Rural America an Afterthought in GOP Health Plan

An initial review shows that the American Health Care Act does little to address healthcare access woes in rural America.

House Republicans this week made public their replacement plan for the Affordable Care Act. The so-called American Health Care Act does not have much support beyond House leadership, but before it collapses under relentless blowback from all corners, let's look at what it might have done for rural health.

Maggie Elehwany, government affairs and policy vice president at the nonpartisan National Rural Health Association, is still sifting through the fine print, but she offered a few thoughts after an initial reading of the proposed law.

"Our concern is that it does nothing to address basic access issues," she says.

"We're in the midst of a rural hospital closure crisis, where at the current rate of closure we are going to lose 25% of all rural hospitals in this country in less than a decade if Congress doesn't act. One in three rural hospitals is currently at financial risk and is vulnerable to closure. That is what we need to see in any healthcare reform bill."

"Because this bill specifically reformats Medicaid, we would have liked to have seen them address Medicaid equity for rural providers," Elehwany says.

"We have concerns over the phasing out of the FMAP and introducing the per capita cap. We strongly support the federal government's maintaining its moral obligation to ensure that Medicaid funding goes to needed populations. Rural America is disproportionately dependent upon Medicaid. They are poorer, they are sicker, they are per capita older."

To be clear, the plight of rural hospitals predates the American Health Care Act, but states that refused to expand Medicaid under the ACA didn't do their rural hospitals any favors either. Elehwany says non-expansion states are still contending with high percentages of uninsured citizens.

"If you are a rural state, more likely than not you didn't expand Medicaid, but they are still showing up in hospitals sick and these small, rural hospitals are subsidizing care," she says.

"Additionally, in the exchanges we saw that rural Americans were mostly buying bronze plans, maybe not realizing how high the deductible was, but they couldn't afford their insurance. So, they're still showing up in the emergency room, still getting sick, not being able to be treated. Those bad debt cuts are really harming rural providers. We would like to see that addressed."

Improving access to healthcare in rural America isn't simply a matter of expanding health insurance, which remains a valid criticism of the ACA.

"Just because you have an insurance card doesn't mean you can access care," Elehwany says.

"And like we saw the high-deductible plans on the federal exchanges, it didn't mean you could actually afford your healthcare coverage. It didn't mean that, with the workforce shortages that are plaguing rural America, you could find a doctor in your rural community."

A Matter of Access
"Twenty percent of the U.S. population lives in a rural community, but only 9% of physicians practice there. It doesn't mean that you can access care if you live in a community where your rural hospital has closed, and now you have to drive 50 miles to the nearest emergency room," she says.

"It doesn't mean that you can access care if the plan you purchased has a narrow network created by the insurance company and you can't go to your local provider."

NRHA also has concerns about the per capita Medicaid funding scheme proposed in the House bill.

"We don't have a specific policy on a per capita cap, which looks like the movement in the House bill. We're trying to develop that rapidly and probably will have concerns that the federal government shouldn't abdicate oversight authority to ensure that federal tax dollars go to the neediest populations," Elehwany says.

"You can certainly have local and state control. We just don't want to see the federal government abdicate all its authority."

Elehwany found some positives for rural health in the House bill.

"It does look like there is safety net funding; $10 billion over five years. We strongly hope that that money is going to be targeted to help the safety net of rural America," she says.

"The bill summary says non-expansion states would receive an increased matching rate of 100% for calendar years 2018 through 2021, and then it would be reduced to 95%. So, it looks like they are trying to help states that haven't expanded Medicaid, which is a good thing."

"Is that going to do enough? We're concerned about that. We would love to see them allow safety net providers to have cost-based reimbursement in Medicaid similar to how they have cost-based reimbursement in Medicare, and have that enhancement come through the federal funding."

Let's Be Blunt
The ink is still wet on this bill, but it is DOA, even before the Congressional Budget Office has scored it. Democrats are unified in opposition, as are powerful lobbies, including the American Hospital Association, which has influential members in every Congressional district.

Republicans have majorities in the House and Senate, but intraparty support is already splintering and it's not going to coalesce in the coming weeks as the costs and other unsavory details emerge, even as leadership fast-tracks the bill.

For moderate Republicans, the bill goes too far. For conservatives, it doesn't go far enough. So far, President Trump has offered only tepid support.

However slim its chances, the American Health Care Act remains the most aggressive attempt to fundamentally revise Medicaid since its creation in 1965, so it bears watching.