Republicans control or represent most rural areas in the U.S., but they might be responsible for some of the biggest issues plaguing providers in those areas.
Despite the amount of attention rural issues get from congressional lawmakers, doctors and hospitals in such areas continue to struggle, mostly due to low admission rates, cost of transportation and inability to keep their heads above water financially. At least 83 rural hospitals have closed since 2010, according to the University of North Carolina Cecil G. Sheps Center for Health Services Research.
During Thursday's Senate Finance Committee hearing on rural health issues, witnesses and committee Democrats placed some of the blame on policies backed by state and national Republicans.
Sen. Ron Wyden, D-Ore., ranking member of the committee, said providers in his home state are worried about possible cuts to Medicaid that have been pushed by the Trump administration.
"Medicaid is a lifeline for rural hospitals and patients, and those who have been on the front-line will tell you … if you want to turn rural American into a sacrifice zone, the fastest way to do it is by slashing Medicaid," he said.
President Donald Trump's 2019 budget called for roughly $1.4 trillion in cuts to Medicaid, and Republican party leaders have pushed block granting the program that provides coverage for almost 1 in 4 Americans.
Medicaid expansion has made a "positive difference"
Witnesses also appeared critical of some Republicans' stance on Medicaid expansion.
Konnie Martin, CEO of San Luis Valley Health in rural Colorado, said at the hearing that the program's expansion under the Affordable Care Act, which Republicans have attempted to dismantle, has made a "very positive difference" in the rural health community.
"Seventy percent of our population is Medicare or Medicaid, so our relationship with government payers is critical to our survival," she added.
Interestingly, many rural states, including Wyoming, Idaho, South Dakota, Nebraska, Kansas, Oklahoma and Missouri have not yet expanded the program, mainly driven by resistance by Republican state lawmakers. Idaho and several other states are attempting to work around Republican opposition by putting expansion on the ballot this November. According to the Kaiser Family Foundation, about two million people in rural areas gained coverage under expansion between 2013 and 2015.
George Pink, Ph.D., deputy director at the North Carolina Rural Health Research and Policy Analysis Center, also noted that about 60% of abandoned rural hospitals are in southern, historically Republican states, where 10 of the 18 nonexpansion states are.
"It is difficult to accurately determine whether it is the expansion decision … that has led to higher closure rates, or whether states that have not expanded Medicaid have other factors leading to higher closure rates," he added.
Maggie Elehwany, vice president of government affairs at the National Rural Health Association, told FierceHealthcare that more rural Americans need to be insured, including through Medicaid.
"Bad debt from Medicaid and Medicare has gone up drastically in recent years, and if you look at the map you can't deny that this is higher in nonexpansion states," she said.
Telehealth could ease the burden
Witnesses also corralled around telehealth as an easier and less costly way to get care to patients but said providers struggle with technical requirements and startup expenses. The Trump administration has been largely supportive of telehealth policies.
"One of the best things we could do is to invest in the startup expense for rural hospitals and then allow those services to be reimbursed on a fair basis," Martin said. She added that telehealth services would save providers by reducing the costs of expenses like air ambulances.
The Centers for Medicare & Medicaid Services recently proposed that hospitals adopt 2015 Edition Certified EHRs beginning in 2019, a transition many rural providers have resisted due to the cost of upgrading systems.
Tweaking quality measures
Susan Thompson, senior vice president at UnityPoint Accountable Care in Iowa, recommended the agency "renovate" accountable care organizations and value-based payment models to include separate reimbursements for costs unique to rural healthcare, along with quality measures that are relevant to rural providers.
"Right now we report so many different measures to so many different agencies and they're not always meaningful in moving us ahead with our quality," she said, adding that the lower admission rates for rural hospitals can lead to lopsided quality reports.
The Trump administration, however, has been pushing accountable care organizations to take on more financial risk instead of providing more flexibility, despite many organizations saying they're not ready. This push could cause more than a majority of Shared Savings ACOs to leave the program altogether, setting back the transition to value-based care.
But CMS is also planning to reduce the amount of reporting measures for hospitals under value-based plans starting next year, which came as a relief to many providers.
The Federation of American Hospitals, which represents investor-owned hospitals, said the hearing was an "important first step" to solving rural healthcare issues.
“Hospitals are the foundation of health care in small communities from coast to coast," Chip Kahn, the group's president and CEO, said in a statement. "With a hospital close by rural Americans have access to timely, quality care and frequently depend on that hospital as their sole source of care."
Elehwany also said she was pleased with the hearing and hopes lawmakers can come together and create new payment models for rural America.