Confronting Rural America’s Health Care Crisis

The rapid spread of the new coronavirus has awakened the nation to the dire access problems that have long plagued rural communities and has underscored the need for immediate change. The COVID-19 pandemic has highlighted the fragility of the rural health care system, in which hundreds of hospitals have already closed or are in imminent risk of folding. The pandemic now threatens to heap additional financial pressures onto these hospitals, leaving millions in fear that they won’t receive care.

COVID-19 prompted a flurry of legislative and regulatory action in early 2020, marking the first important steps in addressing access to care through telehealth. Some of these actions align with recommendations in this report. However, these measures were generally limited to temporary fixes, while the problems need long-term attention.

The Bipartisan Policy Center’s Rural Health Task Force has developed recommendations over the last year to stabilize and improve the urgent problems challenging rural communities and to do it permanently. Launched in June 2019, the task force consists of health care experts, business leaders, physicians, and former elected officials. The aim was to produce policy recommendations to stabilize and transform rural health infrastructure, promote the uptake of value-based and virtual care, and ensure access to local providers.

The recommendations in this report are the product of extensive outreach, including roundtable discussions with experts and stakeholders, public comments, and multiple site visits in Iowa, Maine, Vermont, Wisconsin, Tennessee, and New Hampshire.

Even before coronavirus struck, rural Americans experienced significant gaps in care and a unique set of circumstances. They often must travel long distances to see a doctor or visit the emergency room. Rural communities struggle to recruit and retain health care providers and many areas aren’t equipped with broadband. This makes it difficult for residents to make use of telehealth and virtual care technologies.

The rural population is older, sicker, and less likely to be insured or seek preventive services. According to the Centers for Disease Control and Prevention, this population is more likely than their urban counterparts to experience potentially preventable death from five leading causes: heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke.iii Maternal and infant mortality rates are also on the rise in these areas.

The steady stream of recent hospital closures launched rural health care into the national spotlight; COVID-19 has only drawn further attention to the plight of these hospitals and communities. Since January 2010, 126 rural hospitals have closed, and an additional 557 are currently at risk.iv Of the rural hospitals that closed from 2005 through 2017, 43% were more than 15 miles away from the next closest hospital and 15% were more than 20 miles away. According to the Government Accountability Office, rural residents delay or neglect to seek care if they have to travel longer distances to access services after a local hospital has closed. This is particularly problematic for those who are geographically isolated, elderly, or low income.

The loss of a hospital in remote areas may lead to a decline in the number of local providers and reduced access to critical and specialist services, including obstetric and maternal care. Local economies are also significantly impacted. On average, the health sector makes up 14% of employment in rural communities, with hospitals typically being among the largest employers. The average Critical Access Hospital, or CAH, employs 127 people with an annual payroll of $6 million.vii Other data show that hospitals in larger rural communities have an average of 520 employees, while those located in smaller, more isolated areas employ an average of 138 staff.

In March 2020, as coronavirus evolved into a pandemic, Congress voted to temporarily waive telehealth requirements for Medicare providers, allowing the Centers for Medicare and Medicaid Services, or CMS, to reimburse clinicians for telehealth visits with patients at home in an area with a designated emergency. The Trump administration has built on this effort and temporarily expanded access to care by providing regulatory flexibility around the use of telehealth for all Medicare beneficiaries. The flexibilities that have been utilized to address this public health emergency highlight opportunities for permanent improvements to rural health care access.

In addition to addressing telehealth, the task force recommendations include short-term stabilization for struggling rural hospitals and multiple pathways to transform into models that are customized to meet the needs of individual communities. For example, following a comprehensive community needs assessment, a hospital might transform into a stand-alone emergency department with new outpatient capacity. A community that lost its hospital might see a new emergency department as part of its existing Federally Qualified Health Center, or FQHC.

The report also includes recommendations for enhanced payments to keep obstetric units open, and tax credits to encourage physicians and advanced practice clinicians, or physician assistants and nurse practitioners, to stay in rural communities.

The task force’s proposals build on BPC’s 2018 report, Reinventing Rural Health Care: A Case Study of Seven Upper Midwest States. That report described the 10 challenges of rural health care access and delivery, and highlighted opportunities for improvement, including:

• Rightsizing Health Care Services to Fit Community Needs: In order for communities to build tailored delivery services, policies need to be flexible and not just have a one-size-fits-all approach.
• Creating Rural Funding Mechanisms: Funding mechanisms and payment models should reflect the specific challenges that rural areas face, such as small population size and high operating costs per unit of service.
• Building and Supporting the Primary Care Physician Workforce: With the appropriate services and funding, rural communities can build a health care workforce that suits their needs.
• Expanding Telemedicine Services: As workforce models change, rural health professionals should be equipped with the tools necessary to provide quality care to patients.

Understandably, rural health care has emerged as an important issue going into the 2020 presidential and congressional elections. According to a poll by BPC and the American Heart Association, conducted with Morning Consult, a strong majority of voters in the United States said increasing access to health care in rural areas is important to them. In fact, 3 in 5 voters said they would be more likely to choose a candidate in the 2020 election who prioritized access to health care in rural America. Not surprisingly, we have seen rural health efforts from the Trump administration, Democratic presidential candidates, and Congress.

As part of our survey, more than half of rural residents (54%) said access to medical specialists, such as cardiologists or oncologists, is a problem in their local community, and more than one-quarter (27%) said it is difficult to access behavioral health professionals. Rural Americans are also more likely than their urban and suburban counterparts to agree that availability of appointments (56% vs. 50%) and the distance to receive care (50% vs. 37%) are barriers to health care.

Three in five voters (61%) would be more likely to vote for a candidate in the 2020 election cycle who says he or she will address access to health care in rural America. Would you be more or less likely to vote for a candidate in the 2020 election cycle who says he or she will address access to health care in rural America, or would it have no impact on your vote either way?