- Mobile Clinics Really Got Rolling in the Pandemic. A New Law Will Help Them Cast a Wider Safety Net.
- Opioids Are Devastating Cherokee Families. The Tribe Has a $100 Million Plan to Heal
- Less Staff, Longer Delays and Fewer Options: Rural America Confronts a Health Care Crisis
- The Pandemic Pushed Rural Philanthropy to Change
- Warner, Blackburn Lead Bipartisan Effort to Preserve Access to Rural Health Care
- Tackling Rural America's 'Hidden' Housing Crisis
- Experts: National Physician Shortage Will Hit Rural Areas Harder
- Ensuring Health Care Quality in Rural America
- Rural Communities Want to Tap Federal Funding. But It's Hard to Know Where to Start
- Nearly Half of All Rural Hospitals Are Operating in the Red, Study Says
- Home-Based Care: Fixing the Childcare Drought in Rural America
- Rural Hospitals That Were Struggling Financially Even Before the Pandemic Are Running Out of COVID Aid
- Oklahoma Researchers Aim For More Mental Health Resources In Rural Schools
- Q&A: A Rural Healthcare Hub for Doctors and Policymakers
- February in Brief: Expanding Access to Health Care in Rural Areas and Improving Early Access to Cancer Screenings in Underserved Communities
USDA Begins Accepting Applications for $1.15 Billion in Loans and Grants to Help People Living in Rural Communities Get Access to High-Speed Internet
U.S. Department of Agriculture (USDA) Secretary Tom Vilsack announced the Department has begun accepting applications for up to $1.15 billion in loans and grants to help people in rural areas get access to high-speed internet. This announcement comes on the heels of the recently enacted Infrastructure Investment and Jobs Act (IIJA) which provides another nearly $2 billion in additional funding for the ReConnect program. USDA anticipates issuing a new Notice of Funding Opportunity to make the additional funds in the IIJA available in 2022.
Read the full news release here.
New HHS Initiative Launched to Improve Outcomes Via Primary Care
The Agency for Healthcare Research and Quality (AHRQ) is among federal partners and stakeholders that have joined a new initiative to strengthen primary health care nationwide. The effort, launched by the HHS Office of the Assistant Secretary for Health (OASH), follows a National Academies of Sciences, Engineering, and Medicine report that documented the weakening of primary care and called upon the Department of Health and Human Services (HHS) to take a leadership role in ensuring high-quality primary care for all. Judith Steinberg, MD, MPH, a leader in primary healthcare transformation and former chief medical officer at HRSA Bureau of Primary Health Care (BPHC), will lead development of an HHS plan to strengthen primary healthcare with the aim of improving health outcomes and advancing health equity.
The plan, which will be presented to HHS Secretary Xavier Becerra for his review, will include the role of HHS in leading this effort and specific actions to be taken across HHS.
Court Rules in Favor of Pennsylvania in Two Separate HealthChoices Award Protests
The Commonwealth Court of Pennsylvania upheld on November 17, 2021, the state’s decision to deny protests filed by Aetna Better Health of Pennsylvania and Centene/Pennsylvania Health & Wellness after the two plans failed to win contracts in the state’s recent Medicaid managed care procurement. Rulings on protests from Gateway Health Plan and UnitedHealthcare have not been released publicly.
Implementation of the new contracts, originally slated for January 1, 2021, had been suspended until the protests are resolved.
DEA Considering Regulation of Telepharmacy Practice
Advanced notice of proposed rulemaking from the Drug Enforcement Administration (DEA) seeks to obtain further information regarding the practice of telepharmacy, which is not specifically defined by the Controlled Substances Act (CSA) or DEA regulations. DEA is considering implementing regulations regarding telepharmacy and seeks to be fully informed about the practice, industry and state regulations.
Comments are due by Jan. 18, 2022.
