What Should Rural Healthcare Look Like After Reform?

Numerous proposals in the various reform bills under discussion in Congress are designed to improve healthcare for rural communities. But one issue that seems critical in the eyes of some advocates is that of insurance coverage, whether it is public or private.

It must be affordable, available, and allow choice.

Sure there are issues with comparative effectiveness, medical home models, pay for performance, and preventing infections and acute care readmissions. There’s too much health care fraud, waste and abuse, providers don’t talk with each other about their patients enough, and there is a whole range of other problems.

And there are big time workforce issues—problems occurring in rural as well as urban areas too.

But in rural communities, much of the issue boils down to a problem of inadequate coverage.

That's part of the thrust of a 12-page report released last week by the Rural Policy Research Institute, a joint program of Iowa State University, the University of Missouri, and the University of Nebraska.

The report "Assuring Health Coverage for Rural People through Health Reform," carries some good news about a solution.

Senate and House proposals under discussion as of Oct. 26 (just before H.R. 3962 was introduced) would, when fully implemented, reduce the number of uninsured by 6.2 million in non-metropolitan areas, leaving 1.9 million persons uninsured, it says. That would lead to a coverage rate of 96% in rural areas, largely through tax credits, subsidies, and public program expansions to rural people who seek insurance.

A greater percentage of people in rural areas are uninsured, compared to people living in urban areas, so programs like the proposed health insurance exchanges would go a long way to fill the gap.

I asked one of the report’s authors, Keith Mueller, chairman of Department of Health Services Research and Administration at the University of Nebraska Medical Center, to list three of the most important policy measures required in any health reform package.

He listed four.

1. It should have meaningful health insurance reform, including a guarantee that no one could be turned down for a health insurance policy because of age or a pre-existing condition. Health insurance exchanges are an effective way to accomplish this. And everyone would have to buy an insurance policy.

2. It should make sure that competition in the insurance market is there to keep quality up and premiums affordable. "We need to make sure there are competing plans, or if there are places where the market can’t work because the population is too dispersed, you need to have something else that guarantees that the plans are affordable," Mueller says.

"If there’s only one choice and it’s not affordable, then perhaps open up Medicaid to a different population, or offer a public plan."

For large portions of rural areas today, Mueller says, there is only one health insurance company actively selling health insurance packages.

3. It should guarantee that patients should have access to a healthcare delivery system that is local and offers choice. "A health plan that is based on use of provider networks must contract with local providers," he says.

The latest health reform proposal, H.R. 3962, addresses "standards for network adequacy," but is not specific and leaves the details up to a "Health Choices Commissioner," he says.

4. It remedies the declining health practitioner workforce in rural communities through subsidies, loan forgiveness programs, and incentives to encourage younger providers into rural areas.

The report, funded in part by the Robert Wood Johnson Foundation, says that without health reform policy change, "rates of employer sponsored health insurance coverage in rural areas will continue to decline."

It recommends, "because a greater percentage of rural residents are self-employed, some form of subsidy (e.g., tax credits for individual insurance purchase) should be part of an effective solution."