Author Archives: Maggie Elehwany

Election Takeaways for our Rural Agenda

Well, yesterday was another fascinating exercise in democracy. And while there is much to analyze, the significant takeaway is this: Rural America continues to turn a brighter shade of red as the rural/urban electorate seemingly grows further and further apart. The expanding rural/urban divide could even be seen in not-so-rural states like Maryland who shockingly elected only their second Republican Governor in nearly 50 years. This is entirely because the voter turn-out was low in Baltimore but high in eastern and southern Maryland, the rural portions of the state.

Yesterday’s election has two other significant underlying stories…

(for the rest of the blog visit NRHA Connect.)

Veterans’ Access Bill Falls Short for Rural Veterans

NRHA is disappointed that final language of the Veterans’ Access, Choice and Accountability Act does not do more to improve access for rural veterans across the nation.

Our nation’s veterans are disproportionately from rural America. The legislation had an opportunity to remove significant barriers and allow rural veterans the choice to access quality health care close to their home, yet fell short.

A significant barrier for many rural veterans is that there will be no ability to choose a local rural provider, even if they live well over 40 miles from a Veterans Health Administration hospital. This is due to the inclusion of Community-based Outpatient Clinics (CBOCs) in the definition of VA medical facility within the Act. There are over 800 CBOCs scattered across the county. These outpatient-only facilities offer varying degrees of limited primary care during limited operating hours.  Including these facilities within the bill virtually negates the intent of providing rural veterans true choice in their health care.

NRHA is also disappointed that language was not included to ensure appropriate rural representation on the Commission on Access to Care established within the Act. Rural veterans, like rural Americans in general, are older, poorer and sicker than their urban counterparts and have unique challenges accessing care. Both workforce shortages and sheer geography make the health care delivery in rural areas extremely challenging. Like other health commissions currently charged with reporting to Congress, there should be proper rural representation on the Commission in addition to a representative from the VA Office of Rural Health.

For more information on the health needs of rural veterans, please view NRHA’s recent policy paper:  Rural Veterans: A Special Concern for Rural Health Advocates

NRHA Defends Importance of 340B Drug Program

Today NRHA joined forces with the Safety Net Hospitals for Pharmaceutical Access (SNHPA) in a press event to set the record straight on the importance of the 340B drug discount program to rural and other safety net hospitals.
NRHA has long fought for the inclusion of rural hospitals in the 340B program, and with the passage of health care reform, finally won the fight. The program allows certain safety net hospitals who provide care to vulnerable populations to purchase drugs at a discount from the manufacturer.
Critics of the program, largely from pharmaceutical companies and a few members on Capitol Hill, claim the program provides too great of a financial benefit to hospitals. For rural hospitals this is untrue. Half of all the hospitals participating in the 340B discount are rural facilities. It is important to note that over 40 percent of rural hospitals operate at a financial loss. With Medicare cuts looming for many rural hospitals, threats of more cuts on the horizon, and the impact of Sequestration cuts kicking in, the 340B program has been a beacon of light for many rural hospitals. The program has allowed hospitals to maintain many critical services, critical staff, and in certain cases, keep their doors open – - maintaining them as a critical access point for both the delivery of health care and life-saving medications. Rural patients have been able to access life-saving drugs at an affordable price at a local hospital – - ending extensive travel time for many specialty drug treatments.
SNHPA issued an important new report this morning that explains the 340B program’s intent, describes how it supports participating hospitals’ safety net mission, and rebuts the mischaracterizations of 340B being circulated by its critics. The report and other facts about the program can be found at
NRHA will continue to fight for the expansion of the 340B program to all rural provides, as well as the expansion of the program to include inpatient drugs.

NRHA Supports Renewed Push to End Bay State Boondoggle

NRHA is pleased that Senators Claire McCaskill and Tom Coburn are renewing their push to repeal the piece of the health law that resulted in a wage increase for all Massachusetts hospital physicians and staff at the detriment of rural hospitals across the nation.

The provision required that Medicare reimbursements to all providers in a state be higher than the wage at the state’s rural hospitals. Massachusetts has only one “rural” hospital to set that floor, resulting in all wages in the state rising at the expense of other states. The lawmakers say that nine states benefit from the provision and 40 see a negative impact.