NOW OPEN 2022 NHSC Loan Repayment Programs
Application closes on December 16, 2021 at 7:30 PM ET
A historic $800 million in American Rescue Plan funding will allow HRSA to award more applicants than ever before. Last year, every eligible applicant received an award.
About the programs:
- The NHSC Loan Repayment Program awards up to $50,000 in exchange for a two-year commitment to provide primary medical, dental or mental/behavioral health care at approved sites in high-need, underserved areas.
- The NHSC Substance Use Disorder Workforce Loan Repayment Program provides up to $75,000 in exchange for a three-year commitment to health care professionals who provide substance use disorder treatment services.
- Providers in rural communities may apply to the NHSC Rural Community Loan Repayment Program, which awards up to $100,000 for three years of service.
For additional information, including eligibility and program fact sheets, visit the NHSC LRP website. Find NHSC-approved sites on the Health Workforce Connector.
CMS Adds Two Reports on Rural Health
The Centers for Medicare & Medicaid Services (CMS) published two reports on rural health care, including the annual report on rural health accomplishments: Improving Health in Rural Communities: FY 2021 Year in Review as well as CMS recognizes the more than 57 million Americans who live in rural areas and face several unique challenges that can differ dramatically among the different kinds of rural areas across the country. These reports will assist in identifying and addressing some of these challenges.
Improving Health in Rural Communities: FY 2021 Year in Review
In its annual report, CMS demonstrates its commitment to improving the health and wellbeing of individuals living and working in rural areas. Rural, frontier, tribal, and island communities face structural barriers to achieving equitable health outcomes, including practitioner shortages, hospital closures, and long travel distances to access care. CMS is committed to working with rural communities to address these barriers and build on existing advancements to achieve optimal outcomes for all rural Americans.
Through its Rural Health Strategy, CMS is working with federal partners, community organizations, and Tribes to achieve equity in access to care, quality of care, and health outcomes for rural individuals.
The activities and accomplishments outlined represent CMS’s commitment to designing programs and policies that affect rural, frontier, and tribal communities in fiscal year (FY) 2021. They are presented across 10 focus areas: the coronavirus disease 2019 (COVID-19); the Federally Facilitated and State Marketplaces; Medicare Payment and Policy; Practitioner Workforce; Medicaid and Children’s Health Insurance Program Enrollment, Payment, and Policy; Long-Term Services and Supports; Maternal Health; Mental Health and Substance Use Disorders; Models and Demonstrations; and Quality and Equity.
Examining Rural Hospital Bypass for Outpatient Services
CMS has also recently published a report on rural hospital bypass. This report provides an overview of a study, which sought to explore the drivers of rural hospital bypass for outpatient services. This national mixed methods study explores the relationship between hospital outpatient services and inpatient utilization to address the extent of rural hospital bypass, patient characteristics, and utilization of outpatient services.
For more information, visit https://go.cms.gov/ruralhealth or contact RuralHealth@cms.hhs.gov.
Paid for by the US Department of Health and Human Services.
HHS Announces Record Health Care Workforce Awards in Rural and Underserved Communities
The Biden-Harris Administration has awarded the largest field strength in history for its health workforce loan repayment and scholarship programs thanks to a new $1.5 billion investment, including $1 billion in supplemental American Rescue Plan (ARP) funding and other mandatory and annual appropriations. More than 22,700 primary care clinicians now serve in the nation’s underserved tribal, rural and urban communities, including nearly 20,000 National Health Service Corps (NHSC) members, more than 2,500 Nurse Corps nurses, and approximately 250 awardees under a new program, the Substance Use Disorder Treatment and Recovery Loan Repayment Program. The U.S. Department of Health and Human Services’ (HHS) Health Resources and Services Administration (HRSA) oversees these critical programs.
“Thanks to the American Rescue Plan, we now have a record number of doctors, dentists, nurses and behavioral health providers treating more than 23.6 million patients in underserved communities,” said Health and Human Services Secretary Xavier Becerra. “This demonstrates the Biden-Harris Administration’s commitment to advance health equity and ensure access to critical care across the country. We will continue to invest in our health workforce to make life-saving support within everyone’s reach.”
