Delivery of Care
The hospitals’ survival polka
A new version of musical chairs has begun in Rhode Island, with patients’ debt and health insurance cliffs creating a downward spiral.
Photo by Richard Asinof/File photo
The Warren Alpert Medical School at Brown University, one of the continuing investments that Brown University has made to grow the innovation economy in Providence.
By Richard Asinof
Posted 12/1/25
The fate of Rhode Island’s future prosperity is intrinsically linked to the health of its health care delivery system. And, the hospital system is in crisis. Both the patients and the hospitals are burdened with too much debt, with no easy way to repay it. The only savior on the horizon is Attorney General Peter Neronha, and his efforts to keep the state’s safety net hospitals open. His plans for a single payer health insurance plan will be introduced in February. Stay tuned.
Why are all the care delivery systems now in transition or facing labor problems — Brown Phyicians Inc being taken over by Brown University Health, South County Health being acquired by as yet unnamed partner, and Care New England’s Women & Infants Hospital nurses struggling with staffing issues — grappling with data system turmoil and the switch to Epic data systems? What is the status of the state’s efforts to coordinate the health care data systems? How is the affordable housing conundrum connected to the health care delivery system’s staffing problems? Is there a way to build a campus system for doctors and nurses to live in communities with patients? How can we find connections that improve our sense of families and neighbors?
In the coming months, Rhode Islanders, like our forbearers who rebelled against a tyrannical king 200 years ago, may have the opportunity to shape a newly energized democratic republic, in the aftermath of President Trump’s impending demise. The question is: how can we find common ground that unites us, enabling the pursuit of happiness and rejoicing in the reaffirmation of our liberty.
Much will depend on our ability to listen and to share stories about our lives, believing in the serendipity that can reinforce our sense of narrative, our sense of belonging.
Much will depend on our ability to listen and to share stories about our lives, believing in the serendipity that can reinforce our sense of narrative, our sense of belonging.
PART Two
PROVIDENCE — The game of musical chairs for hospitals in Rhode Island has begun again in earnest. Much of the attention has been focused on the outcome related to Roger Williams Medical Center and Our Lady of Fatima hospitals, working against the perceived deadline of Dec. 31, 2025. Will they stay open? Will they close their doors? Will Prime Healthcare, for-profit owners of Landmark Medical Center, swoop in and seize the financially fragile hospitals?
Now, a new tremor to the hospital fault line has been detected: South County Hospital in Wakefield announced that it was going to be acquired in the next 120 days in a new partnership, according to a news report aired by WJAR-TV, without naming any names.
Cue the accordion music as the painted ponies go up and down on the carousel of life and death. Who is the most likely candidate to grab the brass ring? From ConvergenceRI’s perspective, it sounds like the academic medical enterprise of Yale New Haven may be consolidating its hold on the southern tier of Rhode Island and Connecticut, given that it now owns Westerly Hospital as well as the acute community hospital in New London, Conn.
All these musical-chair dance moves make the observations of investigative reporter Maureen “Moe” Tkacik that much more prescient. Here is PART Two of a conversation with ConvergenceRI, talking about how hospitals make money and what regulations, if any, exist around the aggregation of patients’ debt.
As detailed in PART One, Brown University Health has emerged as one of the largest aggregators of patients’ debt in Rhode Island, working in partnership with Frost-Arnett, a national debt collector with corporate headquarters in Tennessee.
ConvergenceRI: An attorney, one of the good guys, asked me: “What good is health insurance if folks can still rack up thousands of dollars in debt?
TKACIK: That is a question that a lot of people are asking themselves right now.
I have been studying this "subsidy cliff" problem that we are facing.
And, what I have learned, I am sure that you have read about or you may know some people who are up there in New England. I think one of the single states most affected by a certain component of this problem is Vermont.
Health insurance in Vermont is extremely, extremely expensive. For reasons they don’t wholly understand.
But, the American Rescue Act expanded the pool of the population, (when it) eliminated ... a 400 percent of the federal poverty level income cap on households that were eligible to receive subsidized health insurance through the Affordable Care Act (ACA).
Anyone making over $62,000 or something along those lines, as a single person or a household of four earning more than $128,000 was not eligible for subsidized health insurance under Obamacare marketplaces; they had to pay full price.
Now, after the American Rescue Act passed, they were eligible to receive subsidies up to ...8.5 percent of their income. So, as a result of this, there were a sliver of households who were receiving insurance through the Obamacare marketplaces right now, you know, because they are self-employed, or they work for very small businesses, or whatever, or they are between jobs, but now, their health insurance premiums are about to triple or quadruple in certain states.
Vermont, Alaska, and West Virgina (are the states with) the most profound (cliff). Because that is going to be so insane for a certain segment of society, that is, again, if you are making that kind of a sort of slightly upper-middle-class income, you are more likely to be aware of the news, able to call your Congressman.
