Speak Your Piece: History Repeats Itself With Attacks on Rural Healthcare

The threats facing the nation’s rural healthcare system are as daunting as any we’ve seen since the 1980s. There’s one big difference, though. This time around, there’s a strong advocacy community in place to help protect and improve the policies that affect rural healthcare.

We need to make the best use of those advocacy resources to protect rural people.

There’s a lot at stake. A new study from the Federal Centers for Disease Control (CDC) shows that Americans living in rural communities are more likely to die prematurely from the top five causes of death (heart disease, accidents, stroke, cancer, and respiratory disease), than are their urban counterparts.

At the same time as rural and urban mortality rates have been diverging, 80 rural hospitals have closed over the last few years. In addition, according to iVantage, nearly 700 rural hospitals are vulnerable and could close, representing over one-third of rural hospitals in the U.S.

On top of this, Medicare’s per capita expenditure for rural beneficiaries has historically been well below that for urban beneficiaries.

If we don’t act now, we will see a massive round of rural hospital and clinic closures.

Compared to the 1980s, some policy details are different, but the challenge is the same – the need for strong, vigilant rural advocacy to inform and protect against wholesale changes in Medicare, Medicaid and commercial insurance that gloss over their impact on rural health care and communities.

The challenges in 1980s were similar, and we were less prepared to deal with them.

The biggest similarity between then and now is that Medicare had just implemented an entirely new way of paying providers – the Prospective Payment System (PPS) that “threw the rural baby out with the reform bathwater.” Today, a shift to premium support, block grants or reducing state oversight of insurance companies, would be at least as devastating unless the rural context is fully taken into account.
Initially, rural health advocates had almost no presence in Washington. The National Rural Health Association was just getting organized, there wasn’t a Federal Office of Rural Health Policy, and there were very few state offices of rural health.
We didn’t have the rural Critical Access Hospital (CAH) designation until 1997. Much of the 1980s and 1990s were spent trying to adapt the Prospective Payment System to the rural context. Contrary to current mythology, Critical Access Hospitals were not developed as a federal charity but were the results of a long search to develop a rural alternative to PPS, which never worked for small rural hospitals.
There was only a small and fragmented rural research community who were just beginning to gather the data and do the analysis needed for us to understand our work and how we might think differently about it.
Very relevant to a far-flung network of advocates, we didn’t have email and the internet to bring us together across significant distances so the exchange of experience and ideas was a lot slower.
On the positive side, health insurance plans had fewer closed networks to steer patients out of rural communities (more on that in a minute).

Today, we are well positioned to not repeat our history, but only if we make sure Washington pays attention.

Overwhelmingly, it was the implementation of Medicare’s Prospective Payment System that created the rural hospital closure crisis in the 1980s.

On the first of October, 1983, Medicare implemented a payment model for most hospitals that was tested only in several large teaching hospitals in New England. They didn’t do a trial run in small rural settings. To the best of my knowledge, think didn’t very deeply about the impact on smaller, rural hospitals.

Through the 1980s, with the unexpected closure of hundreds of rural hospitals, a broad acceptance all too slowly developed that the design of PPS was totally urban-centric and hurt rural hospitals in ways that made neither professional nor political sense.

We have learned nothing from our past if we allow this to happen to us once again.

For the communities who lost a local hospital, it was very personal. It meant a loss of jobs, a blow to pride in their local community, less ability to attract new job-creating businesses and above all, a loss to a closer source of care during a medical emergency.

For the rest of us, it created a feeling of being attacked by our own government and reinforced the stereotype that rural wasn’t very important–that we didn’t need rural hospitals.

There was a very strong sense of anger, not all that different than that seen in the 2016 election cycle driving Donald Trump and Bernie Sanders’ supporters in the primaries – and beyond.

Today the National Rural Health Association is a national group with more than 20,000 members. It was started by a hand-full of activists who merged three smaller associations, one each for community health centers, researchers and rural hospitals.

NRHA’s roots have always been a “big tent” – a diverse community of individuals and organizations with one overriding common interest: the health of rural communities.

In times of crisis or threat, like today, we have always stood together and had each other’s backs.

We need to fight for values that support keeping local care local. In policy talk that means we need Network Adequacy Values that reflect the context of rural insurance markets. The Network Adequacy Council at the Wisconsin Hospital Association has developed these standards to guide our work:

Accessibility – Consumers must have access that reflects “historical patterns of care” and/or improved practices and standards of care in their community.
Transparency and Consumer Engagement – Consumers must have the ability to determine which providers are in the network and which providers are accepting new patients.
Choice – Consumers must have access to a choice of insurers and providers.
Affordability and Cost Effectiveness – Network adequacy standards must not result in unaffordable health insurance costs.

In Wisconsin and nationally, we have already seen what happens when these values are neglected:

Health plan does not offer a contract with local hospital.
Health plan offers a contract at only Medicaid rates or admits that they really don’t need or want a contract.
Health plan has contracted with the hospital, but does not contract with or credential employed physicians.
Hospital has a contract with health plan, but no one is referred to the hospital.
Health plan contracts only with the clinic, but not the specialists or hospital affiliated with the community clinic.
Contracted providers are not listed as available.

Bottom line, as bad as the rural hospital closure crisis already is in many, but not all, parts of the country, it will become a tidal wave across all of rural America if Medicare, Medicaid and insurance market reforms, due to political expediency, turn its back on rural providers and the communities they serve.

I have had the honor to work in rural health for almost 40 years – at the Rural Wisconsin Health Cooperative in Sauk City as well as with the National Rural Health Association and the U.S. Department of Health and Human Services. I hope we learn from and build on the “early days” of the rural healthcare movement of the 1980s and 90s.

Tim Size is executive director of the Rural Wisconsin Health Cooperative.

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