During the pandemic, thousands of NHSC and Nurse Corps health care providers have served in community health centers and hospitals across the country, caring for COVID-19 patients, supporting the mental health of their communities, administering COVID-19 tests and lifesaving treatments, and putting shots in arms.
Connecting Skilled Providers with Communities in Need
HRSA’s workforce programs directly improve the nation’s health equity by connecting skilled, committed providers with communities in need of care. National Health Service Corps, Nurse Corps, and Substance Use Disorder Treatment and Recovery Loan Repayment Program members work in disciplines urgently needed in underserved tribal, rural and urban communities.
“Today’s awards, which represent a more than 27 percent increase in scholarship and loan repayment awards, support current and future providers who are committed to working in vulnerable communities,” said HRSA Acting Administrator Diana Espinosa. “These awards also provide critical support for health care sites that need to recruit and retain clinicians to meet increasing demand.”
- Today’s field strength includes more than 11,900 members working in behavioral health disciplines, including psychiatrists, substance use disorder (SUD) counselors and psychiatric nurse practitioners.
- Nurses represent the largest proportion of the field strength, numbering more than 8,000 across all scholarship and loan repayment programs. National Health Service Corps nurse practitioners make up its largest discipline at approximately 5,400 and fill a critical need for primary care where shortages exist throughout the country.
- Currently, one-third of HRSA’s health workforce serves in a rural community where health care access may be especially limited or require patients to travel long distances to receive treatment.
- More than half of all National Health Service Corps members serve in a community health center where patients are seen regardless of their ability to pay.
Providing Treatment and Care to Patients with Substance Use Disorders
Through dedicated funding for substance use disorder (SUD) professionals, HRSA is now supporting more than 4,500 providers treating opioid and other substance use disorder (SUD) issues in hard-hit communities. The Substance Use Disorder Treatment and Recovery Loan Repayment Program was launched in FY 2021 to create loan repayment opportunities for several new disciplines that support HHS’ comprehensive response to the opioid crisis, including clinical support staff and allied health professionals. In addition, this year’s NHSC awards include 1,500 substance use disorder (SUD) clinicians at approved treatment sites through the NHSC’s Substance Use Disorder and Rural Community loan repayment programs.
Investing in the Future Health Workforce
Through scholarship programs, HRSA is investing in the next generation of providers committed to working in communities most in need. The American Rescue Plan supplemental funding announced today allowed HRSA to award almost 1,200 scholarships — a four-fold increase — in the National Health Service Corps and nearly doubled the number of Nurse Corps scholarship awards to 544. In addition, new awards to 136 nurse faculty are supporting training for the future nursing workforce. This year’s scholarship recipients join 2,500 current National Health Service Corps medical, dental, and health professions students and residents and approximately 900 current Nurse Corps scholars preparing to serve in high-need communities across the country.
HRSA also recently awarded approximately $28.4 million in ARP funding to create new accredited teaching health center primary care residency programs in rural and underserved communities. To further support the expansion of primary care, the Administration plans to continue awarding the full $330 million in ARP funding for Teaching Health Center Graduate Medical Education in the coming months. This additional funding will support the expansion of the primary care physician and dental workforce in underserved communities through community-based primary care residency programs in family medicine, internal medicine, pediatrics, internal medicine-pediatrics, psychiatry, obstetrics and gynecology, general dentistry, pediatric dentistry, or geriatrics. They are based in the communities they serve, with 80 percent located in community-based health centers, such as Health Center Program-funded health centers, Health Center Program look-alikes, rural health clinics, community mental health centers and tribal health centers.
Opportunities Now Open for Loan Repayment Programs
American Rescue Plan funding has made it possible for the National Health Service Corps to make a historic number of awards to all eligible applicants. Additional American Rescue Plan-funded awards are planned, with the next application cycles for the National Health Service Corps and Nurse Corps loan repayment programs now accepting applications.
