Governor's Budget

2017 WRHA Legislative and Policy Agenda



While members of Congress are home in their states and districts, tell them to repair the harm the ACA causes to rural America and to build upon the provisions that work in rural America. Attending town halls and meetings will be a great opportunity to share your experiences with health care reform and what changes are needed.  

In this recess packet, NRHA and WRHA has provided:

  • a one-pager on provisions that need to be included in any health care reform (click here)
  • talking points to share with your members of Congress (below)
  • a sample letter to send to your members of Congress about the important rural Medicare extenders that expire this year (click here)
  • recess tips (below)

*Please note, we welcome you to personalize the materials to better tell your members of Congress about your facility and the issues you and your community are facing.

Talking points to tell your member of Congress on health care reform:

Health care reform has not worked in rural America. Lack of plan competition in rural markets, exorbitant premiums, deductibles and co-pays, the co-op collapses, devastating Medicare cuts, and the lack of Medicaid expansion have created a health care access and coverage crisis in rural America. 

The Senate had an opportunity to fix the great inequities in the ACA for rural America, but instead has offered a plan that will lead to more uninsured, greater health disparities and ultimately poorer health outcomes for rural populations nationwide. Additionally, the Better Care Reconciliation Act will be the death sentence for many rural hospitals across the country. 

Rural hospitals are already facing a rural hospital closure crisis – 82 rural hospitals have closed since 2010; 673 additional facilities are vulnerable and could close; and 41% of rural hospitals operating at a loss. The hospital closure crisis will explode under the Senate bill for two reasons:

  • Drastic Medicaid Cuts. Rural Americans are often poor and more dependent on Medicaid. According to new data released by the non-partisan The Chartis Group, in the first year alone, if the Senate bill were enacted into law, the average loss per rural hospital in an expansion state is $442,000 and $224,000 per rural hospital in a non-expansion state. These margins are significant to small rural providers and cuts of this magnitude will result in rural hospital closures and the loss of 33,980 jobs in rural communities (Chartis).
  • Subsidy Reductions. Rural Americans currently can't afford their insurance under the ACA. Rural Americans are more likely to have higher deductible plans, higher co-pays, and higher premiums than their urban counterparts. When a rural patient can't pay their bill, the rural hospital is forced to absorb the non-payment - - bad debt has already increased for rural hospitals by 50% since the ACA went into effect, and has, in large part, created the rural hospital closure crisis. Instead of helping rural hospitals with their rising bad debt, the Senate bill makes the problem much worse. Because the Senate bill moves the subsidy benchmark down from 70% to 58%, the deductible will become even more significant. According to Vox, a plan that covers only 58% of costs amounts to about a $7000 or more deductible! This means health care will become even more unaffordable for rural patients and rural hospitals will be forced to absorb even greater losses. This will absolutely cripple rural hospitals and will explode the closure crisis.

The 3 provisions that must be included in any modification to the Affordable Care Act are:

1. Medicaid - Though most rural residents are in non-expansion states, a higher proportion of rural residents are covered by Medicaid (21% vs. 16%).

  • Any federal health care reform proposal must protect access to care in Rural America, and must provide an option to a state to receive an enhanced reimbursement included in a matching rate or a per capita cap, specifically targeted to create stability among rural providers to maintain access to care for rural communities. Enhancements must be equivalent to the cost of providing care for rural safety net providers, a safeguard that ensures the enhanced reimbursement is provided to the safety net provider to allow for continued access to care. Rural safety net providers include, but not limited to, Critical Access Hospitals, Rural Prospective Payment Hospitals, Rural Health Clinics, Indian Health Service providers, and individual rural providers.

2. Market Reform – Forty-one percent of rural marketplace enrollees have only a single option of insurer, representing 70 percent of counties that have only one option. This lack of competition in the marketplace means higher premiums. Rural residents average per month cost exceeds urban ($569.34 for small town rural vs. $415.85 for metropolitan).

