Supreme Court upholds ACA subsidies in states using federal insurance marketplace

Today, the Supreme Court decided the case of King v. Burwell, permitting subsidies for the purchase of insurance in states that rely on the federally run health insurance marketplace.

A little bit about the case: This case (or actually cases, the court put together a number of cases asking the same question) asked whether the Affordable Care Act (ACA) allows for subsidies for the purchase of insurance when a state relied on the federally run exchange. The language in the law allows subsidies in exchanges “established by the state;” however, IRS rules provided for subsidies in the federally operated exchange (

It will take some time before we fully know what today’s decision will mean for rural health.

But we do know rural Americans tend to be older, sicker and poorer than their urban counterparts. So they are more likely to be in need of health care and less likely to have employer-provided insurance to help pay for that care.

While the National Rural Health Association did not take a position on ACA, we have continued to fight to ensure access to health care in rural America. Because so many rural Americans live in states with state exchanges and are in the income bracket eligible for subsidies, NRHA is pleased these vulnerable rural Americans can continue to receive the subsidies necessary to allow them to afford health insurance.

Currently, 18 percent of rural Americans are uninsured. And about three in four rural uninsured are eligible for premium subsidies.

Only those living in states that rely on the federal insurance exchange are impacted by this decision. However, nearly 80 percent of rural Americans live in states using the exchange (vs. 60 percent for urban). Thus, the impact of this decision is felt particularly acutely in rural America.

According to a 2014 Kaiser Family Foundation report, 50 percent of rural residents (vs. 43 percent of urban residents) have family incomes between 100 percent and 400 percent of the federal poverty level (FPL). It is in this income range where people are potentially eligible for subsidies to purchase of health insurance.

While some of these people receive insurance though their employer, Kaiser reported rural residents are less likely to have coverage though a job (51 percent of rural Americans vs. 57 percent of urban residents). Those without insurance though their employer face higher out of pocket costs for their premiums, which means many in this income bracket may simply not be able to afford coverage without subsidies, according to the report.

NRHA will continue to examine the potential rural impacts of this decision. Join us at 11 a.m. CDT June 30 for a call regarding the Supreme Court ruling, the latest Senate Appropriations news impacting rural health and our recent #SaveRural Hospitals Rally.

We will also update this blog with more details as we break down the decision and the accompanying dissent.

Sen. Grassley introduces additional rural hospital model bill

The Rural Emergency Acute Care Hospital Act of 2015 (S.1648) was introduced today by Sen. Chuck Grassley (R-IA), to establish a new Medicare payment designation, the Rural Emergency Hospital to sustain emergency services in rural communities.

Rural hospitals are critical to the 62 million rural Americans that rely on them to receive necessary local care. Rural hospitals provide care to vulnerable rural Americans as well as serve as an important economic and social anchor for their communities. However, far too many of these hospitals are in trouble.

Since 2010, 55 rural hospitals have closed, 283 more are on the brink of closure. And the pace of closures is increasing, since January 2013, more rural hospitals have closed than in the previous 10 years combined. Continued cuts in hospital payments have taken their toll, forcing closures and leaving many of our nation’s most vulnerable populations without timely access to care. If Congress doesn’t act to stop the bleeding and prevent further closures of rural hospitals, 700,000 patients would lose direct access to care; patients and local economies will suffer.

Our health care system is undergoing dramatic changes.

As stated in NRHA’s policy paper, providers have become increasingly aware that the current rural safety net programs are not structured for success in this new environment.

While it is critically important to sustain the rural safety net providers such as Rural Health Clinic, Federally Qualified Health Center, Critical Access Hospital, Medicare Dependent Hospital, Sole Community Hospital, physicians and other rural programs and providers during this time of change and uncertainty, it is equally important to outline a meaningful phased and non-destructive transition strategy that successfully links today’s payment and patient care delivery structures to the health care systems of the future.

NRHA applauds the forward thinking of Sen. Grassley by introducing a new model of rural health care to provide rural hospitals and communities a path forward to provide local care.  NRHA remains committed to advancing legislation that will also stabilize the rural health care safety net by stopping the numerous Medicare cuts that are significantly harming the financial viability of many rural hospitals.

Appropriations season in full swing

The Fiscal Year 2016 appropriations are underway.

The Senate Appropriations Subcommittee will markup FY 2016 Labor, Health and Human Services Funding Bill, which includes funding for multiple important rural health programs, at 3 p.m. ET today. To listen live, click here.

