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Rural Hospitals Face Renewed Financial Challenges, Especially in States That Have Not Expanded Medicaid
Zachary Levinson Follow @zlevs100 on Twitter , Jamie Godwin , and Scott Hulver
Published: Feb 23, 2023
Policymakers have had ongoing concerns about the financial health of rural hospitals and the implications for access to care and the local economy. Rural hospital finances improved during the COVID-19 pandemic as a result of government relief funds. However, industry reports suggest that the outlook for the hospital sector as a whole deteriorated in 2022 as these funds have gone away and due to ongoing effects of the pandemic (such as labor shortages), rising prices, and investment losses. Concerns about the viability of rural hospitals have been cited as one factor that could potentially motivate lawmakers to expand Medicaid in the eleven states that have not already done so. These non-expansion states collectively account for about one-third (34%) of rural hospitals, based on our analysis of 2021 hospital cost report data.
In this data note, we provide a background on rural hospital finances and use hospital cost report data to describe operating margins among rural hospitals before and during the COVID-19 pandemic (see Methods for details). We find that median operating margins among the rural hospitals in our analysis increased earlier in the COVID-19 pandemic, likely as a result of government relief funds, but that these facilities face renewed financial challenges, especially in states that have not expanded Medicaid (Figure 1). Among rural hospitals in non-expansion states, median operating margins were 2.1 percent during the July 2021-June 2022 period and were -0.7 percent when excluding documented relief funds. In Medicaid expansion states, median operating margins dropped, but remained positive even after excluding documented relief funds.
Pennsylvania Governor’s Administration Opens a Pennsylvania Health Resource Center in Beaver County
Gov. Shapiro has mobilized a whole-of-government response and is committed to providing the resources and care Pennsylvanians impacted by the Norfolk Southern train derailment need.
The Shapiro Administration announced today that the Pennsylvania Department of Health (DOH) is opening a Health Resource Center in Darlington Township, Beaver County for residents of Beaver and Lawrence counties who have health concerns following the Norfolk Southern train derailment in East Palestine, OH on February 3, 2023. The Pennsylvania Department of Environmental Protection (DEP) and the Pennsylvania Department of Agriculture will also be on hand at the Center to help interested residents sign up for free, independent water testing and to provide guidance on food and animal safety, respectively.
The Pennsylvania Department of Health (DOH) is working with local leaders and healthcare providers to open the center starting Tuesday, February 28 at the Darlington Township Building, 3590 Darlington Rd., Darlington, PA 16115. The Center will be open weekdays from 10:00 AM to 8:00 PM, and is scheduled to operate through March 10.
“Today, my Administration is taking another step to ensure the health, safety, and well-being of every Pennsylvanian affected by the Norfolk Southern train derailment,” said Governor Shapiro. “Starting Tuesday, Pennsylvanians who are concerned about the impacts of the derailment on their health will have an additional resource to turn to, where they can talk to public health experts right in their own community from the Pennsylvania Department of Health and Department of Human Services, to receive treatment should they need it. From the beginning of our response to Norfolk Southern’s derailment, my Administration has worked hand-in-hand with first responders and emergency management personnel, our partners in Ohio, and the federal government to ensure our citizens in Western Pennsylvania have the resources and information they need to be safe and healthy.”
The Shapiro Administration has been working closely with leaders from both parties to help protect Pennsylvania communities affected by the Norfolk Southern train derailment — and the input and support from Sen. Elder Vogel, Sen. Camera Bartolotta, and Rep. Jim Marshall has been critical in opening this Health Resource Center.
DOH is inviting healthcare providers in the region to join an educational webinar to provide information on what they should be looking for in patients who visit their offices, and how to address any health concerns from residents affected by the derailment aftermath. Healthcare providers, including family/primary care physicians and nurses, emergency department staff, and urgent care providers who are seeing patients with health concerns related to the derailment – and who are interested in joining the webinar – can register online here.
