The circumstances around early childhood development have ramifications throughout a person’s life. Ronnie Musgrove, Governor of Mississippi between 2000 and 2004 discusses his conviction that early intervention is vital to good outcomes across education, health and the local economy. Mr. Musgrove describes his concerns about many divisions in society, such as urban and rural, racial, access to online resources, access to healthcare, and divisions in opportunity. He believes that “when you narrow those divides, you give a better opportunity to children”. He details his experiences along the hard road of bipartisan wrangling which ultimately brought about progress in tackling some of those divides, and he shares his hopes for improving rural healthcare in the future. With Bonnie Simpson Mason.
Podcast Episode 36: Tackling disparities from kindergarten up: a Mississippi Governors’ tale. Featuring Ronnie Musgrove.
[Posted on April 22, 2020]
Dr. Mason: Hello, and welcome to a new episode of the Health Disparities Podcast, conversations about health disparities with people who are working to eliminate them. I am Dr. Bonnie Simpson Mason, your host, and this week we are recording our conversations at the National Harbor in Maryland, where we are enjoying a power pack program of speakers and workshops at the annual Movement Is Life Caucus. Today, we have the pleasure of having the honorable David Ronald “Ronnie” Musgrove, who is the former Lieutenant Governor, and then the Governor of the state of Mississippi. He was raised in the town of Toccoa, Mississippi population of 42, and he worked several jobs to put himself through college and law school. He is the first person in his family to graduate from college, and then, throughout his career in public service, Governor Musgrove focused his attention on building a solid foundation for economic growth through Mississippi’s public schools. He focused on the basics of air conditioning, textbooks and the healthcare benefits for educators along with school supplies for Mississippi’s teachers as the chair of the Senate Education Committee, and as Lieutenant Governor. His successful push for quality education through adequate and equitable funding for every public school in Mississippi as a part of the Adequate Education Act changed the face of public education in Mississippi. Wow. So, with that talk about being an effective advocate and politician. We welcome you to the podcast, today.
Mr. Musgrove: Thank you, Dr. Mason, a pleasure to be with you.
Dr. Mason: Oh, well thank you so much for your time. So, I was struck by a statistic recently that for every $7 that is spent by the federal government on people over the age of 65, only $1 is spent on children under the age of 18. It sounds like you’ve always believed that investing in children is how we could build a solid future. And now, we also know that education level predicts the health of a population. Could you talk a little bit about how you came to that conclusion about putting the emphasis on education and why you think that is so important?
Mr. Musgrove: I’ve often believed that because of all of the statistics and the data that early pre-school is one of the most important things we can do for children. Even when children are trapped in bad situations, bad home life, et cetera, if we can get to them early, then we have a chance of helping them succeed because, if they can read by the time they’re in third grade, on third grade level, their chances for success increase dramatically. So, I’ve always believed that, and then had a personal experience. My mother and father did not graduate from high school. It wasn’t that they weren’t intelligent. They just did not graduate from high school. My mother graduated from or finished the 10th grade. Her favorite author was William Faulkner. And if you have ever read William Faulkner’s work, the Nobel Prize winner is a difficult person to read.
Dr. Mason: Yes.
Mr. Musgrove: The older that I got and the more education I received, the smarter I realized my mother was. But when I was young, I got sick with the flu and missed several weeks of school. I was in the hospital for probably two weeks. My first-grade teacher came every Thursday and spent from three o’clock to six o’clock going over what I had missed in school. The one key thing back then is there was no TV in the room. So, all I had time to do was to read and I read emphatically. And I remember my first-grade teacher telling my mother, if you do not slow down, he is going to be ahead of the class. Now, today, we would not even think about stopping someone or curtailing someone’s success. But that told me how important that early childhood learning and education was. And when you look at the politics of today’s world, young people do not really have the ability to speak for themselves. They don’t have lobbyists, they don’t have advocates, but yet it’s the most important thing we can do for them personally, for quality of life, for education and for our economy because it ultimately ends up being a better worker, being a better person for our communities.
Dr. Mason: Overall, it just has a positive impact when we invest early.
Mr. Musgrove: No question, plus, the child’s capability of success in the classroom now is shown by so many metrics that when a company is looking to locate in a state, all they need to do is go look at the statistics of the state department of education. They know how capable the workforce is, how educated they are and how trainable they are. And they know whether they’re going to have to spend three months training, six months training or more. And my guess is, and my belief and my work with companies show me that they want to go to the place with the most educated workforce to reduce the extra training and to have a more productive worker.
Dr. Mason: And, with this stance and your position, how much support do you garner for this particular position? And I think I probably already know the answer, but I’d like you to share.
