6

Rural Health Policy

The workshop’s session on rural health policy introduced a variety of U.S. federal policies affecting rural health. It featured presentations on shifting rural health policy and practice toward value-based care, strategies for engaging health care providers to confront the health care crisis in rural America, the structure and function of tribal rural health policy, and the implications for rural health of the congressional response to the coronavirus disease 2019 (COVID-19) pandemic. Karen Murphy, chief innovation officer at The Steele Institute for Health Innovation at Geisinger Health, moderated the session.

SHIFTING RURAL HEALTH POLICY AND PRACTICE TOWARD VALUE-BASED CARE

Tim Putnam, president and chief executive officer (CEO) of Margaret Mary Health in Indiana, discussed how rural health organizations focus on population health, form collaborative partnerships, and create policy and practices centered on prevention and primary care. He described how a rural hospital can shift from focusing on medical interventions to prioritizing prevention and population health using the example of Margaret Mary Health, a small community hospital in Batesville, Indiana (see Box 6-1). He shared lessons his institution has learned in making this transition, as well as how the hospital has been affected by, and has responded to, the COVID-19 pandemic. He also highlighted the value of prevention efforts and the role of rural hospitals in this work.

Rural health care has been and will continue to be the leader in population health, Putnam said. By nature, rural physicians focus on primary care and prevention, which includes addressing social determinants of health (SDOH). He suggested that small rural communities are microcosms of health care delivery and that rural models prioritizing prevention and primary care can be highly effective. The mission of Margaret Mary Health—like many rural hospitals—is to focus on improving the health of community members, which is aligned with the aims of population health to make populations healthier.

Transitioning to Population Health and Value-Based Care in a Rural Hospital

Putnam explained that Margaret Mary Health began transitioning to a focus on population health approximately 7 years ago in order to better serve its community by keeping people healthier. This transition was catalyzed in part by the hospital board’s realization that the hospital was neither paid nor incentivized to focus on prevention and control of chronic conditions, such as diabetes. The board decided to make the changes necessary to transition to value-based care and focus on delivering population health services to their community, especially primary care. This transition required establishing multiple new partnerships and coordinating with other rural community health systems. Putnam said

the hospital initially considered becoming an accountable care organization (ACO) as the most viable solution, but like most rural hospitals, it did not have the adequate population size to meet the 5,000 Medicare beneficiary minimum required to participate in an ACO. Instead, Margaret Mary Health joined with nine other hospitals in California, Michigan, Oklahoma, and Texas to form the first national rural ACO. This union allowed the hospitals to reach the ACO minimum threshold of 5,000 Medicare beneficiaries. This partnership has created a collaborative effect in improving health care, Putnam noted. When hospitals create partnerships like this, each hospital can share its successes and failures with the others. He added that unlike the competitive relationships between some urban hospitals, rural hospitals tend to be less competitive and more supportive in wanting other rural hospitals to be effective and successful, and to have good outcomes.

Putnam described several lessons learned during Margaret Mary Health’s transition to a focus on population health. Initially, the institution adopted a “hospital perspective” in focusing 80–90 percent of its health care costs on 10–20 percent of its patients (e.g., people with severe chronic conditions). Hospital management soon realized the need to shift from a predominant focus on high-end patients to a greater focus on keeping people healthy. Margaret Mary Health engaged with primary care physicians to gain insights about how to focus on prevention, finding that they needed to get closer to patients and learn how their lifestyles and home life related to health. This can allow for strategies to address SDOH and encourage people to have annual wellness visits. Hospital management also learned that care coordinators can be instrumental in this effort, because physicians trust the care coordinators and convey that trust to patients. Putnam suggested that this type of shift from a “hospital focus” toward emphasizing primary and preventive care for communities enables rural health systems to lead the effort in population health.

Data are a core component of delivering population health services effectively, said Putnam. Being part of an ACO enables health systems to request Medicare claims information about patients, which provides a “treasure trove” of data that make it possible to build the knowledge base and avoid guesswork. To illustrate, he described a physician whose patients’ pharmaceutical costs were 20 percent higher than those of other physicians’ patients. She was perplexed because she was prescribing the same medications as her colleagues. In analyzing the data, they found that her patients’ emergency department (ED) costs were much lower, indicating that the decrease in ED visits and the higher prescription expenditures were the result of that physician’s efforts to motivate her patients to take their medications as prescribed without lapses between refills.

Effect of COVID-19 in a Rural Hospital

Putnam used the experience of Margaret Mary Health to describe the effect of COVID-19 on rural hospitals early in the pandemic (Goodnough, 2020). Margaret Mary Health treated its first patient with COVID-19 on March 13, 2020, and had to adapt quickly as the hospital exceeded regular capacity when the hospital’s service area was hit hard by the virus early on, causing a huge increase in patient load. Typically, the hospital’s inpatient services account for about 20 percent of care provision and outpatient services account for 80 percent. As more patients with COVID-19 crashed within hours of arrival at the hospital, this ratio shifted to 20 percent outpatient services and 200 percent inpatient services. Putnam said the transition to value-based care was helpful during the COVID-19 response as it allowed them to simultaneously meet the needs of patients with COVID-19 as well as the needs of their existing 2,000 ACO patients. With care coordinators in physician offices already in place, a structure existed for meeting the needs of regular patients through these trusted professionals. Many of the patients with COVID-19 were receiving primary care services from Margaret Mary Health, so the hospital had prior knowledge about their medical histories. Furthermore, Putnam said some of the patients most vulnerable to COVID-19—such as those with diabetes, high blood pressure, chronic obstructive pulmonary disease, and congestive heart failure—already had those chronic conditions under control prior to the pandemic. Putnam suggested that having a healthy population—in this case, a result of the shift in focus to population health—was a major boon to the COVID-19 response at Margaret Mary Health.

