Today, Reps. Annie Kuster (NH-02) and Xochitl Torres Small (NM-02) championed the health care needs of rural communities by leading a bipartisan letter to Speaker of the House Nancy Pelosi and Senate Majority Leader Mitch McConnell requesting additional resources for rural health care providers during the COVID-19 (coronavirus) outbreak. The letter was signed by a bipartisan group of 27 Members of Congress. Rural communities face unique challenges when it comes to health care access, and these challenges are exacerbated by the current public health crisis. As Congress begins consideration of a third legislative package to address the coronavirus pandemic, this letter outlines specific policy actions that can be taken to support rural health providers.

“At a time when access to care is of paramount importance, rural communities are facing unprecedented rates of hospital closures,” wrote the Members. “Additionally, workforce shortages are significant and further impede access to care for the communities they serve. Health care worker shortages and the physical geographic barriers – such as distance, terrain, and seasonal weather – make it especially difficult to access care in normal circumstances, let alone a global pandemic.”

“Rural hospitals are not only emergency care providers during a time of crisis, but often are primary health care access points for the communities they serve,” the Members continued. “In many rural communities, Critical Access Hospitals (CAHs) are the economic engines of the local economy, often serving as the largest employer and economic developer of the medical service area. They fill this role despite the many fiscal constraints they face, and the Coronavirus emergency exposes some of the biggest financial vulnerabilities of these providers. Given the increasing severity of this public health crisis, I respectfully request your prompt attention to the unique challenges facing our rural communities, and the critical role rural providers serve in protecting our most vulnerable populations.”

The letter specifically outlines the following priorities:

1. An increase in currently low reimbursement rates for rural hospitals’ budgets who are already stretched thin.
2. A temporary suspension of the “Medicare sequester” to rural hospitals would help their financial viability during the Coronavirus pandemic.
3. Federal support for the unique staffing crisis rural healthcare providers are facing in order to maintain access to care for communities across the country.
4. Payment structure changes in response to current patient surges
5. A guarantee that rural localities have access to COVID-19 related testing
6. An appropriate increase in medical products, supplies, and Personal Protective Equipment (PPE)
7. An immediate expansion of telehealth services

The full text of the letter is available here and below:

Dear Speaker Pelosi and Majority Leader McConnell,

As we continue to address the health and economic response to this Coronavirus pandemic (COVID-19), additional resources must be given to our rural providers. Rural communities face unique challenges in access to health care, all of which are exacerbated by the current public health crisis.

Data from the Centers for Disease Control (CDC) makes evident the significant health disparities already facing the 46 million Americans living in rural areas. Rural Americans tend to be older and sicker, and far more likely to die from the five leading causes than their urban counterparts.^[1] They also have higher rates of poverty, less access to health care, and are less likely to have health insurance. In short, they are highly vulnerable to COVID-19.

At a time when access to care is of paramount importance, rural communities are facing unprecedented rates of hospital closures. Additionally, workforce shortages are significant and further impede access to care for the communities they serve. Health care worker shortages and the physical geographic barriers – such as distance, terrain, and seasonal weather – make it especially difficult to access care in normal circumstances, let alone a global pandemic.

The expanded authority for telehealth included in H.R. 6074, the Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020 will help ameliorate the challenges discussed, while also mitigating risk of exposure to Coronavirus for both patients and providers. However, the financial vulnerability of rural providers is especially acute during this crisis and demands our immediate attention.

Rural hospitals are not only emergency care providers during a time of crisis, but often are primary health care access points for the communities they serve. In many rural communities, Critical Access Hospitals (CAHs) are the economic engines of the local economy, often serving as the largest employer and economic developer of the medical service area. They fill this role despite the many fiscal constraints they face, and the Coronavirus emergency exposes some of the biggest financial vulnerabilities of these providers. To address both the near and long-term concerns of rural hospitals, I request the below considerations for the next legislative package.

