Rural America supported President-elect Trump. Now the Trump Administration needs to support Rural America in addressing their health challenges

President-elect, Donald Trump received staunch support from Rural America in this past election.  Hopefully, President-elect Trump will reward this support by aggressively addressing the healthcare and quality of life needs in rural America that have been long neglected by both Democrat and Republican administrations.

Approximately sixty million people live in rural areas across the United States, including millions of Medicare and Medicaid beneficiaries.

As noted by Economic Research Service of the Department of Agriculture in its March 2024 Report, “Working-age people living in rural areas are 43% more likely to die from natural causes than in urban areas.  Over the past 20 years, the death rate for working-age adults living in rural areas increased, while mortality decreased for those in urban areas”.  

 The recommendations identified in this blog will go a long way in positively impacting the lives of rural Americans. President-elect Trump has the power through the Executive Branch of the federal government to implement many of these recommendations. Mr. Trump can also aggressively influence both branches of Congress, State governments, and applicable organizations such as the American Medical Association and the American Hospital Association to implement these recommended initiatives and more.

The following is an abbreviated list of healthcare and quality of life challenges facing rural America:

• The COVID-19 pandemic impacted rural areas more severely than other regions in the country, which resulted in more financial challenges for their hospitals, healthcare workforce, and overall economy.
• Statistics have shown that, as a result of the impact of social determinants of health residents of rural counties face greater health issues and quality of life challenges  than most Americans.
• What is considered a health system in urban areas of our country, is not the case in rural America. While urban areas have an abundance of primary care, specialists, and hospitals availability, rural areas have no “real” health system available to them. There may be a patchwork of primary care providers, very few if any physician specialties, and minimal or no hospitals with easy access for residents. Hospitals, when available, have limited services, and those hospital services that are available are at risk of being discontinued, as is the case with maternity service lines.
• Transportation challenges present a major obstacle for access to needed healthcare services in rural areas.
• While urban areas mostly experience the benefits of telehealth, because of the lack of broadband availability, rural areas face major barriers.
• Compared to urban areas, there is a greater percentage of Americans over sixty-five in rural areas compared to urban areas and there is a shortage of long-term care and rehab facilities.
• Per the National Rural Health Association (NRHA) 2022 Policy Agenda , “77% of rural counties are Health Professional Shortage Areas, and nine percent have no physicians at all. The shortage of primary care physicians in rural areas continues to trend downward. In fact, the federal government projects a shortage of over 20,000 primary care physicians in rural areas by 2025.”

 Initiatives that can positively impact the healthcare and quality of life challenges in rural America:

• Increase the number of primary care residency programs in rural areas. Physicians tend to end up practicing for the long term close to where they perform their residencies. As noted by the Government Accounting Office (GAO), “98 percent of the residencies funded by Medicare are in urban hospitals. Because the formulas that dictate Medicare’s residency funding have mostly been left unchanged since they were created in the mid-nineties, the medical training pipeline has not been meaningfully remade to address the current misdistribution of the country’s physician workforce.”
• Enhance recruiting of students from rural areas into medical schools - Studies have consistently found that physicians who grew up in rural areas are more likely to stay and practice in rural settings (assuming they are linked to a rural residency site), and that counties with providers who have strong ties to the local community have better health outcomes.
• Increase reimbursement for primary care to not lose students to other physician specialties. As we transition to a risk/value-based health system that is focused on keeping patients and populations healthier, the role of the primary care physician should be moved to center stage. Primary care physicians’ compensation needs to be commensurate with their increased value-based role.
• Implement loan repayment programs that specifically focus on medical students who select primary care as their specialty, especially in rural America.
• Increase access to primary care physicians in rural areas through the J-1 Visa Waiver
• Maternity Deserts recommendations as noted by the March of Dimes:

1. Expand scope of practice and reimbursement for advanced practice providers (e.g., nurse practitioners, physician assistants, nurse midwives, certified midwives, and non-traditional providers such as doulas, community health workers) subject to state regulations for professional practice to maintain or improve access to local maternity care for rural women.
2. Develop and support rural-specific obstetrics-focused residency programs.
3. Leverage the National Health Service Corps Loan Repayment program to fill workforce shortage areas.

• Enhance financial support for Federally Qualified Health Centers (FQHCs) since in many cases they are the lifeline for healthcare services in rural America
• Enhance financial support for hospitals in Rural America:

1. Large urban hospital systems, many of which are tax-exempt non-profit hospitals, are the beneficiary of specialty referrals from rural areas of their state. There should be contribution requirements (financial or in-kind) levied on these urban referral centers that would help fund needed “community benefit” initiatives in rural counties within their state and to ensure essential hospitals services in rural counties are not eliminated.
2. If appropriate, financially support Rural Emergency Hospitals  - In 2023, a new Medicare provider type was implemented - the Rural Emergency Hospital is designed to maintain access to emergency and outpatient care in rural areas.
3. Increase the percentage of DISH payments to rural hospitals within the state.
4. Increase the percentage of 340-B payments to rural hospitals within the state. Many well-funded urban hospital systems receive this funding at the expense of inner-city and rural hospitals that desperately need it.
5. During the COVID pandemic, large financially stable urban hospital systems received funding from the federal government, while small rural hospitals either closed or were forced to shut down essential services, such as maternity care.  There should be a deliberate federal policy to direct payments such as these to hospitals in “real” financial need such as small independent rural hospitals in crisis.

