For decades, rural communities have been all but ignored when it comes to health, workforce and economic development, technology infrastructure, and health professional shortages. This is as rural populations grow older, sicker, poorer, and resource strapped.

Finally, these longstanding deficits are getting some attention. The U.S. Department of Health and Human Services (HHS) recently released its Rural Action Plan. Albeit ambitious and long overdue, the Plan’s four-point strategy aims to:

1. Build a sustainable health and human services model for rural communities by empowering rural providers to transform service delivery on a broad scale.

2. Leverage technology and innovation to deliver quality care and services to rural communities more efficiently and cost-effectively.

3. Focus on preventing disease and mortality by developing rural-specific efforts to improve health outcomes.

4. Increase rural access to care by eliminating regulatory burdens that limit availability of needed clinical professions.

According to HHS Secretary Alex Azar, work on the Plan begin prior to the COVID-19 pandemic in 2018 with the creation of a rural task force that included key leaders and stakeholders across HHS. The goal was “to bring together disparate efforts across HHS and develop the best understanding of where policy and program changes bring about the needed transformation,” Azar prefaces in the Plan. He said these four strategies will build upon key initiatives already in motion like increasing access to care in rural communities by opening more community health centers, focusing on value-based health care to improve quality while reducing health care spending, addressing the opioid epidemic in rural communities, and making changes to Medicare to expand access to telehealth services.

The move comes at a critical time. As rural hospital closures increase, with at least 10 in Missouri alone, the need for a health care lifeline is crucial. According to the 2010 Census, there are approximately 59.5 million people who live rural across the U.S., making up nearly 20% of America’s population. Health disparities and mortality rates are even more dire than those living in urban underserved communities.

The rural health landscape as noted in the Rural Action Plan

  • Rural residents are more likely to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than the urban dwellers. Some researchers estimate the hospital rate for preventable disease is 40% higher for rural people, coupled with a 23% higher mortality rate.
  • Rural closures are often linked to a lack of patient volume due to population size and other factors. Most of these hospitals do not provide obstetric (OB) services, leaving pregnant women without accessible maternity care and long commutes to deliver. Rural areas have higher maternal and infant mortality rates.
  • Rural areas struggle to attract, recruit, and retain health care providers – with a particularly lean number of behavioral health providers. According to the Plan, 17% of non-metropolitan counties lack behavioral health providers compared with three percent in metropolitan counties. The Plan notes there are fewer physicians, nurse practitioners, and physician assistants (primary care providers or PCPs) practicing in rural areas compared with urban areas. Specifically, there are 5.4 PCPs per 10,000 population in rural areas compared with 7.9 PCPs in urban areas. Rural areas have 3.6 dentists per 10,000 population compared with 5.9 in urban areas. The Plan also notes that rural adults tend to see the dentist less and experience higher rates of permanent tooth loss compared with urban adults. As for mental health services, of the 1,971 rural counties in the U.S., 252 counties have no mental health provider.
  • Rural seniors, individuals with disabilities, and other rural residents most likely do not have access to specialty services and must travel to neighboring urban centers for services. Due to flagrant transportation barriers, and limited appointment availability, needed specialty care services are too often forfeited.
  • Suicide rates in rural areas tend to be higher than in urban areas. According to the Plan, individuals working in mining, quarrying, oil and gas extraction, and agriculture, are among the top five industries with the highest suicide rates.

Broadband access and telemedicine

According to the Federal Communications Commission (FCC) one-fourth of rural Americans, or 14.5 million, lack internet access. Although not a direct outcome of the Rural Action Plan, but closely aligned, the FCC, HHS, and U.S. Department of Agriculture announced in early September a memorandum of understanding (MOU) to collaborate and address internet deserts in rural areas. In this joint effort, Team Up for Rural Health Initiative, the aim is to share information to address health disparities, resolve service provider challenges, and promote broadband services and technology in rural areas.

The move, which came as more than a million people tested positive for COVID-19 in the U.S., with nearly 200,000 people succumbing to the virus, is slated to prop up the role telehealth will play in rural communities as infection rates increase during this pandemic.

“From the beginning of my tenure at the FCC, I’ve heard and shared the view that telemedicine is a game-changer for rural America,” said FCC Chairman Ajit Pai. “The COVID-19 pandemic has made the rural health care challenge even more serious and has complicated health care providers’ efforts to serve rural Americans.

The USDA is also working to do its part with its Rural Broadband ReConnect program that delivers nearly $650 million in loans, grants, and loan-grant combinations to deploy high-speed broadband to rural communities without access.

