the American Association of Colleges of Osteopathic Medicine

This analysis was prepared by McDermott+ Consulting, on behalf of AACOM.

PURPOSE

The purpose of this hearing is for the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies to examine the challenges faced by those living in rural America and discuss solutions to address these challenges. While the hearing focused on a number of issues impacting rural America, including challenges related to lack of access to education and insufficient workforce opportunities, this summary document is focused on the health-related issues that were discussed during the hearing.

MEMBERS PRESENT

Chair Aderholt, Ranking Member DeLauro, Representatives Letlow, Hoyer, Moolenaar, Pocan, Harris, Harder, Ellzey, LaTurner

WITNESSES

Ms. Carrie Cochran-McClain, Chief Policy Officer, National Rural Health Association
Dr. Tearsanee C Davis, D.N.P, Director of Clinical Programs and Strategy, University of Mississippi Medical Center
Dr. Brittany Hott, Associate Professor, University of Oklahoma
Ms. Lenita Jacobs-Simmons, Deputy Assistant Secretary, Employment and Training Administration, Department of Labor
Mr. Tom Morris, Associate Administrator for Rural Health Policy, Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS)
Ms. Ruth Ryder, Deputy Assistant Secretary for Policy and Programs, Office of Elementary and Secondary Education, Department of Education
Ms. Laura K. Scheibe, Director of Career and Technical Education, South Dakota Department of Education

KEY TAKEAWAYS

Those in rural parts of the country have limited access to health care and disproportionately have worse health outcomes than those residing in urban areas.
One of the greatest challenges facing rural communities is rural hospital closures, which have been exacerbated due to workforce shortages, payer and administrative challenges due to high volumes of Medicaid and Medicare patients with low reimbursement rates, and lack of funding/resources.
There have been multiple initiatives taken by HRSA and other agencies to address these challenges, such as the Rural Residency and Planning Development Program, Rural Hospital Flexibility grants, and state initiatives such as partnerships between state telehealth agencies and schools.

OPENING STATEMENTS

Chairman Aderholt (R-AL) stated that rural parts of his district face many unique challenges such as limited access to health care, insufficient workforce opportunities, and an education system that is unable to meet the needs of students. They face health-specific challenges such as access to health care and specialty care, nursing shortages, high rates of opioid addiction, lack of facilities, and disproportionate burden of chronic disease. He shed light on challenges with maintaining a highly skilled workforce. He also discussed how the gap in broadband access between urban and rural areas is exacerbating disparities between rural and urban populations.

Ranking Member DeLauro (D-CT) explained that rural communities are integral to our national economy and one fifth of all Americans live in rural communities. Rural Americans are more likely to die of chronic illnesses in comparison to their urban counterparts, and have less access to health care and health insurance. She noted that since 2010, 147 rural hospitals have closed in the United States. She explained the Committee has increased funding for targeted programs that specifically address rural communities’ most pressing health crises, including the Rural Communities Opioid Response Program, Rural Emergency Hospitals Technical Assistance Program, and the Rural Maternity Obstetrics Management Strategies Program (RMOMS). She expressed her support for telehealth programs and other critical tools that help people access the health care that they need.

TESTIMONY

Ms. Cochran-McClain provided recommendations to strengthen the rural health care safety net and ensure that rural Americans maintain access to critical health care services. Due to COVID-19, many rural health care providers and rural hospitals face a crisis that continues to intensify. The pandemic exacerbated workforce shortages that have plagued rural communities for decades. The maldistribution of health care providers between rural and urban areas has resulted in unequal access to care and negatively impacts rural health outcomes. She encouraged the Subcommittee to recognize that rural America has a health care crisis and appropriate targeted funding to support programs that address rural hospital closures, building a robust rural health care workforce, the rural opioid epidemic, rural maternity deserts, and rural public health. She calls on Congress to continue support for Rural Hospital Flexibility grants to provide relief and resources to struggling rural hospitals and the Financial and Community Sustainability for At-Risk Rural Hospitals Program, which will target rural hospitals at-risk for imminent closure. She supports the Rural Residency Planning and Development Program and hopes that the Subcommittee will continue funding HRSA workforce development and distribution programs.

