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National Rural Health Association Policy Institute

January 30, 2012
Washington, D.C.

I came to Washington from a state where 98 of our 105 counties are rural and our 63,000 farmers produce more wheat every year than any other state in the union.

So for as long as I have worked in public service, I’ve worked on rural issues, including health.  And in that time, I’ve encountered the many challenges we all face in improving health care for rural Americans.

First, nearly one in five uninsured Americans, or 8.5 million people, live in rural areas. With so many rural families lacking coverage, it’s no surprise that the average rural family pays for nearly half of their coverage out-of-pocket and that one in five farmers is in medical debt.

Second, many rural communities can’t properly access care. Even though a quarter of America’s population is rural, less than 10 percent of our nation’s doctors serve rural areas. In many rural communities, the question is not which doctor or hospital to visit, but whether or not there’s a doctor or hospital at all.

When a Critical Access Hospital in a rural area shuts down or when a doctor decides to relocate, it’s not just wiping out a choice of provider, it might be wiping out a town.

Third, it can also be harder to make healthy choices.  Most rural towns don’t have a gym down the street or a grocery store around the corner to purchase fresh fruits and vegetables. 

For all of these reasons, rural Americans suffer disproportionately from the kind of health problems that can undermine their quality of life or their ability to work.  One in five rural Americans is obese and there are higher occurrences of cancer and heart disease than in urban settings.

In the Obama Administration, we firmly believe that every American should have access to quality, affordable health care.  We have spent the last 3 years in office working towards that goal.  We passed a health care law that is all about this fundamental belief:  Whether you’re black, white or Latino; rich or poor; young or old; urban or rural – you have the right to the safety, freedom and security of quality health care.

Today I want to tell you how we’re doing that.

First, we’re going to increase access to care.

In rural settings, community health centers are a critical part of the health care safety net – along with rural health clinics and small rural hospitals.  I remember talking to a woman who runs a community health center in rural Ohio, east of Cincinnati where I grew up.  Her health center served five counties.  In some areas, if it weren’t for their local community health center, pregnant women would have to drive more than 90 minutes to get the prenatal services they need to make sure their baby is delivered healthy.

So we’re making these institutions stronger. The law has supported the largest capital expansion in community health center history, allowing centers to add hours, staff and space.  For rural Americans who count on this proven model for comprehensive, affordable care, this will have an immediate impact on their health and the health of their families.

We’ve also made a historic investment in the National Health Service Corps that has allowed us to triple its size to over 10,000 primary care providers.  These doctors and nurses will serve in underserved areas where they’re needed most.  Community health centers and rural health clinics have long benefited from this program and under the Obama Administration, Critical Access Hospitals will now be able to recruit these providers for the first time to fill their staffs.

There’s more work to do, and Mary will go into more detail on this vital HRSA program. But we’re on the right track thanks to the health care reform law which has done more to improve the primary care workforce in rural America than any initiative in decades.

The second thing we’re going to do is fix the health insurance market.

For years, this market has worked very well for insurance companies, but not for families and small businesses. The health insurance system was broken for most Americans, but it was especially broken for rural Americans.

Many rural areas had one large insurer dominating the market.  No competition and no transparency meant it was hard to get coverage, and if you could find coverage, the rates were high and could go up by double or triple digits each year.

The law puts an end to that.  We’re giving states the resources to review and turn back exorbitant rate increases. There are new rules that outlaw the worst abuses of the insurance industry like denying your children coverage because they have a pre-existing condition like diabetes or asthma. In 2014 that protection will apply to every American.  And rural small businesses also have access to tax credits to help them cover their employees.

But the biggest leap will come with the creation of Affordable Insurance Exchanges in 2014.  These marketplaces will introduce competition and choice into the rural health insurance market.  So if you’re a family run farm or an individual without insurance, you’ll be able to enter the Exchange with the same clout and negotiating power that large corporations have. And whether you’re from a big state or a small one, you’ll be able to find quality coverage you can afford.

So, that’s the second thing we’re doing. 

Now, the third area we’re focusing on is preventive care.

As you all know, this was the kind of care that too many rural Americans over the years have gone without.  But the law is taking concrete steps to make this care accessible no matter where you live.

That means new free recommended preventive care in most health care plans. It means a stronger Medicare that includes free preventive care and an annual wellness visit – which is especially important in rural America where almost one in five people are covered by Medicare. And it means supporting community-level prevention and wellness.