• Where appropriate, expand funding for Freestanding Emergency Departments (FSEDs) in rural America which are defined by the American College of Emergency Physicians (ACEP) as a “facility that is structurally separate and distinct from a hospital and provides emergency care.”
• Expand the scope of practice for Nurse Practitioners, Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs) who provide care in rural America.
• Expand the financial support for Community Paramedicine. Community Paramedicine is a model of care wherein paramedics and emergency medical technicians (EMTs) operate in expanded roles to assist with healthcare services for those in need without duplicating available services existing within the community.
• Expand the financial support for the Community Health Worker Model (CHW) in rural America!  

a.    As stated in the Rural Health Information Hub:

1. “CHWs promote health within a community by assisting individuals and communities to adopt healthy behaviors.
2. Serve as an advocate for the health needs of individuals by assisting community residents in effectively communicating with healthcare providers or social service agencies.
3. Act as liaison or advocate and implement programs that promote, maintain, and improve individual and overall community health.
4. May deliver health-related preventive services such as blood pressure, glaucoma, and hearing screenings.
5. May collect data to help identify community health needs.”

b.    A value added to this model is that it becomes a source of employment for rural residents.

• Medicaid Managed Care & Medicare Managed Care Plans (MA) have a significant role in addressing the healthcare and quality of life needs in rural America.

1. Two thirds of the states have Medicaid Managed Care plans managing their Medicaid population.
2. Fifty-five percent of seniors are members of Medicare Advantage plans.
3. There is a greater percentage of Americans over sixty-five in rural areas compared to urban areas.
4. A significant percentage of residents of rural America are dual-eligible for both Medicare and Medicaid.
5. Both these plans enter risk arrangements with their states or the Center for Medicare & Medicaid Services (CMS), usually some form of capitation
6. In theory, the ultimate objective of Medicaid Managed Care and Medicare Advantage plans is to keep their membership healthy which, given the risk arrangements with the state and CMS, would result in enhanced profitability for the plans.
7. Both these plans, either through their own initiatives or state/CMS directives, also play a role in addressing social determinants of health.
8. Medicaid Managed Care and Medicare Advantage plans should be required to collaborate with each other as well as other community stakeholders to proactively address the healthcare and quality of life needs of residents in rural America.
9. Medicare Managed Care (MA) and Medicaid Managed Care plan should also be required to provide enhanced financial assistance in the form of higher reimbursement to rural hospitals, especially independent rural hospitals, in need.

•  Expand Medicaid to cover individuals who fall at or below 138% of the federal poverty level and raise income eligibility thresholds for parents.
• Rural Healthcare HUBs, which provide the needed infrastructure to support collaborative initiatives that address health and quality of life initiatives for the residents in rural America, should be aggressively financially supported by the federal and state governments.

1.  The U.S. Department of HHS (HRSA) report A Guide for Rural Health Care Collaboration and Coordination emphasizes the importance of collaboration and coordination to better serve the health needs of rural Americans.
2. As the report noted, “Safety net providers, such as health centers, rural health clinics, Critical Access Hospitals, public health departments, and others, can play a key role helping to meet the needs of so many rural communities. Collaboration among rural providers can enhance service delivery and improve coordination by building economies of scale and leveraging the strengths of each individual organization.”

• Broadband expansion

1. Broadband expansion is a critical foundational step to improve the health status and quality of life for rural America.
2. The government (both national and state) and internet providers need to collaborate on an income-based voucher system to address the affordability barrier of internet services.
3. A collaborative plan is needed to address computer literacy which could involve the utilization of classes at libraries, schools, churches, and retail establishments (Walmart, Dollar General, etc.) in rural communities.
4. Broadband expansion will allow virtual healthcare providers to play a greater role in rural America.
5. Broadband expansion will provide increased virtual job opportunities for residents in rural America.

•  Economic development - Public/Private partnerships focused on economic development in rural America is a critical priority. The most proactive solution to positively impact social determinants of health is the creation of jobs.  Rural America was already suffering from a loss of jobs prior to the COVID-19 pandemic, and the economic landscape has become even worse after the pandemic. Innovative public/private initiatives and collaborations are needed to revitalize the rural economies. Federal and State financial incentives, including tax abatement, should also be utilized if needed to incent rural economic development initiatives.
• Transportation challenges continue to plague rural America. There are multiple collaborative opportunities for community public/private stakeholders to find innovative approaches to address some of the transportation challenges that directly impact the health and quality of life of rural residents. The specific answer to these challenges needs to be addressed at the local level.

Conclusion

There is a "scarcity of resources" to address all of our societal priorities and, consequently, any initiatives that focus on making our rural communities healthier must also be done in a cost-effective manner.  

To be sustainable, any initiative must aggressively engage each of the rural communities from both a planning and implementation perspective, taking a ground-up approach.

Community public and private partnerships and collaborations have the potential to address both social determinants of health and needed services that impact health status and the quality of life of rural Americans. Ideally these collaborations and initiatives should be coordinated to ensure that they are being done in a cost-effective and impactful manner.

There is no cookie cutter answer for addressing the healthcare and quality of life needs in rural communities. Each rural community has its own profile and, consequently, requires a strategic plan linked to a needs assessment that addresses and prioritizes the specific needs and initiatives within that community.

The healthcare and quality of life challenges impacting residents of rural America can no longer be ignored. The time for immediate action is now and President-elect Trump and his Cabinet need to make this a priority.

Given the fact that many of the recommendations listed here, as well as other needed rural health initiatives, involve different areas and levels of government, the Trump Administration should appoint a rural health champion that has a dotted line to all the initiatives that would positively impact rural America.

There are many dedicated individuals and organizations whose mission is focused on the health and quality of life needs in rural America.  They are much more knowledgeable than I on the issues that are addressed in this blog as many of you.

Finally, I would like to extend a heartfelt Thank You to all of you for your commitment to rural America.

As always, I welcome the readers of this blog to share their own perspective on this critical issue.