You can do it another day

CBS’s 60 Minutes on the Health Wagon!

Health Wagon AppalachiaApril 6, 2014 — Tonight a segment on CBS’s long-running news show 60 Minutes offered a very good portrait of two nurse practitioners (NPs) who provide vital health care to still-uninsured residents of rural western Virginia from an old Winnebago called “The Health Wagon.” Correspondent Scott Pelley explains that many residents of that poverty-stricken part of Appalachia, along with nearly 5 million others nationwide, have fallen between the cracks because they do not earn enough to afford coverage under the Obamacare health exchanges, but they live in one of the 24 states that has refused to expand Medicaid coverage despite federal subsidies. The report focuses mostly on the plight of the poor and uninsured–many of whom work full time–whose lives are at risk because they lack access to care. But the piece also conveys that NPs Teresa Gardner and Paula Meade are skilled and autonomous professionals, showing them examining, counseling, cajoling, and laughing with patients. Pelley notes that “with advanced degrees in nursing, Gardner and Meade are allowed to diagnose illnesses, write prescriptions, order tests and X-rays.” And there is no real suggestion that they report to physicians, although the report also briefly profiles the “volunteer medical director” Joe Smitty, who drives a tractor-trailer X-ray lab around. The piece does emphasize how challenging the NPs’ work is, particularly in view of the shortage of funds that means the nurses must wrestle with the battered RV (which breaks down at one point) and that they must work into the night writing grant proposals, while worrying about their own futures. One third of the Health Wagon’s funds come from federal grants, and the rest are from private donations. But the report avoids the angel image. Toward the end, when Pelley asks if the nurses sometimes feel they can’t do it anymore, Meade says yes, but it’s the patients’ gratitude and reliance on them that reminds them that they have “a purpose.” And then, as Gardner adds, “you can do it another day.” The report was produced by Henry Schuster and Rachael Kun Morehouse, and we thank all of those responsible.

Affordable Care for Those Still Uninsured

I don’t think I’d be here today

No one here to take care of them but us

See the video here

Affordable Care for Those Still Uninsured

The 12-and-a-half-minute report is entitled “The Health Wagon: Affordable Care for Those Still Uninsured.” Pelley begins by noting that although President Obama recently announced that more than 7 million people had signed up for the new health reform law’s coverage, millions more can’t afford the new exchanges. For them, he says, Obamacare told the states to expand Medicaid, the government insurance program for the poor. But 24 states declined, even though the federal government pays the extra cost for the first three years, out of “fear that the cost in the future could bankrupt them.” So in those states, nearly 5 million people fall into the gap — too well-off for Medicaid, but not enough to afford insurance.

To meet some of these people, the 60 Minutes crew went to Virginia, one of the states that declined to expand Medicaid, and rode along in “a busted RV called the Health Wagon, medical mercy for those left out of Obamacare.” Specifically, the Health Wagon operates by visiting parking lots in six counties in southwestern Virginia, in the Cumberland Mountains, the center of Appalachia. The report makes clear that times have been tough there, not only as a result of a failure to recover from the Great Recession, but because the coal industry has become far less labor-intensive in recent years (“they just take the top off the mountain”) and unemployment is high. During a visit to one depressed area, the segment notes that about 12% of residents don’t have enough to eat. And the report shows some of them waiting for food at a church where the charity Feeding America is handing out just enough to get through a week “if you stretch.”

Health Wagon signThe report introduces us to the two NPs and provides basic information about their work. We see Pelley in the passenger’s seat of the Winnebago as he tells how Gardner “muscles” the 13-year-old “ruin” around “the hollers.” She has trouble seeing, since the wipers and defrosters don’t work well, and Pelley tries to help. He explains that the Health Wagon is “a charity that puts free health care on the road.” The small operation started in 1980 and is funded by federal grants, as well as corporate and private donations (later he says that it’s about one third federal funding). Pelley notes, and viewers see, that it’s not long after they stop at the next parking lot on their route that the waiting room is packed and the two exam rooms are full. We see the NPs greet and examine patients in a very friendly way, using good psychosocial skills, although many viewers may figure they are just nice people from the local area. But Pelley explains: “With advanced degrees in nursing, Gardner and Meade are allowed to diagnose illnesses, write prescriptions, order tests and X-rays.” He also says that they see an average of 20 patients per day, a number that is recently up by 70%.