  • Any federal health care reform proposal must address the fact that insurance providers are withdrawing from rural markets. Despite record profit levels, insurance companies are permitted to cherry pick profitable markets for participation and are currently not obliged to provide service to markets with less advantageous risk pools. Demographic realities of the rural population make the market less profitable, and thus less desirable for an insurance company with no incentive to take on such exposure. In the same way that financial service institutions are required to provide services to underserved neighborhoods, profitable insurance companies should be required to provide services in underserved communities.

3. Stop Bad Debt Cuts to Rural Hospitals – Rural hospitals serve more Medicare patients (46% rural vs. 40.9% urban), thus across the board Medicare cuts do not have across the board impacts. The fact that according to MedPAC "Average Medicare margins are negative, and under current law they are expected to decline in 2016" has led to 7% gains in median profit margins for urban providers while rural providers have experienced a median loss of 6%.

  • Congress must stop bad debt cuts for rural hospitals.

Here are some recess tips:

1) Contact the offices of your members of Congress and schedule a meeting to let them know the health care issues impacting their constituents. Send an email or call and talk with their Health Legislative Assistant (HLA). Share NRHA materials, but most importantly, personalize it to tell them about your facility and the issues you and your community are facing.
2) Attend a town hall or other event with your member of Congress. Members of Congress list these on their webpage and often times on Facebook or Twitter as well. If not, call the office and ask.
3) Invite your member of Congress and staff to tour your facility. This is a great opportunity to show them just what your facility does for your community.
4) And remember, to have an "ask." Members of Congress want to know how they can help you, your facility, and your community.

Thank you for all you do for rural health. 


Hi Everyone - 

Congratulations and thank you so much!  Last night, the Senate voted no on the bill to take health care away from millions.  In statements today, Senators are saying that is because of the tremendous work of the grassroots community.  We can't thank you enough for protecting Medicaid and coverage for our country.

WRHA urges the Senate to work together to fix rural health care.  Any repeal and replace efforts must provide improved access to care in rural America and ensure vulnerable and underserved rural Americans are not left without access to care.  At minimum, Congress needs to address Medicaid, insurance market reform and stopping bad debt cuts to rural hospitals.

There will doubtless be other rounds of this fight, but this is an enormous victory!  You made your voices heard! WRHA thanks you and thank you, Senators.

CLICK HERE to view a one-page notice related to preventing bad debt cuts to rural hospitals, due to treatment of dual-eligible patients, which could have a staggering economic effect.  Rural areas have a higher rate of dual eligible patients than urban areas. 

Finally, the Centers for Medicare & Medicaid Services (CMS) has completed its review of the State Plan Amendment (SPA), Transmittal Number 17-0018.  This SPA allows eligible dentists to be paid an encounter rate for dental services provided at Rural Health Centers (RHC).  Most every other state across the country covered dental as an RHC services and FQHCs always did.  This is great news for Washington state!



Despite Changes, Senate Health Reform Bill Still Very Problematic for Washington

While the Washington Rural Health Association is pleased the bill includes an additional $100 billion to help low-income Americans buy coverage and to combat the opioid epidemic, we are disappointed that the BCRA still falls woefully short in making health care affordable and accessible to rural Americans. The bill maintains some of the provisions that led to WRHA's opposition of the original language. WRHA is disappointed that the bill continues to include deep Medicaid cuts that change the program from an open-ended federal commitment to a capped federal payment that limits federal spending, leaving either states, patients, or providers to struggle with the loss of funds.

The Medicaid expansion is also eliminated, being phased out over a four-year period from 2020 to 2024. Tax credits to assist individuals in purchasing insurance remain in the bill, even with the increased levels to assist some low-income individuals, the premium assistance is still likely to fall short of making health insurance affordable for many rural Americans. While the bill does keep in place some of the taxes included in the Affordable Care Act (ACA) to pay for the coverage expansion, many are rolled back or eliminated. Furthermore, this bill continues to eliminate the individual and employer mandates.