Mr. Musgrove: Well, it is a whole hard road many times —
Dr. Mason: Sure.
Mr. Musgrove: — because that’s not where a lot of politics happen to be. When you look at educating the entire population in public schools, many times people have a different view of how—
Dr. Mason: Sure.
Mr. Musgrove: Our public schools should be run, the options you should have. But yet, if we focus on our public schools and focus on our young people, then we produce a better opportunity for them. We produce a better opportunity for our communities and our state. In today’s world, we have so many different divides. We have the digital divide, the racial divide. We have the rural and urban divide when it comes to healthcare and we have opportunity divides. When you narrow those divides, then you give a better opportunity for all children.
Dr. Mason: And that is what’s important.
Mr. Musgrove: Absolutely.
Dr. Mason: I agree 110%. So, speaking of the rural communities and I’m sure you have the plethora of those in Mississippi you were chair, or maybe you’re currently chair of the National Advisory Committee on Rural Health and Human Services. You’ve been quite vocal about advocating for those in rural areas, using the social determinants of health as a framework for understanding and solving population health problems. Now, which social determinants are specifically important, maybe particularly important to the rural health community? Are there some social determinants that differ from those in urban areas that we should be aware of?
Mr. Musgrove: The major social determinants, to me are education and economic. But when you look at lifestyle, when you look at exercise, when you look at those kinds of things, all of them are important. And then when you look at the statistics and lay the rural over the urban, you see that those social determinants are much better in urban areas and much worse in rural areas. You have a higher population of people who smoke, a higher population of people who are overweight, a higher population of people with diabetes, higher population of people who are just overweight. All of those factors, one, make for a less healthy person. You add the problem of the rural areas’ transportation lack of access. Then it becomes a very, difficult endeavor to bring the health problems down and to bring the quality of health based on social determinants.
Dr. Mason: Oh, so in the talks that you are going to be giving here at the movement is life caucus. You’re talking about a variety of things around the theme of rural health. So, starting with health disparities, what conditions are you particularly concerned about? And you’ve highlighted some of the social determinants that are particularly concerning, which as you have indicated are worse in these rural areas when compared to the urban areas, what types of conditions are most prevalent in these rural areas that you have a significant concern about? How do health disparities tend to manifest themselves in these environments as well?
Mr. Musgrove: When you look at the chronic disease problem that we have in the United States, 90% of the healthcare spent is on chronic disease. When you look at cancer, when you look at diabetes, when you look at other factors like stroke, there is somewhere between 40% and 50% higher in the rural areas. So, when you factor those things into the equation of how much we spend $3.3 trillion and 90% of it is on chronic illness, and then the greatest percentage of that is in the rural area, then what you have is you have a cry out to look at policies that help make the rural areas healthier. It’s not that we’re not concerned about and don’t want urban areas to be healthy, as well, but the statistics are so much greater for the problems that we find in rural areas. And so, when you look at the healthcare policies that are on the table or should be on the table, do they in fact address the issues of the rural person who lives all across America. And the one thing I wanted to say about the Movement Is Life part, and the Caucus is that they are focusing on the disparities of rural and urban, and I believe to put it on the table to discuss and to make people aware is an education in and of itself.
Dr. Mason: And very needed because even some of the information you are sharing with me today is enlightening, especially with the exacerbation of both the chronic disease and the social determinants of health being worse in the rural areas. So, I think all our listeners need to know that because that is just not, like you said common conversation.
Mr. Musgrove: It is common sense, and for those of us who are educated, we think about it in this light. The more educated you are, the better you take care of yourself, the more prevention health care you go and get. When something is a problem, you go and have it fixed. But when you’re in a rural area and the education level is not to the point where you know the options and you’re educated about what’s wrong with you. then it exacerbates itself, and then the cost of treatment skyrocket.
Dr. Mason: Absolutely, and that certainly translates into reduced life expectancy in these communities reduced quality of life.
Mr. Musgrove: When you look at all the mortality rates for African Americans, for white, Native-Americans, for Asians in every one of those, it is much higher in rural areas than in urban areas. It is sobering when you look at it. We recognize that only 15% of America lives in rural areas. However, that’s still a large figure and a large percent. And then when you look at that 15%, probably a fourth of that, just do not do the common things we think about that is good for your health, you’re eating, your exercise, don’t smoke. You know, those are the kinds of things that I believe are important. And yet those are the ones that cause the rural health of people across America to have the disparity between urban and rural.
