly situated to expand employment through health care.

Medicaid expansion is one several important ways the Affordable Care Act (ACA) makes it possible to bring health care jobs home. Another has to do with the state-based Medicaid Reform prompted by the ACA.

In New Mexico, the health care delivery system is fragmented. In fact, use of the word 'system' in the same sentence as 'healthcare' is an oxymoron. Trying to make sense of the cacophony is like trying to put together a thousand piece jigsaw puzzle in which few of the pieces fit.

 photo imgres-1_zpsd7ce9a27.jpegIn 2008, the Rio Arriba Community Health Council produced a report demonstrating that, while the State of New Mexico spent $6.6 million providing behavioral health services to residents of Rio Arriba over 18 months, 75% was spent out-of-county, much of it on youth residential services in Texas or southern New Mexico without family involvement or aftercare based in our own community.

Basic services remained unavailable in-county because this huge expenditure was draining the budget. Local government has been forced through mandatory sentencing and other laws, to spend extraordinary amounts of money on law enforcement and preventable emergency room costs. Medicaid reform offers us the opportunity to build a health care system that focuses on producing health over profit, and enables us to provide basic preventive care close to home. Working with state government to return $3.3 million per year to our county for badly needed preventive care could result in 60-70 jobs. We will keep people healthy while enabling an additional 70 adults to remain close to families and neighbors during daytime hours.

There are numerous provisions in the ACA that encourage hospitals to reduce readmission rates for preventable conditions. The ACA provides incentives to  hospitals to keep people healthy, and penalizes them for failing to connect discharged patients to follow-up care. The Center for Medicaid and Medicare Services (CMS) tracks hospital quality, and assists the public to compare hospitals online at Hospital Compare. Rural hospitals that capture 75% of the Medicare market share qualify for substantial federal subsidies, adding a further incentive to improve care and build relationships in the community.

 photo imgres-1_zps712e5a23.jpegInstead of wasting money on billboards, Rio Arriba County is collaborating with Española Hospital to coordinate a series of immunization clinics designed to entice seniors with free preventive care including immunizations for pneumonia, influenza, tetanus, whooping cough and shingles; medication reconciliation clinics where a medical professional examines all of a patients' medicines to insure they can be taken together; and enrollment fairs.

We hope the fairs will increase our share of the Medicare market, qualifying the hospital for a $1.8 million subsidy, decrease hospitalization rates through proper prevention, and increase payment sources through Medicare and Medicaid enrollment. It is much easier for me as a local government official to work with our hospital to improve care when the system incentivizes collaborative hospital behavior. Moreover, a further revenue capture of $2 million to our system could mean an additional 40 jobs.

Changing the shape of our healthcare system to one that produces healthy people strengthens communities by building community networks and community attachment.

It's a win-win for everyone!


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