As goes the country

Uncle Sam has shut itself down now for three days. But the scale of change in the three quarters of our country’s territory that is home to a sixth of our population is something else entirely.

Rural America has 46 million residents, more aging, more cancer, more heart disease and stroke, fewer health care professionals per capita than urban America, and more diversity than some may expect. Its health care sector is long known to be under stress. A forum at the Bipartisan Policy Center (BPC) Jan. 17 featuring two rural U.S. senators, Sens. Mike Rounds (R-SD) and Heidi Heitkamp (D-ND) and a handful of leading experts offered up a few solutions based on recent new study.

But for rural America to succeed, Uncle Sam must act. And to act it must overcome some bad habits.

With support from the Helmsley Charitable Trust, the report outlined by the BPC panelists said:

·       The federal rules governing rural Critical Access Hospitals (CAHs) should be loosened to allow them to offer more primary care and community-based illness prevention services;

·       Value-based payment models should be brought into rural America with revised Medicare and Medicaid payment rules. This is no small feat when individual rural health facilities serve small populations;

·       Rural America’s primary care workforce needs a boost; and,

·       Telemedicine can help, but to really work correctly rural America needs better, more reliable broadband.[1]

The BPC’s recommendations come with three significant cautions, though.

First, the present of rural America – older, sicker, with health care professionals themselves approaching retirement age – is the future of the rest of America. The countryside is one important laboratory where alternative methods of payment for improved care delivery can be put to the test. What significantly distinguishes rural American health care from urban is the volume of services made per provider and per facility is lower in the country. The benefits of scale are difficult to achieve in rural America.

Second is that the main health advisor to Congress, the Medicare Payment Advisory Commission (MedPAC), said otherwise. In 2012, MedPAC reported that rural hospitals were doing fine as any other hospitals, and that the assertion that rural America was older and less healthy than urban areas was mostly a regional issue reflecting the South.[2] MedPAC’s report drew significant and merited criticism from rural health advocates like the National Rural Health Association.[3] But the MedPAC in its more recent reports on rural health[4] has stuck with 2012 conclusions. Most recently it suggested that some critical access hospitals (CAHs) convert to remote emergency departments.

Last is that political structure and demography present significant barriers to progress in rural American health policy - especially where it costs more money. All Senators represent some rural population. By 2040 70% of Americans will live in the 15 largest states, represented by 30 Senators[5]. Arguably rural is overrepresented in the Senate. But only 113 of 435 House seats have more than one-third rural population.[6] Thus rural initiatives that the Senate can pass may struggle to find majorities in the House unless they are framed with policies appealing to cities and suburbia.

And so the most difficult barrier to surmount is this: In the modern hyper-partisan age, the power tool needed to save health care in rural America is compromise.


Frank Talk is a product of Cardinal Waypoint LLC, a new consultancy for health policy and leadership. Contact me here.


[1] Hoagland B et al. Reinventing rural health care, a case study of seven upper Midwest states. Bipartisan Policy Center, Washington DC, January 2018., retrieved 1/22/2018.

[2] Medicare Payment Advisory Commission. Chapter 5: serving rural Medicare beneficiaries. Report to Congress, June 2012., retrieved 1/22/2018.

[3] News release. MedPAC’s report is inaccurate, harmful to rural Americans. National Rural Health Association and Medicare Dependent Rural Hospital Coalition. June 15, 2012., retrieved 1/22/2018.

[4] Medicare Payment Advisory Commission. Chapter 7, Improving efficiency and preserving access to emergency care in rural areas. Report to Congress, June 2016., retrieved 1/22/2018. “Among CAHs that closed in 2014, the median aggregate Medicare payments for acute and post-acute inpatient services were $500,000 above PPS rates in aggregate. Despite the relatively high Medicare payment rates, these facilities were not able to stay open.”

[5] Lawler D. Urban v. rural tug of war across the U.S. Axios, July 2, 2016., retrieved 1/22/2018. The report quotes the findings of David Birdsell.

[6] ProximityOne. 113th/114th congressional districts rural/urban interactive table. ProximityOne., retrieved 1/22/2018.

Frank PurcellComment