From FIERCE Healthcare

Rural residents were the most likely to benefit from enhanced subsidies for Affordable Care Act coverage and face the greatest danger of losing coverage if those benefits expire after this year, a new study finds.

The study, released by the Robert Wood Johnson Foundation Tuesday, comes as healthcare groups are making a major effort to get Congress to renew the boosted subsidies. ACA enrollment grew to a record-setting 14.5 million people this year thanks in part to the higher subsidies.

“The enhanced premium subsidies have been transformational in high-cost rural areas,” said Kathy Hempstead, Robert Wood Johnson’s senior policy adviser, in a statement. “If the tax credits are allowed to expire, rural residents will have few if any policies to choose from that are both affordable and comprehensive.”

Researchers with the Urban Institute on behalf of the foundation looked at average benchmark premiums across several states on the ACA exchanges. The benchmark plan—which is the second-cheapest silver tier plan—is what the federal government uses to calculate income-based subsidies. The government ties the benchmark premium to a certain percentage of the household income.

“Because the percentage-of-income caps do not vary with premiums, the higher the benchmark premium, the greater the size of the federal government’s premium contribution for the household,” the study said.

Read more.

Before the COVID-19 pandemic began, hospital closures were increasing in rural communities across the nation: 116 rural hospitals closed between 2010 and 2019. Over the past two years, federal relief has helped stabilize facilities, and the pace of closures slowed. However, this assistance was temporary, and rural hospitals continue to struggle financially and to recruit and retain nurses and other health care employees.

Against this backdrop, the Bipartisan Policy Center (BPC) conducted a series of interviews over the last year with rural hospital leaders from eight states—Iowa, Minnesota, Montana, Nebraska, Nevada, North Dakota, South Dakota, and Wyoming—as well as with health policy experts from federal and state government, national organizations, provider organizations, and academia. The goal was to gain on-the-ground insights into today’s rural health care landscape, where the population is older, sicker, and less likely to be insured or seek preventive services than in urban areas.

Today in rural America, roughly 1 out of every 3 individuals are enrolled in the Medicare program and nearly 1 in 4 individuals under age 65 rely on Medicaid as their primary source of health care coverage. Although all payers should be part of the solution in ensuring access to quality rural health care, this report largely focuses on strengthening rural health care delivery in Medicare and Medicaid given the outsized role these public programs play in rural communities.

Read more and access the full report.

Dr. Sharon Bernecki DeJoy and Dr. David J. Doorn of West Chester University of Pennsylvania examined access to maternity care in rural Pennsylvania. It included a workforce analysis and a survey of stakeholders and key informants.

The research projected that the supply of obstetricians in rural practice will not increase over the next five years. However, there was a projected growth in the number of midwives and family practice physicians in the next five years, which may partially help with the shortage of obstetricians.

Eighteen rural Pennsylvania counties are or are forecasted to be “maternity care deserts,” where there are not enough providers to ensure access for all pregnant people.

Three broad areas for policy development : recruit more maternity care providers to work in rural areas, encourage innovation in interprofessional maternity care models, and maintain and place resources for maternity care in locations where they are scarce.

Here’s the full report, Access to Maternity and Obstetric Care in Rural Pennsylvania.

A large number of rural hospitals that cease obstetrics programs wind up closing later, researcher says.

About 40% of rural hospitals are losing money on their obstetrics programs, but many continue to provide the service because of its importance for community health, a new study shows.

Losing child-birth services can also be a harbinger of hard times for a rural hospital, oftentimes serving as a precursor to closure.

A study conducted by the University of Minnesota Rural Health Research Center found that some rural hospitals keep their obstetrics programs open even after they have stopped being financially viable.

In large part, researcher Julia Interrante said, rural hospitals that close their obstetrics units are more likely to close their doors for good.

“Usually the obstetrics unit will close, and then other services will start to close before the entire hospital closes,” she said. “It’s not always the case – sometimes we see things where hospitals will enter into mergers or move those services to another hospital location… But often when they end up closing OB services, then it usually kind of leads toward the hospital closing.”

A survey of obstetric unit managers or administrators at nearly 300 rural hospitals found that whether the program was in the black wasn’t as important to these leaders as how much the community needed it.

Hospitals reported they needed 200 births per year to maintain safety standards and to remain financially viable. More than 40% said they had fewer births than needed to sustain operations financially.

“I think that’s really striking,” Interrante said. “But so many of them also reported understanding the need and importance of having those services in rural communities, because people are still giving birth, and they have to have somewhere to go.”

The survey respondents said it was important to keep the obstetrics units open because of the complications patients could encounter if they had to drive long distances to give birth.

