Rural hospitals continue to close, and patients would be better served if Republicans would stop blocking Medicaid expansion. But constraints in rural healthcare can be overcome through innovation and collaboration.
As I peck out my last column of 2015, scrolling through stuff I've written over the past 12 months, I am struck by the tremendous challenges and changes underway in rural healthcare delivery. I don't know whether to be depressed or heartened. As with so many things, I suspect it's a dose of both.
On the negative side, the biggest challenge facing rural health is the hard-headed refusal by Republicans in 20 states to expand Medicaid under the Patient Protection and Affordable Care Act. By no coincidence, many of these holdout states score lowest on national health rankings.
Let's be clear: this is a political issue, not a healthcare issue, which is why I don't spend a lot of time writing about it. It must be said, however, that this is all on Republicans, who irony tells us are the intellectual godparents of Obamacare and the individual mandate that they now so roundly despise.
There is no valid policy argument for blocking the expansion of Medicaid. No reputable study has made a compelling argument that expanding Medicaid is a net negative for any state. In large part, that is because Medicaid does not create the need for healthcare. The need already exists. Simply ignoring the problem and refusing to expand the program doesn't make those care costs evaporate. People still get sick and need care, whether or not they're on Medicaid, and someone has to pay for it.
This is all particularly mean-spirited because it needlessly harms the poorest and most vulnerable people in our nation. Fortunately, there are signs that resistance is splintering as Republican governors with reality-based budget challenges push for expansion. Let's hope more states end this embargo in 2016. Unfortunately, it would not be surprising if the expansion blockade—which seems based on personal animus against President Obama—remains in effect until he leaves office in 2017.
A far more complex issue these past several years and into 2016 is the financial status and survivability of rural hospitals, particularly low-volume and critical access hospitals. Since 2010, 61 rural hospitals have closed, according to a watch list that's updated, all too often, by University of North Carolina researchers.
While there is no easy solution, that's not necessarily a negative. It's becoming obvious that rural care delivery is in the midst of profound and fundamental change. There aren't enough doctors or money in many parts of rural America to maintain a shaky status quo, and that means that the very process of providing care in rural areas is transforming. How that happens, and what the end product resembles, are subject to conjecture, but I choose to believe that ultimately this will be a very positive development.
I got some sense of what could transpire in the coming months and years after speaking with some rural healthcare visionaries over the past few months. In Beulah, ND, for example, Coal Country Community Health Center, a federally qualified health center, has learned the value of cooperation with one-time rival Sakakawea Medical Center, a 25-bed critical access hospital in nearby Hazen.
Darrold Bertsch, CEO of Sakakawea, told me the two providers—neither with resources to spare—found themselves fighting for market share and competing for redundant primary care and ancillary services. The inefficiencies threatened to shutter Coal Country Community in 2011, before the two sides forged a pact to coordinate care services.
This idea resonates. Two of the most urgent healthcare needs for rural healthcare are access to primary and emergency care, so it seems downright silly that rural hospitals and FQHCs don't coordinate and collaborate to effectively use precious resources. Turf wars are ridiculous when you can't afford the fertilizer. I expect we are going to see more of these sorts of alliances in 2016.
I was also impressed by a number of initiatives detailed in a piece I wrote about rural population health management for HealthLeaders magazine. What was particularly striking was that some very smart rural healthcare innovators who I spoke with were not content with adapting to a healthcare delivery and payment model designed around urban settings. They recognize that population health in rural America poses its own unique problems, with a generally older, sicker, isolated, and less-educated patient mix.
The common theme in the several initiatives detailed in the magazine article was the recognition that resources are scarce and collaboration is vital. It should be glaringly obvious that not everyone can provide every service to everyone, but some rural hospitals out there are still trying to do exactly that. They probably won't be around much longer.
For 2016 and beyond, we can expect to see more of these collaboration models among rural providers of all stripes, including hospitals, FQHCs, physicians, nurses, pharmacists, mental health professionals, and dentists. This teamwork will be facilitated by continually improving electronic medical records that allow every provider along the care continuum to access and monitor their patients' progress.
On balance, this outlook for rural healthcare in 2016 is heartening.
John Commins is the news editor for HealthLeaders.