HHS believes the health and well-being of rural America is just as important today as ever before, and the opportunities for improving rural healthcare are greater than ever before.
As Prepared for Delivery
Good afternoon. Thank you, Mark [Jones], for that kind introduction. Groups like the Minnesota Rural Health Association are an important voice for rural communities across the United States.
Thanks for inviting me to speak to you all. Summertime has descended upon D.C., so it’s nice to beat the heat in the District and come to Minnesota.
We’re all here because we care about rural healthcare and have a passion to see it improve in our country.
At HHS, our mission is to improve the health and well-being of every American, and that includes a particular focus on the health and well-being of the 57 million Americans who live in rural areas.
Why is that? First off, these 57 million Americans are spread across 80 percent of the country’s land mass—growing our crops, producing our minerals, and so much more. Further, approximately 2,000 of the country’s 5,000-plus acute care hospitals are located in rural America.
And we know that many of these hospitals are in crisis: The Government Accountability Office found that 64 rural hospitals closed from 2013 to 2017, representing about 3 percent of all the rural hospitals we had in the country in 2013.
HHS also has a special responsibility to provide healthcare to American Indians, which includes some rural communities across the upper Midwest.
We’ve also seen particular health challenges burden rural areas. The opioid epidemic, unlike past drug crises, has hit rural areas harder than urban ones.
One of the reasons I’m glad to speak to you is because I have a personal connection to rural areas and rural healthcare. Some of you may know that I was raised in the Midwest—in Mounds, Illinois, a small town of 1,500 that has since dwindled to about 800—the kind of population trend so many rural towns have seen.
My mother was born and raised not far from here, in Esko, Minnesota where her relatives still live today.
She eventually left Minnesota and moved to Southern Illinois to take a job that paid her 10 cents more an hour. She met my dad there, got married and started a family. She was a working woman: when she wasn’t with us at home she was at her job in the local hospital. She gave that hospital and the patients it served 58 years of dedicated service.
Ironically, even though she worked in a hospital, it didn’t have any specialists. So, when I was about to be born, my mom and dad had to drive two hours to Cape Girardeau, Missouri, to find a proper OB-GYN to deliver me. I wasn’t this tall when I came out of the womb, but I guess I presented a few challenges.
My experiences and the experiences of my family have given me a firsthand look into life in rural America and the struggles that accompany it, including opioid addiction.
The scourge of prescription opioid addiction first came to towns like Mounds decades ago, as it did to so many towns in the Midwest. It was years ago that a close relative of mine died after a long struggle with prescription opioids—and she was not the last. In fact, when I first spoke of this issue publicly, my family started sending me pictures and notes about others in my family who have suffered or died the same way.
The Trump administration has proposed rural-specific programs to tackle the crisis, through the Rural Community Opioids Response initiative, which has produced a two-year investment of $265 million to target the epidemic in rural areas.
But our work on opioids is not our only rural focus—we know we need a holistic approach. Last year, Secretary Azar created a rural healthcare task force with key leaders and stakeholders from across the department, with the goal being to bring together disparate efforts across HHS and develop the best understanding of where policy changes can help bring about the transformation to improve care in rural areas.
I want to talk briefly about three key strategies the Secretary has now laid out for this kind of transformation: sustainability, innovation, and flexibility. I’ll address each of them in turn.
First, we need to think about how to deliver care in rural areas in a sustainable manner—sustainable for providers, for patients, and for the taxpayer.
There is no reason to invest new resources and stretch existing ones to prop up models that are not going to be economically sustainable long-term.
As I mentioned, we are concerned about the closure of rural hospitals, and we’re working to understand how we can support them. But we also need to think broadly about what rural healthcare may look like in the future: the right sustainable model for healthcare in an area may not always be the traditional 1960s hospital model.
We do know there are some longstanding, structural challenges in payments for rural hospitals, including CMS’s wage index formula. That’s why, earlier this year, CMS proposed increasing reimbursement to rural hospitals that would allow them to improve quality, attract more talent, and expand patient access. In fact, we laid out several paths, with different impacts, that we could choose from, so we look forward to hearing from all of you.
