PHM and Rural Healthcare — Part 1

With the recent passage of the bipartisan fiscal year 2023 omnibus appropriations legislation, and considering its positive impact on rural healthcare, I figured this was a good time to focus on rural population health. In this first of a two-part series, I’ll focus on the state of healthcare in rural America, and in the second part I’ll look at why a population health approach in rural settings is being touted by many as a viable solution to improving overall health.

Among many other provisions in the $1.7 trillion appropriations bill, there are two in particular that bolster rural health: an extension of flexibilities that ensure continued access to telehealth put in place during the Covid-19 public health emergency (PHE), as well as new rules that, while soon ending restrictions against disenrolling Medicaid beneficiaries who no longer qualify during the coverage redetermination process, bolsters support for other underserved groups.

I’ll come to why these two aspects of the new law are of particular note when it comes to rural population health a little further on. But first, let’s establish a baseline understanding of what healthcare looks like in more rural areas. 

Rural Health in the U.S. 

For starters, let’s define what we mean by “rural.” The authority for this in the United States is the U.S. Census Bureau, which considers rural areas to be “any population, housing, or territory NOT in an urban area.” This is obviously tied to their definition of an urban area, which the Bureau has broken down into two parts:

  • “Urbanized Areas” have a population of 50,000 or more.
  • “Urban Clusters” have a population of at least 2,500 and less than 50,000.

Now that we understand the difference between what constitutes an urban versus a rural environment, let’s look at health in these areas by the numbers. Depending on the source, between 15% and 19% of the U.S. population lives in rural counties. Despite these differing population estimates, there is a broad consensus that rural residents tend to be older, sicker, and less affluent than their urban counterparts. As of 2015, the median age in rural settings was 51, whereas it was 45 in more urban places.

Educational attainment also maps well onto underserved rural populations, with districts populated by those with lower academic achievement often experiencing worse health outcomes than higher-achieving districts. According to the County Health Rankings & Roadmaps, which is put together by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation (and which I discussed in a previous blog post), rural counties are “disproportionately represented among counties with school funding deficits, particularly those with large deficits. On an annual basis, 70% of counties with deficits of more than -$4,500 per student are rural.”

A key marker of health, the uninsured rate, can also help explain the health disparities that exist between urban and rural counties. Between 2010 and 2019, the uninsured rate for rural residents was about 2-3 percentage points higher than those in urban areas. Provisions of the American Rescue Plan (which I wrote about in a previous post) and Medicaid expansion have improved things somewhat, but uninsured rates remain disproportionately higher in states that haven’t yet expanded Medicaid. And perhaps most significantly of all, between 1999 and 2019 the age-adjusted death rate in rural areas worsened from 7% above that in urban areas to 20% higher.

As with other underserved groups, the COVID-19 pandemic shone a spotlight on rural health disparities and, in many cases, made them even worse. Rural health researchers with the National COVID Cohort Collaborative (N3C) examined data collected during much of the pandemic, and found that health outcomes in rural areas were far inferior to those in urban centers. The authors found the following:

“In rural communities that are near urban areas, people with COVID-19 were 18% more likely to be hospitalized, and those who lived far from urban areas were 29% more likely to be hospitalized. Mortality rates showed an even sharper disparity. After adjustments, rural residents — no matter how near they lived to urban areas — were about 36% more likely than urban residents to die within 90 days after COVID-19 hospitalization.”

These numbers are unbelievably high, and they bear some exploration. But before we go any further, let’s define what we mean by “health disparities.” There are a number of definitions out there, but the one I prefer comes from the U.S. Department of Health and Human Services’ (HHS) Healthy People 2030 initiative: 

“(A) particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”

Populations in Rural America

Although some folks may have a preconceived notion that rural America is mono-cultural and its landscape reflects a bygone era, that is a bit of a misconception. While it’s true that, as mentioned above, rural areas have higher poverty rates and that they’re populated by more elderly residents — and that on average the populations there are less diverse than their urban counterparts — it’s also true that, for instance, these areas are becoming more racially and ethnically diverse by the year, with people of color making up 24% of rural America in 2020. This represents an increase of 3.5 percentage points between 2010 and 2020.

In other words, a number of subpopulations reside outside the borders of most cities, many of which can be seen to one degree or another in urban settings as well. This segmentation is an important consideration when applying a population health approach to improving health outcomes, which we’ll further explore in a subsequent blog post. For now, let’s be content to say that individual subpopulations like military veterans or people in certain age groups can be targeted for healthcare interventions. 

So with limited resources and, on average, a higher disease burden to contend with, how do rural healthcare providers keep these populations healthy? For some insight into this, I’ll spotlight two provisions in the new omnibus appropriations bill, telehealth and an altered Medicaid coverage redetermination process, to see how the federal government is helping rural residents continue to fight the pandemic and improve health outcomes. 