1.  Low Reimbursement Rates: Struggling rural hospitals disproportionately serve patients who are underinsured or uninsured. Low reimbursement rates across payors, along with uncompensated care and a sicker patient population threaten the financial sustainability of rural hospitals. Federal support for the Small Business Administration loan program should be prioritized for small rural health providers and all interest fees should be waived.

2.  Medicare Sequester: The Medicare sequester reduces payments for most benefits by two percent and is a contributing factor to the rural hospital closure crisis. A temporary suspension of the sequester to rural hospitals would help their financial viability during the Coronavirus pandemic.

3.  Workforce Shortages: Health care provider shortages are more profound in rural areas. Frontline providers, especially lower-wage hospital employees, are especially impacted by competing demands of the Coronavirus emergency, such as the need for childcare while schools are closed. In order to maintain current staffing levels, rural hospitals have had to provide financial incentives for lower wage employees to continue their shifts, and federal support for this unique staffing crisis is critical to maintaining access to care.

4.  Patient Surges: CAHs are not traditionally equipped to handle the patient surges associated with a global health pandemic. At the same time, rural providers are experiencing a decrease in volume of elective procedures, which help ensure financial viability. Legislation should instruct CMS to provide a plan for periodic interim payments (PIP) to supplement the impact of cash flow during a high cost, high volume period of these provider’s operations.

5.  Ensure rural localities have access to testing: Many rural areas do not have robust public health infrastructure, and much of the resources related to testing are coordinated between state and federal entities. As Congress considers joint-agency coordination for community-based testing and other resources, it is prudent to consider the unique challenges of rural communities' public health infrastructure and ensure they are fairly represented in access to these critical resources. This will help ensure rural hospital emergency departments treat more people who need to be seen in-person and mitigate the spread of the virus.

6. Medical Products, Supplies, and Personal Protective Equipment (PPE): During periods of supply shortages, it is essential that rural hospitals and providers are fairly represented and adequately supplied all necessary equipment for both providers and patients, including but not limited to medicinal therapies, vaccines, ventilators, other medical products and supplies such as PPE. The National Strategic Stockpile should be responsive to the needs of rural providers and updated for rural emergency operations.

7.  Telehealth: Steps taken to expand telehealth in H.R. 6206 will have an immediate impact on ensuring emergency departments and hospital beds are available to address the most urgent COVID-19 cases and reduce the risk of additional infections. However, public health experts do not know how long this crisis could continue, and the Administration has not yet defined the length of the 1135 waiver authorized by H.R. 6206. It is critical that we examine more permanent telehealth policies to protect the most vulnerable populations and help increase hospital capacity. The following two bills support Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) and Skilled Nursing Facilities (SNFs) through telehealth to help ensure the system is not overwhelmed in the current and future public health emergencies.

• Even with the expanded telehealth authority, RHCs and FQHCs are not considered “eligible providers”. This means patients in underserved rural areas cannot access telehealth services and must physically go into a clinic to receive care. Section 7 of the bipartisan, bicameral CONNECT for Health Act would allow for RHCs and FQHCs to bill as distant site providers to provide telehealth services.
• The mortality rate attributed to COVID-19 is disproportionately high in the elderly population, and in the United States the majority of deaths so far are in the SNF population. H.R. 6209, the RUSH Act – bipartisan, bicameral legislation - would allow for SNFs to furnish telehealth services for acute care needs and thereby reduce unnecessary hospital transfers, delivering care in the most appropriate setting and allowing hospitals to keep beds open for the patients who need them most.  

Given the increasing severity of this public health crisis, I respectfully request your prompt attention to the unique challenges facing our rural communities, and the critical role rural providers serve in protecting our most vulnerable populations. I urge you to consider these policies as part of the ongoing negotiations in addressing the Coronavirus pandemic, and appreciate your consideration of this urgent matter. 

Sincerely,

Ann McLane Kuster

Member of Congress

Xochitl Torres Small

Member of Congress

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