Around the country, there are rural communities taking innovative approaches to improve health.  In rural Wisconsin they’re creating a Farm to School program to improve the quality of school lunches.  In South Dakota they’re creating smoke-free outdoor spaces like parks and public gathering areas. Through Community Transformation Grants in the law, we’re putting real money behind these projects to expand them and see if they can become models for the rest of the country.

That’s how the law is helping us breakdown the barriers to care that rural Americans face.

And the fourth thing we’re doing is working with hospitals, doctors and nurses to improve the quality of that care.

Our administration believes you shouldn’t have to live in a big city to get the best care. That’s why we’ve put our full weight behind the promise of health information technology. We want to give doctors and nurses the ability to seamlessly share patient information with one another to coordinate care and give rural Americans access to specialists and care in the next town or the next state.  And we want to give patients the ability to be better informed and more engaged with their own health.

Let’s say a kid in Bird City, Kansas get’s a rash and his parents take him to their local primary care provider who may want a consultation from a specialist.  Today that provider would have to send the family on a trip to the see that specialist, which could mean a few hours of driving, a hotel room and a day of missed work.

But as more and more rural providers take up electronic health records, things are changing. Soon that provider will be able to snap a picture, get a consult from experts in Denver or Kansas City, send the family home with a treatment plan and email a prescription directly to the closest pharmacy.

This technology will also give doctors the confidence to move to a rural area, knowing they can still easily connect with peers and experts in their field.  And our administration has launched a historic effort to bring electronic health records to doctors and hospitals around the country.

We’ve provided incentive payments to help providers adopt the technology.  We also created 62 Health IT Regional Extensions Centers – based on the agriculture model – to help providers take advantage of those incentives.

These efforts have already begun to pay off. Already, more than 120,000 primary care providers, including over 70% of rural primary care providers in small practices, have registered for assistance with Regional Extension Centers. And around the country, we have nearly doubled the number of practices who have adopted basic electronic health records in their practice in just two years.

But we also recognize that challenges remain.  Health IT equipment is expensive and can be hard to maintain. Many rural areas lack access to the broadband they need to support the technology.  But HHS, led by HRSA and our Office of the National Coordinator for Health IT, is working across the administration to remove these barriers one by one.  We created the Rural Health IT Task Force to make sure rural communities had a voice at the health IT table. We’ve partnered with USDA to expand their loan programs to include health IT equipment purchases.  And we continue to work with rural health leaders and across the Administration to bring broadband to rural America.

This technology will be vital in our efforts to improve the quality of care in rural America.

As part of that effort we’re also giving rural doctors and hospitals a new menu of options to improve care while also saving money.  These ideas have come out of our CMS Innovation Center which, was launched under our former CMS Administrator, Dr. Don Berwick, and which you’ll hear more about from Nancy Nielsen later today. This center was built on the idea that it is possible to bring down costs by improving care.  We know it’s possible because we see it happening all over the country.  But we also know that what works for a large city hospital, might not work for a 15-bed Critical Access Hospital, and one of the missions of this center is finding solutions that fit rural America.

One of the ways we’re doing that is including rural providers as we test these pilots around the country.  And in many cases, we’ve seen them eager to be a part of this changing tide in care. 

For example, last year we put out a call for providers to become Pioneer Accountable Care Organizations, a program that has the potential to change the way we pay for care. We heard from many rural providers wanting to be a part of it. And when we chose the 32 Pioneer ACOs, they included two rural partnerships including two Iowa Health System affiliates in Fort Dodge – Trimark Physicians Group and Trinity Regional Medical Center. They were making coordinated care work in their region and wanted more tools to improve their patients’ health.  Now, they will continue to serve as a model for rural partnerships around the country.  The head of Iowa Health System put it best, when he acknowledged that the way we pay for care today needs to be redesigned. He said, “We prefer to be part of the solution.”

As we continue to implement the law, the Administration and HHS will remain committed to the goal of improving rural health.  The creation of the White House Rural Council ensures that every cabinet department will have rural communities on their minds. At HHS, we’ve breathed new life into the National Advisory Committee on Rural Health and Human Services, meaning that at every turn, we ask ourselves, “What does this mean for rural America?” And I’ve directed senior leadership across the department to look for places to collaborate in the name of improving rural health.

When you’ve worked on rural health as long as all of us have, it can be hard to see the light at the end of the tunnel.  Today, I can tell you, that light is there.  Thanks to the commitment of President Obama, the tools in the Affordable Care Act, and all of you, we have the power and momentum to bring fairness and equality in health care to rural America.

We’re at a turning point.  In the coming months and years we will see huge improvements in the health of rural Americans.  And we’ll keep working towards the day when we can make quality, affordable health care a reality for all Americans, no matter where they live.

Thank you.