Telehealth and Rural Residents

Gaining a better understanding of how these two provisions from the omnibus bill work will provide a backdrop to how creative thinking can be employed to shore up healthcare gaps in rural America. First off, let’s look at telehealth. During the early part of the PHE, when social distancing was key and it was advisable to avoid elective procedures in medical settings, telehealth became an important mechanism for delivering care.

A report by the Assistant Secretary for Planning and Evaluation noted that “The use of telehealth services surged during the COVID-19 pandemic. A 2020 study found that telehealth use during the initial COVID-19 peak (March to April 2020) increased from less than 1 percent of visits to as much as 80 percent in places where the pandemic prevalence was high, and a recent ASPE report found that Medicare telehealth utilization increased 63-fold between 2019 and 2020.”

As the PHE stretched on, telehealth became a significant component of healthcare: telehealth utilization peaked at more than 32% of Medicare claims in April 2020, then came down to between 13% and 17% by July of 2021. This is still orders of magnitude higher than its usage before the pandemic started. According to the Harvard Business Review, “The investments that have already been made in technology and training were only possible due to the waiver of a mountain of federal regulations that have hampered telehealth adoption for decades.”

The bottom line is this: telehealth adoption has opened up care access to underserved groups in general, and to rural populations in particular — especially as it pertains to Medicare and Medicaid beneficiaries. For the Medicare population, the omnibus spending legislation extends by two years certain telehealth flexibilities. Among other provisions, during the PHE (which is still ongoing at the time of this writing), beneficiaries are permitted to remain in their homes for telehealth visits that are reimbursed by Medicare; previously, beneficiaries needed to travel to a healthcare facility in person for these services to be covered.

In addition, telehealth visits have been authorized to take place on smartphones for those enrolled in Medicare, as opposed to being restricted to only taking place using equipment with both audio and video capability. This is key for rural residents, who on average have lower levels of access to broadband internet than do their urban counterparts. Indeed, according to the Federal Communication Commission’s 2020 Broadband Deployment Report, “22.3% of Americans in rural areas and 27.7% of Americans in Tribal lands lack coverage from fixed terrestrial 25/3 Mbps broadband, as compared to only 1.5% of Americans in urban areas.”

For Medicaid enrollees during the PHE, telehealth extensions have been similarly effective, and they’ve been ubiquitous:

“All 50 states and DC expanded coverage and/or access to telehealth services in Medicaid. States have broad authority to cover telehealth in Medicaid and CHIP without federal approval, including flexibilities for allowable populations, services and payment rates, providers, technology, and managed care requirements.”

Although these allowances may be tied to either the federal or state PHEs, states are planning to enshrine some Medicaid telehealth flexibilities into law.

Medicaid Coverage Redetermination

Another change enacted during the PHE that impacted rural residents was a change in Medicaid coverage redetermination requirements. At the beginning of the pandemic in March of 2020, Congress enacted the Families First Coronavirus Response Act (FFCRA), a piece of legislation that I wrote about in a previous blog post. Many of the provisions of this law, including enhanced federal funding for Medicaid and also for maintenance of effort (MOE) protections, were put in place with the understanding they’d be phased out at the end of the PHE.

More specifically, for anyone enrolled in Medicaid as of March 18, 2020, or for anyone newly enrolled between that date and the end of the national PHE, the FFCRA made it so states could not disenroll any beneficiary. CMS permitted states to “suspend or continue income checks or redeterminations during the emergency,” and conduct regular renewals. But importantly, the MOE prevents states from dropping Medicaid coverage during the PHE. Put another way, it mandated that these enrollees be given continuous eligibility unless they decided to move out-of-state, or they requested voluntary termination from the program.

Since nearly a quarter of individuals under the age of 65 who reside in rural areas are covered by Medicaid, and since 22 percent of them are dually enrolled in Medicaid and Medicare, the FFCRA had an outsized impact on rural residents. That said, the Consolidated Appropriations Act, 2023 actually makes changes to “the continuous enrollment condition and availability of the temporary increase in the Federal Medical Assistance Percentage (FMAP) under section 6008 of the Families First Coronavirus Response Act” such that it separates the end of the continuous enrollment condition from the end of the PHE, ending that condition on March 31, 2023.
This will allow states to terminate Medicaid enrollment of those beneficiaries who no longer meet Medicaid eligibility requirements. While in many ways this move is suboptimal, the coverage redetermination process restart will likely result in savings that will in turn be put toward funding other Medicaid coverage priorities such as “making permanent the postpartum coverage state option and requiring all states to establish 12 months continuous eligibility for children.”

The kind of creativity and flexibility demonstrated by the administration in extending telework allowances and amending the Medicaid coverage redetermination process during the PHE should be used when thinking about how to apply a population health mindset to rural healthcare delivery. I’ll examine how this might work in my next blog post.

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