About two-thirds of survey respondents said meeting their community’s needs was the most important factor in keeping their obstetrics units open, even if there weren’t enough births in the area to warrant it financially. Only 16.5% said their top priority in making that decision was the financial aspect. Nearly 13% said their top priority was staffing.

Nationally, birth rates have been falling since 2008, according to the U.S. Census Bureau.  Birth rates tend to be higher in rural areas, around 1,900 births per every 1,000 women, compared to 1,600 births for 1,000 women in urban areas. However, because there are fewer women of child-bearing age in rural areas, hospitals tend to see fewer births per year.

“Many hospital administrators in rural communities care deeply about the health of pregnant rural residents,” Katy Backes Kozhimannil, director of the Rural Health Research Center and lead author of the study, said. “Rural hospital administrators prioritized local community needs over finances and staffing, keeping obstetric units open because local pregnant patients need care. Policy investments are needed to help rural hospitals and communities support safe, healthy pregnancies and births.”

Interrante said insurance reimbursement is one issue rural hospitals face in keeping the obstetrics units open. Rural areas tend to have more patients on Medicaid, she said, which only reimburses a percentage of what it costs hospitals to provide those services. According to the CDC, half of the women who give birth in rural areas are on Medicaid, compared to 41.9% in urban areas.

More than a quarter of those responding to the survey said they were not sure if they would continue providing obstetrics. Or they said they expected to stop offering the service, indicating a continued downward trend in health care access, researchers said.

“The responses from the rural hospital administrators strongly highlight the fact that they provide obstetric services because they are so necessary and important for the health of rural communities they serve,” Bridget Basile Ibrahim, a co-author of the study, said. “For many of the patients who give birth at these hospitals, it would be a huge burden for them to travel to the next nearest hospital to give birth.”

Researchers concluded that any policies to improve rural obstetrics care should take into account community needs, clinical safety, and rural hospital finances. How low-volume, rural hospitals are reimbursed should be investigated to ensure those hospitals’ financial viability, they said.

The Appalachian Regional Commission’s (ARC) new report, “Agriculture and Local Food Economies in the Appalachian Region,” examines the impact and potential of Appalachia’s food systems.

Based largely on U.S. Department of Agriculture Census of Agriculture data, the report is filled with recommendations and success strategies that can help communities cultivate thriving food economies.  The research also includes overviews and case studies that will prove useful to Appalachian stakeholders interested in developing their own local food systems.

Learn more about opportunities to strengthen Appalachian food economies by clicking here.

The Weitzman Institute is pleased to share its latest policy brief, “Understanding Adverse Childhood Experiences in the Context of COVID-19.”

Adverse childhood experiences (ACEs) are potentially traumatic events that occur in childhood (0-17 years). They are a major public health concern that will worsen as a result of the health, social, and economic repercussions of the COVID-19 pandemic.

This policy brief examines how the health, social, and economic impact of COVID-19 may result in an increase in ACEs, especially in our most vulnerable populations, and discusses the public health responses needed to effectively address ACEs in our communities.

The brief builds upon Weitzman Institute staff Dr. April Joy Damian, Daniel Bryant, and May Oo’s recent article in Psychological Trauma: Theory, Research, Practice, and Policy, and forthcoming chapter in the book Handbook of Adverse Childhood Experiences (ACEs): A Framework for Collaborative Health Promotion.

Click HERE to read the policy brief.

The U.S. Census Bureau released estimates of the total population as of July 1, 2021 at the county level. Population estimates are calculated using administrative records to estimate components of population change such as births, deaths, and migration.

In 2021, fewer births, an aging population, and increased mortality – intensified by the COVID-19 pandemic – contributed to a rise in natural decrease. The statistics released today include population estimates and components of change metropolitan statistical areas, micropolitan statistical areas, and counties.

Thirty-six counties experienced population decline from 2020 to 2021. Click here to read more.

A report from by Dr. Diane Shinberg of Indiana University of Pennsylvania, provides a profile of the lives and livelihoods of rural Pennsylvania women.

The research noted that rural Pennsylvania’s population is aging more rapidly than the rest of the state, so the rural population, in general, includes relatively fewer younger adults (aged 25-34 years) compared to older adults (aged 35-64 years).

Educational attainment among rural women has increased from 2005-2009 to 2014-2018, however, high school graduation remained the most common level of completed schooling for rural women. About two-thirds of rural women participated in the labor force, and the most commonly held jobs among rural women were at risk of replacement due to automation or other economic restructuring. The research also revealed that more rural women work now than in the past, and their time “on the clock” increased. While personal wages and salaries of working rural women increased from the previous decade, they also earned the least among rural men and urban women and men.

Access the report here.