The Changing Rural Health Landscape

Jun 20, 2014 at 08:57 am by Staff

Will the Affordable Care Act help or hurt Americans living in rural areas? As is true of many complex laws, there probably isn’t going to be a single, simple, clear-cut answer. Some of the elements should be beneficial; others could have unforeseen or unintended consequences that ultimately limit access to care.

Noted rural health expert Keith Mueller, PhD, head of the Department of Health Management and Policy for the University of Iowa College of Public Health and director of the Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis, has been an integral part of preparing two policy briefs focused on ACA’s impact on rural America. Mueller also serves as chair of RUPRI’s Rural Health Panel, which released “The Patient Protection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Providers: A Second Look” in late April. The new review is a follow-up to the original analysis released shortly after the legislation was signed into law.

“Like a lot of people, we were pleasantly surprised at the level of enrollment,” Mueller said of the panel’s reaction to recently released health exchange numbers. He explained that on top of the 8-plus million that was widely reported, there has also been a fair amount of enrollment in qualified health plans (QHP) on the open market. At this point, Mueller noted, it isn’t clear what the urban/rural breakdown is among enrollees.

However, Mueller continued, the number of uninsured individuals in rural areas is generally about the same or a little higher than in urban areas. “Small employers in rural areas are less likely to have made an employee plan available than small employers in urban areas,” he noted.

While having more people insured is a positive, Mueller pointed out coverage comes with a presumption that someone will actually be there to deliver care. “You have to address both the financial access and the availability of services,” he continued. “You’ve increased the demand so you also have to increase the supply.”

Mueller continued, “In rural areas where there’s already a shortage of providers, you’ve exacerbated the situation. There are still many more counties that are primary care shortage areas than there ought to be … and that’s a fundamental service.” In addition, he said there are pockets where there is a shortage of emergency services and general surgeons. Mueller said the health delivery system has to be integrated locally across the full continuum of care from primary through quarternary care. “You need to have a system where no matter where I live, there is a point of entry for me to get all those services,” he stated.

On a more positive note, Mueller said Title 5 of ACA, which deals with workforce issues, did increase funding for the National Health Service Corps. There has also been increased attention regarding how providers could be used more efficiently in federally qualified health centers, including a push to have non-physician providers practice at the top of their licensure.

Even before ACA, Mueller pointed out, healthcare systems were already evolving with pilot programs testing innovative payment and delivery models. Technology, he said, will provide a critical role … particularly the use of telehealth in rural areas. Instead of having to bill for each discreet service, Mueller said newer payment models allow for bundled services, “leaving it up to doctors to figure out the best way to get to the value proposition.”

That is a win for telehealth, he noted, since the service is often left out of traditional payment plans. Another plus for telehealth is that patient satisfaction also plays into reimbursement … being able to ‘see’ a specialist at home using technology to assist in a consult rather than driving to an urban market, should increase convenience and satisfaction for rural patients. It allows them to receive the care, albeit differently, that would be found in a much larger city.

“That, to me as a researcher and analyst, is the most exciting direction because it means that people will get the care they need when they need it no matter where they are living,” Mueller said.

Of serious concern, however, is the financial fallout in states that did not opt to expand Medicaid as was intended by ACA to help offset payment reductions in other areas, such as those to disproportionate share hospitals. “The states that did not expand Medicaid are states with larger rural populations so the non-expansion has a disproportionate rural effect,” Mueller said.

He added, “So far there hasn’t been a huge effect because those reductions are scheduled to happen over time.” However, Mueller continued, “The longer those states don’t expand (Medicaid), the greater the impact.” He noted the financial strain would be felt more sharply in rural areas because those hospitals tend to have much thinner operating margins in the first place.

Mueller noted, “We have put in place over the last couple of decades various ways to sustain service delivery in the rural areas. The scary scenario would be because of financial pressures, we pull the rug out from under (them). If that happened, there would be places in rural America where access would be severely limited.”

He concluded, “You don’t stop what has been working, even if it isn’t perfect, until you have a better solution in place. I think we’re working on a better solution right now … but it’s not in place, yet.”

Access “The Patient Protection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Providers: A Second Look” under the quick link for the Rural Health Panel at


Full report (PPACA of 2010: A Second Look) at:

Sections: Events