On September 25, the Senate Committee on Health, Education, Labor and Pensions (HELP) Subcommittee on Primary Health and Retirement Security held a roundtable entitled, "Health Care in Rural America, Examining Experiences and Costs." Senators Mike Enzi (R-WY) and Bernie Sanders (D-VT) kicked off the roundtable by discussing what they hoped to learn from the group, highlighting access and cost issues facing rural America in the health care space. Sen. Enzi expressed a desire to look at high out-of-pocket costs, issues with provider retention and recruitment, and methods of increasing competition and access through telemedicine and other rural-specific solutions. Sen. Sanders drilled down on the issue of high costs in the US in comparison to other countries and the inability of Americans to afford their health care, suggesting a single-payer solution is the answer to rural problems and the American health care system more broadly.

Panelists represented the insurer, provider, health system and technology spaces. While each panelists had a different viewpoint, all of them flagged the issues of access and quality facing rural America. Tom Glause, Commissioner of the Wyoming Department of Insurance, discussed the severe shortage of health care providers in the area and high prices due to lack of competition and cost shifting, flagging issues such as inadequate Medicare reimbursement rates and the need to incentivize providers to enter rural areas while focusing on other rural-specific issues such as air ambulance rates. Morgan Reed, President of the App Association and Executive Director of Connect Health Initiative, echoed the issues with provider shortages and discussed how better understanding of and payment for telehealth as well as other technology-driven tools can be part of the solution, but noted that restrictions in Medicare and inadequate infrastructure hinder advancement. Alan Levine, Executive Chairman, President and CEO of Ballad Health, spoke about the epidemic of rural hospital closings and the need for a different model for rural health care, explaining that value-based models are not the solution for hospitals that lack capital, technology and population to succeed, instead suggesting they revamp the area wage index and look at new models for rural health care facilities. Dr. Deborah Richter, Family Physician and Addiction Medicine Specialists and Chair of Vermont Healthcare for All said that many issues plaguing the American health care system are amplified in rural areas as people are older, sicker and poorer, suggesting that a single-payer system would simplify billing and administration and allow them to look at the system and address problems more holistically.

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Roundtable discussion

Senator Lamar Alexander (R-TN) asked about the issue of the area wage index, and Mr. Levin said that it is a huge problem, with only 10% of the counties reaching a wage index 1, suggesting they pass Senate Bill 397 to fix this problem and help rural hospitals. He also discussed how they created a community health clinic after closing hospitals, resorting to an alternative model that was extremely successful as it was able to manage 90% of the population's issues and ensure sustainability. Mr. Glause cautioned that moving to such non-hospital models are also tricky, as the costs of air ambulance rates have skyrocketed, suggesting they look at those rates as part of the reauthorization of the Federal Aviation Administration (FAA)

Sen. Bernie Sanders (D-VT) discussed the physician shortage and noted that the Affordable Care Act (ACA) doubled funding for community health centers (CHCs) and the national service core. The panel agreed that these programs, in theory, are helpful and Mr. Levine added that exploring additional residency slots would also be helpful. When asked about proposed cuts to Medicaid in the President's budget request, Dr. Richter said it would be devastating and could cause more providers to leave those communities. When asked about the difference between government and private payers, Mr. Levine and Mr. Glause said they generally have higher reimbursement from commercial insurers and Dr. Richter said that private insurance can pay lower rates when it comes to addiction issues.

Sen. Michael Bennett (D-CO) discussed the Medicare X bill as a way to create a bigger risk pool and help eliminate some of the issues faced by rural Americans struggling with low costs and limited insurance choices. Dr. Richter added that they should also focus on first dollar coverage for all Americans, as it is the only thing proven to reduce costs and improve outcomes. Mr. Reed added that they need to get people engaged earlier on in their health care journey and said they should reevaluate the CBO scoring window so they're not only paying for the most expensive people when they're already sick. Mr. Levin added that 70% of reimbursement is dictated in government options and it doesn't respond to the local environment and market-specific issues, which could mean they will still lose doctors.

Sen. Maggie Hassan (D-NH) spoke about maternal health care and asked the panel how to address the issues facing pregnant women with less access and poorer outcomes. Dr. Richter said they must provide transportation for these women as well as increase advocacy efforts. Mr. Levine said that repurposing hospitals can be a helpful solution, but added that funding streams are fragmented across health care, food, housing and other necessary services. Mr. Reed added that they need to leverage technology and appropriately reimburse for using telehealth to provide access to necessary maternal care.

Sen. Tim Kaine (D-VA) discussed the inclusion of a directive in the opioids bill to clarify Medicaid reimbursement for telemedicine and added that the Connect Act would do the same for Medicare. Dr. Richter added that a single-payer system could help to streamline fragmented payments to help solve some of the previous issues being discussed.

Sen. Mike Enzi (R-WY) asked the panel how to recruit providers to rural America, expand access to digital health and use transparency to provide more insight into pricing, among other things. Mr. Levine said that Stark and anti-kickback laws are an impediment to paying providers what they need to in order to retain them in rural America and added that they recently merged two hospitals due to duplicative technology and negative margins but that it was fought at the state level even though it has been very successful. Mr. Reed discussed how incentives are not aligned for increasing the use of technology, such as inadequate reimbursement for remote patient monitoring and inappropriate coding, adding that competition from the digital space can help provide insight into pricing through transparency tools as well as more advanced and predictive analytics. Mr. Glause spoke about outmigration from Wyoming to other states for health care and said insurers are not interested in coming because it is not good for their bottom line. Dr. Richter added that as a provider they often don't know what drugs will cost because they are constantly changing, and that while transparency isn't easy due to the intricacies of the system, it will be hugely beneficial.

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