Sustainability of Local Healthcare Services

Keith Muellerby Keith Mueller, Director, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis

Rural America has many reasons to celebrate the 50 years of Medicare and Medicaid. Foremost among them is direct impact on the lives of rural residents who during that time relied on those programs to pay for essential services as they accessed the healthcare system. Rural communities are characterized as disproportionately poor with higher percentages of elderly persons as compared to urban areas, making the two public programs a critical pathway to paying for healthcare services, and in recent years (predating the Patient Protection and Affordable Care Act and continuing with its implementation) reasons for narrowing the rural-urban differential in rates of uninsurance.

A second related reason to celebrate these programs is that they are opportunities for public policy to influence the sustainability of local services, through payment and policy activities. Recognizing the struggles and frustrations of our rural advocates in the policy arena, we should be grateful that these programs, with their goals of assuring access to essential health services, create the platform for policy change. During the past 50 years we have seen dramatic changes in Medicare and Medicaid payment, how providers are deemed eligible for payment, and most recently development and use of quality standards. Strengthening and sustaining the rural healthcare infrastructure through the policy vehicles inherent in Medicare and Medicaid is a long, winding, sometimes tortuous, and seemingly never ending road. That said, it is a road well- traveled by rural advocates and paved with analysis taking advantage of the pubic nature of the programs (access to data) and opportunities to leverage public resources (through payment policies and through research and demonstration programs).

As we look to the future of these programs their critical importance to rural America needs to be front and center in the minds of policy makers looking to change their design and continue the tradition of them being programs assuring access to services where people live. Specifically Medicare and Medicaid payment and regulations will influence how to continue access to acute care services (i.e., how we provide the array of inpatient and outpatient services historically provided within the walls of hospitals), how primary care (including essential services such as behavioral health) is organized and reaches into communities (i.e., rural systems adopting best practices of medical home models), and how emergency care services are sustained and integrated into the continuum of health care services. The challenges may at times seem overwhelming, but the successful efforts over the past 50 years (e.g., The Medicare Rural Hospital Flexibility Program, growth in Rural Health Clinics, spread of public health services, and early uses of telehealth) give us reason to forge ahead to work on behalf of rural Americans through these two critical public programs.


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