The report spends a little time with “Dr. Joe Smitty,” a “lung specialist who’s the Health Wagon’s volunteer medical director.” He sets the stage for the health situation they confront:

Smitty:  This is a third world country of diabetes, hypertension, lung cancer, and COPD.

The piece explains, and shows, that Smitty drives a second health wagon, a tractor-trailer X-ray lab. Pelley rides along, remarking on Smitty’s diverse skills in learning to drive the big truck. Pelley says that X-ray screen is “a window on chronic untreated disease, including black lung from the mines.” He also notes that the Health Wagon team negotiates with hospitals to try to get treatment and care for the patients who need it but are not getting it.

I don’t think I’d be here today

And the piece focuses closely on some of the Health Wagon’s patients. Meade notes they are people in desperate need with “nowhere else to go.” She says that “they usually wait, we say, until they are ‘train wrecks,’ their blood pressures come in emergency levels, we have blood sugars come in five, six hundreds, because they can’t afford their insulin.” They wait, she explains, because they have no insurance or money, so they can’t pay an ER bill or fill any prescription they do receive. And they are “very proud people.”

obese and smokingThe report probably spends more time with Glynda Moore than any other patient. Pelley explains that Moore had nowhere to go but the Health Wagon when her leg pain became unbearable. He says her McDonald’s job, which pays $7.80 per hour, did not include insurance she could afford, and the only physician she could see wanted $114 up front just to see her. That’s half her weekly pay. The report says Moore had a blood clot and needed Lovenox, a clot-busting drug that costs about $500 for a full treatment. We see Meade on the phone trying to get information about Moore’s hospital treatment with the drug. Evidently, the ER called the Health Wagon because they did not want to bear the cost, and the Health Wagon gave Moore the drug free. Pelley adds that “there was no charge for some stern medical advice.” We see Meade telling Moore: “You are gonna die if you don’t quit smoking. And it could be within a week. You need to stop now.”

Pelley says that Moore took that advice and the drug, but later, she felt so bad that she returned to the ER. The hospital did scans revealing that the blood clot had gone to her lung, and there was another mass on her lung and lesions in her brain–stage IV lung cancer and brain cancer. Pelley asks Moore what the “doctors” tell her, and she says she will start radiation treatment soon; the physician “seemed very optimistic” and so Moore was hopeful. But toward the end of the report, Pelley notes that Moore had smoked for 25 years, and he says that she died three months after their interview. The show offers one more bit of the interview. In that part, Moore says that she hates getting charity, but she says that things with her health would have been different had she been able to (in Pelley’s words) “go to the doctor more often.”

Health Wagon AppalachiaPelley also spends time with three other patients. They show how vital the Health Wagon is–and how unfair it is that people have to resort to it. First, sitting with all three, Pelley asks if any of them have tried to sign up for Obamacare (here he calls it “the President’s health insurance plan”; some research suggests people like the law if it is not described as “Obamacare”). The three patients say no because they can’t afford it. The report says that one patient, Cissy Cantrell, was laid off from work at a Head Start Center. She suffers migraines and seizures, and she says she cries for no reason. We see Meade ask Cantrell if she has been seeing a counselor. She hasn’t. She gets some medication from the Health Wagon. Another of the patients, Britney Phipps, reportedly works more than 50 hours per week, but that is at two part-time jobs, so she has no insurance for her diabetes. She gets her insulin from the Health Wagon; otherwise, she doesn’t know where she would get it. And Walter Laney’s diabetes has blinded him in one eye and is threatening the other. The Health Wagon stabilized him and set him up with a specialist, with whom we see him speak on a video link from the Wagon. Laney says that the Health Wagon got his blood sugars under control; before he saw them, he was in the hospital several times. Laney declares: “If it hadn’t been for them, I don’t think I’d be here today.”