Tomorrow the full House Appropriations Committee will markup the bill. The House report is here.

NRHA continued to support robust funding for the rural health safety net in the FY 2016 funding measures.

Stay tuned to NRHA’s blog for the latest appropriation news.

NRHA asks Congress to support Border Health Security Act

The National Rural Health Association (NRHA) urges members of Congress to support the Border Health Security Act introduced by Senators Tom Udall (D-NM) and Martin Heinrich (D-NM). NRHA believes Congress must continue to make investments in emergency preparedness, health surveillance, and rural community infrastructure, particularly, at our nation’s borders.

The United States-Mexico Border Health Commission has worked over the past decade to address major bi-national health issues that strain the public health systems of both nation’s along the shared border. A major focus is on communicable diseases, such as H1N1, hepatitis, and measles, since these diseases do not recognize nor respect borders. As the Commission enters its second decade, the focus must be broadened and strengthened to improve defenses against bioterrorism, to warn of communicable disease outbreaks, and address the many health disparities in the border region.

The legislation would reauthorize the Early Warning Infectious Disease Surveillance (EWIDS) program. Created in 2003, it provide states along the U.S.-Mexico and U.S.-Canada borders with funding to detect, identify, and report outbreaks of infectious diseases. The bill also authorizes $7 million per year for border grants and operations.

The House companion bill will be introduced by Rep. Rubén Hinojosa (D-TX).

House Appropriations Committee markups FY 2016 Labor, Health and Human Services Funding Bill

The House Committee on Appropriations will mark up today the Fiscal Year 2016 Labor, Health and Human Services Funding Bill, which includes funding for health programs through the Department of Health and Human Services.

The total package is about $14.55 billion or a 9 percent cut from the President’s budget request for health, labor and education appropriations for FY 2016.

The bill includes $71.3 billion for HHS funding, which is an increase of $298 million above last year’s level and $3.9 below the President’s request. Funding for the Health Resources and Service Administration (HRSA) is $6 billion, which is $299 million below last year’s level and $413 million below the President’s request.

The bill does not include the President’s cuts to Critical Access Hospitals.

Watch the markup live here.

Stay tuned to NRHA’s blog for the latest appropriation news.

NRHA speaks at Rural Health 101 for senators

Maggie Elehwany, National Rural Health Association vice president of government affairs, discussed the importance of rural health care today during a Rural Health 101 policy briefing on Capitol Hill.

Elehwany spoke on the significant role rural providers play to the older, sicker, and poorer population they serve.

“Sixty-two million patients rely on rural providers,” Elehwany said. “These providers are facing unprecedented challenges from Washington, from challenges in Medicaid expansion, continued cuts in Medicare and continued threats of additional Medicare cuts.”

Elehwany urged the Senate to protect access to care for these vulnerable populations, and to save the 283 rural hospitals that are on the brink of closure. Already 53 rural hospitals have closed since 2010. Without congressional intervention, layoffs, wage cuts, economic loss, reduced services and closed doors will occur in more rural communities across America.

“If Congress doesn’t act to stop the bleeding and prevent further closures of rural hospitals, 700,000 patients would lose timely access to care,” Elehwany cautioned. “Patients and local economies in your state will suffer.”

In addition to NRHA, representatives from the Office of Rural Health Policy, National Association of Rural Health Clinics and the American Hospital Association participated in the Rural Health 101 briefing, sponsored by the Senate Rural Health Caucus. The caucus is chaired by Sens. Pat Roberts (R-KS) and Al Franken (D-MN).

NRHA encourages senators to join the caucus and its members to ask their elected officials to #SaveRural hospitals and patients today.

Join the walk to save rural hospitals

Fifty-three rural hospitals have closed; 283 more are on the brink of closure.

Since January 2013, more rural hospitals have closed than in the previous 10 years combined.

It’s clear continued cuts in hospital payments have taken their toll, forcing closures and leaving many of our nation’s most vulnerable populations without timely access to care.

Led by Mayor Adam O’Neal, a group of advocates from 14 states are walking 283 miles – one for each at-risk hospital – from rural Belhaven, N.C., and arriving at 11 a.m. June 15 at the U.S. Capitol to draw attention to the dire situation rural hospitals and communities are facing.

If Congress doesn’t act to stop the bleeding and prevent further closures of rural hospitals, 700,000 patients would lose direct access to care; patients and local economies will suffer.

Without congressional intervention, layoffs, reduced wages, economic loss, reduced services, or worse, closed doors will occur in more rural communities across America.