As for the MOU, the agencies plan to establish an interagency Rural Telehealth Initiative Task Force, comprised of representatives from each department, to meet regularly and establish future guidelines to exchange expertise, scientific and technical information, data, and publications.

Bridging gaps through partnerships

HHS’s Rural Action Plan is also comprised of key partnerships to tackle everything from increasing funding for school-based mental health services to expanding telehealth options for rural beneficiaries of Medicare Advantage.  Key partners include USDA, the U.S. Department of Veterans Affairs (VA), FCC, and the Appalachian Regional Commission (ARC), and Delta Regional Authority (DRA). ARC and DRA primarily serve rural regions and hold federal-state partnerships with HHS. Additional partners will include the U.S. Department of Housing and Urban Development, the U.S. Department of Education, and the U.S. Department of Labor.

Leveraging these partnerships, HHS has set forth numerous initiatives in its Plan. Although too numerous to mention in this article, notable initiatives include:

  • Elevating the role of the Office for the Advancement of Telehealth (OAT) to address key regulatory and program investments due to COVID-19 to expand the use of telehealth nationally.
  • Revisiting the definition of “rural” to help nonprofits, community health centers, and other organizations to compete for grant funding more effectively. The Health Resources & Services Administration (HRSA) Federal Office of Rural Health Policy (FORHP) will issue a Request for Information to seek public comment on ways to revise its definition of rural, as some stakeholders are denied access to needed funding because their area is misclassified as urban.
  • The Administration for Children and Families will produce a Human Services Program in Rural Contexts report to better understand the intricacies of rural human service needs, determine unmet needs in rural contexts, and identify opportunities for strengthening capacity for economic and social well-being of rural individuals, families, and communities. Among the programs that will be examined under a rural prism are Health Profession Opportunity Grants, Healthy Marriage and Responsible Fatherhood, Maternal, Infant, and Early Childhood Home Visiting, and Temporary Assistance for Needy Families. This effort, which began in October 2019, will continue through September 2022.
  • HRSA’s FY 2020 budget included $30 million in funding to support 62 awardees to advance the use of telehealth to meet the needs of rural and medically underserved areas with a focus on tele-emergency and tele-behavioral health.
  • Expanding Medicare Fee-for-Service’s telehealth benefit by removing existing barriers for telehealth services for participating providers. In another move, the Plan looks to expand Medicare Advantage options for rural beneficiaries enrolled in the program. This provision would allow patients to receive telehealth care from their home without being required to travel to a health care facility, among other reduced CMS regulations.
  • The FY 2020 budget included an additional $110 million dollars in the Rural Community Opioid Response Program to reduce morbidity and mortality from substance use disorder and opioid use disorder. This includes prevention, treatment, and recovery services in rural underserved areas.
  • The Rural HIV/AIDS Planning program targets seven states, including Missouri, with a disproportionate number of HIV diagnoses in rural communities. The purpose of the program is to assist with planning and development an integrated rural HIV health network for HIV care and treatment. The program offers rural health care providers the opportunity to address community HIV needs, gaps, and challenges. This includes barriers to early diagnosis, comprehensive care that encompasses transportation, substance use treatment, stigma, innovative care models aimed at improving health outcomes, and reducing the number of new HIV infections.
  • The FY 2021 budget proposes $12.4 million to expand funding for healthy pregnancies and births by improving the quality of care in rural areas. This includes improved coordination of maternal and OB care, leveraging regional partnerships, and expanded use of telehealth.
  • To address health care professional shortages in rural areas, HRSA is injecting $178 million to enhance support training programs and incentives to clinicians who work in rural underserved communities.

“Six Missouri rural counties lack a primary care provider and 71 counties lack obstetrics,” said Missouri Rural Health Association (MRHA) Executive Director Melissa VanDyne. “These health disparities persist in rural communities due to health care workforce deficits, distance to care, little or no transportation options, and socioeconomic factors. Rural residents are poorer and must overcome practically insurmountable barriers to access quality care. As a result, emergency departments become their entry to care in hospitals that are workforce and cash strapped.”

Although this article barely scratches the surface of the current and planned initiatives detailed in the Rural Action Plan, it is important to note that this emphasis on rural population health is welcomed and grossly overdue.“Anytime the needs of rural people are being considered and addressed, and the challenges of rural health is closely examined, it is a win,” said Toniann Richard, CEO of Health Care Collaborative (HCC) of Rural Missouri.  “The collaborative approach the federal government is taking to address everything from broadband connectivity to rural maternity and infant mortality is very hopeful. We will be watching as these proposed initiatives unfurl, and while current programs play out. We also welcome opportunities to have a seat at the table to convey our shared experience as rural health policy is revisited.”