But only addressing something like the wage index isn’t the endgame—we all know that. The rural health task force is examining all aspects of our rural health policies, looking closely at how payments are affecting rural hospitals, and considering where the most sustainable models may not be hospitals at all.
One model for sustainable, low-cost, high-quality care is HRSA’s community health centers. Most health centers are located in rural areas or urban areas with other challenges, and yet they have shown success in beating the national averages with their patients’ results in blood pressure control, diabetes treatment, and more. The last time I was here in Duluth, actually, I was able to see firsthand the work being done at a health center around here—the work they do is remarkable.
Sometimes, however, complicated medical conditions require not just going to a hospital, but actually getting really advanced medical expertise.
This brings me to the second strtegy I want to discuss, innovation: We need to think innovatively about how to bring the best care to as many patients in rural areas as possible.
This is an interesting challenge when it comes to something like cancer care.
As we’ve ventured into the world of precision medicine, academic medical centers are playing a more and more important role in cancer care. Providing follow-up care for a unique treatment regimen is quite complicated.
But new technology also offers ways to improve access to top quality doctors and diffuse knowledge and best practices across the country.
There is no reason why we shouldn’t be able to extend the reach of, say, incredible cancer doctors at the Mayo Clinic to help improve care in Esko, Minnesota.
With modern technology, your survival rate should not depend on your ZIP code.
On other health challenges, we have already seen some promising ways to extend expertise to rural communities. The state of Mississippi, for instance, has just one academic medical center, the University of Mississippi Medical Center in Jackson.
In 2003, with support from USDA, they began equipping ambulances and emergency rooms across the state with more sophisticated diagnostic equipment and telehealth capabilities. This allowed specially trained EMTs, nurse practitioners, physicians in rural areas to communicate in real time with emergency medicine physicians in Jackson.
We’re going to continue looking for ways to remove needless barriers and restrictions on telehealth so we can increase access to care and decrease costs.
Last year, I visited tribal communities in Alaska and saw firsthand how telehealth’s two-way diagnostic tool can be used to exam and diagnose patients and then guide doctors and pharmacists in providing needed prescriptions. This was done in Alaska: you can’t get more rural than that!
We’re making progress on telehealth, but roadblocks still remain. While some of these barriers, like licensing and supervision requirements at the state level, are well-intentioned, they can also impede access to the right solutions for patients and providers in unique and challenging rural circumstances.
That brings me to the final strategy I want to touch on, flexibility.
As some of you may remember, last year, the Trump administration released a report on choice and competition in American healthcare. It laid out a number of places where existing regulations, from the federal to the local level, may be raising the cost of healthcare and reducing the supply of practitioners, and many of these issues are especially relevant to rural areas that face provider shortages.
I’ll give you just one example: There’s a category of nurses technically known as advanced practice nurses, which includes nurse anesthetists, nurse midwives, clinical specialist nurses, and nurse practitioners. They are explicitly trained to offer primary care and certain specialized care.
Yet, as the administration report notes, more than half of states impose on them either supervision requirements or “collaborative practice” requirements, which can have the same cost and inconvenience. These nurses are qualified, capable and ready to serve, but these regulations make it costly or even impossible to practice to the top of their license. And of course, there’s potential not just to empower advanced practice nurses, but also physician assistants and other health professionals.
So what I’ve laid out for you today is a huge range of possibilities for improving rural healthcare in America. HHS believes the health and well-being of rural America is just as important today as ever before, and the opportunities for improving rural healthcare are greater than ever before.
I can assure you that rural America, rural health, and rural healthcare are and will continue to be a priority for this administration. It is an issue close to my heart, close to the Secretary’s heart, and of great importance to President Trump. But we need your help, support, and partnerships to achieve the transformation we need.
So, please continue to engage with us on improving healthcare in rural America. I’m confident that our collaborations will lead not only to better health for every rural American, but every American. Thank you again for having me here today.