Toward Value-Based Care

Putnam remarked on how rural health systems can lead the way in the shift to value-based care moving forward. Although “an ounce of prevention is worth a pound of cure,” the axiom of Benjamin Franklin, the current reimbursement models for health care are focused on paying for and incentivizing cures rather than prevention. He noted that rural health care providers are able to witness the positive effects of prevention because of their close relationships with patients in their small communities. Moving forward, Margaret Mary Health is emphasizing annual wellness visits so patients see their physicians before they are sick. This is a challenge, as many people do not see the value of wellness visits, but the care coordinators and nurses in the system are helping patients understand that wellness visits—which may include screenings, prevention efforts, and immunizations—are a way of keeping people healthy.

Putnam said the rural setting is a microcosm of the world and that it is well suited for prevention work. Rural health systems are small, and the chief of staff is typically a primary care physician rather than the cardiovascular surgeons or high-end researchers who typically hold those types of positions in urban hospitals. The hospital CEOs and other leaders in rural health systems meet on a regular basis to connect with one another. The shared mission is to keep their communities healthier, so prevention is a priority from the start. In an urban setting, hospital board meetings may address topics such as the latest cancer proton beam therapy or the transplant program. In contrast, rural boards of directors focus on how to offer basic services to keep patients healthy. Putnam emphasized that these features of rural health settings are at the core of successful population health efforts. He noted that the same types of shifts in focus toward prevention and primary care efforts that were undertaken at Margaret Mary Health are also occurring in other small communities across the country, which will contribute to the success of broader population health efforts.

ENGAGING HEALTH CARE PROVIDERS TO CONFRONT RURAL AMERICA’S HEALTH CARE CRISIS

Keith Mueller is a Gerhard Hartman professor and head of the Department of Health Management and Policy from The University of Iowa and director of the Rural Policy Research Institute Center for Rural Policy Analysis. He provided an overview of recommendations from a report prepared by the Rural Health Task Force of the Bipartisan Policy Center (BPC)—Confronting Rural America’s Healthcare Crisis.¹ These recommendations address issues such as short-term financial stabilization, long-term financial sustainability, workforce shortages, infrastructure needs, and the development of new models of service financing and delivery. The recommendations include measures to (1) strengthen financial stability and sustainability; (2) increase flexibility in using resources, including the health care workforce; (3) create new models of financing and delivering services; and (4) improve health infrastructure. The task force included an array of rural health experts, such as rural health policy experts, health care systems leaders, and clinical practitioners. The report was developed via a series of roundtable discussions featuring stakeholder presentations, site visits, and work with congressional staff.

___________________

¹ The report is available at https://bipartisanpolicy.org/report/confronting-rural-americas-health-care-crisis (accessed September 9, 2020).

Strategies to Engage Health Care Providers in Population Health

In his presentation, Mueller focused on the report’s recommendations that he described as essential to engaging health care providers in population health, including short- and long-term financial stability, flexibility in resource use and incentives, and infrastructure support.

Short-Term Financial Stability

Stabilizing health care delivery in rural America is the first step in engaging providers in population health, said Mueller. Stabilization efforts involve addressing short-term circumstances for rural hospitals. One of the report’s recommendation to improve hospitals’ short-term financial stability is relief from Medicare sequestration payment reductions for rural hospitals. Sequestration relief was put in place for the duration of the COVID-19 pandemic,² and the task force recommends that this be extended through the year 2023. In addition, the group advised increasing payments to critical access hospitals (CAHs) by 3 percent. Other recommendations pertain to the criteria for designating rural health care facilities: reestablish the “CAH necessary provider” designation,³ and make permanent both the Medicare-dependent hospital designation and the low-volume adjustment hospital designation, rather than being subject to periodic renewals. Beyond hospitals, the task force also made recommendations regarding other providers, added Mueller. These include (1) paying rural clinicians reporting data under the Quality Payment Program, (2) extending bonus payments for new advanced alternative model participants, and (3) leveraging patient engagement incentives to decrease rural bypass and incentivize local care utilization.

Long-Term Financial Sustainability

The BPC Rural Health Task Force made a separate set of recommendations for improving long-term financial stability, said Mueller. For example, grants and loans for capital infrastructure could enable the maintenance of service lines and improve both structural safety and

___________________

² Sequestration is the automatic reduction (i.e., cancellation) of certain federal spending, generally by a uniform percentage. The sequester is a budget enforcement tool that was established by Congress in the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA, also known as the Gramm-Rudman-Hollings Act; P.L. 99-177, as amended). See https://crsreports.congress.gov/product/pdf/R/R45106 (accessed October 20, 2020).

³ Mueller noted that in the early years of the CAH program, states were able to designate facilities as CAH even if they did not meet federally designated CAH criteria, such as being at least 35 miles from another hospital.

patient safety. Capital infrastructure could also include converting facilities from the classic inpatient model into alternatives featuring increased outpatient services. Another recommendation was to enact payment reforms that would stabilize rural health clinics and expand access to advanced practice clinician services in these rural clinics. Mueller said he believed that certain existing Medicare-related regulations inhibit the success of rural health clinics and should be removed.

The task force also recommended that the Medicare-capped reimbursement rate for physician-owned rural health clinics should be increased. Currently, the physician-owned clinic reimbursement rate is lower than that for hospital-owned rural health clinics. It was recommended that enrolled ACO beneficiaries should be excluded when determining regional benchmarks in rural areas. Many of the beneficiaries in rural areas are ACO-attributed lives, and the shared savings of ACOs drive down expenditures for these individuals. Therefore, Mueller suggested that these beneficiaries not be accounted for in benchmarks, because doing so would affect the ability to generate shared savings in subsequent years. The shared savings of ACOs can be assessed based on benchmarks derived from data on previous practices, he added.