The National Health Service Corps helps medical, dental, and behavioral health clinicians pay off their student loan debt through scholarship and loan repayment programs in exchange for working in a Health Professional Shortage Area (HPSA). Nurse Corps participants commit to providing care in facilities with a critical shortage of nurses or as nurse faculty and help reduce the nursing shortage issues experienced across the nation. The Substance Use Disorder Treatment and Recovery Loan Repayment Program makes awards to clinicians, allied health professionals, and support staff who provide substance use disorder (SUD) treatment and recovery services to patients at treatment facilities located in a Mental Health Professional Shortage Area or in a county (or a municipality, if not contained within any county) with a threshold drug overdose death rate defined in statute.
Today’s funding announcement is directly responsive to the recommendations in the final report of the Presidential COVID-19 Health Equity Task Force.
More information on clinician, program, location and site attributes can be found on HRSA’s Bureau of Health Workforce Clinician Dashboards.
Rural America’s False Sense of Security
From The Atlantic, November 18, 2021
Every few months throughout the pandemic, Wesley Thompson, a communications consultant in Washington, D.C., has driven to Indiana with his wife and two kids to visit his parents. He wanted to escape COVID cabin fever and give his 4- and 2-year-old some room to run around, which they could do more easily in his parents’ small town.
The trips have offered him a glimpse into how Americans who live between the coasts have been spending the pandemic. In the summer of 2020, some people around his parents’ hometown “would look at us like we’re crazy for wearing masks in public,” Thompson told me. At one point, the family ate at a Mexican restaurant where the workers weren’t masked and thought the Thompsons were strange for wanting to sit outside on a hot day.
That winter, the pandemic became so bad that Hoosiers largely donned masks too. But once vaccines rolled out this past spring, they seemed quick to lose them. “This year, we went up for the Fourth of July, and we still had our kids wearing masks when they’re on the playground,” Thompson said. “And other parents would be like, ‘Why are you doing that? Are they sick?’”
When he goes to the grocery store in Indiana, he can wear a mask, or, like some fellow customers he encounters, just go without—the state has no mask mandate. But, he said, “if I went into a grocery store here in D.C. without a mask on, someone’s gonna say something.” His kids are now so accustomed to masks that his 2-year-old recently asked to wear one around the house.
Technically, the Washingtonians, in their strictness, are doing it right. The CDC now recommends that fully vaccinated people wear a mask indoors if they live in an area of “substantial or high transmission”—a definition that both the District of Columbia and almost the entire state of Indiana meet. Going maskless if you’re vaccinated might be an acceptable choice. The problem, though, is that Indiana also has a lower vaccination rate: About half of its residents are vaccinated, compared with about two-thirds of the population of Washington.
The difference between the COVID-19 precautions Thompson has observed at home in D.C. and the looser rules he’s witnessed in Indiana are part of a common—and, for public-health workers, vexing—trend emerging at this point in the pandemic. Some parts of the country have given up on masks, outdoor socializing, and working from home. They feel, in short, that the pandemic is “over.” Unfortunately, those are also some of the areas where COVID-19 vaccination rates are lowest.
According to a recent Atlantic/Leger poll, compared with people in urban or suburban areas, people in rural areas are most likely to feel like things are “back to normal” where they live—45 percent thought so, compared with 30 percent of urbanites and 36 percent of suburbanites. Rural Americans were also the least likely group to say they wished their neighbors would be more cautious about COVID-19.
People in rural areas are also significantly less likely than the other two groups to wear a mask indoors at restaurants and bars, or at work. They were the least likely group to say that their kids are required to wear masks to school or day care. They are also more likely to socialize with friends indoors without masks on: 68 percent said they now do this, compared with 54 percent of urbanites. A typical worker in D.C. might send his kid to preschool in a mask, ride to work on the Metro in a mask, and meet friends for drinks at an outdoor café, just in case. An hour and a half away, a typical worker in Culpeper, Virginia, might spend her day exactly as she would have in 2019.
