Bringing Reform to Rural Health Care

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Jon BaileyHealth-care reform—specifically, the Patient Protection and Affordable Care Act (PPACA)—mandated sweeping changes to the US health-care system. Some of the more controversial of these, such as the individual mandate to purchase health insurance, are being contested in court, but Jon Bailey, JD, director of the Rural Research and Analysis Program at the Center for Rural Affairs, Lyons, Nebraska, notes that among the law’s less publicized effects are some important changes for rural health care. “There’s a lot of emphasis on prevention and public health,” he says. “This is a major change to our public policy. We liken it to Social Security and Medicare, which continue to evolve; perfection from the start is unrealistic, but there are a lot of possibilities here.” In 2009, Bailey wrote a paper on behalf of the Center for Rural Affairs that outlined key rural issues that health-care reform could potentially address. The paper, “The Top 10 Rural Issues for Health Care Reform,” highlights areas of particular vulnerability for rural, underserved areas, including an aging health-care workforce, lack of access to preventive services, financially stressed health-care facilities, and lack of infrastructure. Unique Needs What’s more, Bailey says, many of these issues interconnect, ensuring that there will be no easy fix for rural health care’s woes. “There’s been a lot of emphasis, in recent years, on health-care IT and electronic medical records, and that emphasis represents a lot of challenges to rural hospitals, clinics, and provider offices,” he says. “The broadband-technology infrastructure is not always the greatest in rural areas, and the workforce tends to be older, so workers may not be as familiar or comfortable with that technology.” Access to specialists (including radiologists) has long been a challenge in outlying areas, meaning that many smaller hospitals have turned to telemedicine to provide them with specialty expertise. “We’re not seeing many radiologists and other specialists coming into rural communities,” Bailey says. “If we can devise systems that allow people to have access to them where they’re practicing, that provides a great alternative for rural patients.” Unfortunately, the weak broadband infrastructure in many of these areas still presents an obstacle: “It’s a big cost investment up front,” he notes. “Over the long term, however, it becomes cost effective when people don’t have to travel from their home communities.” These issues are even thornier to address because of the razor-thin margins at which many rural hospitals and clinics operate. “Rural hospitals really have a tough time with nonpaying, uninsured, or underinsured patients, and they wind up eating a lot of the cost of their care—which really eats into their resources,” Bailey says. “They’re not swimming in money. They have to make decisions based on immediate patient-care needs, rather than long-term goals.” Add to these factors a workforce that is aging, with many caregivers on the verge of retirement, and you have a perfect storm of challenges, Bailey says. “A lot of rural areas are struggling with their health-care workforce as people retire, and it’s increasingly difficult to recruit newer and younger health-care professionals to rural areas,” he says. “Because of the cost of the education they undergo, the lack of potential patients, and other problems, in most cases, it’s just not financially feasible to establish a rural practice.” This goes double for specialists. He adds, “The issue of specialists in rural areas is probably a bigger problem than that of primary-care providers. As people get their training in specialties, there’s less inclination to practice in rural areas.” Solutions and Ongoing Challenges The PPACA contains a multitude of provisions that aim to (or have the potential to) create solutions for rural health care, Bailey says. “It’s understated,” he notes. “Most people don’t even know it’s in there. Many of the provisions and programs already existed, and the PPACA expanded them or provided more resources for them. In the long term, the law could be very helpful for health care in rural communities.” One of the law’s most debated mandates, which would require all US residents to have some form of health insurance, stands to benefit rural providers enormously—once it takes effect. “The law tries to address some of the financial challenges faced by hospitals and other health-care institutions by having nearly everybody insured,” Bailey says. “The health-insurance exchanges don’t go into effect until 2014, however, so we won’t see a change until 2015 or 2016. Financial issues will remain, for a lot of rural providers, in the near future.” Access to preventive services such as cancer screenings is also addressed, Bailey says—and indirectly, so is access to specialists like radiologists. By providing federal dollars to bolster local networks, both the PPACA and the American Recovery and Reinvestment Act make telemedicine programs more feasible for rural hospitals and clinics. “A lot of states are looking at how to set up these networks or make them better, and the government is helping them with the financial resources to make it possible,” he notes. “The easier you make it for people to access these services, the more likely they are to get them. We have to come up with alternatives to bring people the service in a way that allows them to access it in their home communities.” The issue of the aging workforce in rural areas is partially addressed by new programs that will help recruit and engage rural students who are interested in health care, Bailey says. “The data are pretty clear: If you’re a rural kid interested in this, you’re much more likely to return to a rural community to work,” he says. “We have to start mentoring our own young people who are interested in these careers, and there are a lot of provisions in the PPACA related to bringing more people into the rural public health-care system: getting more spots in medical schools and residency training, and recruiting people who are interested in these careers as early as junior high.” Bailey says that the workforce issue “may, in the long run, be the most important thing that comes out of this law.” From the Center for Rural Affairs’ perspective, the PPACA represents an important first step toward finally addressing issues that have been endemic to rural health care for far too long. “We understand the law isn’t perfect, and there are going to have to be changes,” he says, “but for a lot of the issues the rural United States faces, it’s a good start.”