On Sunday, February 26, DOH began partnering with the U.S. Department of Health and Human Services (HHS) to conduct door-to-door visits, starting with residents who were evacuated within the one-mile radius of the train derailment. They are conducting Assessment of Chemical Exposure (ACE) surveys that include discussing symptoms, experiences, and concerns about the impact of the train derailment. If residents aren’t available, information will be provided, and clinicians will schedule a follow-up visit. The ACE surveyors are expected to reach other residents in the coming days and weeks, including residents who visit the Health Resource Center.
Health, environmental, and safety officials from Pennsylvania, Ohio, and multiple federal agencies are working together to continually monitor air and water quality in the region. Monitoring has been in place since the incident began. Pennsylvania continues to see no concerning air or water quality readings following this incident.
The Shapiro Administration announced DEP will conduct its own independent water sampling to closely monitor water contamination risks.
Visit the Pennsylvania Emergency Management Agency’s (PEMA) online train derailment dashboard for details about the derailment response.
New Report: Bank Branch Closures and Banking Deserts in PA, NJ, and DE
A new Philadelphia Fed report finds that the loss rate of bank branches in the Third District states of Pennsylvania, New Jersey, and Delaware more than doubled during the pandemic. Here are some of the highlights from the study.
- The three states combined experienced a net loss of 627 branches and a significant increase in the number of banking deserts, census tracts without nearby bank branches, during the pandemic.
- The number of lower-income, non-White, or rural banking deserts increased from six to 11 from 2019 to 2022.
- The share of low- and moderate-income (LMI) individuals living in banking deserts increased by 30 percent.
Increasing bank branch closures are a cause for concern, as banking deserts can limit opportunities for lower-income residents to improve their financial health and accrue wealth.
Read the report.
Looming Cuts to Emergency SNAP Benefits Threaten Food Security in Rural America
On a cold morning in early February, Tammy King prepared and loaded boxes and bags of vegetables, fruits, milk, frozen meat, and snacks into cars lined up outside the Friends in Service Helping food pantry, known in rural northeastern Nevada as FISH.
The beginning of the month is busy for the food pantry, King said, because people who receive benefits from the federal Supplemental Nutrition Assistance Program, known as SNAP, come to stock up on free food that helps them stretch their monthly allotments. The food pantry, one of a few in this city of about 20,000 people, serves more families now than at any point in King’s 20 years of working there, she said. In January, FISH provided food boxes to nearly 790 people.
But King and other food bank managers fear that demand will spike further in March, when officials roll back pandemic-era increases to SNAP benefits. The program, administered by the Department of Agriculture, provides monthly stipends to people with low incomes to spend on food. Before 2020, those payments averaged a little more than $200 and were hiked by a minimum of $95 during the pandemic.
Officials estimate families King works with will see a 30% to 40% decrease in SNAP payments as emergency allotments tied to the public health emergency halt in 32 states, including Nevada. Other states, such as Georgia, Indiana, Montana, and South Dakota, have already ended the emergency allotments.
The cuts to SNAP benefits will uniquely hurt people living in rural America, said Andrew Cheyne, managing director of public policy for GRACE, a nonprofit run by the Daughters of Charity of St. Vincent de Paul focused on reducing childhood hunger. A higher percentage of people depend on SNAP in rural areas compared with metro areas. And those areas already have higher rates of food insecurity and poverty.
“We have so many households who simply aren’t going to know that this is happening,” Cheyne said. “They’re going to go to the grocery store and expect to have money in their account and not be able to buy the food they need to feed their families.”
And as the fallout from those cuts hits, food pantry managers in rural areas find themselves on the front lines trying to fill gaps in their communities. They and food policy experts fear it won’t be enough. For every dollar worth of groceries a food bank distributes to a community, SNAP delivers $9.
Public Health Emergency (PHE) 1135 Waivers: Updated Guidance for Providers
On February 9, the Department of Health and Human Services (HHS) announced the Public Health Emergency (PHE) for COVID-19 will end on May, 11, 2023. COVID-19 remains a significant priority for the Biden-Harris Administration and over the next several months, the Centers for Medicare & Medicaid Services (CMS) will work to ensure a smooth transition. During the PHE, CMS has used a combination of emergency authority waivers, regulations, enforcement discretion, and sub-regulatory guidance to ensure easier access to care during the PHE for health care providers and their beneficiaries.
