What is the state of rural health care in Missouri? Some might say fragmented, while others see hope. For rural America, the glass may be half full, or at least trending in that direction.  

During the Missouri Rural Health Association’s 2021 Get Link’d Annual Conference, Brock Slabach, chief operating officer of the National Rural Health Association (NRHA), delivered the keynote address that talked about the state of rural health, as well as advocacy efforts underway to implement health policy changes that address some of Missouri’s most flagrant health inequities.

This advocacy has gained momentum after the COVID-19 pandemic provided an impetus for policy makers to see, clear eyed, what’s broken, and with pressure from advocates, how to fix it.

“We have unprecedented challenges that exist right now in the rural safety net,” Slabach said. “We were already stretched to the limits before the pandemic with comorbidities and mortalities that challenged our rural communities. Then the pandemic hit. And it has increased the levels of complexity for providing care and taking care of the populations that we serve.”

Policy makers are now connecting the dots and understanding how social determinants of health and a lack of health equity moves downstream to manifest poor health outcomes in both rural and urban communities. 

It’s important to note that access to quality care contributes only 20% to one’s overall health and wellness. Other social determinants of health, which are non-clinical, make up the highest predictors of health outcomes. Socioeconomic factors make up 40% and include things like education, job status, family and social support, income, and community safety. One’s physical environment makes up 10%. Health behaviors like tobacco and alcohol use, diet and exercise, and sexual activity make up the remaining 30%.

Two sides of the same coin

Although resilient, rural and urban communities share many of the same social determinants of health, like access barriers to care, poverty, food deserts, transportation, and broadband access.

Broadband redlining, which occurs when certain communities are denied access, is another shared problem. Not everyone can afford satellite or cable broadband services when available. Without this basic need, crucial telehealth services remain inaccessible. According to the Federal Communications Commission, 19 million Americans still lack access to high-speed internet.

Missouri is ranked 34th nationwide for broadband access. In a survey by the Missouri Department of Elementary and Secondary Education,  23% of Missouri students lack broadband access, 258 school districts reported that students lack access due to broadband affordability, 84 school districts lack physical access to broadband, and Missouri ranks in the bottom five for low-cost internet access. In May, the $3.2 billion FCC Emergency Broadband Benefit Program was launched to help lower the cost of internet for eligible households. Missouri continues to make strides to address the digital divide, but there is a long way to go.

As for transportation, where it may take rural people two or three hours by car to see a provider, it may take urban people two or three hours on the bus to see a provider. 

A fragmented system of care

However, rural Missourians face a particular hurdle-the damning number of hospital closures and hospitals at-risk for closure continues to pack a resounding blow to the small-town safety net.

Since 2010, 138 rural hospitals have closed. Nine of these hospitals have closed in rural Missouri — and that’s not all. Fifteen of Missouri’s 60 rural hospitals are at risk for closure, 26 are vulnerable, and 11 are most vulnerable according to statistics Slabach cited from the Chartis Center for Rural Health. This equates to more than 40% of Missouri’s rural hospitals falling along the vulnerable or at-risk spectrum.

Slabach noted that rural communities are older, sicker, and poorer. He added that premature deaths outpace urban rates, rural communities have historically high health professional shortages compared with urban communities, and oral health care availability is much more scant.

“All of these things combine to have a convergence of pressure points that impact clinics and federally qualified health centers (FQHCs), social service agencies, nursing homes, long-term care facilities, and hospitals,” he said. “All of these issues create a fragile safety net.”

Missouri’s at-risk status is second to states like Texas, Georgia, Oklahoma, and Mississippi, to name a few. But unlike these states, Missouri voters opted to expand Medicaid in 2020.  Missouri’s legislature—through a court orderis now obligated to comply and allow new Medicaid enrollment to take place, which could address the low uninsured rate and increase access to care across the state.

COVID funding windfall not enough to resolve vaccine hesitancy

The influx of federal dollars also offers hope. For many rural health clinics (RHCs) and hospitals, it provided security in very uncertain times. Since July of this year, $100 million have been allocated to (RHCs) for COVID-19 outreach, $398 million for small rural hospitals for COVID-19 testing and mitigation, and $103 million to reduce burnout and promote mental health for the health workforce. This is a short list and does not include state funding and more localized grant dollars—funds often earmarked to address vaccine hesitancy.