Flexibility in Resource Use

Flexibility in resource use—including human resources—is central to engaging providers in population health, said Mueller. He highlighted several of the task force’s recommendations that allow for greater flexibility in using resources. For example, it recommended that rules around colocation or shared space arrangements should be clarified to enable rural hospitals to partner more effectively with other health care organizations. It also recommended that advanced practice clinicians should be allowed to work up to their state’s scope of practice in rural health clinics. Similarly, the task force recommended removing regulatory and legislative barriers that prevent nonphysician providers from practicing at the top of their license. Mueller noted that steps have been taken during the COVID-19 pandemic to remove these restrictions and suggested that this flexibility be extended beyond the pandemic. Billing regulations currently prohibit Medicare beneficiaries from receiving multiple same-day services within the same specialty, which limits a provider to payment for one service per day. Therefore, the task force recommended exempting rural Medicare beneficiaries from this prohibition to allow greater flexibility for rural providers.

Incentives and Flexibility

Mueller noted that the task force emphasized the need for hospital transformation plans that allow facilities in rural areas to reflect the needs of their service areas more appropriately. Thus, it recommended putting in place incentives for rural facilities and communities that develop hospital transformation plans. The task force also suggested moving toward three alternative models of financing. The first is a new “rural and emergency outpatient hospital” designation that would include cost-based reimbursement. Moving away from inpatient-centered care, this designation would be an option for communities whose needs are largely emergency and outpatient care.⁴ The second model would establish an Extended Rural Services Program. To support communities where hospital-level services become unavailable because of hospital closures or reductions in capacity, this program would allow federally qualified health centers (FQHCs) and rural health clinics to offer hospital-level services that would otherwise be unavailable. The third is a multipayer global budget model that would shift the focus from hospital expenditures to total expenditures. Global budget models are currently being demonstrated in Pennsylvania, and one is operating in its second generation in Maryland. The task force also recommended decreasing participation thresholds for rural providers for all these alternative payment models, as well as rural health clinics and FQHCs, added Mueller. Program participation criteria are often biased toward larger populations, so alternative payment models for smaller population sizes are needed for rural areas.

Infrastructure Support

Mueller explained that the task force made an additional set of longer-term recommendations to address infrastructure support. The need for broadband services in rural areas has gained attention during the pandemic, leading to legislation being passed to extend and augment current provisions. The task force recommended prioritizing the connection of rural areas with broadband through anchor institutions and direct-to-home services, as well as ensuring effective implementation of the Broadband Deployment Accuracy and Technological Availability Act.⁵ They recommended that telehealth service use could be supported

___________________

⁴ Mueller noted that this model is included in legislation co-sponsored by Senator Chuck Grassley of Iowa, who served as a member of the Honorary Congressional Task Force on Rural Health that collaborated with the BPC Rural Health Task force.

⁵ More information about the Broadband Deployment Accuracy and Technological Availability Act is available at https://www.congress.gov/bill/116th-congress/house-bill/4229/text (accessed September 9, 2020).

by changes in payment policies, provider eligibility, location of sites of service, and eligible services. In response to COVID-19, all of these issues were included in legislation and regulatory changes. However, those provisions are time limited and will expire with the public health emergency. Mueller suggested that the temporary changes that worked effectively should be extended beyond the pandemic.

Additional Recommendations Related to Population Health

Mueller outlined several other recommendations related to population health made by the task force:

• Increase the number of rural-specific Center for Medicare & Medicaid Innovation demonstrations and expedite the expansion of promising models to the national level.
• Reduce the administrative burden on rural providers by using readily available claims data for quality performance.
• Improve access to quality maternal care in rural areas (four specific recommendations, including increasing the funding for maternal health training programs for primary care providers).
• Improve use of the currently available workforce (five specific recommendations, including expanding reimbursement to additional provider types and extending Medicare-covered status to additional mental health providers).
• Strengthen the Health Resources and Services Administration (HRSA) rural workforce programs (two specific recommendations).
• Expand federal rural workforce recruitment and retention initiatives (four specific recommendations).
• Authorize licensed clinicians to provide interstate services to Medicare beneficiaries.⁶
• Direct The Office of the National Coordinator for Health Information Technology to prioritize rural-specific training curricula for the health information technology workforce.

Conditions for Addressing Population Health

Mueller concluded by listing a set of necessary conditions to address population health from his perspective. These conditions include a financially secure delivery system with predictable financial resources and payment systems that support engagement in community-driven population

___________________

⁶ Mueller noted that this has been enacted temporarily in response to the COVID-19 pandemic.

health programming. He called for flexibility in how health systems are built and restructured through transformation plans. Flexibility is also needed in how professionals practice and how patients interact with a range of professionals. Finally, Mueller suggested that the BPC Task Force recommendations are building blocks for moving toward population health.

TRIBAL RURAL HEALTH POLICY

Benjamin Smith, deputy director for intergovernmental affairs for the Indian Health Service (IHS), provided an overview of the origin of IHS and its role in health policy development for American Indians and Alaska Natives. He described the breadth of facilities within IHS and outlined some of the current health challenges faced by American Indians. He also discussed the effect of the Indian Health Care Improvement Act (IHCIA) on current and future policy decisions related to the health of American Indians and Alaska Natives.