Some of the flexibilities that were created during the pandemic were recently expanded by the Consolidated Appropriations Act, 2023. Others, while critical during our initial responses to COVID-19, are no longer needed. CMS has made further updates to our CMS Emergencies Page with useful information for providers – specifically around major telehealth and individual waivers – that were initiated during the Public Health Emergency (PHE).
Please reference the following guidance in response to the PHE ending May 11, 2023:
Provider-specific fact sheets about COVID-19 Public Health Emergency (PHE) waivers and flexibilities: https://www.cms.gov/coronavirus-waivers
CMS COVID-19 Waivers and Flexibilities for Providers include:
- Physicians and Other Clinicians
- Hospitals and CAHs (including Swing Beds, DPUs), ASCs and CMHCs
- Teaching Hospitals, Teaching Physicians and Medical Residents
- Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities)
- Home Health Agencies
- Hospice
- Inpatient Rehabilitation Facilities
- Long Term Care Hospitals & Extended Neoplastic Disease Care Hospitals
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
- Laboratories
- Medicare Shared Savings Program
- Durable Medical Equipment, Prosthetics, Orthotics and Supplies
- Medicare Advantage and Part D Plans
- Ambulances
- End Stage Renal Disease (ESRD) Facilities
- Participants in the Medicare Diabetes Prevention Program
- Intermediate Care Facility for Individuals with Intellectual Disabilities
Department of Health & Human Services Fact Sheet: https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html
In the coming weeks, CMS will be hosting stakeholder calls and office hours to provide additional information. Please continue to visit the CMS Emergencies Page for continuous updates regarding PHE sunsetting guidance as information becomes available to the public.
HRSA Makes $30 Million Available for Health Centers to Expand Early Childhood Development Services
Funding will help health centers provide recommended developmental screenings and follow-up services for children and further integrate early childhood development into care teams.
The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services (HHS), announced the availability of approximately $30 million for HRSA-funded health centers to expand early childhood development care through increased screenings and follow-up services.
“HRSA-funded health centers are dedicated to meeting the unique needs of their communities – including providing key preventive services and care to help their youngest patients thrive,” said Administrator Carole Johnson. “This funding will strengthen and expand the availability of early childhood screenings and follow-up services that are vital for ensuring that kids get the support they need and have the tools to lead healthy, happy lives.”
Health centers provide essential preventive and primary care services to underserved communities across the country. Children undergo rapid physical, cognitive, linguistic, and emotional growth and development at this stage, and screening efforts help identify developmental or behavioral conditions, language delays, or other needs, such as food insecurity and housing instability, that can contribute to gaps in school readiness and impact a student’s ability to succeed.
Health centers that receive these awards will use the funding to strengthen their capacity to provide more children with recommended developmental screenings and follow-up services, including by developing the health center workforce necessary to deliver these services and focusing on the patient and caregiver experience.
Applications are due in Grants.gov on March 17, 2023 and in HRSA Electronic Handbooks on April 18, 2023. Visit the Early Childhood Development Technical Assistance Webpage for the notice of funding opportunity, technical assistance information, and other resources.
HRSA-funded health centers served 30 million people through nearly 1,400 health centers across the United States, collectively operating more than 14,000 service delivery sites in communities across the country.
To locate a HRSA-supported health center, visit: https://findahealthcenter.hrsa.gov/.
USDA Seeks Feedback from Broadband Technical Assistance Providers and Rural Communities
The Infrastructure Investment and Jobs Act (IIJA) (Pub. L. 117-58) provided the Rural Utilities Service (RUS) Telecommunications Program with funding for technical assistance and pre-development planning activities to support the most rural communities. RUS received additional funding for these purposes in the Consolidated Appropriations Act, 2023 (Pub. L. 117-328). RUS will host two listening sessions to solicit important feedback from rural communities interested in receiving broadband technical assistance and technical assistance providers serving rural communities.
