Washington, D.C. got a little louder last week, and it wasn’t just the sound of snow removal – it was the collective voice of the National Rural Health Association (NRHA) mantra of “your voice louder,” as spoken by a united throng of nearly 500 rural health leaders attending the NRHA’s 27th Annual Policy Institute.

“The conference focused on delivery system reform and alternative payment models, the changing healthcare system, and evolving regulations, (which) were a primary driving interest for attendance at this event,” said Alan Morgan, NHRA’s CEO, noting that the annual event drew its largest-ever attendance. “At the core of rural health concern are hospital closures/stop closures, and that continues to drive the agenda and … policy leaders.”  

The “stop closures” Morgan refers to is the Save Rural Hospitals Act – legislation introduced by U.S. Rep. Sam Graves (R-Mo.) and Rep. Dave Loebsack (D-Iowa) to end the closure crises. Sixty-six rural hospitals have closed during recent years, impacting 700,000-plus Americans, and an additional 673 rural facilities are vulnerable and could close in the near future. This represents one-third of rural hospitals in the U.S.
What’s more startling is that in 2015, rural hospitals closed at a rate six times higher than in 2010.  Since January 2013, more rural hospitals have closed than in the previous 10 years. Although there are many variables causing this impact, closures of hospitals have increased since bad debt began to hit, including in states where Medicaid expansion wasn’t passed. The result is that continued cuts in hospital payments have forced closures, leaving many of our nation’s most vulnerable populations without much needed access to care.
If that isn’t concerning enough, consider the following:
If Congress doesn’t act to stop the crises and step in with legislation to prevent closures of rural hospitals, 11.7 million rural patients (of the almost 90 million residents the latest U.S. Census identified as living in rural/small communities) would lose direct access to care, which would have a devastating impact on the rural landscape – the breadbasket of the nation. This impact would extend to local economies, agriculture, agricultural-related work, and business industries, resulting in property value changes, layoffs, reduced wages and workforce opportunities, reduced services and more hospital doors being closed, putting pressure on the viability of schools. 
Putting this into context, the average critical access hospital has nearly 200 employees and generates approximately $8.4 million in annual payroll – each drives and stimulates the vibrancy of its local economy. So the big picture is that if rural hospitals, often seen as the bedrock of their communities, close, then lives will be lost and perhaps entire communities erased, never to return. 
According to a recent iVantage study, a total of 210 U.S. hospitals are at a high risk of closing, with 463 at a lower risk of closing. Using their specialized analytic formula and a deep-dive review of what is driving closures and the downward trajectory of the stability of hospitals into the vulnerability category was a complex assessment based on multiple factors, such as lower patient volumes, declines in quality and outcomes, loss of market share, and a sharp decrease in reimbursement. Other relevant factors include the aforementioned variables of sequestration, bad debt, and Patient Protection and Affordable Care Act (PPACA) inclusion of Medicaid expansion, in addition to programmatic reimbursement cuts for swing beds (along with other revenue pressures).
As such, it only makes sense that the NRHA would endorse the Save Rural Hospitals Act, which would provide rural hospitals with financial and regulatory relief to allow them to stay open and care for rural residents who typically are older, poorer, and have higher rates of chronic disease than their urban counterparts. Ironically, the Centers for Medicare & Medicaid Services (CMS) actually spends 2.5 percent less on rural beneficiaries than on urban beneficiaries.
At its core and seen as the comprehensive pathway to help rural providers the bipartisan legislation would stabilize and strengthen rural hospitals by:

  1. Stopping the many cuts in Medicare that rural hospitals have endured for years;
  2. Providing rural hospitals with new funding so they can provide quality primary care to rural patients across the nation; and
  3. Creating a path forward for struggling rural hospitals by allowing them to provide care that makes sense in their communities and receive fair reimbursement for emergency room and primary care.

Armed with all of this information at the Policy Institute, NRHA members were provided congressional action kits to take to their representatives on Capitol Hill. The NRHA developed three requests for members to ask their respective members of Congress:

  1. Protect and strengthen all rural hospitals.
  2. Support robust funding levels for all rural health programs for the 2016 and 2017 fiscal years.
  3. Join the Senate Rural Health Caucus or House Rural Health Care Coalition and sponsor key legislation to ensure the future of rural America.

Across the Hill this week, Policy Institute attendees reported that members shared our concern on the rural hospital closure crisis, and members are receptive to proposals to address the crisis,” Morgan said.“As a result, we are certainly encouraged by the strong support we are hearing this week.”

A final consideration regarding the future of rural hospitals is that 2016 is an election year, and while presidential candidates aren’t talking much about rural health (and it remains unclear how the election might impact rural America as a whole), the headlines keep coming, whether in South Carolina, where three hospitals closed since 2011, or Georgia, where four hospitals closed since the beginning of 2013, or Missouri, where currently almost 20 percent of rural hospitals are at risk of closure. Indeed, the national map is speckled with rural hospital vulnerability.

 “There are many anxious NRHA members worried about their short- and long-term survival,” said Brock Slabach, NRHA’s senior vice president for member services.
The voice of NRHA’s 21,000-strong membership is focused on advocacy, communications, education, and research – and that voice is getting louder, making sure it has a seat at the table and on the Hill versus being on the menu of cuts.

About the Author
Janelle Ali-Dinar, PhD,  is the chief operations officer at MedFirst Partners and a senior rural health expert at Healthcare Solutions Connections. She has more than 10 years of experience in rural health policy, legislation, strategy, and operations, having served on the National Rural Health Association’s national rural congress. Dr. Ali-Dinar is also an NRHA Rural Fellow. 
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