Smith is a member of the Navajo Nation and grew up on the Navajo Reservation in a rural, remote area. He is a second-generation federal employee within IHS, as his father was an IHS physician. Therefore, he has the dual perspective of witnessing firsthand the provision of federal services to American Indians and understanding how policy decisions are made within the federal government. He explained that IHS is committed to providing quality health care consistent with statutory authorities and the government-to-government relationship of the United States with American Indians and Alaska Natives. Serving members of 574 federally recognized tribes, IHS is a comprehensive health service delivery system for approximately 2.6 million individuals. IHS has an annual budget appropriation of approximately $6 billion and employs more than 15,300 people, including nurses, physicians, pharmacists, sanitarians,⁷ physician assistants, and dentists.

History of the Indian Health Service

To provide historical context, Smith traced the origins of what would later become IHS back to the 18th and 19th centuries. During that time, the U.S. government entered into treaties with American Indians and

___________________

⁷ A sanitarian is an investigator of health and safety within an environment. This may be the workplace, food preparation facilities, industrial producers, or even the general environment. Sanitarians not only enforce health and safety regulation, but they also identify risk factors between people and in specific spaces. See https://www.careersinpublichealth.net/careers/sanitarian (accessed October 20, 2020).

Alaska Natives. In trading land for education, health care, and other services, a relationship was formed between the U.S. government and American Indians and Alaska Natives that required a series of policies to manage this partnership. Beginning in the early 1800s, the Administration of Indian Affairs was located in the Department of War. He noted that this may seem an unusual location for an organization focused on government-to-government relationships. However, as the United States was expanding westward, many health care services were located in military forts providing episodic care. The Department of War was therefore seen as the most effective department for housing the Administration of Indian Affairs and responding to the health care needs of American Indians and Alaska Natives. In 1849, oversight and administration of Indian health was transferred from the Department of War to the civilian Bureau of Indian Affairs located within the Department of the Interior. Congress first appropriated funding specifically for health services to Indians in 1911 in the amount of $40,000, which would be approximately $1 million today. Milestone legislation came in 1921 with the Snyder Act, which defined the U.S. government’s responsibility for American Indian health care. IHS continues to work off the Snyder Act today, in addition to other subsequent milestones.

Smith explained that IHS was formally established by law through the Transfer Act of 1955, which transferred all health facilities operated by the Bureau of Indian Affairs—many of which were in schools or health centers attached to schools—to what is now called the Department of Health and Human Services (HHS). Around that time, the Committee on Appropriations of the House of Representatives directed the U.S. Public Health Service to conduct a comprehensive survey of the status of Indian health in general and report the results to Congress. Published in 1957, this report is commonly referred to as the Gold Book (owing to the color of its cover) and included several notable conclusions, said Smith. First, it found that a substantial federal Indian health program is required. Next, community resources should be developed in cooperation with the American Indian and Alaska Native communities on a reservation-by-reservation basis. Third, federal Indian health programs should be planned in each community and services made available to Indians under state and local programs. Finally, efforts should be made to recognize the obligations and responsibilities to Indian residents on a nondiscriminatory basis from the state and local communities.

Smith emphasized the ramifications of these findings. With 574 federally recognized tribes having government-to-government relationships, developing policy addressing all of these findings is no easy task. Therefore, the Gold Book led to other key legislative efforts, such as the Indian Sanitation Facilities Act. Enacted by Congress in 1959, this legislation

expanded the Snyder Act and the Transfer Act to include sanitation facilities and services as part of the health care services provided to American Indians. Sanitation construction projects, environmental health programs, and hospital and health clinic construction became public services offered by IHS. Smith noted that water access continues to be a challenge for many American Indian and Alaska Native communities.

Throughout much of the 20th century, federal tribal policy took a “termination” or “assimilation” approach in trying to bring rural communities into urban health centers, Smith said. While each of the federally recognized American Indian and Alaska Native tribes was to have a government-to-government political relationship with the United States, prior federal policies of relocation and assimilation resulted in a large population of native peoples residing in urban centers. In the 1970s, a dramatic policy shift took place, moving from termination to self-determination. The Indian Self-Determination and Education Assistance Act of 1975 authorized government agencies to make grants directly to federally recognized tribes, who then had authority over how they administered the funds. This renewed the government-to-government relationship the U.S. government has with each individual tribe. In 1976, the Indian Healthcare Improvement Act was first enacted, expanding the types of services IHS could provide.

The legislation of the 1970s brought about a new contracting mechanism, noted Smith. Rather than being regulated by the Federal Acquisition Regulations or by the rules and regulations of grants or cooperative agreements, it is a unique contracting mechanism in which the federal government transfers program service functions and activities directly to American Indians and Alaska Natives. This contracting method continues to be reflected in today’s IHS through service delivery mechanisms described in the next section.

Indian Health Service Delivery Mechanisms

Smith described three types of service delivery mechanisms available for American Indians and Alaska Natives to choose from. The first is direct service provision from the federal government. The next option is for a tribe or tribal organization to exercise self-governance authority under the Indian Self-Determination and Education Assistance Act in contracting health care programs from the government and operating them tribally at the local level. Norton Sound Health Corporation Hospital is one such facility, operated and managed in Alaska by the Alaska Natives. Some benefits of this option include added flexibility in redesigning programs and the ability to retarget funds to meet health care needs within that local community, he said. The third delivery mechanism is an option

for meeting the needs of the large population of American Indians and Alaska Natives residing in urban settings. This involves contracting with nonprofit organizations and nongovernmental, urban Indian organizations. The Indian Healthcare Improvement Act authorized IHS’s Urban Indian Health Program and funds 41 urban-centered, nonprofit organizations nationwide.⁸

IHS has a diverse range of health care facilities across the United States that use these three delivery mechanisms, said Smith. These facilities include those directly operated by IHS, tribal health programs, and the urban-centered organizations. With hospitals, health care centers, clinics, health stations, school health centers, and youth regional treatment centers, great variety exists in IHS-affiliated facilities. The majority of facilities are tribal health programs, meaning a tribe or tribal organization operates the facility pursuant to the Indian Self-Determination and Education Assistance Act. This is evident in the state of Alaska, which is home to more than 200 federally recognized Alaska Native villages. Alaska has 58 tribal health centers, 160 tribal community health clinics, and 6 tribally operated hospitals.⁹ Smith noted that since populations can be very small, village clinics are important. Furthermore, he pointed out that at these smaller facilities, health objectives at the local level are targeted in decision making and policy setting within a tribal government.