The provision was dubbed the “Bay State Boondoggle.” The bill already has 24 co-sponsors.  If you don’t see your senator listed below, please call 202-224-3121 and ask your senator to cosponsor S.183, the Hospital Payment Fairness Act of 2013.

Sen Baldwin, Tammy [WI] – 3/22/2013
Sen Blunt, Roy [MO] – 2/7/2013
Sen Brown, Sherrod [OH] – 2/25/2013
Sen Burr, Richard [NC] – 2/4/2013
Sen Chambliss, Saxby [GA] – 2/4/2013
Sen Coburn, Tom [OK] – 1/30/2013
Sen Enzi, Michael B. [WY] – 2/13/2013
Sen Franken, Al [MN] – 3/12/2013
Sen Grassley, Chuck [IA] – 2/11/2013
Sen Hagan, Kay [NC] – 1/31/2013
Sen Inhofe, James M. [OK] – 2/11/2013
Sen Isakson, Johnny [GA] – 2/7/2013
Sen Kaine, Tim [VA] – 3/11/2013
Sen Klobuchar, Amy [MN] – 3/5/2013
Sen McConnell, Mitch [KY] – 1/31/2013
Sen Merkley, Jeff [OR] – 2/26/2013
Sen Moran, Jerry [KS] – 2/7/2013
Sen Portman, Rob [OH] – 3/7/2013
Sen Pryor, Mark L. [AR] – 2/7/2013
Sen Roberts, Pat [KS] – 2/14/2013
Sen Shelby, Richard C. [AL] – 4/11/2013
Sen Vitter, David [LA] – 2/14/2013
Sen Warner, Mark R. [VA] – 1/31/2013
Sen Wicker, Roger F. [MS] – 5/23/2013

Sequestration harms rural providers

As we head into our first full week of sequestration, many in Washington are seemingly ho-hum about the repercussions of the cuts.  In fact, just yesterday, the House of Representatives released its spending request for the remainder of this year (a continuing resolution for funding for the remainder of FY2013), and sequestration cuts were included in the proposal.

An attitude in DC is growing that the cuts just aren’t that big of a deal:  If partisan bickering prevents a thoughtful budget plan, the hatchet-approach cuts, though not ideal, are better than no cuts at all.  This is a dangerous situation for rural safety net providers and the rural communities they serve.

Small rural hospitals and health provider groups operate at the narrowest of financial margins – NRHA has long argued that a two-percent across the board cut to Medicare providers disproportionately harms rural providers and will cause damaging repercussions.  The data backs this up.  An independent company that tracks financial quality of U.S. hospitals, iVantage Health Analytics, conducted a recent analysis of the impact of sequestration on rural hospitals by measuring patient revenue, impact of operating profit margin and job loss results.  The study concluded that sequestration will result in over $482 million in lost Medicare revenue for rural hospitals, averaging -6.27% in profit margin.  In fact, nearly twice as many rural hospitals would switch to negative financial margins as urban hospitals.  Such losses will force many rural hospitals to reduce staff and services to Medicare beneficiaries.

A loss of revenue to a rural hospital directly equates to a loss of revenue for the entire rural community.  Over 2000 job losses in rural America are projected due to sequestration.  That’s significant – - a rural hospital is often the largest or second largest employer in a rural community.  If the hospital suffers, the rest of community suffers due to loss of direct revenue, and also the inability to retain or recruit not only health care providers but other businesses.

Rural hospitals are safety net providers.  Rural populations are older and poorer than their urban counterparts.  Additionally, they are more likely to not have private health insurance and have a higher percentage of chronic disease such as heart disease and diabetes.

Sequestration cuts are a big deal in rural America.  Rural safety net providers should be carved-out of sequestration cuts to protect the 62 million rural patients they serve.

