Politics could drive 2019 congressional action on rural health

Several bipartisan rural health bills in the Senate and House went nowhere this year, despite the steadily rising number of rural hospital closures. Eight rural facilities have closed so far in 2018, including several in recent weeks, bringing the total number of shuttered hospitals to 90 since 2010, according to the University of North Carolina's Sheps Center for Health Services Research.

Many Democrats believe their party needs to improve its standing with rural and small-town voters in key swing states like Florida, Ohio and Pennsylvania. Many Republicans believe the Trump administration needs to prove it can govern and actually improve the lives of the people in those communities who have strongly supported the president.

"One would think this would be politically savvy," said Dr. Anand Parekh, chief medical adviser at the Bipartisan Policy Center. "Hopefully they'd do it for health reasons. But politics is another reason to focus on this."

While rural health long has been a second-tier issue in Congress, legislative action to address it could prove an easier and less-risky political lift than tackling contentious top-tier issues such as reducing prescription drug costs and stabilizing the Affordable Care Act insurance markets.

Still it's unclear whether Democrats, who will control the House, and Republicans, who will continue to run the Senate, see greater political advantage in working together to get things done or blaming the other party for gridlock.

Dealing with rural healthcare could draw politicians' attention at least partly because five public health statistics correlated strongly with Trump's support in the 2016 election. Counties showing poorer statistics on obesity, diabetes, heavy drinking, physical exercise and life expectancyvoted significantly more heavily for him, according to an analysis by the Economist magazine.

"Poor health was essentially driving why voters voted the way they did in 2016," Parekh said. "The corollary is that if you improved health for those voters, that could affect how they vote."

And preserving healthcare in rural communities is key to maintaining their economic stability, a major concern for rural voters. "Having access to a hospital or health center is as intrinsically important to the infrastructure of a rural community as the sewage system or the power lines," said Maggie Elehwany, vice president of government affairs at the National Rural Health Association.

Experts say Congress and/or the CMS should make it possible for rural communities to create alternative models for providing healthcare for their residents, including replacing inpatient care with emergency and outpatient services and using telehealth to connect with specialty services.

One reason advocates are cautiously upbeat for action in 2019 is that Republican Sen. Chuck Grassley of Iowa, who long has been a champion for rural health, will become chairman of the powerful Senate Finance Committee in January.

His bipartisan bill, the Rural Emergency Acute Care Hospital Act, would let small rural hospitals continue to receive Medicare payments if they dropped inpatient care and shifted to providing only emergency and outpatient services on a 24/7 basis. Payment rates would equal 110% of the reasonable cost of providing outpatient and transportation services.

There were similar bipartisan bills in the House, the Save Rural Hospitals Act and the Rural Emergency Medical Center Act.

But rural health advocates will have to cultivate new congressional leaders on these issues. The co-chair of the Senate Rural Health Caucus, Democratic Sen. Heidi Heitkamp of North Dakota, lost her re-election bid. Dozens of new members, many from suburban areas, will need to be brought up to speed.

"It's a big new class of freshman, and we need to have them meet with providers and patients to educate them on the challenges of rural areas such as workforce shortages, long distances, and the hospital closure crisis," Elehwany said.

Rather than starting with building new rural healthcare models, which could take several years, she would like Congress and the Trump administration to take immediate steps to stop the financial bleeding at rural hospitals.

That would involve rolling back the Medicare sequestration cuts and letting rural hospitals resume writing off uncompensated care. Otherwise, dozens more rural facilities will close over the next several years, she warned.

Parekh said instead of waiting for legislation, Congress could nudge federal agencies to take helpful steps. For instance, the Federal Communications Commission could expand broadband in rural areas to promote telehealth services.

In addition, the CMS and the Center for Medicare and Medicaid Innovation could launch rural demonstrations to promote accountable care organizations and improved information technology.

The CMS also could expand a demonstration in Pennsylvania to other states, testing a new payment system based on all-payer global budgets for rural hospitals. That payment model could free rural facilities to shift resources from inpatient care to services that are more needed by their communities, such as mental healthcare and addiction treatment.

Public health statistics show public health measures, including death rates, are significantly worse in rural America than in urban and suburban parts of the country. Experts say that's related to poorer healthcare access and less economic opportunity.

Elehwany argues that it's a no-brainer for politicians to kill two birds with one stone by investing in rural healthcare, improving both health and the economy in rural communities—even if they're thinking mostly about political strategy. "We don't mind being political pawns," she said.