Dr. Davis thanked the Committee for past funding that has allowed them to implement programs, test models of care, and integrate innovation into practice in Mississippi. Provider shortages have directly affected the health of the community, with fewer services being offered locally, more transfers to other facilities, and unnecessary delays in care. UMMC created the Telemergency program to provide remote support to more than 20 critical access emergency departments across the state, but challenges remain. She also discussed payer challenges that contribute to fewer providers choosing to practice in rural primary care clinics. CMS reimbursement rates are not increasing with the rate of inflation, resulting in overall reduction in provider reimbursement. She added that more Medicare beneficiaries are moving to Medicare Advantage plans. These plans pay providers less and often will mislead patients into a false misunderstanding of benefits. Dr. Davis then discussed how telehealth has improved access to behavioral health services. She thanked the Office of Advancement of Telehealth (OAT) for their funding to test a model to help expectant mothers in rural areas reduce their risk of pregnancy complications and screening for social determinants of health, mental health needs, and domestic abuse. She is also seeking additional funding for school-based telehealth programs to continue to serve students statewide without regard for their ability to pay.

Ms. Jacobs-Simons stated that nearly 63% of U.S. counties are primary care health professional shortage areas. Many rural hospitals closed, threatening rural residents’ access to services provided by those hospitals, and many of those in low-income households and rural communities are significantly less likely to have health insurance coverage. She explained that the Department is providing job training and supportive services to workers in rural communities and expanding job training and workforce pathways for underserved and marginalized youth in rural communities. To address barriers to good jobs, the Department is helping individuals and communities impacted by the opioid epidemic. She discussed various grant programs that provide grantees with resources to offer workforce services for individuals in communities impacted by the health and economic effects of opioids.

Mr. Morris discussed HRSA’s investments in rural health and their initiatives to support rural hospitals, expand access to health care in rural communities, and grow the rural health workforce. All the members of the panel are working together as part of the Administration’s Rural Partner Network to link rural communities to grant and technical assistant resources. Rural hospitals provide essential care to small, isolated communities and they are an essential part of health care delivery in rural communities. These hospitals face challenges such as low patient volume, high fixed costs, payer mix that is heavily dependent on Medicare and Medicaid, and financial risk. Considering these, the President’s FY24 budget proposal includes $30M to support these facilities. They will continue to provide support through the Rural Health Outreach Program and will address maternal care through the RMOMS program. He discussed how those residing in rural communities have worse health outcomes due to lack of access to treatment facilities. The expansion of behavioral health care services in rural communities is a priority for the Administration. Rural areas face many challenges with the recruitment and retention of health care professionals and HRSA is working to train professionals in underserved areas through the Rural Residency Planning and Development program.

QUESTIONS AND ANSWERS

Chairman Aderholt asked about challenges to expanding telehealth in rural areas. Mr. Morris answered that expanding PHE telehealth flexibilities was crucial for rural areas. He outlined several challenges such as cross-state licensure burdens for physicians, broadband access issues, and lack of workforce. The number one use of telehealth has been ensuring access to mental health services. Chairman Aderholt then asked how we are encouraging medical schools to establish a rural residency track or include a rural rotation. Mr. Morris answered that HRSA has a number of programs that support primary care training and allow for medical schools to apply for funding and develop rural training tracks and targeted admissions within their curriculum. On the residency side, Mr. Morris added that they provided support to residency programs in rural communities to aid the accreditation process and take advantage of flexibilities under Medicare for rural hospitals.

Ranking Member DeLauro asked how they can expand the RMOMS program to all rural areas. Mr. Morris answered that the RMOMS program hopes to regionalize maternal health care which they have found to be challenging, so there is not a robust number of applications for that program. But he will provide more information later.

Representative Letlow (R-LA) asked how to help rural organizations help with the grant writing process. Ms. Jacobs-Simmons answered that the Department of Labor has changed their grant application process so that community organizations can easily apply and they conduct various webinars and trainings on how to apply for funding opportunities. Ms. Ryder explained that the Department of Education is trying to diversify the grantee pool. Mr. Morris answered that HRSA works closely with the 50 state offices of rural health and has targeted assistance for organizations that either haven’t applied or are not scoring well.