Rural Americans are returning back to normal even though they are less likely to say that most adults they know are vaccinated: 48 percent of rural respondents answered “yes” to this question, compared with 68 percent of suburbanites and 63 percent of urbanites. (To be fair, 24 percent of rural respondents said they weren’t sure, compared with about 15 percent of the other two groups.) This result mirrors the lower vaccination rate among rural adults found in other research.
For the poll, Leger surveyed 1,006 American adults from November 5 to November 7. The urban-rural divide is the strongest difference that emerged in current attitudes toward the pandemic, but we did not control for education or political orientation, which might explain some of the disparity. We also allowed respondents to self-select as urban, rural, or suburban, and some people might have thought they were “rural” without meeting the census definition. Thompson’s parents’ town is not technically “rural”—it’s at a juncture between developments and farmland. But his experience shows how even in more developed areas, large swaths of America are through with the pandemic. “For a lot of people who aren’t wearing masks or getting vaccinated, they think that this has just been blown out of proportion, and that people are just too fearful and need to go about their lives,” says Marcus Plescia, the chief medical officer at the Association of State and Territorial Health Officials.
Among the rural unvaccinated, this is a false sense of security. COVID is spreading rapidly in rural areas, which is worrisome because rural people tend to be older, poorer, and in worse health to begin with. If they do get sick, they have less access to hospitals—more than 100 rural hospitals have closed since 2013. The COVID-19 death rate in rural America is now twice the death rate in urban areas. And the longer that pockets of unvaccinated Americans remain, the greater the likelihood that new variants will take hold and spread elsewhere.
The urban-rural split in COVID-19 caution is in part a reaction to early pandemic restrictions, such as limits on gatherings, that were targeted at cities but also hit rural areas where cases were initially low. Standing in the middle of a midwestern cattle ranch in the spring of 2020, you might have been confused as to why a disease in Manhattan was affecting your life. “Rural communities were swept up in that and may not have agreed with those policies, and now they’re taking back control,” says Brian Castrucci, the president of the de Beaumont Foundation, a public-health nonprofit.
Meanwhile, policy makers haven’t tried very hard to understand rural America’s view of the pandemic. “Who’s even talking to these folks? Who got out to the rural communities to talk to them about why we should have these policies and the importance of vaccination?” Castrucci says. Many counties in rural America lack health departments, doctors, and now, news outlets. Of course they feel abandoned, and at this point, defiant.
At the Pennsylvania Office of Rural Health, the COVID-19 program manager Rachel Foster has noticed “rising levels of resistance” to measures such as vaccination and masking. Her department recently interviewed 57 Pennsylvanians around three counties about their views on COVID vaccination. Among those who were vaccine-hesitant, the top reasons were that “the vaccines are unsafe, that people can actually get COVID-19 from the vaccine, or that the rollout was too fast. We’ve heard that people feel if they already had COVID-19, that they’re safe. We’ve heard some strong expressions of freedom and personal choice,” she says. In the words of one of her respondents, “If I have gotten this far without getting COVID, why would I need a vaccine?”
People who live in rural areas are also more likely to be Republican, and as COVID-19 became politicized, Republicans grew less likely to get vaccinated voluntarily or to endorse masking and other restrictions. Rural areas and red states issued fewer restrictions, such as mask mandates, throughout the pandemic, so it makes sense that they’d have fewer restrictions now. “This is a very long-standing difference in our country of what sort of pandemic measures we had,” says Polly Price, a law and global-health professor at Emory University. “You had different pandemic experiences depending on where you live.”
