Access to healthcare in rural America is a big and growing problem, with over 100 rural hospitals having closed since 2010 and hundreds more at risk of shutting their doors in the near future. Election years don’t tend to be conducive to the passage of meaningful legislation, but healthcare access may be an exception this year, given that healthcare was a top concern for voters in the 2018 midterms.

By one key measure of healthcare access, availability of emergency care, rural America is in crisis. Nineteen rural hospitals closed last year, the highest number in the past decade, according to a report released last month by the Chartis Center for Rural Health. The closure rate has, for the most part, been in a steep rise since 2010, resulting in the closure of 120 rural hospitals.

What’s more, the Chartis report said that of the 1,844 rural hospitals still in operation nationwide, 453 of them, or nearly one in four, are “vulnerable” to closure. Almost half of those vulnerable facilities, in turn, fall into the subcategory of “most vulnerable” to closure.

The Chartis researchers identified several key risk factors that were contributors to past rural hospital closures and are possible predictors of future ones, including facility age, case mix and occupancy rate.

There’s also a political component to the rural hospital closures. The report indicates that most of the closures over the last ten years have been in red states that have refused to expand Medicaid under Obamacare. Being located in a Medicaid expansion state, on the other hand, reduces the likelihood that a rural hospital will close by 62 percent, according to the report.A review of research by the Kaiser Family Foundation, likewise, found that Medicaid expansion “has significantly improved hospital operating margins and financial performance,” including in rural areas. Consequently, hospitals have been among the strongest supporters of Medicaid expansion.

The rural healthcare crisis isn’t limited to just emergency care, however. Rural areas also suffer from a lack of other basic services like primary care, dental care and mental health care. The reason is largely a matter of simple arithmetic: Roughly 25 percent of Americans live in rural areas, while only about 10 percent of doctors practice in such locations.

States are approaching the problem from a variety of different angles. According to LexisNexis State Net’s legislative tracking system, at least a dozen states have introduced legislation in the 2019-20 session that would provide funding for rural healthcare facilities and services. The measures include enactments last year in Minnesota (SB 1 a), North Carolina (HB 200) and Pennsylvania (SB 314).

Measures concerning Medicaid reimbursements for rural healthcare facilities have been introduced in nine states, including Washington, which enacted HB 1534, increasing medical assistance payments for certain rural hospitals. Medicaid expansion bills have also been introduced in 38 states, eight of which have enacted them.

In addition, four states - Georgia, Illinois, South Carolina and Washington - have proposed legislation that would provide certificate-of-need or other regulation exemptions for emergency departments and other healthcare facilities in rural areas.

At least 10 states have introduced bills that would provide incentives, such as income tax deductions and education loan forgiveness, for physicians, nurses and other healthcare professionals that practice in rural locations. One of those measures, Hawaii’s SB 1404, has been enacted.

Bills are also under consideration this session that deal with rural training programs for physicians and nurses (Minnesota HB 3966, Nebraska L 666, Utah SB 16 and Washington HB 1942); the transportation of Medicaid recipients in rural areas (New York AB 380/SB 2918); rural telehealth (California AB 1759); and the licensing of foreign trained medical professionals to practice in rural communities (Massachusetts HB 1952).

Election years tend to inhibit the passage of meaningful legislation. As Charlie Dudley, a lobbyist for some of the biggest companies in Florida, told Politico last month, ahead of the state’s 2020 session: “Generally, you can’t get much done during an election year unless you have a sweet-spot issue that matches up with the Republican messaging for GOP House and Senate races, or in support of the president.”

That may be particularly true this year with a presidential election that promises to be one of the most contentious ever.

“On both sides of the aisle everything is going to be molded in some form or fashion by a cycle dominated by the presidential election,” said Florida House Minority Leader Evan Jenne (D), according to Politico. “All of that will be ratcheted up quite a bit.”

Healthcare issues could remain above the fray of presidential-year politics, however. Andis Robeznieks, senior news writer for the American Medical Association, recently reported that “according to a Gallup poll, health care concerns such as cost, access and coverage were the top issues on voters’ minds in the 2018 midterm elections, and politicians want to be viewed as being on the right side of those topics.” He also noted that at the AMA’s State Advocacy Summit in January, AMA Senior Vice President of Advocacy Todd Askew said gridlock in the nation’s capital opened the door for significant healthcare reforms in the states.

Ways to improve rural healthcare will be discussed in Alabama’s Legislature this session, according to WSFA 12 News in Montgomery. Potential topics of that discussion will reportedly include improving transportation to medical care, relying on medical clinics instead of hospitals and incentives to encourage physicians to work in rural areas.

Rural telehealth programs are another possibility. But that option could be hampered by another problem afflicting rural America: a lack of broadband access. Alabama enacted legislation targeting that issue just last year.

What won’t be talked about, however, according to WSFA, is Medicaid expansion, despite ongoing pressure from Democrats and the Alabama Hospital Association to end the state’s status as one of fourteen that have not expanded Medicaid.

“Because of the politics itself I think Medicaid expansion is a term that will not be discussed,” said House Speaker Mac McCutcheon (R).

Democratic state Sen. Bobby Singleton still holds out hope for it in the future.

“We are always going to keep Medicaid expansion out there,” he said. “It is something we believe that can happen in this state.”

The Alabama Hospital Association also said it would continue advocating for Medicaid expansion but that some sort of action needed to be taken now. Seven rural hospitals have closed in the state over the past decade. And the association said that with 88 percent of the remaining rural hospitals operating in the red, some of them won’t make it to 2021, if conditions don’t change.

“We can’t sustain what we have now,” said the organization’s executive vice president, Danne Howard.

Florida House Speaker Jose Oliva (R), meanwhile, said healthcare would continue to be “the central focus” of the agenda it has been for his chamber in recent years, according to the Politico report. Several bills dealing with rural healthcare are under consideration in that chamber. And Politico quoted Gus Corbella, a Florida lobbyist and former Senate Chief of Staff, as saying Oliva and Senate President Bill Galvano (R) “got 99.9 percent of their agenda passed last year.”

For a free, sample report showing the current status of all the bills mentioned in this story click here.


Rural Healthcare Access Big Concern in States

At least 33 states have considered legislation dealing with rural healthcare in the 2019-20 session, according to LexisNexis State Net’s legislative tracking system. Eight of those states have enacted such measures.