NBC Political Director Says Rural/Urban Divide “Stark”

NBC political director and chief White House correspondent, Chuck Todd, today declared the “Rural-Urban political divide is as stark as it has ever been.”  In speaking on a Washington, D.C. news radio station this morning, Todd said today’s divided nation is no longer “red state verses blue state, it’s rural verses urban.”  He went on to say that many of the politically divisive issues such as gun control and abortion stem from rural and urban differences that are “cultural.”   Is he right?  In the 2008  Presidential election, much of rural America was “purple.”  In 2012, the color was definitely more red.   We hope to hear more of this interesting discussion during the 24th annual Rural Health Policy Institute, the largest rural advocacy event in the nation, where  Chuck Todd has been invited to speak.  For more details on the Policy Institute .  You can listen to Chuck Todd’s full interview at

Please retweet Chuck Todd to let him know you’d like to hear more at our event.

Rural Fiscal Cliff Averted

Rural Fiscal Cliff Averted

Hundreds of millions of dollars in rural health cuts were prevented by Congress as part of the last-minute “fiscal cliff” legislation passed late in the night on New Year’s Day.  While many were watching an underwhelming Orange Bowl, the President signed-into law legislation that reinstates critical Medicare reimbursement payments to over 850 rural hospitals, as well as prevented cuts to rural primary care physicians and rural ambulance providers.

The fiscal cliff bill, which included large tax provisions and an extension of unemployment compensation, also reinstated the Medicare Dependent Hospital program and the Low-Volume Hospital adjustment, which both expired October 1.  Had Congress not restored these payments, many rural fiscally fragile facilities likely would be forced to close their doors.

This is a big win for rural providers and NRHA wishes to thank all of grassroots advocates who made their plea to Congress to prevent these harsh cuts. Stay tuned, we aren’t completely out of the woods.  The 2% across-the-board sequestration cuts were delayed for two months, but the battle will begin again soon. Additionally, all rural payments were extended for a temporary  period and additional calls for cuts are surely just around the corner.   This means, this year’s Policy Institute, where rural advocates appeal to their Members of Congress, significant than ever.

Below is a list of the rural Medicare provisions included in the fiscal cliff legislation:

Medicare Physician Payment Update.  This provision guarantees seniors have continued access to their doctors by fixing the Sustainable Growth Rate (SGR) through the end of 2013.  Medicare physician payment rates are scheduled to be reduced by 26.5 percent on December 31, 2012.  This provision would avoid that reduction and extend current Medicare payment rates through December 31, 2013.

Work Geographic Adjustment. Under current law, the Medicare fee schedule is adjusted geographically for three factors to reflect differences in the cost of resources needed to produce physician services: physician work, practice expense, and medical malpractice insurance.  This provision extends the existing 1.0 floor on the “physician work” index through December 31, 2013.

Payment for Outpatient Therapy Services.  Current law places annual per beneficiary payment limits of $1,880 for all outpatient therapy services provided by non-hospital providers, but includes an exceptions process for cases in which the provision of additional therapy services is determined to be medically necessary.  This provision extends the exception process through December 31, 2013.  The provision also extends the cap to services received in hospital outpatient departments only through December 31, 2013.

Ambulance Add-On Payments.  Under current law, ground ambulance transports receive add-on  to their base rate payments of 2% for urban providers, 3% for rural providers, and 22.6% for super-rural providers.  The air ambulance temporary payment policy maintains rural designation for application of rural air ambulance add-on for areas reclassified as urban by OMB in 2006.  This provision extends the add-on payment for ground including in super rural areas, through December 31, 2013, and the air ambulance add-on until June 30, 2013.

Extension of Medicare inpatient hospital payment adjustment for low-volume hospitals. Qualifying low-volume hospitals receive add-on payments based on the number of Medicare discharges.  To qualify, the hospital must have less than 1,600 Medicare discharges and be 15 miles or greater from the nearest like hospital.  This provision extends the payment adjustment until December 31, 2013.

Extension of the Medicare-Dependent hospital (MDH) program.  The Medicare Dependent Hospital (MDH) program provides enhanced reimbursement to support rural health infrastructure and to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This greater dependence on Medicare may make these hospitals more financially vulnerable to prospective payment, and the MDH designation is designed to reduce this risk. This provision extends the MDH program until October 1, 2013.

For a full copy of the legislation, click here. The bill passed the Senate by a vote of 89-9 and the House 257-167.