But, on the other side, lower down on the income spectrum, those subsidies really made insurance "free" for a lot of the population.
Now, that may sound like a good thing. And, certainly, in states that did not expand Medicaid, that’s where a lot of these health insurance policies grew the fastest.
The single biggest Obamacare insurance plan is called “Ambetter,” and it is marketed by this company called Centene, which is, sort of like, I call it the “UnitedHealthcare of poor people.”
They do prison health care. They administer Medicaid programs in many, many states.
They offer extraordinary executive compensation at this company, but they don’t get a lot of media coverage, because UnitedHealthcare is so much more of (an alleged) menace to the average patient — and the average physician.
Centene is just not a company that you are working with very much unless you specialize in low-income health. Anyway, Centene offers this health insurance plan called “Ambetter.”
I don’t know if you are “am better" off with having this insurance, or not having any insurance at all.
You can get their “zero deductible plans,” but their co-pays are a $100 a pop for primary care (visits), the maximum out of pocket is around $20,000 for a household. They seem to make a practice of advertising certain providers as being in network when they are not in network at all. And, not taking those providers off their provider list when they get complaints about it.
Doing this to the point where people are — and doctors are — hiring lawyers to sue them. This is many cease-and-desist letters later that you are getting to that point.
So, a lot of folks, when they are shopping around the Obamacare (marketplace), will choose Ambetter because, you know, maybe the premium is $10 cheaper than the competition, thinking that their physician relationships will transfer, and then they find out, oh no, actually, there is not (a physician network) at all.
Ambetter does employ some of their own physicians, but we are talking about a very, very low quality of health care, if you can get it at all.
I’ve seen a lot of stories about patients who are stuck in hospitals, racking up charges in hospitals, but aren’t able to get approval for any of the procedures or diagnostics they need.
So, (it is) really poor, really, really poor health insurance (in Tkacik's opinion).
So, if you are making the decision, ( the question is:) “Do I shell out $40,000 a year, out of my $120,000 (annual) paycheck, for health insurance, or do I just go without? It is increasingly difficult to say, “This makes any sense at all" to purchase this kind of protection.
And, it’s getting to the point now, where it’s feeling like buying cell phone insurance.
I remember, you know, there was this period, this is still the case, every time you lose, or have a cell phone stolen, you have to pay this deductible to receive a new phone. And, deductibles are usually around $150 - $200.
Often times, you are being equipped with a phone that has been refurbished. So, you start to wonder: “Are they actually making money? “
Ambetter is our biggest Obamacare health insurance policy; it covers nearly 6 million Americans (out of the 24 million) who are enrolled in these ACA plans.
And, the reviews of this product are almost universally (bad); there are things that you have to cover to be in the Obamacare marketplace. I remember six years ago, reading about a lot of these fly-by-night insurance policies that weren’t really insurance policies. And, they weren’t offered on the marketplace, and people got them through other means, and they didn’t actually cover anything.
These guys seem to be doing the bare minimum that they need to do to maintain their status in the marketplace.
Ultimately, I don’t think that they cover very much, or you are going have to fight tooth and nail to get them to cover anything.
Obviously, that is an enormous problem; and it results in more and more people saying: “Hey. Health insurance, it’s just not worth it. Fuck it.”
Then, (by choosing to go without health insurance), you make your risk pool that much sicker.
And, you are driving up the cost of health insurance for people who really do need it. This is a spiral that is inescapable.
And, it is so enraging to realize that we are subsidizing the ACA to the tune of $143 billion this past year; and, in many states, we have well exceeded per capita our ACA subsidies -- past the per capita cost in Canada of the entire fucking health care system.
So, Canada pays $9,910 per capita for its health care system.
In Vermont, they are paying $11,500 a year per capita to subsidize the ACA marketplace.
And, this is on top of what you are paying for your premiums — and on top of the co-pays.
I mean, it’s absolutely absurd. And, it goes back to the original absurdity of why would you think that you could bring a bunch of cash to publicly traded insurance companies and expect that you are going to get affordable health care from that.
It is every bit as asinine as assuming that if you just remove all of the regulations and essentially give a massive pay day to property developers that that will result in affordable housing. Capitalism does not want to make anything affordable.
The government has to fucking get off its ass and do it.
They need to build capacity. They need to end Medicare Advantage. Which now costs 22 percent more, that’s the latest (numbers) I’ve seen. Medicare Advantage patients are 22 percent more expensive for taxpayers than patients on traditional Medicare.
And yet, they are the very same patients who are having all of their procedures denied, or they are having to haggle with their insurers to get anything. They are constantly being kicked out of rehab after four days when they really need a couple of months to recover from surgeries.
We are paying so much more to get so much less from our health care system right now because of very basic, entirely predictable market incentives.