Community Health Representatives Program

Another long-standing aspect of rural health care provision to American Indians and Alaska Natives is community outreach, Smith said. In response to the needs expressed by tribal governments, organizations, and IHS, Congress established an outreach program in 1968. The Community Health Representatives (CHR) program was designed to bridge the gap between patients in the community and health care facilities providing care.¹⁰ Predating the Indian Self-Determination and Education Assistance Act, the CHR program was the first formal assumption of an IHS-supported program by an Indian tribe. Smith suggested that rural health can be conceptualized as community members responding

___________________

⁸ More information about the geographic location of these health facilities and the types of programs they offer is available at https://www.ihs.gov/locations (accessed September 9, 2020).

⁹ More information about IHS in Alaska is available at https://www.ihs.gov/alaska (accessed September 9, 2020).

¹⁰ More information about the CHR program is available at https://www.ihs.gov/chr (accessed September 9, 2020) and https://www.ihs.gov/ihm/pc/part-3/p3c16/#3-16.3C (accessed September 9, 2020).

to health care needs and using their own language to translate needs and services in a culturally appropriate and acceptable way.

Challenges Faced by the Indian Health Service

Smith remarked that tribal governments and IHS face great health challenges, like much of the rural United States. For example, life expectancy is substantially shorter for American Indians and Alaska Natives (at 4.4 years less) than the average for the entire U.S. population.¹¹ Funding is a barrier, as reflected in data from the National Congress of American Indians and the National Indian Health Board indicating that per capita expenditures are lower for IHS than for other groups. IHS uses a pricing model called the Federal Disparity Index to compare IHS funding for medical services with that of the Federal Employees Health Plan.¹² This index shows that current funding meets 48.6 percent of the need, Smith said, and Congress appropriates less than half of what IHS requires to carry out its statutory authorities each year. Remote locations and government hiring freezes make workforce recruitment and retention difficult. Furthermore, Smith noted challenges related to government parity in salary and leave. Aging facilities and equipment are issues, with outdated main facilities held over from the transfer from the Department of the Interior and equipment shortages in hospitals, clinics, and service units. This also affects recruitment and retention, as candidates who have just completed years of training and education may not be familiar with the outdated equipment still used in some IHS facilities. Smith added that IHS is working toward electronic health record (EHR) modernization, but it continues to face health information technology challenges related to data security and lack of infrastructure in rural sites.

Policy Ramifications of the Indian Health Care Improvement Act

Smith said that the IHCIA,¹³ made permanent with the passage of the Patient Protection and Affordable Care Act of 2010, covers a number of topics and underscores federal policy related to Indian health. It sets the goal of ensuring the highest possible health status for American Indians and Alaska Natives, benchmarked with the objectives of the

___________________

¹¹ Life Expectancy American Indians and Alaska Natives Data Years 2007–2009. See https://www.ihs.gov/sites/dps/themes/responsive2017/display_objects/documents/LifeExpectancy2007-09ReportMemo.pdf (accessed October 26, 2020).

¹² More information about the Federal Disparity Index is available at https://www.ihs.gov/fdi (accessed September 9, 2020).

¹³ More information about the IHCIA is available at https://www.ihs.gov/ihcia (accessed September 9, 2020).

federal Healthy People initiative. He noted that IHS has been working to update those objectives to include the rural component, because tribes and tribal organizations fall into this category. He said that American Indian participation has been ensured and maximized by the IHCIA, which defined a new form of communication through tribal consultation and conferral with urban Indian organizations. When the federal government sets policy, the process needs to include tribal and urban partners. Smith said that the IHCIA sets forth objectives for health professionals, uses a government-to-government relationship, and provides the funding necessary for facilities operated both by the Indian Health Service and by tribes. Smith emphasized that as tribes set policies in the future, it is important that the federal government underscore its commitment to providing access to health care to American Indians and Alaska Natives, as established by treaties and within the bounds and scopes of the laws that set forth their authorities.

CONGRESSIONAL RESPONSE TO COVID-19 FOR RURAL AMERICA

Kate Cassling, director of the BPC Action and Bipartisan Policy Center, described the four COVID-19 pandemic response bills passed by Congress between March 6 and April 26, 2020: the Coronavirus Preparedness and Response Supplemental Appropriations Act; the Family First Coronavirus Response Act; the Coronavirus Aid, Relief, and Economic Security (CARES) Act; and the Paycheck Protection Program and Health Care Enhancement Act. She highlighted major components of the legislation, with an emphasis on provisions related to health care and ramifications for rural providers. A discussion of future pandemic legislation ended the presentation.

Coronavirus Preparedness and Response Supplemental Appropriations Act

Cassling explained that the Coronavirus Preparedness and Response Supplemental Appropriations Act (H.R. 6074)¹⁴ was the first bill passed in response to the COVID-19 pandemic. Enacted into law on March 6, 2020, it allocated $7.8 billion to a variety of agencies addressing pandemic-related issues such as health problems and economic challenges. Funding included $2.2 billion to the Centers for Disease Control and Prevention

___________________

¹⁴ More information about the Coronavirus Preparedness and Response Supplemental Appropriations Act is available at https://www.congress.gov/bill/116th-congress/housebill/6074 (accessed September 9, 2020).

