New from the RUPRI Center for Rural Health Policy Analysis

Distributional Analysis of Variation in Medicare Advantage Participation Within and Between Metropolitan, Micropolitan, and Noncore Counties
Dan Shane, PhD; Ufuoma Ejughemre, MD, MSc; Fred Ullrich, BA; Keith Mueller, PhD

This policy brief uses county-level information from 2017-2022 on population and MA plans to analyze relative MA participation rates by geographic classification. We use Urban Influence Codes to split counties into metropolitan, micropolitan, and noncore categories. Within each geographic classification, we order counties into quintiles by MA penetration rate (MA enrollees / Medicare-eligible enrollees) with the lowest 20% of county penetration rates comprising the first quintile. We find consistent growth in the median number of plans and median enrollment across all geographic classifications and all quintiles between 2017 and 2022, with slightly higher growth in micropolitan and noncore counties. We also find that growth rates were consistently higher in the lowest quintiles (lowest penetration rates) in each geographic classification. However, the absolute differences in median number of plans and median enrollment between these lowest-ranked counties and higher ranking counties in MA participation remained the same.

Key Findings

• From 2017 through 2022, growth (measured as percent increase) in the number of MA plans and MA enrollment rates was higher in noncore and micropolitan counties than in metropolitan counties, but metropolitan enrollment rates remained higher than nonmetropolitan enrollment rates. The median number of MA plans in metropolitan counties is higher than that in micropolitan counties which is higher than the median number of plans in noncore counties.
• Within each rural-urban classification, percent growth in MA penetration rates, plans, and enrollment has been highest in counties with the lowest participation rates in 2017.

Population size is closely tied to higher participation rates both within and across geographic classifications, with the important caveat that micropolitan and noncore counties with higher MA participation exceed rates that population only would suggest.

Click here to read the full report.

 Among key findings from the University of Minnesota Rural Health Research Center: rural residents are more likely than urban residents to have lived in their homes for more than 20 years (27 percent vs. 20 percent); more likely to have a disability (17 percent vs. 13 percent), and/or be in poor health (24 percent vs. 17 percent).

A coordinated early care and education system ensures infants, toddlers, and preschoolers succeed in school and allows parents to work while knowing their children are safe and learning in high-quality care. Yet, inequities exist, causing too few children to have access and a historic early learning workforce shortage, as shown in our first-ever State of Early Care and Education report.

Working with Pre-K for PA and Start Strong PA as part of Early Learning Pennsylvania (ELPA), a statewide coalition of advocates focused on supporting young Pennsylvanians from birth to age five, the report uses data and research to show that without new investments in the child care workforce, Pre-K Counts, or the Head Start Supplemental Assistance Program, early learning providers will continue to lose teachers and close classrooms.

The growth and development of young children in high-quality early care and education is the start of a continuum with benefits that last into adulthood. Providing every child—regardless of race, ethnicity, geography or income—access to high-quality early care and education programs ensures an equitable start to their academic careers.

A coordinated child care system serving infants and toddlers is vital to the economy, allowing parents to work while knowing their children are safe and learning in high-quality care.

According to the report, inadequate funding for the child care system has led to issues of supply and demand that impact a family’s ability to find affordable, high-quality child care, and child care providers’ ability to be compensated fairly to pay their teachers and maintain business expenses:

• Unlivable wages of less than $12.50/hour are causing a historic workforce shortage that is closing classrooms and driving up wait lists for working mothers and families.
• Child care providers can’t raise teacher wages because families are already struggling to afford the costs of care. On average, costs for infant child care comprise approximately 17.5% of the Pennsylvania median family income.
• Only 21% of eligible children under three are served by Child Care Works, leaving over 83,000 eligible infants and toddlers unserved.

The next step in the academic continuum for children is access to high-quality pre-k programs, but only 43% of eligible 3- and 4-year-olds participate in high-quality, publicly funded pre-k, leaving over 87,000 without access to a high-quality program.

The workforce is essential for delivering high-quality pre-k. Yet, while the level of quality expects and demands the appropriate knowledge and credentials of professionals, the compensation for pre-k teachers remains significantly lower than their colleagues in K-12 settings.

Unlike child care, publicly funded pre-k programs in Pennsylvania rely on annual state budget funding appropriations. High-quality pre-k has historically been a consensus issue, aligning political parties and enjoying a decade of growing investment. However, policymakers have flat-funded pre-k in the 2023-24 state budget, which is baffling.