Representative Hoyer (D-MD) asked all of the witnesses about their views on how impactful the legislation passed by the Committee has been on rural areas. Mr. Morris answered that any investments in rural communities is a plus and all the legislation that had health care aspects to it has been beneficial. He added that the broadband legislation in particular is fundamental to health care and the dramatic expansion of health professional training dollars through the appropriations process will definitely benefit rural communities.

Representative Moolenaar (R-MI) asked how to define health care clinician. Mr. Morris answered that he uses it to refer to physician, nurse practitioners, allied health professions, anyone that has a clinical role. Representative Moolenaar asked how to support initiatives in local areas. Mr. Morris replied that partnerships with the Department of Labor have been really valuable and provide communities with flexibility.

Representative Pocan (D-WI) asked each of the panelists which program should be protected if there was a 22% cut in funding. Mr. Morris answered that it is hard to pinpoint one program over the others and any cuts result in fewer grants and fewer people served. Specifically, HRSA would not be able to make any new grants in the coming new year or any continuation grants for those community initiatives already funded.

Representative Harder (D-CA) asked about the criteria HRSA uses to allocate grants and what it takes to be both a rural and underserved community. Mr. Morris answered that there is no perfect definition, and they identify rural census tracts within metro counties and make a special adjustment for California because some census tracts are bigger than others in the country. They recently identified metro counties that had no urban populations and made those areas eligible.

Representative Ellzey (R-TX) asked how HRSA programs help rural providers treat those with substance use disorder. Mr. Morris answered that rural targeted funding helps address unique needs that rural communities face by allowing them to come up with their own solutions.

Representative LaTurner (R-KS) asked about the primary lessons learned from the expansion of telehealth services within the past few years. Mr. Morris answered that the need to reimburse telehealth services is important and there are still challenges with cross-state licensure where physicians have to be licensed in multiple states to provide services. He also added that we need to make sure that we have the workforce and need to expand the behavioral health workforce to provide telehealth services. Representative LaTurner then asked whether Mr. Morris would support expansion of REH eligibility to facilities who previous had inpatient designation and are still serving the same community. Mr. Morris answered that they will work with Congress to identify where people believe they will benefit from REH status but are currently precluded because of the existing statute.

Chairman Aderholt asked about the factors leading to rural hospital closures and what efforts should be done to support these hospitals. Ms. Cochran-McClain answered that factors that lead to rural hospital closures include declining financial performance due to reimbursement from Medicare and Medicaid, lower number of patients with higher numbers of health care challenges, workforce staffing shortages, and regulatory and administrative burden caused by Medicare and Medicaid patients because policies are created for larger health care systems.

Ranking Member DeLauro asked about the impact of lack of Medicaid dollars on the closures of hospitals in rural communities. Dr. Davis answered that without the appropriate funding, the hospitals don’t have what they need because the cost of providing care is increasing. More patients are on Medicaid, and they need the most care, but hospitals are unable to provide care for them without funds to operate. Ms. Cochran-McClain added that states that have not expanded Medicaid have higher rates of rural hospital vulnerability and closure. Ranking Member DeLauro then asked about the partnership between the Center for Telehealth in Mississippi and connecting students to behavioral health counseling in schools. Dr. Davis answered that they were awarded the opportunity to provide K-12 students with behavioral health services, urgent care services and lifestyle coaching. There are notable challenges such as all of the schools not having the same resources and there are many schools in the state that do not have school nurses.

Chairman Aderholt asked about the biggest challenges facing rural communities and what the Subcommittee can do to address them. Dr. Davis answered that one of the biggest problems is sustainability of telehealth programs because they rely on funding to begin the programs and test models of care but there is an issue with continuing the program and other administrative burdens. Ms. Cochran-McClain added that one of the biggest challenges is the closure of rural hospitals and we need consider the President’s proposals to help stabilize rural hospitals. She also stated that there is a workforce shortage, and we need to increase our capacity to grow the workforce.

CLOSING STATEMENTS

Chairman Aderholt thanked the witnesses for their time at the hearing.

Watch the full hearing here.