(CDC), $836 million for the National Institute of Allergy and Infectious Diseases, $61 million for the Food and Drug Administration, and $20 million for disaster loans via the Small Business Administration (SBA). The Public Health and Social Services Emergency Fund received $3.1 billion with this measure, including $100 million for HRSA for grants under the Health Centers Program.

Families First Coronavirus Response Act

Given the rapid deterioration of the health situation and the problematic nature of the economic situation in the early phases of the COVID-19 pandemic, Congress quickly realized further support was needed, said Cassling. On March 18, 2020, the Families First Coronavirus Response Act (H.R. 6201)¹⁵ was signed into law, providing an additional $3.47 billion in funding. A large portion of this support was dedicated to maintaining access to nutrition services that are critical for many people in both urban and rural environments, such as the Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; and the Emergency Food Assistance Program. It also allocated an additional $1 billion to the Public Health and Social Services Emergency Fund specifically to help health care providers cover the cost of COVID-19 testing for the uninsured. Furthermore, the bill provided a temporary increase in the federal match for Medicaid, expanded access to paid sick leave, and required that COVID-19 testing and related services be covered without cost-sharing across payers such as Medicare, Medicaid, and private insurance.

Coronavirus Aid, Relief, and Economic Security Act

Signed into law on March 27, 2020, as the largest stimulus bill in U.S. history, the CARES Act (S. 3548)¹⁶ allocated more than $2 trillion for economic relief in the wake of the pandemic. Cassling remarked that the speed with which this large spending bill passed with bipartisan support is rare, indicating the importance of the pandemic-related problems and profound concern on the part of members of Congress. She added that the bill touched every part of the economy and the health care industry. The CARES Act included economic measures, such as expanding

___________________

¹⁵ More information about the Families First Coronavirus Response Act is available at https://www.congress.gov/bill/116th-congress/house-bill/6201 (accessed September 9, 2020).

¹⁶ More information about the CARES Act is available at https://www.congress.gov/bill/116th-congress/senate-bill/3548 (accessed September 21, 2021) and https://home.treasury.gov/policy-issues/cares (accessed September 9, 2020).

unemployment insurance with a $600 per week benefit increase. Cassling noted the July 2020 expiration date for this benefit has become a focus of conversations around needed future steps should economic conditions not improve. Also included in the CARES Act were recovery rebates of $1,200 issued to many Americans below an income cap. State and local governments received $150 billion in funding, and $500 billion was allocated to mid-sized and large businesses. Additionally, this legislation created the Paycheck Protection Program (PPP) through SBA, which provided loans to small businesses with fewer than 500 employees, including rural health providers. Although $350 billion was initially allocated to PPP, there were some early implementation difficulties. Cassling commented that challenges will arise any time a bureaucracy is tasked with pushing out large amounts of money in a short amount of time, but, in this case, rural health providers, “mom and pop” business owners, and minority-owned businesses struggled to access the first round of PPP funding. Since then, the Department of the Treasury, SBA, and Congress have taken steps to address this issue, making it easier for rural providers and others to access PPP loans, added Cassling.

CARES Act Funding for Rural Providers

Cassling explained that many rural health care providers received some type of financial support via the CARES Act because it included numerous provisions related to health care. An allocation of $100 billion was designated for hospitals, physician practices, and other health care providers. This funding was two-fold: first, to compensate for revenue lost to canceled elective procedures, and second, to cover the increased costs of pandemic-related needs such as personal protective equipment (PPE), testing supplies, and emergency operations. Cassling said HHS was balancing between the need to transfer large amounts of money quickly on the one hand, and ensuring that funds are sent to appropriate recipients on the other. Initially, HHS used past Medicare payments to determine amounts sent to individual providers. This worked well for some providers, but the method was problematic for children’s hospitals and facilities that traditionally relied on Medicaid payments. Over time, HHS determined that funding set-asides were needed to ensure that particular populations were not overlooked. To that end, HHS set aside $10 billion specifically for rural providers.

Additional measures for economic stability include the suspension of the 2 percent Medicare sequester until December 31, 2020, which was referenced early by Mueller. A 20 percent Medicare add-on payment was provided for treating COVID-19 patients. The CARES Act also expanded the Medicare Accelerated Payments Program, which provides upfront

loans for providers based on what future Medicare payments are expected to be. Cassling said this was rolled out fairly smoothly, yet it was suspended by HHS because of its effect on the Medicare trust fund. She said that some rural providers report that they cannot necessarily repay these loans under current circumstances, however. This has led to bipartisan conversations at the federal level about how to adjust repayment for those loans, whether by lowering interest rates, changing the payment schedule, or forgiving the loans entirely. In spite of bipartisan support, Cassling stated that the major challenge to adjusting loan repayment is funding, given the state of the Medicare trust fund and issues with solvency. The CARES Act also provided grant funding, including $1.32 billion for community health centers and $180 million in HRSA grants designated specifically for strengthening telehealth and rural community health.

Additional CARES Health Provisions

Cassling noted that the CARES Act includes additional provisions regarding extending health care programs, the health care workforce, and telehealth access. “Health extenders” are a group of provisions extending funding for a collective of health care programs such as the Community Health Centers Fund, the National Health Service Corps, and the Teaching Health Centers Graduate Medical Education program. Because of ongoing debate about how to fund health extenders, they were set to expire in May 2020. COVID-19 raised concerns about ending health programs during a pandemic, thus the CARES Act reauthorized the health extenders through November 30, 2020. The legislation also includes several provisions to meet the increased demand for health care services, such as immunity from malpractice lawsuits to health care professionals who volunteer to provide medical care during the pandemic. It also authorized the reassignment of National Health Service Corps providers to respond to COVID-19 and established a Ready Reserve Corps of trained doctors and nurses to respond to this pandemic as well as future health emergencies.

