Dialysis patients could face especially daunting obstacles to treatment if the rule is approved, according to the author. Left: Fran Stowell gives a ride to Mary Carter from her home in Camp Verde, Arizona, to her dialysis appointment at Verde Valley Caregivers Coalition in Sedona. Right: Stowell (middle) assists Mary Gramling and Mary Carter (far left) to their dialysis appointments. Photos by Nick Oza/The Republic.

Not again! That was my first reaction to being asked to comment on the rural impacts of new rules coming out of the Centers for Medicare and Medicaid Services (CMS) in an 85 page letter titled Draft 2017 Letter to Issuers in the Federally-facilitated Marketplaces (PDF). At first glance it seemed to be just a technical publication of requirements for Qualified Health Plans participating in the Affordable Care Act.

Anyone who lives outside of a Large Metro or Metro area should have major concerns about Table 2.1 (to the right, and on page 25 of the report). The table undoes more than 40 years of access standards for health care in one fell swoop.

Chart shows the proposed times and distances to various specialties based on location. CEAC are counties with extreme access considerations. See chart below for more on definitions.
Chart shows the proposed times and distances to various specialties based on location. CEAC are counties with extreme access considerations. See chart below for more on definitions.

History of Access to Care Standards – 30 Minutes/30 miles

In the 1970s, the U.S. Department of Health, Education and Welfare (now Department of Health and Human Services) established the goal that primary health care should be available to every person in the United States with no more than 30 minutes’ travel time.

Congress established the National Health Service Corps in 1970 to help meet that goal. Over the decades, programs such as Migrant and Community Health Centers and Rural Health Clinics have been created and expanded. New provider types such as Physician Assistants and Advanced Practice Nurses have been developed and grown into a crucial element of the health care system. These programs were all trying to meet the goal of providing access to health care, service located no more than 30 minutes of travel time. Comprehensive primary care includes family practice doctors, pediatricians, obstetrician-gynecologists, dentists and behavioral health care providers.

Thirty minutes is a lofty goal to achieve, especially in rural and frontier areas. While some regions and communities have not yet met the goal, the access standard itself continues to stand because it represents what has been determined to provide the best access to health care. Better access leads to better health. The National Rural Health Association reaffirmed these distance and travel time goals as recently as April 2015 when it passed as official policy Designation of Frontier Health Profession Shortage Areas.

While the goal was originally established for prioritizing placement of National Health Service Corps providers in Health Professional Shortage Areas (HPSA), over the years other programs adopted the methodology. HPSA criteria are now used by more than 20 federal health programs. This fact alone is what makes Table 2.1 so dangerous.

The Great Leap Backward

The following proposed standards for the insurance marketplace at this time are for insurers certified as Qualified Health Plans under the Affordable Care Act, not all insurers, just those being offered through federally facilitated marketplaces. No big deal, right? Wrong, very wrong.

Look at the CEAC column. (CEAC stands for counties with extreme access considerations. These are counties with a population density of less than 10 per square mile – generally what we would call frontier counties.) CEAC is on the far right. Travel time and distance are now more than double the national goal for primary care. The table also separates provider types that have been included as primary care for more than 20 years. Now they are considered specialists, and insurers are being allowed to dangerously reduce access for both rural and CEAC residents. This is not good.

While the Health Resources and Services Administration (HRSA) of HHS works to improve access to health care, CMS over in Baltimore has proposed standards to undo the work of HRSA and worsen access to care for all Americans outside of Metro areas.

Among all of the proposed reductions, access to dialysis stands out as especially cruel. CMS is planning to allow insurers to be qualified in the marketplace if dialysis is available within 110 miles or 125 minutes. Dialysis is a medical procedure for End Stage Renal Disease (ESRD) that needs to be done very frequently. The Dialysis Patient Citizens advocacy group has been asking CMS to establish realistic access standards for a number of years. In a 2012 letter to CMS they state:

more than 485,000 Americans suffer from ESRD and 341,000 are on dialysis, a number that is expected to double over the next decade. With most ESRD patients requiring dialysis treatment three times a week, access to facilities is key … having a treatment center of choice within a reasonable distance can mean the difference between life and death. …

we understand the accommodations that need to be made for the rural and counties with extreme access considerations (CEAC) categories. For this, we urge CMS to look at data analyzing actual current distance and drive times for patients. … [a study] showed that patients in urban areas traveled on average 5-8 minutes to the closest facility, patients in suburban areas traveled between 12 -22 minutes, and rural patients traveled between 30-39 minutes.

People who purchase insurance through the federally facilitated marketplaces will assume that they are covered and will have access to care. The standards in Table 2.1 fail to provide reasonable access to the beneficiary.

What to Do

Comments on this draft letter are due in a few days. Because CMS released the draft letter on December 24th, this proposal is only now receiving the attention it deserves. The deadline for comments to CMS is January 17, 2016. (Comments may be sent to FFEcomments@cms.hhs.gov. Information on how to comment is on page 2 of the proposed rule.)

Despite the comment deadline, there are still ways to improve these standards:

At local and state levels, state insurance commissioners can establish their own access standards for certifying qualified health plans in their state. Advocates can organize for standards that are equitable and provide actual access to care at the state level.

Nationally, rural and CEAC communities need to educate, organize, and demand that their representatives and senators guarantee them access to health care for all plans being offered in the Marketplace.

CEAC communities include the sparsely populated areas generally considered as frontier or remote in a variety of state and federal programs. Caroline Ford, President of the Board of Directors of the National Center for Frontier Communities (www.frontierus.org) has stated that “Unreasonable driving distances for patients and families compromise their health and safety. Creating distance/time standards that conflict with already existing HRSA criteria, sets up inequity in health care outcomes for frontier populations.”

One of the worst things about this table is that it exists and is in the public realm. I am extremely concerned that it might dangerously take on a life of its own. Remember, that just as the Health Professions Shortage Area designation was originally created for use by a single program, there are now are more than 20 programs using it. The standards proposed in this table need to go away and never be used by any program. The goal needs to be access to care for people living in rural and CEAC communities, not distances and travel times that will guarantee not only worse access, but also worse health.

Rural and frontier advocates have always warned that having an insurance card is not the same as access to health care. Only through organizing, will we achieve high quality, affordable and accessible health care.

Carol Miller is a community organizer from Ojo Sarco, New Mexico (population 300) and an advocate for “geographic democracy,” the belief that the United States must guarantee equal rights and opportunities to participate in the national life, no matter where someone lives.


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