Rural Communities interested in receiving broadband technical assistance are encouraged to register to attend the Broadband Technical Assistance for Rural Communities Listening Session on Thursday, February 23rd at 1 PM ET. Register for this session here.
The goal of this listening session is to solicit valuable insight into the challenges communities face in gaining broadband access, the types of technical assistance resources that would best serve these communities, and how RUS can best provide support.
Technical Assistance Providers interested in providing broadband technical assistance to support the most rural communities are encouraged to register to attend the Broadband Technical Assistance Providers Listening Session on Tuesday, February 28th at 1 PM ET. Register for this session here.
The goal of this listening session is to solicit input on the opportunities available to provide technical assistance for rural communities, the barriers to deliver these services, and how RUS can help providers overcome these barriers.
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Pennsylvania Dentists Discuss Oral Health During Children’s Dental Health Month
From WITF, On the Spark
According to the Centers for Disease Control, about 1 in 5 children between the ages of 5 and 11 have at least one untreated decaying tooth and children between the ages of 5 and 19 are twice as likely to have cavities if they come from low-income households.
According to the University of Illinois College of Dentistry, there is a connection between oral health and a person’s overall health and well-being.
February is Children’s Dental Health Month and Dr. LaJuan Mountain, vice president of dental services at Family First Health, and Dr. Sam Mansour, Pennsylvania Dental Association’s statewide national children’s dental health month chair, joined us on The Spark Thursday to discuss the importance of children’s dental health, the barriers to receiving dental care and ways to overcome them.
Dr. Mountain said, a healthy mouth consists of firm and pink gums and no disruptions or discoloration in the enamel. She also said, oral health is not the general consensus that she is seeing in our communities because of a lack of accessibility, high costs, insurance challenges, dentist office schedules, a lack of oral health literacy and more.
On The Spark we also discussed the Family First Health’s Mobile School Dentist program that provides in-school dental care for all ages and grade levels in York, Adams and Lancaster County.
“It’s having a tremendous impact. I’ve been doing this program for almost a decade and I’m actually seeing kids that I first started to treat in Head Start, and they’re now in junior high. So that means we’ve actually followed kids throughout their entire academic life thus far, and we’re seeing improvement,” Dr. Mountain said. “…We’re exposing them to the importance of their oral health, but also opportunities in health care, especially because the individuals we’re interacting with are often in that low socioeconomic environment.”
New Report: The Role of Telehealth in Achieving a High Performing Rural Health System: Priorities in a Post-Pandemic System
Telehealth usage increased during the Public Health Emergency (PHE), and this has fueled discussions on the optimum use of telehealth in healthcare delivery. Based on experiences during the PHE, and new applications of telecommunications technologies, this report assesses potential improvements in rural health service delivery, as well as potential unintended consequences that could undermine goals to improve services for currently underserved populations. The assessment is guided by the over-arching framework of the high-performing rural health system (HPRHS), to understand the benefits of telehealth in improving health equity as affecting four pillars of the HPRHS – access, affordability, community health, and quality.
Click here to open the full document.
Principal Authors: Joel M. James, MPH and Keith J. Mueller, PhD (Panel Chair)
Prepared by the RUPRI Health Panel: Alva O. Ferdinand, DrPh, JD; Alana D. Knudson, PhD; Jennifer P. Lundblad, PhD, MBA; A. Clinton MacKinney, MD, MS; Timothy D. McBride, PhD; Nancy E. Schoenberg, PhD
USDA Rural Development Launches the Rural Data Gateway Expanding Access to Data on USDA Funded Projects in Rural Communities
New integrated Rural Investment Dashboards make more than a decade of USDA Rural Development (RD) investment history instantly accessible to the public!
This uncomplicated interface allows users to sift through RD data gleaned from investments in rural housing, health care, broadband, businesses, infrastructure and much more. With its project-level county and congressional district data, the Rural Data Gateway opens a new chapter in RD’s ongoing commitment to investment transparency. To learn more, read the full news release.