Cassling stated that a series of governmental actions in response to COVID-19, such as appropriations bills and regulatory changes, have dramatically increased access to telehealth services. The CARES Act allowed FQHCs and rural health clinics to provide telehealth services to Medicare patients in their homes, which opened the door to phone-based services for patients who do not have high-speed Internet access. HRSA telehealth grant programs were expanded to specifically help providers set up this service and obtain the tools and technical assistance needed to use it. The CARES Act also included funding for broadband investment, providing $125 million to the Rural Utilities Service. Cassling contended that the

broadband investment gap is in the billions, rather than the millions, but he said this step recognized that providing telehealth in rural communities requires access to high-speed Internet. She continued that the U.S. administration has pushed for reimbursement parity and has increased the number of people eligible for various types of telehealth programs. Moving forward, she predicted a continued relaxing of telehealth regulations that will be of particular benefit to rural health communities contending with access issues.

Paycheck Protection Program and Health Care Enhancement Act

Cassling described the fourth bill in response to COVID-19—the PPP and Health Care Enhancement Act (H.R. 266). Passed on April 26, 2020, the legislation allocated $500 billion in additional funding and addressed some technical problems in the CARES Act. As it went into law only 1 month after the $2 trillion CARES Act, the need for this bill reflects the high level of challenges brought on by the pandemic. The bulk of funding, $321 billion, was for the PPP, which extends to rural employers with fewer than 500 employees. An additional $75 billion was allocated to hospitals and other health care providers faced with COVID-19 revenue losses and cost challenges. The Disaster Loans Program received $50 billion, and $25 billion was allocated for testing, including $825 million designated for community health centers and rural health clinics.

Prospect for Further COVID-19 Legislation

Cassling considered the prospect for further legislative response to COVID-19 (as of June 25, 2020). Conflicting priorities between Republicans and Democrats make it difficult to predict what will happen next, she said. She also noted discussions of incentives to encourage a safe economic reopening versus a continued reliance on federal stimulus. Cassling said that support for rural hospitals comes up repeatedly in legislative discussions, reflecting substantial concern about the financial state of a number of hospitals, especially as COVID-19 cases rise in rural communities. In May 2020, Democrats passed a $3 trillion relief package through the House of Representatives that included every democratic priority related to the pandemic. However, the bill did not have enough support to pass through the Senate. She said that Democratic priorities for the next COVID-19 bill include funding for state and local governments, with an additional Federal Medical Assistance Percentages rate increase; further relief for health care providers, including rural hospitals; national plans for testing, contact tracing, and future vaccine distribution;

improving access to health insurance coverage;¹⁷ addressing racial and ethnic health disparities; and support for essential workers, including health care providers, with a provision for hazard pay. Cassling concluded that in response to current unrest in the United States around issues of race, racial and ethnic health disparities have moved to the forefront of these priorities. Although bipartisan conversations are necessary for additional legislation to become law, this had yet to happen as of June 2020, she added.

DISCUSSION

Addressing Social Determinants of Health in Rural Settings

Noting that urban hospitals have access to support from community agencies, Murphy asked Putnam how SDOH are to be addressed in rural areas that lack this type of support. Putnam agreed that lack of access to community agencies is a challenge for rural providers, so ingenuity is required to address SDOH. He gave an example focused on behavioral health, mental health, and addiction needs. While rural providers are able to perform surgeries and treat conditions such as pneumonia, they do not have access to the range of services found in urban areas. Rural providers found that some patients were unable to manage their chronic diseases properly because of mental health issues, so they had to create their own programs. Putnam gave the perspective that mental health services are not “acute care,” which fueled initial reluctance to expand these services. However, he suggested that over time, there has been increasing acknowledgment that rural providers should build programs to provide mental health services.

Putnam also emphasized the need to take advantage of available resources. In rural communities, social services are often not provided through formal programs, but instead come from area churches and other civic organizations. In the absence of government solutions, tightknit communities work together to address issues related to transportation needs and other barriers. Putnam gave an example of the lack of PPE as the pandemic began, saying that health care team members were becoming ill from exposure to COVID-19 because they were running out of masks. The community began sewing masks to build up the mask supply and protect the team. Community members have also volunteered to take

___________________

¹⁷ Cassling noted that the Health and Economic Recovery Omnibus Emergency Solutions Act created a new special enrollment period for the Patient Protection and Affordable Care Act, as well as Consolidated Omnibus Budget Reconciliation Act coverage for people who had lost their jobs.

patients to physician appointments or to the pharmacy to have prescriptions filled. Creativity and community are required to address these barriers in the absence of formal programs, he emphasized, and he said that there is no single answer to the question of how to address SDOH without agency support. Instead, he said, there are “as many answers as there are small communities.”

Rural Issues as National Issues

Murphy asked Mueller to comment on the view that challenges of rural communities are rural issues rather than national issues. She also asked how advocacy efforts can most effectively make this an issue of national prominence. Mueller replied that the interconnectedness of society allows us to see that we have much to learn from one another, and the pandemic has highlighted this. Rather than developing a demonstration in a city and scaling it down to rural, or scaling a rural demonstration up to urban, Mueller suggested examining the elements of each organization’s or community’s efforts and learning from those. He cited the House Committee on Ways and Means’s newly formed Rural and Underserved Communities Health Task Force as an initiative that can determine relevant characteristics common at the neighborhood or community level. Mueller said the interconnectivity across urban and rural settings is already evident, but the new knowledge and innovations would be fostered more rapidly if the current siloed circumstances can be changed to allow more mutual learning from demonstrations.