The National Rural Health Association invites you to the conclusion of The Walk for Rural Hospitals at 11 a.m. June 15 on the east grounds of the Capitol, between the Capitol building and the Supreme Court building. This is a free event and all are encouraged to attend to show their support for rural hospitals.

If you are unable to attend, join NRHA’s Virtual March for Rural Hospitals on June 15. Call, email, Tweet and Facebook your members of Congress, and ask them to protect rural hospitals and patients.

Be sure to also:

• Attend town halls. Be prepared to ask questions and share your stories about rural hospitals.

• Write a letter or op-ed to your local media.

• Invite your members of Congress and health legislative assistants to tour your facility.

• Hold a press conference about what these programs mean to your hospital and town.

For more information and ways to #SaveRural hospitals and patients, visit NRHA’s Save Rural Hospitals Action Kit.


Contact your Senate Finance Committee member now to support amendments

This morning, the Senate Finance Committee will markup Chairman Orrin Hatch’s (R-UT) Audit & Appeal Fairness, Integrity, and Reforms on Medicare Act of 2015 which includes several changes to how Medicare contractors will review providers’ Medicare claims.

NRHA is urging you to call your Senators on the Finance Committee now and urge them to support three amendments to the mark:

– Cardin Amendment – “Improving Accuracy and Transparency of Federal Reporting of Recovery Auditor Auditing and Appeals”

– Heller Amendment – Section 12 “Availability of Medical Records Based on Accuracy”

– Stabenow Amendment – Section 12 “Strike Contractor Document Collection Language”

Continue monitoring our blog for the latest government affairs news.

Conrad State 30 & Physician Access Act introduced in Senate

The National Rural Health Association applauds the introduction of the bipartisan S.1189, the Conrad State 30 & Physician Access Act introduced by Sens. Jerry Moran (R-KS), Susan Collins (R-ME) and Heidi Heitkamp (D-ND).

This legislation will improve and make permanent the Conrad State 30 program, also known as the J-1 Visa Waiver program. This program was enacted in 1994 as a national initiative that permits states to recommend visa waivers for physicians recruited to care for patients in rural and underserved areas. The Conrad State 30 & Physician Access Act removes the sunset of the program, improves its functioning, and allows it to expand its scope to better meet the needs of rural America.

NRHA supports this legislation, which makes great strides in the recruitment of physicians to rural areas and the delivery of vital health care services in rural America. The Conrad State 30 program will help hospitals, clinics and group practices increase access to health care in rural America.

NRHA’s Rural Health Congress approves new policies

The Rural Health Congress recently approved five new policy papers.

The National Rural Health Association’s policy-making body, the Rural Health Congress, determines the association’s positions on public policy through a series of policy briefs and issue papers. The congress consists of elected representatives from each of the association’s constituency groups and councils as well as Board of Trustees officers.

The Comprehensive Quality Improvement in Rural Health Care policy paper is an update of the 2007 paper. It updates the definition of quality of care with a renewed focus that emphasizes patient and family engagement, care coordination, and population health. NRHA can play an essential role to ensure that local, state and federal partnerships are strong, committed and aligned to support comprehensive quality improvement strategies and infrastructure needed to promote continuous quality improvement in rural health care.

The Designation of Frontier Health Professional Shortage Areas policy paper demonstrates that the additional resources available to communities federally designated as Health Professional Shortage Areas (HPSA) are critical to allow safety net providers, including those serving populations in frontier areas, to serve their patients with adequate support staff, up-to-date equipment, and appropriate medications. The HPSA criteria currently in place does not ensure access to federal resources in areas with sparse or geographically isolated populations, which often experience the greatest challenges to recruiting health care professionals. The paper recommends the HPSA criteria take into account the unique characteristics and challenges of sparsely populated and geographically isolated areas. A separate designation of frontier HPSA would address many of these issues.

The Future of Rural Behavioral Health policy paper outlines the limits rural residents have in accessing behavioral health care. Attracting, broadening and training the workforce, addressing reimbursement and financing issues with appropriate compensation for professional behavioral health care providers and affordable options for patients, fostering the integration of health care services with care coordination and referral networks, being mindful of the changing cultural landscape in rural areas, and utilizing tele-behavioral health will all play essential roles in reducing health disparities in rural communities. Leadership is critically needed to advance comprehensive policies at every level that ensure the availability, accessibility, affordability and acceptability of quality behavioral health services for rural Americans.

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