When the U.S. Congress signed the Affordable Care Act (ACA) into law in 2010, the promise of Medicaid expansion and increased consumer access to health insurance through state-run individual marketplaces gave hope to rural health care providers who anticipated benefitting from a decrease in uncompensated care. The ACA was also designed to reduce Disproportionate Share Hospital (DSH) payments as the rates of the uninsured declined.
Now, eight years later, we can look at how the ACA has affected the regulatory direction of rural health care and where things might be headed in 2019.
How the ACA has changed rural health
The decisions of elected officials at the state level – on Medicaid expansion and implementing state-based health insurance exchanges – have been the largest factors in how rural populations across the country have fared under the ACA.
According to the Kaiser Family Foundation (KFF), studies conducted in 2017 and 2018 found that Medicaid expansion had a disproportionately positive impact on reducing the number of uninsured people in rural areas. Rural communities in expansion states experienced uninsured rate drops that exceeded the rates of the metropolitan areas in the same states. Additionally, Medicaid expansion was associated with improved hospital financial performance and significant reductions in hospital closures. A recent study published in Health Affairs also found significant benefits to patients from Medicaid expansion. Measured results revealed an increase in the quality of care in Medicaid populations for prevalent conditions such as hypertension, diabetes, certain cancers and obesity.
Given many current state and federal executive branch efforts to limit the implementation of the ACA, the impact on rural health care has the potential to be significant. For example, plans in certain states to place work requirements on Medicaid eligibility could prove challenging to rural populations who have limited access to transportation, work opportunities and child care compared to those in urban populations. The Georgetown University Center for Children and Families estimated 8,700 families in Alabama alone could lose Medicaid eligibility in the first year of such a program.
States that have not accepted expansion are also experiencing rural access issues. The Health Affairs study found that more than 80 rural hospitals have closed since the passage of the ACA – with most closures occurring in non-expansion states. In contrast, expansion reduced the rate of hospital closures by 11 per year nationwide. Some communities have repurposed their former hospitals as stand-alone emergency rooms or outpatient clinics in an attempt to preserve access to services.
Regulatory direction to advance rural health care
The Centers for Medicare and Medicaid Services (CMS) created a Rural Health Council in 2016 to address the health and care needs of rural markets, including access to care, economics and innovation. CMS recently published its first rural health strategy, which centers on five key objectives:
- Apply a rural lens to CMS programs and policies
- Improve access to care through provider engagement and support
- Advance telehealth and telemedicine
- Empower patients in rural communities to make decisions about their health care
- Leverage partnerships to achieve the goals of the CMS Rural Health Strategy
Rural health improvements through telehealth
As the CMS strategy suggests, major investment and expansion in telehealth could transform rural health, and there are several indicators that this idea is catching on.
First, in two recent Requests for Information from CMS and the Office of the Inspector General (OIG) of Health and Human Services, the federal government asked for public comment on how to reduce barriers – posed by the Anti-Kickback Statute and the Self-Referral Law (aka “The Stark Law”) – to build out the use of telehealth and telemedicine for rural beneficiaries of Medicare and Medicaid who receive treatment for End Stage Renal Disease (ESRD).
Second, in its recent proposed rulemaking for a reboot of the Medicare Shared Savings Program, CMS recommended the expansion of telehealth services and the relaxation of supervision requirements and geographic restrictions on where telehealth services can be originated and accessed. These proposals are in response to requirements of the 2018 Bipartisan Budget Act.
Third, the recently signed SUPPORT Act includes significant provisions for expanding telehealth services for behavioral health and substance use disorder treatment. While principally geared to address the opioid crisis, these provisions build on expanding the availability of telehealth for addiction treatment as an alternative to facility-based outpatient treatment.
Finally, CMS is expanding on telehealth services and service provisions in their Physician Fee Schedule rulemaking for 2019. While these additions may not have gone far enough in certain minds, CMS is encouraging public input to propose new services that may be appropriate for the Medicare telehealth benefit.
Overall, telehealth strategy, when paired with efforts to maintain access to larger health networks for acute care, could improve health care access by eliminating the need for rural patients to travel long-distances for care that can be delivered remotely.
After nearly a decade in action, the ACA is a major influence on rural health, and the regulatory path from here will be directly tied to what happens to this legislation and the priorities of those in charge of the local, state and federal governments.
Cerner empowers rural health care organizations to keep up with the ever-changing health care landscape through our CommunityWorksSM offering that has delivered cloud-based EHR technology paired with managed services since 2009. Learn more here.