No one here to take care of them but us

60 Minutes is interested in how the NPs keep doing this work, which is clearly a big challenge. Pelley asks the NPs why they keep doing it.

Meade:  Because somebody has to. … We had dreams, we wanted to move away from here. And then we come back, and we saw the need. And actually there is a vulnerable population here that’s different from the rest of America. … We’re kind of forgotten. There’s no one here to take care of them but us.

health wagon Francina McMahonThe report says that the Health Wagon’s work costs about a million and a half dollars a year. Physicians volunteer and drug companies donate drugs, but when 60 Minutes was visiting, the NPs “sure could’ve used a new truck battery”– we see the Wagon apparently broken down, and Gardner telling a repair crew that they have no electricity on the health side of the Wagon. After it’s fixed, the NPs offer the mechanics a free flu shot for helping them! And we see Gardner and Meade working on grant applications and visiting local churches, “praying for donations and passing the plate.” Pelley asks if there are days they feel they can’t do it anymore.

Meade:  Oh, every day. (Pelley gives her a look.)  Not every day, I shouldn’t say every day. There are a lot of days that you go home you’re so frustrated, because we’re writing grants till 10 o’clock at night, we’re beggin’ for money, and you’re almost in tears, because what are we gonna do? Because I’ve got a family too. It gets frustrating, it gets hard.

Pelley suggests that it’s enough to wear you out.

Gardner:  We’re pretty beat down by the end of the day on most days. [But] we do get more out of it than we ever give.

Meade:  When you look at it practically, you think, what in the world am I thinking? Terry McAuliffeBut then I have that one patient that may come in and say, couldn’t bring you anything, not gonna pay you anything, here’s a quilt I want to give you. And when they do that, and they’re so heartfelt, and they put their arms around you, I don’t know what I’d do without you, it lets you think, OK, I was put here for a purpose.

Gardner:  And you can do it another day.

Meade:  It’s them. And that’s what touches our heart.

Pelley wraps up the segment by noting that Virginia’s new Democratic governor (right) now wants the Republican-controlled Virginia House to expand Medicaid. However, he says, it’s a standoff, and now there is the threat of a possible state government shutdown. But, Pelley concludes, there is no shutting down the Health Wagon — Gardner and Meade have raised the money for a new truck and they hope to get it on the road in the spring.
health wagon Francina McMahonOverall the report is a very helpful portrait of NPs providing high-quality care to a greatly underserved patient population, which is exactly what many advanced practice nurses do now, and what they will presumably do more of as Obamacare takes hold and millions more begin getting primary health care. We wonder what these NPs think of Obamacare and Virginia’s refusal to expand Medicare, but we can guess why 60 Minutes decided not to ask, or not to use the response. The report focuses on the human drama and does not make a direct political statement, although obviously what we see here will suggest to most viewers that expanding insurance coverage to people like those in the segment would be a good idea. Heroic as the efforts of the Health Wagon are, it’s unlikely to be perceived as taking care of the problem.

Gardner and Meade NPsIn any case, Gardner and Meade are clearly running the Health Wagon and providing all the hands-on care, so the report is a good example of nursing autonomy. The piece also strongly suggests that they are not just changing lives but saving them (like Laney’s), even if they can’t save everyone (like the unfortunate Moore). Pelley makes clear that the nurses have “advanced degrees in nursing”–something news reports don’t do that often–and he summarizes what they can do, without physicians. It’s true that we could have used more specifics about the nurses’ skills. But viewers do get some sense that they have technical and psychosocial expertise from their accounts of the patient’s problems and the interactions we see. And although it might have been tempting for the producers to present the NPs as angels in light of the role they play for their community, the report resists that and focuses on their real challenges and rewards. It is only Meade who makes a reference to the “heart,” and that is to explain how the NPs keep going–fair enough–not a suggestion that the NPs themselves are all about touching hearts.

We thank 60 Minutes for this very helpful report.

See the 60 Minutes piece “The Health Wagon: Affordable Care for Those Still Uninsured,” produced by Henry Schuster and Rachael Kun Morehouse, and broadcast on CBS on April 6, 2014.

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