The report shows inequitable access to early care and education opportunities for children in Pennsylvania:

• As of March, only 1 in 4 income-eligible infants, toddlers, and preschoolers who are Black, Indigenous, and children of color participated in Child Care Works, with only 40% enrolled in a high-quality child care program. Of the 12% of income-eligible non-Hispanic white infants, toddlers, and preschoolers participating in Child Care Works, 51% were enrolled in a high-quality child care program.
• Only 23% of all children served in Pre-K Counts and Head Start Supplemental Assistance Programs in Pennsylvania are Non-Hispanic Black, compared to 41% of children identifying as Non-Hispanic White.
• Researchers at Penn State University found white preschoolers accounted for the majority of program participants in Pre-K Counts, and white children were increasingly more likely to be enrolled in a high-quality pre-k program compared to Black children. Recommendations from the report specifically called for Pennsylvania to increase funding for pre-k access and to serve more Black children from urban and high-poverty communities.

And compared to the K-12 and post-secondary education systems, the sector is the most diverse yet the lowest paid.

• Racial disparities exist within the professional child care sector, with Black educators earning approximately 2% less than their white counterparts. Hispanic educators earn approximately 5% less than white educators, exacerbating the already low wages of the sector and deepening inequities and gaps in pay.
• There is a pay gap between pre-k and kindergarten teachers, but an even larger wage gap between Black and non-Black educators. A $1/hour wage gap exists between Black and non-Black teachers at the preschool level.

The evidence is clear that access to a high-quality early care and education system positively impacts the lives of Pennsylvania children. Unfortunately, the state is falling short for children, families and providers across the commonwealth. Comprehensive policy solutions and increased investments are needed to change the system’s trajectory. Working together, we can build Pennsylvania’s early care and education system as a leading model.

The Rural Health Value team is pleased to release a new Rural Innovation Profile: A Rural Accountable Care Organization’s Journey

For more than a decade, South East Rural Physicians Alliance Accountable Care Organization (SERPA‐ACO), a physician‐led ACO that includes 16 physician-owned clinics in Nebraska has been leveraging health care payment and delivery models to provide high quality, comprehensive, coordinated, and patient‐centered care at a lower cost.

Related resources on the Rural Health Value website:

• Demonstrating Your Value: A Guide to Potential Value-based Care Partnerships for Rural Health Care Organizations. This Rural Health Value resource assists rural health care leaders in demonstrating the value their organizations can bring to networks, affiliations, payers, systems, or accountable care organizations.
• Catalog of Value Based Initiatives for Rural Providers – One-page summaries describe rural-relevant, value-based programs currently or recently implemented by the Department of Health and Human Services (HHS), primarily by the Centers for Medicare & Medicaid Services (CMS) and its Center for Medicare & Medicaid Innovation (CMMI).
• Medicare Shared Savings Program: Rule Changes and Implications for Rural Health Care Organizations – A summary of the changes made to the Medicare Shared Savings Program taking effect January 2023 and 2024. This Rural Health Value analysis outlines how the changes would reduce barriers to participation for potential or reentering ACOs that operate in rural contexts.

For more information, contact Clint MacKinney, MD, MS, Co-Principal Investigator, at clint-mackinney@uiowa.edu

Centers for Medicare and Medicaid Services (CMS) regulations at 42 CFR § 438.66(e) require states to submit a Managed Care Program Annual Report (MCPAR). Under the regulation, each state must submit to CMS, no later than 180 days after each contract year, a report on each managed care program administered by the state. In June, Pennsylvania submitted four MCPA Reports: Behavioral HealthChoices, Community HealthChoices, Physical HealthChoices, and Adult Community Autism Program (ACAP).

  The University of Minnesota Rural Health Research Center examines information collected by the U.S. Census Bureau’s ongoing, annual survey that collects information on social, economic, housing, and demographic characteristics.

On August 1, 2023, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the Inpatient Prospective Payment System (IPPS) and Long-term Care Hospital payments (LTCH-PPS) for fiscal year 2024. Effective October 1, 2023, the IPPS rates will increase by 3.1% overall, increasing hospital payments by $2.2 billion. The rule continues the low wage index policy for FY 2024 and will treat rural classified hospitals as geographically rural for purposes of calculating the wage index. It finalizes a policy designating Rural Emergency Hospitals (REHs) as graduate medical education (GME) training sites and codifies in regulation the information hospitals must include in their application to convert to an REH. The rule addresses policies around quality measurement, including the incorporation of a health equity adjustment for the Hospital Value-Based Purchasing (VBP) Program. In addition, CMS received feedback from stakeholders on the potential future inclusion of two geriatric measures and on the establishment of a publicly reported hospital designation for geriatric care.

 CMS released final rules for Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Inpatient Psychiatric Facilities (IPF), and Hospices.   Each rule updates Medicare payment and quality measurement policies for Fiscal Year 2024, which begins October 1. The final rules indicate a 3.3 percent increase in payments for rural SNFs, a 3.6 percent increase in payments for rural IRFs, a 2 percent increase in payments for rural IPSs, and a 2.8 percent increase in payments for rural hospices.