Global Budgeting Model for Financial Stability

Murphy asked Mueller to comment further on the Pennsylvania Rural Health Initiative and global budgets. Mueller referenced a recent opinion piece from a group at Harvard University working on the Pennsylvania model (Fried et al., 2020). It made the case for global budgeting, as innovation often arises during a crisis but will be more effective with long-term stability in financing. As the global budgeting model provides annual budgets rather than dependence on billable services, this model would be more secure and flexible during crises such as a pandemic and its consequent lost revenue sources, he added.

Federal Response to the COVID-19 Navajo Nation Outbreak

Murphy asked Smith to provide his perspective on the federal response to the COVID-19 outbreak among the Navajo Nation, the challenges involved, and the steps that are being taken or that should be taken

to prepare the entire population for the second wave of the virus. Smith responded that some tribes have been hit hard by COVID-19 more quickly than others, and tribal leaders and Indian urban organization leaders are discussing the best ways to prepare. Smith said that as COVID-19 continues to spread to other parts of the country, disseminating informational materials to tribal governments is key. IHS is relying heavily on CDC as the primary source of information, he noted. However, to ensure that the requisite tribal consultation and conferring with urban Indian organizations are taking place, IHS is taking an all-of-government approach. For instance, weekly calls with the White House Office of Intergovernmental Affairs have recently increased to biweekly frequency to create opportunities to hear the issues and needs firsthand. Smith stated that these communication chains have provided the most substantial and direct assistance in reaching directly to the top levels of government.

A unified coordination group is necessary, Smith said. This is occurring in the Navajo Nation, where the Navajo Nation partners with the federal government in a unified command to address the issues. Smith noted that challenges requiring amplified messaging range from access to PPE to broader issues—related to housing, for example—that are common in rural communities and perhaps even more frequent in Indian communities. He added that when multiple family members reside together in a small residence, it is difficult to maintain the proper social distance. Communication has been the cornerstone of IHS’s approach to the COVID19 pandemic thus far, said Smith. From helping with direct resources from the federal government to assisting with donations coming from philanthropies and churches, the pandemic response requires an all-of-government partnership approach.

Pandemic Response in Rural Areas

Putnam was asked to comment on the rural response to the COVID19 pandemic. He responded that the limited number of ER physicians, respiratory therapists, and imaging technicians is a particular challenge for rural areas during a pandemic. When rural health professionals contract the virus and can no longer work because of illness and the potential to spread the virus to others, there are no other departments to pull workforce from. Therefore, Putnam advised rural facilities to plan for situations that can occur if rural health professionals test positive for COVID-19, such as closed ERs. He added that “there are no competitors during a pandemic” in describing the importance of collaborating in preparation efforts among hospitals, physicians’ offices, dentists’ offices, and nursing homes.

As rural facilities have communicated their needs, communication and resources have been shared across state lines, said Putnam. He said

his top priority has been protecting his team, but he has faced severe shortages in PPE such as N95s, controlled air purifying respirators, powered air purifying respirators, regular masks, and isolation gowns. It has been a difficult leadership challenge to keep his team safe in the absence of adequate protective equipment, he emphasized. However, facilities have worked together to address the PPE shortages. For example, other hospitals have offered to share what little surplus of equipment they have, and dentist offices have offered to shut down for 1 week to make masks available for the hospital.

Rural Policy Initiatives

Murphy remarked that before the COVID-19 pandemic hit, she and other colleagues who are focused on rural health policy felt momentum building for this policy area. She asked Cassling what rural policies to expect moving forward and whether she feels that rural policy has a strong foothold in national politics. Cassling stated that there will be many opportunities for action on rural health priorities. The most evident is the telehealth movement, which has strong bipartisan support for its continued expansion because of the benefits it has shown during the pandemic. She sees the expansion of telehealth as a long-standing outcome of the pandemic, but it will take time to address hospital infrastructure issues that may pose barriers to the expansion. Potential also exists for new models, Cassling said, noting Senator Chuck Grassley’s work to establish a new rural hospital model with more flexibility for communities. In the House of Representatives, Congressman Jodey Arrington is leading the effort for a new model. Cassling said that bipartisan conversations in this area are taking place, but working out the details will be a lengthy process. Cassling concluded that addressing the COVID-19 pandemic has been the central focus of Congress, and whether or not another stimulus package or appropriations bill will be passed is uncertain. Similarly, it is unknown whether any efforts not directly related to addressing the pandemic or funding the government through the end of the year will be feasible.

Role of Electronic Health Records in Rural Care

Murphy asked Smith about policies or regulatory provisions that might be helpful in moving forward with EHRs in tribal communities. Smith replied that tribal health programs have explored commercial products in an effort to find their own solutions to sharing information with IHS. He noted that IHS received additional resources before the COVID19 pandemic from HHS to examine various EHR platforms and that IHS

has also worked with the Department of Veterans Affairs to learn from their process of EHR modernization. Tribes that cover multiple states are a particular challenge for EHRs, Smith noted. For example, the Navajo Nation covers parts of Arizona, New Mexico, and Utah. Smith said that the current telehealth expansion has presented new opportunities, and IHS is working with other federal agencies (e.g., the Federal Communications Commission) to enter into broadband expansion on tribal lands. Additionally, some COVID-19 funding supplements for information technology will enable continued efforts toward EHR modernization.

Murphy closed the final panel of the workshop by thanking the speakers, the National Academies staff, and the workshop planning committee members for organizing the virtual event.