Governor's Budget

2017 WRHA Legislative and Policy Agenda



President Trump signs executive order changing ACA market

Yesterday morning, President Donald Trump signed an executive order to allow small businesses to purchase what are known as “association health plans.”  These plans are a form of insurance in which similar small businesses can group together through an association to negotiate health benefits.  The order also includes an expansion of short-term insurance policies, sometimes known as bridge policies, which are often available to individuals’ ineligible for other plans because of employment, age, or other factors. This is the administration’s largest step forward to change the market established under the ACA. WRHA is working with NRHA to evaluate effects this will have on the quality, affordability, and availability of healthcare on our members and on rural communities.

Medicaid cuts would further rural hospital closure catastrophe

Congress has delayed the implementation of the Disproportionate Share Hospital Program (DSH) cuts for the last few years, but this year legislation to continue delaying the cuts did not pass.  “Hospitals will always have a federal requirement to treat and stabilize individuals who come in, but how far they can go beyond that to provide care, would be very much in question,” says Dave Dillon of the Missouri Hospital Association, an NRHA member.  “Seventy-five percent of our patients either are on Medicare, Medicaid, or they're uninsured,” adds NRHA member Tim Wolters of Citizens Memorial Hospital.  According to NRHA data, 673 rural hospitals are at risk of closure, and 210 are considered to be at an extreme risk for closing.  With your help, NRHA’s Save Rural Hospitals Act will create a unique payment designation to offer a path forward for struggling rural hospitals. 

CBS: Americans living in rural areas more likely to die by suicide

Suicide rates in the United States have been rising sharply in recent decades, and Americans living in rural areas of the country are more at risk than others.  In the latest edition of its Morbidity and Mortality Weekly Report Rural Health Series, CDC researchers examined suicide trends from 2001 to 2015.  "While we've seen many causes of death come down in recent years, suicide rates have increased more than 20 percent from 2001 to 2015, and this is especially concerning in rural areas," says CDC director Brenda Fitzgerald, MD.  Suicide is one of the top ten leading causes of death in the United States, and suicide occurs at a much higher rate in rural areas than urban.



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.