The bill tentatively includes a controversial amendment to allow for the sale of health insurance plans that do not meet the coverage requirements of the Affordable Care Act. While these deregulated plans are likely to have lower premiums, they will offer substantially diminished coverage that will leave many without meaningful insurance. While we support the goal of lowering premiums and the overall cost of receiving health care, simply providing lesser coverage will leave many rural Americans without the care they needAnd at the same time, raise premiums for full coverage marketplace plans even further out of reach of most rural Americans. Furthermore, plans without meaningful coverage will result in greater charity care and bad debt at rural hospitals, further exacerbating the rural hospital closure crisis. It is expected that this portion of the bill will be analyzed by CBO separately.

The Washington Rural Health Association strongly believes that health insurance is necessary for people to live healthy, productive lives. Our goal is to ensure that low- and moderate-income people in our state can continue to be covered by health insurance. Health coverage opens the door to good primary care, it keeps people out of the ER and helps control overall health care costs—costs that are ultimately shared by everyone. 

Similar to the House and previous Senate bills, this iteration falls far short of that goal, and WRHA strongly opposes it. 

Main provisions of the bill include:  

  • Decrease in individual market protections. The bulk of the new changes are intended to stabilize risk pools and drive down the cost of health plans offered in the individual insurance market. Most notably, the bill would allow insurers to offer “non-compliant” plans that do not include many of the existing consumer protections, such as the requirement to cover a package of “essential health benefits.” Provisions such as this will likely result in fewer low-income and vulnerable consumers having access to affordable, comprehensive health plans. The primary health insurance trade association recently rejected this approach, arguing that its adoption would undermine the stability of the exchange marketplaces that are already working. 
  • Medicaid DSH cuts are maintained in expansion states. The new bill offers restoration of Medicaid DSH cuts and a potential increase if Washington State eliminates coverage for Medicaid expansion. While this would provide some relief from the hospital cuts that were in the ACA, but Washington would also have to give up Medicaid expansion and eliminate insurance for the 600,000 people who received coverage. DSH cuts are only a sliver of the cuts hospitals took, so a restoration of these cuts does not make hospitals whole.
  • Decrease in funding for Medicaid expansion. This Senate bill, like the last version, phases out support for Medicaid expansion between 2021 and 2023 – from 90% to 75%. In 2024, the federal government would pay only 50 percent of the cost of services provided to the expansion population, instead of the 90% that in current law. 
  • Elimination of the individual and employer mandates
  • Reduction in subsidies to purchase coverage. The bill reduces subsidies for lower-income individuals to purchase insurance coverage and reduce cost-sharing obligations; and 
  • Continued cuts to hospitals. The new bill maintains the Medicare Disproportionate Share Hospital cuts, as well as Medicare payment cuts. 

Medicaid Quality Incentive Requires Financial Reporting Compliance

Changes to the hospital safety net assessment program law include new provisions for the quality incentive program. The incentive program provides an additional $13 million a year to hospitals. Going forward, hospitals must be in compliance with existing Department of Health financial reporting requirements to qualify for the quality incentive payment. These reporting requirements include timely submission of monthly CHARS data of which the first reporting period begins with May 2017 data due on or before July 15th. Hospitals are allowed only three late submissions of this data before becoming ineligible for the quality incentive payment. We strongly urge hospitals to ensure they are submitting the required data in a timely manner.

The reporting requirements apply not only to timely monthly submission of CHARS data but also to other reporting requirements including timely submission of year-end reports, including employee compensation and hospital-based clinic data.

Legislators Pass Operating Budget Good for Health Care, But Session Continues
On June 30, legislators passed and the governor signed a $34 billion operating budget hour before the new biennium was to begin, avoiding a partial shutdown of state services. The legislature remains at work in what is its third special session. As of yet there is no agreement on a capital budget for the 2017-2019 biennium and it is unclear if there will be agreement this session.

On the whole, the operating budget is very good for hospitals and health care. Specifically, the final budget did not include cuts to hospital clinics, extended the safety net assessment program, and made significant progress on mental health funding and reforms.