Even with the windfall, the vaccine rate in rural communities continues to lag behind urban areas, leading to a higher mortality rate. In a recent report by The Journal of Rural Health, 45.8% of adults in rural counties had been fully vaccinated, compared with 59.8% in urban counties as of August 11. 

The Journal’s rationale for rural vaccination rates is a combination of lower educational attainment and higher Trump vote share. It states that rates are lowest in farming and mining-dependent counties and highest in recreation-dependent counties, noting that vaccine availability (primarily due to the funding windfall) does not equal access.

Slabach said this is where health care practitioners come in. “The local practitioner has a high amount of influence on whether a person is vaccinated or not,” he said. “So, the time you take in your clinic to share information and actually get that shot in the arm is very valuable. You want to get them quickly, because once they leave the clinic, then they may not be back. It’s important to have a vaccine available and ready to give.”

But what about health care providers who are vaccine reticent themselves? President Joe Biden has mandated shots for health care workers and the private sector. The mandate requires all employers with 100 or more employees to require workers to get vaccinated or get tested weekly. Health care workers at Medicare and Medicaid participating hospitals and who work in other settings are now required to get the shot. There are 17 million health care workers in Medicare and Medicaid certified facilities.

Some rural health providers are nervous about the new mandate, according to a recent NPR article. In rural areas where the vaccine rate is low and workforce shortages are high, hospital executives worry staffing shortages could force them to turn patients away. “We’re kind of at that point where everybody that’s willing to get it, got it,” said Adam Willmann, CEO of Goodall-Witcher Hospital in Clifton, Texas.

Value-based care and social determinants of health

Still, there are reasons to remain hopeful, as there is no shortage of rural health advocacy for things like rural hospital sustainability for critical access hospitals, the Rural Physician Workforce Production Act, continued telehealth flexibilities, and rural health clinic modernization, among many other advocacy and health policy initiatives.

Some rural health providers are banking on these efforts, while others are sending a clarion call for them to save themselves. One perceived lifeline is adopting an Accountable Care Organization (ACO) framework. ACOs are groups of doctors, hospitals, and other health care providers that coordinate to provide quality health care to patients who receive Medicare, Medicaid, or have commercial insurance. ACOs provide a value-based model of care, as opposed to fee-based care, and incentivize providers to keep patients healthy, avoid unnecessary procedures, and keep patients out of the hospital by providing preventive care services.

In 2019, ACOs participating in the Centers for Medicare and Medicaid Services (CMS) Shared Savings Program generated $1.19 billion in net savings to Medicare—the largest savings for the program to date, coupled with reported improved patient outcomes.

However, rural health providers have been slow to adopt ACO transformation. This is due in part because RHCs, FQHCs, and critical access hospitals have been exempt from many Medicare and Medicaid requirements to report on quality or provide incentives for quality improvements.

Last year, CMS pulled the trigger to help rural health care providers to transition to a value-based payment model through an initiative called the Community Health Access and Rural Transformation (CHART) Model. CHART would tie payment to value, increase choice, and lower costs for patients. Additionally, CHART would provide support through new seed funding and payment structures, operational and regulatory flexibility, and technical learning support, among other things.

Earlier this summer, CMS halted the CHART ACO program out of the blue and without explanation.

Although urban health care providers are better positioned to adopt an ACO framework, rural health care providers have been prioritizing value-based care by prioritizing social determinants of health. This whole-person approach to meeting patient needs by addressing housing, food, transportation, utility assistance, and interpersonal safety continues to transform health care delivery models and improve patient outcomes.

Federal and state policy makers are still trying to understand the potential impact of social determinants of health on value-based purchasing to ensure a fair balance is struck and supports theTriple Aim” approach of improving the patient experience of care, improving population health, and reducing per capita health care costs.

By centering health equity, which allows everyone to reach their full health potential, value-based care is inherently achieved as it addresses the 80% of [non-health] related factors that determine one’s overall health and wellness. This offers hope for both rural and urban safety nets. 

“We’ve been looking at the exposure of systemic racism and health equity issues all over our country and how that translates to health equity in rural populations,” Slabach said. “We are making sure that we advocate for that as well.”