A single payer could solve the rural hospital crisis


Rural American hospitals are closing at an alarming rate. According to the North Carolina Rural Health Research Program, there were seventy-two rural hospital closures between 2010 and 2016, nearly double the number of closures between 2005 and 2009. Hundreds more are on the brink of closure.

As a result, rural America faces a serious health care delivery challenge, all the more urgent since rural residents tend to be much sicker to begin with. They have higher rates of chronic disease and greater psychological distress. Rural counties have higher death rates from unintentional injuries, more motor vehicle injuries, greater premature mortality (under age seventy-five), higher male suicide rates and higher infant mortality rates.

The health disparities between rural and urban America are very well documented, and geographic access – the ease or difficulty of getting to a health care provider – is one of the commonly offered explanations for this. disparity, especially in the case of traumatic accidents or other medical emergencies. . When these rural hospitals close, the distance between a person’s home and the nearest medical facility increases dramatically, as does the time it would take for an ambulance to reach them in an emergency.

Rural hospitals have been struggling for years, largely due to changing rural demographics. Currently, the strongest predictor of closure is profitability, which is partly a function of the characteristics of the community served by a hospital. As America’s population has moved to urban areas, the populations that remain in rural areas have become older, poorer, sicker, and less likely to be insured. In other words, caring for them costs more. Rural hospitals have been struggling with the financial difficulties caused by these demographic changes for more than a decade.

But when the Affordable Care Act took effect, the rate of rural hospital closures increased dramatically. One reason is that the ACA began penalizing hospitals with high readmission rates, a measure that represents the number of patients who return to the hospital after discharge. This was intended to push hospitals to provide higher quality care and fits with an admirable trend in American health care toward value-based payments. But it’s also an aspect of the law that has a disproportionate impact on hospitals seeing a higher proportion of sicker patients, as rural hospitals do.

In addition, the ACA shifted money from providing reimbursements to rural hospitals to covering the cost of insuring people through Medicaid expansion. But in states that have failed to expand Medicaid, rural hospitals still see a greater proportion of uninsured patients without the corresponding increase in revenue.

Lawmakers have proposed several solutions to this problem, but they all fail. Republican Senators Chuck Grassley and Cory Gardner introduced REACH – the Rural Emergency Acute Care Hospitals Act – in 2015. Democratic Senator Amy Klobuchar signed on this year when the bill was reintroduced. The bill would increase Medicare payments to specially designated rural emergency hospitals. A similar bill was proposed in the House, but neither bill was successful. And even if either had done it, it would have been only a palliative.

Demographic changes that make health care delivery in isolated rural areas costly cannot be addressed through legislation. Those looking for a solution inevitably turn to technological innovations, such as telemedicine, as a way to deliver care remotely. We just have to set up the appropriate payment system, they say. If only we knew how to charge for it, telemedicine would save rural health care. It doesn’t matter that huge swaths of rural America don’t yet have access to high-speed internet. It is true that the potential benefits of telemedicine remain woefully unexplored, and REACH could, in theory, alleviate the crisis somewhat. But ultimately, these hospitals would still be beholden to the ultimate predictor of hospital closure: profitability.

The few success stories that have emerged from the crisis of rural hospital closures are stories of hospitals that have made capital investments in long-term improvements. But when each hospital has to deal with its own outcomes, struggling hospitals cannot afford to invest in new equipment, refurbish their facilities, update their electronic health records system, implement telehealth capabilities or spend money to hire and retain staff. Large hospital groups that own several establishments are not encouraged to make this kind of choice. They have no reason to invest in the community they serve. For large corporations that own dozens of health centers, the most financially sound decision is to simply close struggling hospitals.

Now contrast that with the possibilities of a single-payer health care system, where capital investment in health care is decoupled from individual hospital operating budgets and each hospital’s profitability and, instead of this is driven by the needs of the community. In this system, the fact that a hospital’s operating costs stay below budget would not dictate the decision to buy a needed MRI machine or renovate the emergency room or even keep the doors open. Instead, capital investments would be the product of careful regional planning that incorporates the voices, desires and health concerns of the community served by the hospital.

The crisis of rural hospital closures is driven by the supremacy of capital in our current health care delivery system. Only a system that dismantles the profit motive and prioritizes the welfare of the community will truly provide care to all who need it.

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