Wednesday, October 1, 2014

Will Congress Save Rural Health Care?

12/06/2012

tammy baldwin David Goldman/AP Tammy Baldwin, Democrat of Wisconsin, is among the newly elected senators rural Americans will be relying on to safeguard rural health programs with federal policy.

When newly-elected federal officials are sworn-in in January, the party makeup of Congress and the presidency will be much the same. President Barack Obama, Senate Majority Leader Harry Reid and Speaker of the House John Boehner, in their respective victory speeches, promised more bipartisanship and cooperation to meet the significant challenges facing the nation. But what do these pledges mean for health care providers in rural America? And in January, will Congress remain divided or will promises of unity win the day?

In the immediate term, rural providers and patients continue to have much on the line. Three payments for rural hospitals have already been allowed to expire by the current Congress. The Medicare Dependant Hospital program, the Low-Volume Hospital Adjustment and the “Section 508” Hospital wage index programs provide millions of dollars in reimbursements to rural hospitals treating specific Medicare populations. Unless these payments are restored, many hospitals will likely have to reduce services and staff to stay afloat. 

Threats to other rural provider payments, and to appropriations for numerous rural health training, research and provider programs, have also become the norm on Capitol Hill. Appropriations for Area Health Education Centers, for example, have consistently been below authorized spending allowances. The lack of this money means that AHECs are less able to help in their vital role of reducing physician shortfalls in rural America.

AHEC programs Area Health Education Centers Red dots show Area Health Education Centers around the nation, gray stars show AHEC programs.
The lame duck Congress returned Nov. 13, with major decisions to address: unemployment insurance, expiration of personal and corporate tax provisions, the “doc fix,” as well as the expired or soon-to-expire rural Medicare extenders and the devastating impact of sequestration on rural providers. Will Congress have time to address rural concerns? Will legislators use rural health programs as offsets for other spending? These questions remain critical as the end of the year rapidly approaches.

In the newly elected Senate will be 53 Democrats, 45 Republicans and two independents. Many of the new Senators come from states with histories of advocacy for rural health care. Senators-elect Heidi Heitkamp (D-ND), Tammy Baldwin (D-WI), Joe Donnelly (D-IN) and Debra Fischer (R-NE) take the places of rural health champions Kent Conrad (D-ND), Herb Khol (D-WI), Richard Lugar (R-IN) and Ben Nelson (D-NE). These new senators will be called on frequently to stand up for rural providers in their states and throughout the country.


In the newly elected House will likely be 237 Republicans and 198 Democrats, an increase of eight Democratic seats. The 2013 session is special in the House, as it reflects the new census numbers from 2010 and the new districts drawn in each state. Many longtime House members find themselves representing new geographies and demographic groups and will be faced with learning about new issues. Other representatives are entirely new to the House and must learn the rules, official and unofficial, of Capitol Hill.

ahec skull Southwest Indian Area Health Centers Area Health Education Centers, like this one in SW Indiana, train rural students for health care professions. Funding for AHEC progams has been below authorized spending and may be cut further, even though the number of health care professionals in rural America remains too low. How will health care reform fare with this new Congress? What about the continued funding challenges, regulatory issues and legislative proposals affecting rural health care? Further legislative challenges to the Affordable Care Act (ACA) are unlikely to succeed; however, Republican governors will probably continue attempts to thwart implementation. Congress and the president will then be faced with decisions about if and how to offset these challenges. Suggestions include blunting proposed “disproportionate share” payment reductions and reducing “bad debt” reimbursement for rural hospitals and clinics. Furthermore, since many programs in the ACA were not directly funded (including those affecting rural health educators and providers), opponents of the legislation may look to deny funding for these programs as a means to thwart ACA’s implementation.

On the regulatory front, expect continued roll out of ACA regulations. Several are due for release before the end of the calendar year, and the administration is expected to begin issuing a backlog of rules for ACA’s implementation as early as this week.

obama boehner Carolyn Kaster/AP House Speaker John Boehner and President Barack Obama must compromise to avoid automatic cuts to federal programs. Who will stand up for rural health care in the fiscal decision-making? As the campaign season neared its end, President Obama promised that sequestration would not take effect. The administration likely will have to act immediately to avoid mandated spending cuts under sequestration, including the 2 percent cuts to rural Medicare providers. The offsets or “pay-fors” to avoid this sequestration are unclear.

Now is a key juncture for rural providers, educators, researchers and advocates to educate new and returning members of Congress about the challenges in recruiting and retaining health care providers to rural America. Key rural health problems that now hang in the balance include increased dependence on reimbursements from Medicare, Medicaid, and “self-payers”; longer distances patients must travel for primary and specialty care; fewer providers per capita, which may lead to long waits for visits in the rural health care delivery system; lack of funding in rural health education; and the need for continued rural health research.

The next two years, indeed the future of rural health care, depends on active engagement now.

David Lee is the government affairs and policy manager for the National Rural Health Association.