BY: MAGGIE ELEHWANY, J.D.
Rural America faces a looming health care crisis. It is a crisis in accessing care. For health reform to be effective in rural America, the access-to-care crisis must first be resolved. It does not matter if you have access to insurance, if you lack access to a provider.
Rural advocates such as the National Rural Health Association (NRHA) have long lobbied Capitol Hill and the administration to resolve the access-to-care crisis in rural America. They have argued specifically that if any health reform is to work for rural patients and providers, the law must: 1) resolve the workforce shortage crisis in rural areas; and 2) eliminate long-standing payment inequities for rural providers.
This is not to say that the primary goal of health reform — to reduce the number of uninsured by expanding access to insurance coverage — is not important in rural America. In fact, quite the opposite is true. A greater proportion of rural residents than urban residents are uninsured or covered through public sources (23 percent compared to 19 percent). Additionally, fewer rural Americans receive insurance through their employer than their urban counterparts (64 percent compared to 71 percent), meaning many more are likely to be underinsured.
Though rural patients and providers face many of the same challenges as their urban counterparts — exploding health care costs, escalating charity care and aging infrastructure — it is important to note that there are many unique challenges to the delivery of health care in rural America that only exacerbate the crisis in accessing care.
Rural Americans are, per capita, older, sicker (have higher percentages of chronic disease) and poorer. Distances, topography, weather, culture, language and lifestyle each can create great challenges in accessing care in rural areas.
Most rural states face crippling primary-care vacancy rates — many positions can remain unfilled for years. The crisis will only worsen as the baby boom generation gets older and a large percentage of current health professionals begin to retire. Experts predict that by 2030, when over a fifth of our nation's population is over 65 years of age and needs increasing levels of care, the nation will have shortages of at least 100,000 physicians and perhaps as many as 200,000. A third of the nation's active physicians are older than 55 and likely to begin retiring in the next few years. In fact, by 2020, physicians are expected to hang up their stethoscopes at a rate nearly two and a half times the retirement rate of today. In nursing, the Bureau of Labor Statistics projected that in order to accommodate growth in demand for RNs and to replace RNs leaving the workforce, 120,000 new nurses will be needed per year from 2004 through 2014.
The Patient Protection and Affordable Care Act takes important and positive steps in helping to resolve the access crisis in rural America. Though certain program expansions may depend upon the federal appropriations process, the National Rural Health Association strongly supported the critical investment made in the bill to develop and improve the rural health care workforce — a problem that has plagued rural America for a century.
A few specifics include:
- Vastly improved funding for the National Health Service Corps. Through scholarship and loan repayment programs, the corps helps designated health professional shortage areas in the nation get the medical, dental and mental health providers they need to meet their tremendous need for health care. Since 1972, more than 30,000 clinicians have served in the corps, expanding access to primary health care services and improving the health of people who live in urban and rural areas where health care is scarce.
- Dramatic increases in funding for other health profession training programs including area health education centers and nursing programs.
- Significant increases in funding for community health centers. The new law both authorizes and appropriates billions of dollars to expand the community health centers program. This program is anticipated to provide for many millions of people who will now seek care due to the passage of health care reform.
- Increases in medical residency slots in rural areas. Studies have long shown that students from rural areas, or those who were exposed to rural practice while in school, are more likely to seek employment in these communities.
Additionally, health care reform, at least temporarily, makes many improvements to correct systemic Medicare and Medicaid payment inequities that afflict rural providers. The Medicare bonus payments for primary care practitioners and the additional Medicaid dollars to states and providers included in the bill will not resolve the primary care shortage, but they are critically important and long overdue payment improvements.
Still, more must be done. Many needed reforms for rural patients and providers were left out of health care reform. The National Rural Health Association continues to seek legislative solutions for those omissions. A few of the specifics the organization is requesting of Congress include:
- Reinstate a state's ability to determine that a rural hospital is a "critical access hospital." Additionally, we ask that these facilities have flexibility in their rigid bed-count requirements
- Ensure that rural providers have access to the capital needed to comply with the rigors of electronic health records
- Ensure that rural health clinics, which have long been underfunded, receive federal reimbursement payments that are equitable
- Ensure that the many new and powerful commissions established in health care reform have members who understand the difficult and unique challenges of providing health care in rural America
Additionally, much of the good in health care reform could be lost in the morass of the regulatory and rule making process if the challenges of rural health care delivery are not properly considered. The next several months, as the playbook rules go through the bureaucratic administrative rule making process, will be critical to the success of health reform in rural America.
Stay involved. Everyone's voice is needed.
MAGGIE ELEHWANY is vice president of government affairs and policy for the National Rural Health Association, Washington, D.C.