Dr. Mason: And not just that, then the limitation or lack of access to care in these areas, I mean, that has to just exacerbate the problem beyond belief. And we know that there are a rising number of counties that do not have a hospital of any kind. So, if 15% of the United States population as you state lives in rural America, how many of our citizens are then living in counties where there is no hospital, no access to care?
Mr. Musgrove: Unfortunately, Dr. Mason, that figure is rising because we are seeing more hospitals close in rural America now than any other time. The southeastern part of the United States is really disproportionately affected because you have more hospitals closing, you have less Medicaid expansion under the affordable care act that has taken place in the southeastern part of the United States. More of the people who live in rural areas are more poverty stricken and more people of color. And so, when you add that together, then the real disparities increase dramatically.
Dr. Mason: We really appreciate you coming to the table to shed some light on what is happening in our rural communities.
Mr. Musgrove: Well, what we want to do is one, be educated about what the issues are. Look at the problems, and then, when we address healthcare policies; make sure we include remedies for those rural disparities.
Dr. Mason: Well, we’ve talked with several of our podcast guests today about making sure that there aren’t any regulations passed that do not use the lens of health, that you don’t look at the outcomes as they pertain to the health component of the, of the constituents who will be affected, the equitable component of the healthcare that will be affected. And now, you are challenging us to add both the urban and the rural health areas to those health lenses that we now need to integrate into the conversations. Now, are you able to do that on a local level, state level, national level, because you have had influence across all of those levels of policymaking, you know have you found bringing this conversation to the table being received?
Mr. Musgrove: The answer is yes, we have.
Dr. Mason: Right.
Mr. Musgrove: For instance, in Mississippi, prior to me being governor, the Children’s Health Insurance Program, or as we know it, as CHIP had been in place for about three years or more. We only had 1,400 children in Mississippi who were on the CHIP program. I looked at that and said, something is wrong with this. So, we changed the program. We changed the way that we administered in one year we added 60,000 children in Mississippi.
Dr. Mason: Wow.
Mr. Musgrove: To the Children’s Health Insurance Program. So, you can develop policies that change the trajectory of young people and people not getting healthcare to getting healthcare. And then what you want to do is make sure it’s quality healthcare.
Dr. Mason: Sure.
Mr. Musgrove: And the other thing I might say is when we use this word rural and we give it a single definition that would be a mistake.
Dr. Mason: Okay.
Mr. Musgrove: Because when you say rural in the South versus rural in Montana.
Dr. Mason: Right.
Mr. Musgrove: You’re talking about frontier medicine in Montana, it is rural, but it is a different makeup and the population density, the poverty levels, all of those things matter when you start looking at rural. And so, that’s why it’s important when you develop policies. If you’re developing policy for the upper Midwest, that’s going to look a little different than the Southeast or the Southwest or the Northwest.
Dr. Mason: Well, you are addressing the issue of health equity in these rural areas and giving people what they need versus putting everybody into one big basket.
Mr. Musgrove: Absolutely. And it’s so important because the hospitals and health care are the lifelines for people who live in rural areas.
Dr. Mason: Yeah, so you spoke about, you know, that extraordinary enrollment of pediatric patients in, or I should say children in the CHIP program in Mississippi, I understand the uninsured rate ranks. You guys ranked number 45 out of 50 in Mississippi with only about 20% or with 20% of your population being uninsured. And right now, there’s still a debate about whether or not to expand Medicaid, which could extend health benefits to around another 100,000 people who are living in poverty. You know, what would you say, or how would you address some of the politics of this situation? And certainly, we have the partisan aspects, but we have got real people on the line here who need health insurance.
Mr. Musgrove: I have plead with negotiated with and talked with the people who are in power, who are not in the same party that I am, but, but to me, this is past a partisan issue. And I told them, I said, look, if you want to craft a program of expansion that has different aspects to it than the Affordable Care Act does, that’s fine with me. And we can call it the Ronald Reagan Healthcare Act of Mississippi. It doesn’t matter to me, as long as you increase the availability of healthcare to our area. And most, all our area of the state is a rural considered state underserved by ERSA definition.
Dr. Mason: Sure.
Mr. Musgrove: So, it’s a challenge. It’s one that we continue to work on every day. And it’s the same kind of challenge that we face all across America. A lot of the governors, both Democrat and Republican sat down and realized this is just too valuable to not do in our state. And I encourage the ones that have not. We have 14 States that have not, three States that are considering it now, I would encourage all of the leaders of the States to look at the benefit, to try to figure out their own politics, but try to make sure we can look past the politics and get policies in place that provide better quality healthcare for people all across America.
Dr. Mason: Yeah, at end of the day, these are people’s lives. And these are people with, as you’ve, so aptly reviewed significant healthcare challenges and need access to care and making sure they’re insured is one of those means to access.
