Exploring Federal Programs Designed to Meet Rural Health Needs

June 1997

The Capital Area Rural Health Roundtable held its third forum on June 23 on Capitol Hill. The purpose of this forum was to provide a brief overview of selected federal programs that provide health care services to rural communities.

Some programs highlighted at the forum included:

• National Health Service Corps
• Community Health Centers
• Rural Health Clinics
• Rural Outreach Programs

The National Health Service Corps
Don Weaver, M.D., assistant surgeon general and director of the National Health Service Corps (NHSC), stated that while more than 20,000 clinicians have spent a least part of their careers "choosing to go where others refuse to go," serving the poorest, the least healthy, and the most isolated Americans, this country still confronts a serious problem of maldistribution of health care professionals. The NHSC's two main customers are the underserved communities and the clinicians, and the goal of the corps is to match them as equitably as possible. The NHSC uses an advocacy/mentorship program as well as scholarship and loan programs as part of their ongoing recruitment program. Now in its 25th year, the NHSC continues to serve as "part of the solution" to the problem of meeting health care needs of persons in underserved areas of America.

Community Health Centers
Kate Kellenberg, senior health policy advisor, National Association of Community Health Centers, stated that community health centers (CHCs) are very dependent on the NHSC. Many of the CHC staff of physicians, nurse practitioners, and physician assistants come from the NHSC and are critical to the functioning of CHCs. While the CHC program had received $802 million in federal funds in 1996, the health centers are all locally operated, nonprofit, and community owned. In 1996, there were 940 CHCs, plus some satellite clinics. They served a total of 10 million children and adults; 1.3 million of the children were uninsured. The CHCs also have an economic effect by employing 50,000 people. The most critical challenge facing the 30-year old CHC program is how to meet the health needs of an increasing number of uninsured.

Rural Health Clinics
Bill Finerfrock, executive director, National Association of Rural Health Clinics, described the start of the Rural Health Clinic (RHC) program 20 years ago, with the implementation of the Rural Health Clinics Act. The purpose of the law was to encourage and stabilize the provision of outpatient, primary care in rural areas through cost-based reimbursement for services provided by physicians, physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs). From the beginning, there was a very clear focus on providing health services using a multidisciplinary team approach. RHCs are often owned by a physician or a group of physicians, but the ownership may also include PAs, NPs, or CNMs. Currently, the patients served are 27 percent Medicaid, 29 percent Medicare, and 14 percent uninsured. In the cost-based reimburse-ment system, the government covers the costs of providing services. However, there is legislation now in the House of Representatives that proposes phasing in, over a five-year period, a reim-bursement schedule that would drop the payments to RHCs to less than cost, reportedly

85 percent of cost. After this five-year period cost-based reimbursement would be eliminated. The senate bill retains cost-based reimbursement. The RHC program has grown dramatically, from about 500 RHCs in 1989 to approximately 3,000 RHCs in 1997. Finerfrock attributes this growth to a very strong clinician recruitment effort to improve access to health care in rural America.

Rural Outreach Grantee
Mikal McCartney, Garrett County Memorial Hospital, Maryland, provided an overview of programs she administers through the support of an Outreach Grant from the federal Office of Rural Health Policy. Before initiating specific activities, the county government, in conjunction with Garrett County Memorial Hospital, conducted a community needs assessment. On the basis of their findings, they developed the following programs:

• The Agricultural Care and Education program: A general health and wellness program, designed to educate rural community members about health promotion and disease prevention strategies, especially related to agricultural lifestyles.

• Farmedic: A two-day training program to prepare volunteers to handle emergency farm and agricultural-related injuries and illnesses.
• Smart Hearts Active Risk Prevention. A risk identification and prevention program that focuses on maintaining healthy hearts.

McCartney noted that health-related resources taken for granted in large urban communities are often nonexistent in rural communities. The rural outreach program in Garrett County, Maryland, is helping to address this disparity.

Federal Office of Rural Health Policy
Dena Puskin, Sc.D., acting director, Office of Rural Health Policy, remarked that since the Office of Rural Health Policy was established in 1987, it has focused on ensuring a voice for rural health. The many policy issues addressed by the office include the following:

• Maldistribution of health care practitioners.
• Funding of health professions education.
• Use of high-speed, high-performance telecommunications tools for both telemedicine applications in clinical care and for health professionals' education, supervision, and preceptorships in rural communities. These new telecommunications and computer technologies overcome distance-related barriers. Dr. Puskin noted that a significant barrier to the use of advanced telecommunications has been removed by the FCC in its ruling on Universal Service.
• Evaluation of the effectiveness of telemedicine applications.
• Reduction of isolation and increased peer contacts for practitioners in long-term care, home care, and emergency responders in rural communities.
• Establishment of vertical networks of care.
• Support of State Offices of Rural Health to provide assistance to rural communities.

Dr. Puskin summarized her remarks by stating that the focus of the future in rural health care delivery is to learn how to develop resources and make health services available locally.

June Legislative Update
Heidi Cashman, legislative assistant for Senator Pat Roberts (R-KS), reviewed the budget reconciliation package and described potential changes to the adjusted average per capita cost (AAPCC) as well as to the status of sole community hospitals, Essential Access Community Hospital and Primary Care Hospital programs, payments to rural health clinics, and funding for telehealth programs.

Capital Area Rural Health Roundtable
Center for Health Policy Research & Ethics
George Mason University
Fairfax, Virginia
703-993-1907