Of course, rural America, like the rest of America, contains multitudes. Some attitudes seem to vary by region: In our poll, masks in day cares and schools were more common in the Northeast, and less common in the South. Similarly, northeasterners were more likely than southerners or midwesterners to say they had to wear a mask to the office, but also that most of the adults they knew were vaccinated. (Even though this could not possibly be the case, given that there are roughly equal numbers of men and women everywhere, men were more likely than women to say things are “back to normal,” and that they no longer have to wear a mask indoors in restaurants and bars.) I spoke with John Ortiz, a day-care provider in Louisa, Virginia—population 1,744—who is vaccinated, unlike most of his county, and still avoids crowded places. He has kept his day care closed because he worries he’ll be held liable if a child gets COVID. In other rural places, vaccination rates might be low not because people are hesitant but because pharmacies are scarce in their area, or residents had to move for work. “A person might be in one place and get a vaccination, and then 100 miles away working a different area when it came due for their second shot,” says Daniel Derksen, a public-health professor at the University of Arizona who specializes in rural health.
How can the rural population witness so much death from COVID-19 while simultaneously dismissing the pandemic? Tom Pyszczynski, a psychology professor at the University of Colorado at Colorado Springs, chalks it up to denial. Not everyone dies of COVID. “If you’re motivated to believe that COVID is not a real threat,” he says, “knowing someone who’s had the disease and recovered, or had a mild case, sort of validates that belief.” To those who want to believe, a few vivid stories of miraculous recovery will drown out an impersonal statistic like 760,000 dead.
The other phenomenon is an attitude akin to fatalism. “In some places, there’s sort of a feeling that maybe there’s nothing that can be done, or it’s God’s will,” says Carrie Henning-Smith, a health-policy professor at the University of Minnesota who studies rural health.
Jeani Vichayanonda, a home-based physical therapist in Rolla, Missouri, about 100 miles southwest of St. Louis, says some of her patients need help relearning basic life skills, such as walking and dressing, after they’ve suffered a severe case of COVID. Many didn’t acknowledge COVID until they had it, she says. Some denied it even then: They tried to recover at home until their oxygen saturation dropped too low. “A lot of them were in the hospital because they weren’t vaccinated and they went down really hard, and I see them after they get out of the hospital,” she told me.
When she walks into her patients’ homes, Fox News is often blaring. If a family member dies of COVID, her patients sometimes rationalize it by saying that person must have had other health problems. The attitude seems to be, “Yes, there are these deaths. And it’s very sad, that neighbor down
the road died, but you know, I’m just gonna keep on living my life,” she said.
In September, Vichayanonda contracted COVID from one of her patients. But because she’s vaccinated, she’s doing fine.
Using CPT Charges as an Economic Proxy for Telehealth and Non-telehealth Emergency Department Utilization
The Rural Health Telehealth Resource Center has published a new brief.
Economic analysis of health care utilization is a pressing priority. However, procuring economic data presents many challenges. One approach is to obtain charge and reimbursement data within a single health care organization, but this approach lacks external validity. Another approach is to obtain charge and reimbursement data across health care organizations by analyzing claims databases (e.g., Medicare, Medicaid claims). But this approach restricts the sample to covered beneficiaries (e.g., older, disabled), which restricts generalizability. We aimed to obtain economic data on emergency department (ED) visits from a number of unrelated rural hospitals and sought an approach for doing so. It appeared feasible to have rural hospitals report the Current Procedural Terminology (CPT) code (AMA, 2021) and associated charge for a sample of ED visits, since CPT codes would be generated for billing and insurance claims submission. The specific aim of this analysis is to explore the characteristics of the resulting dataset in terms of distribution and association with related variables.
Please click here to read the brief.
CMS Health Affairs Blog: A Strategic Vision for Medicaid And The Children’s Health Insurance Program (CHIP)
CMS Administrator Chiquita Brooks-LaSure and Deputy Administrator Daniel Tsai published a blog in Health Affairs outlining the strategic vision for the Center for Medicaid and Children’s Health Insurance Program Services.
You can read the blog here: https://www.healthaffairs.org/do/10.1377/hblog20211115.537685/full/