Mr. Musgrove: Absolutely. It’s just the facts and the statistics are devastating. If we don’t make sure that we close those disparities between rural and urban America.
Dr. Mason: Well, let me just ask you about one term that many of our listeners may or may not be familiar with and that’s uncompensated care in rural hospitals. So tell us about this concept of uncompensated care, what the reasons are behind the care not being compensated and who is, well, we know who’s most likely to be affected, but how does that play out in a rural setting?
Mr. Musgrove: Again, you go to the different areas of the country in say the Northwest.
Dr. Mason: Yes.
Mr. Musgrove: The level of uncompensated care is much lower because the number of people that are poverty level people is much lower. So, you have a higher percentage of people who were on health insurance and who have a third-party payer system. If you take a Southwestern state or a Southeastern state where the poverty level is high, then the number of people who are actually paying when they go to a hospital is much lower. The hospital has the duty and the responsibility of taking those patients. So, what happens is over the years to help rural hospitals, Congress came up with what we call the disproportionate share to hospital, to help offset and compensate those hospitals for their higher percentage of uncompensated care.
Dr. Mason: Okay.
Mr. Musgrove: However, with the Affordable Care Act, the idea was that with the expansion of Medicaid, more and more people would be covered, less and less of the disproportionate share of money would be needed, so that is going to be phased out. So for the States who do not expand Medicaid, the disproportionate share dollars, they were receiving will be diminished and be gone, and the extra dollars they would be receiving from the expansion will not be there because the state leaders chose not to expand. For those states, the rural hospitals are really screaming and crying out right now for help. And so, that’s what you hate to see, because what that translates into is that the person in the community who needs healthcare doesn’t get it, or has to travel significantly if that hospital doesn’t make it.
Dr. Mason: You know, the health outcomes of that situation are just devastating across the board. So, if you have any recommendations for our listeners, some of whom are patients, some of whom are healthcare providers giving, you know, your position politically, what would you emphasize, or what would you suggest that our listeners emphasize to their local and state, maybe even national leaders about how to advocate for our patriots in the rural communities.
Mr. Musgrove: Before I get to the advocating part, I would tell all those patients who are listening, who live in rural areas to think about taking better care of themselves. I live in a rural area taking better care of myself. Look at smoking habits, look at the other kind of habits that we have, try to make sure that our habits are good habits that help our health; that’s one thing. My mother died at age 60 because she was a smoker.
Dr. Mason: Okay.
Mr. Musgrove: And died of cancer. And so, to me, we see those kinds of things. So, I would recommend, plead with encourage, whatever term you want to use for people to exercise more, to do healthier things, watch your diet, because those are all things, especially in the South, even though the food is great, sometimes it’s not the best for you. And so, I would advocate that first. Then secondly, I would make sure that people combine together and make sure that they use the power of a vote or make sure you let your voice be known, call your represent, call your local officials, find out what kind of hospital you have, whether it’s a community, whether it’s a private, whether it’s FQHC, whether it’s a critical access hospital, make sure you can do what you can to help out by talking to the local leaders, the mayor, the aldermen, and the supervisors on what it is that you can do and how you can best advocate, because that will ultimately make a difference in the healthcare that you as a citizen will get.
Dr. Mason: The information that you shared with us today is lending a certain level of awareness to many of us who were not aware about the plight of health in rural America. So, we thank you so much, Governor Musgrove for your time today.
Mr. Musgrove: Dr. Mason, thank you for allowing me to be here.
Dr. Mason: Absolutely, I think some of my key takeaways from what you’ve shared, include really emphasizing the importance of early education it’s impact on the workforce long-term and including its impact on the health of future patients, right. And then, also the aha moment for me was that social determinants and the extent of chronic disease is worse, is exacerbated in these rural areas, especially when we compare it to our urban areas. And then, I really appreciate your call for individual behavioral change for folks who live in rural areas, but that applies to all of us as you indicated. And then, leveraging our voices to make sure that our local and state and national officials.
Mr. Musgrove: Dr. Mason, I could not have wrapped it up any better.
Dr. Mason: Okay, well great thank you so much for being here once again, and I would like to thank our listeners for joining us on the Health Disparities Podcast. You can join us again at the movementislivecaucus.com website, or you can subscribe to our podcast at iTunes, Google, Spotify, and Stitcher. New episodes are posted every two weeks and look out for our special series featuring more thought leaders from our partner organizations who are passionate about the mission of ending healthcare disparities. This is Dr. Bonnie Simpson-Mason, thank you for joining us once again.
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