× Expand Monica Potts/The American Prospect

Cumberland, Maryland, is in the western handle of the state, sitting atop Virginia near the narrows that once funneled settlers through the mountains and into the West. It's the biggest city in the area, with about 20,000 people. The railroads were once the largest industry here, and freight trains still rumble through the downtown, past an old sign for the Cumberland Steel Company and a hilly jumble of old red-brick factories, two-story offices, and church spires. Now, as in almost every other rural part of the country, the biggest employer is the local hospital.

The hospital, Western Maryland Health Systems, is participating in a statewide experiment that officials hope will control hospital costs and also make the state's population healthier. The State of Maryland has been trying to control health-care costs since the 1970s, but its efforts are getting new attention because the federal government gave the state a waiver under the Affordable Care Act to continue the experiment and study the effects.

Hospitals like Western Maryland Health will see their reimbursements through Medicare and Medicaid capped and stabilized, replacing a fee-for-service model that reimbursed doctors and hospitals for every test, treatment, and medication administered. Critics of the fee-for-service system have long argued that it underpays doctors for preventive care and rewards them for both unnecessary treatments and substandard care that can result in further illness, like when patients pick up an infection during a hospital stay and must be readmitted. The hope is that Maryland's model will encourage doctors and hospitals to practice more preventive care and work to keep patients healthier.

The challenge for the state becomes apparent in a city like Cumberland, and surrounding Allegany County. The county has a poverty rate of 16 percent. A notch above the national average and seven points higher than Maryland's, the health of the country's population is ranked third poorest in the state. In Allegany County, the particular health problems faced by low-income families are abundant: obesity, poor nutrition, asthma, and untreated mental health issues, just to name a few.

"The single biggest challenge in Allegany County is our poverty," says Dr. Sue Raver, a health officer at the local health department.

"Poverty drives most of our negative health results."

To make these populations healthier, officials must tackle the issues associated with concentrated poverty. For now, state efforts are focused on improving the care of people with particular illnesses, by dispatching community outreach teams who visit homes make sure that a child with asthma or an adult with diabetes is taking his or her medication regularly and following doctors' orders, a routine that would decrease the need for emergency care. In time, however, some advocates hope that the system would reach even further back into preventive care, to provide nutrition and health counseling in ways that prevent illnesses from taking hold in the first place. "The Western Maryland Health System has been involved for years in community needs assessments and providing care appropriate to the needs, but now the shift is moving from more sick-care to more well-care," Raver says.

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The availability of well-care would call for a more encompassing system than most Americans have access to now. "If you begin to work on controlling the health-care spending in an area, you have to be able to confront and understand some of those social determinants of health," says John M. Colmers, chairman of the state's Health Services Cost Review Commission and a vice president at Johns Hopkins Medicine.

In the area around Cumberland, the obesity rate is almost 29 percent, nutrition is poor and food insecurity is high. Educating local people in the basics of food choices and preparation, and the importance of exercise, is seen as critical to improving their health. Several organizations have been working to increase nutrition and physical activity in these communities, and help low-income families stretch small budgets, including their ever-shrinking food-stamp dollars, throughout the month. One is the University of Maryland's extension office for the county, staffed by educators who counsel families with children, run group nutrition and exercise education programs for youth and their parents, and help at local food banks, passing out recipes for healthy meals.

Katheryn Kinsman and Eileen Morgan of the UM extension office have been working in the area for 26 years. Over that time, they've worked with new parents whose electricity has been cut off because they can't afford to pay the bills. They've helped families who rent apartments without appliances in them. At times, they've had to buy clients a pot and wooden spoon before their nutrition classes could begin.

Teaching families to prepare nutritious, home-cooked meals is a key element of their sessions, and often instruction is as basic as teaching someone to chop and stir. Once, one of Kinsman's clients called excited because she'd made a home-cooked meal for the first time: It was Hamburger Helper. The lack of cooking skills seems mostly to be generational, say Kinsman and Morgan: Easy, inexpensive food that doesn't require home preparation has been available for decades. But the health effects of the carbohydrate-laden, fatty, salty diet that is so cheaply available in this country fall hardest on the lowest-income Americans, for whom fresh fruits and vegetables may seem out of reach, and who may not have the space and equipment-or, especially, time-to teach themselves to cook. Finely prepared home meals have become a luxury for the well off.

"If you're a mom with very little resources and several kids, and you go into the market and you can get a box of 12 cupcakes for a dollar, while apples are a dollar apiece, which are you going to buy?" asks Kinsman.

Add to that a general lack of safe space in which to exercise in many rural and urban areas. One of the programs offered by the local extension office is a class on exercise at the Cumberland community center. For families in outlying areas without cars, or who can't afford gas, however, just getting to the city center is a struggle.

Even gaining entry to home-counsel families is a problem. Routinely, Kinsman and Morgan visit homes only to find that no one will let them in. By contrast, large gains in health made in the early days of Britain's National Health Service came about, in part, because citizens there were willing to let the government prod them into living healthier lives. They were more accepting of the supports, interventions, and counseling the health service provided. In rural areas around Cumberland, Kinsman and Morgan have found that people are especially resistant to similar efforts. "There is an extreme amount of pride here, and just forming any kind of rapport here is hard," Morgan says. "Just getting in the door is hard."

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The challenges faced by Kinsman and Morgan and their colleagues over the years hints at a problem that could be shared by the health-care providers in the Maryland plan. The state's health-care plan includes community outreach teams to visit patients' the homes to try to make sure people take their medicines and follow doctors' orders.

It's a tall order. Yet many service providers in low-income areas like Cumberland want a holistic system that incorporates the range of the population's health needs. Kelly Snyder works at HOPE Station in Cumberland, a nonprofit that provides services and peer counseling for people with mental health challenges. Once a month, she and her husband, Dan Snyder, the center's manager, run a local food bank. Employees from the extension office often come to help, pass out recipes, and teach people how to cook healthy food.

The problems HOPE station clients face are manifold: too little money, too little food, poor mental and physical health made worse by the lack of money and food, and a life that is greatly affected by the vagaries of policy changes in Washington, D.C. Kelly Snyder used the example of a potential minimum wage hike from $7.25 to more than $10 an hour, a proposal that is stalled in the gridlocked Congress, but one that President Barack Obama supports. "If you raise the minimum wage, then, for a lot of people who work part-time in low-wage jobs, their incomes will go up and their food stamps will go down," she says.

A similar problem happens when people on disability see their benefits go up-a marginal uptick in income can mean a substantial loss of other benefits. For those people, the changes don't make them any better off. She says she sees it happen all the time in almost every policy area designed to help low-income families, like trying to smooth out an air bubble under plastic, only to see it pop up elsewhere. She wants the state and the government to keep that in mind as they think of making changes in health care. "They have to look at the whole picture," she says. "When you can't feed yourself it's going to cause depression; children are going without food, and that's the truth. Everything is like a ripple effect from there."