Senator Obama responds to NRHA questionnaire
NRHA submitted eight questions on issues important to the rural health community to the candidates for President of the United States. The questions included the following topics:
- Health Insurance Coverage
- Health Care Workforce and the Impact on Access
- Preventive Care
- Reimbursement and Impact on Access
- Health Information Technology
- Veterans Health
- Specialty Care
- Health Care Infrastructure
This week, Sen. Obama sent NRHA his response to these questions. His responses are available below. In addition, Sen. Obama sent a letter last week to attendees of the Rural Health Clinic and Critical Access Hospital conferences.
If NRHA receives a response from Sen. McCain, his answers will be posted as well.
Background: Nearly one in six Americans is currently uninsured and millions more are underinsured. This problem is especially acute in rural America where there tend to be more small businesses and more self-employed individuals, including farmers. Studies indicate that the uninsured population is growing at a faster rate in rural American than in urban areas, especially among working families. Recently, there has been significant discussion of plans to remedy this problem. Additional background.
NRHA Question: How would your administration address the lack of insurance coverage that is so much more acute in rural America?
Senator Obama: Clearly, a major problem facing rural America is access to affordable quality health insurance coverage. I am committed to signing health legislation by the end of my first term in office that ensures all Americans have high-quality, affordable health care coverage.
To achieve this commitment, Joe Biden and I have a plan that builds on and improves our current insurance system, which most Americans continue to rely upon, and leaves Medicare intact for older and disabled Americans. Under the Obama-Biden plan, Americans will be able to maintain their current coverage, have access to new affordable options and see the quality of their health care improve and their costs go down. Beyond our overall plan, I would like to highlight the following three elements of the plan that have important implications for rural America:
First, Joe Biden and I are keenly aware that the rural economy is dependent upon small business and small employers who often struggle to offer health coverage to their employees because it is too expensive. Our plan will help small businesses afford coverage for their employees by offering a voluntary tax credit to them that will cover 50 percent of premiums. They can use the tax credit to cover their employees through the National Health Insurance Exchange, which is a large pool that offers health care at lower costs than the individual or small employer market. They can purchase either a new public plan or choose from a range of private plans for their employees. Small businesses will be exempted from the plan's requirement to pay into the system.
Second, the Obama-Biden plan will require insurance companies to cover pre-existing conditions so all Americans, regardless of their health status or history, can get comprehensive benefits at fair and stable premiums. Rural Americans tend to have more pre-existing conditions than the rest of the country and our plan would assure access to needed coverage.
Finally, the Obama-Biden plan will also provide subsidies for those people who need them and assist the neediest citizens by increasing Medicaid and SCHIP coverage.
Health Care Workforce and the Impact on Access
Background: Unfortunately, even Americans with health insurance do not necessarily have adequate access to care. Currently, nearly 100 million Americans live in areas classified as health professional shortage areas or medically underserved areas. The shortage of health care providers in this country adversely affects the health of all Americans, but the problem is even more acute in rural areas. Rural communities struggle both to recruit and retain health care providers for a variety of reasons, limiting access to care for these populations. Additional background.
NRHA Question: How would your administration address the ongoing health care workforce crisis in rural communities?
Senator Obama: I am acutely aware that financial access through insurance is a hollow victory if there are no facilities and providers available to provide health care. That is often the dilemma in rural areas. Two-thirds of the federally designated health professional shortage areas in the United States are found in rural America.
I believe that success in developing our rural health care workforce relies on a multifaceted effort. Access to an adequate rural health workforce is contingent on producing and deploying more health care providers for rural areas as well as retaining those providers in rural health care settings. Rural America needs a robust health care workforce pipeline that ensures access to essential health care services for rural communities. This is a challenging goal but one that Joe Biden and I are very committed to.
My administration will attract providers to rural America by continuing and expanding loan forgiveness and related types of incentive programs that help attract health care providers to rural areas.
I also believe that community colleges have a special role in workforce development in rural areas and I am prepared to make additional investments in their educational programs as well as support for linking their programs to other institutions of higher education for rural students and clinicians who wish to pursue additional professional education. Keeping education local is particularly important because it can lead to an increase in the local pool of allied health professions. Community college graduates often remain in rural communities. Targeting students from rural areas for health professions training is one of our best strategies to meet workforce needs. Extensive research has clearly documented that recruiting students from rural areas increases dramatically the likelihood they will practice in rural areas.
Finally, we will also expand funding for training curricula and infrastructure support designed to improve working conditions and will encourage the expansion of state-of-the-art health professional online education to make health professions training available to next generation providers in sparsely populated areas. Without such improvements, rural health facilities will struggle to retain their providers. Retention is essential as recruitment can be both expensive and difficult. We must assure that rural health professionals that are already in the community are able to remain there and are given the support they need.
Background: Improving access to preventive care is an excellent way to increase longevity and quality of life for rural Americans. Rural areas have high proportions of poor and uninsured individuals, as well as a large number of elderly. These are all groups for whom early preventive care can greatly reduce health care costs later in life. Many rural communities suffer from a shortage of primary care providers to supply these services. Furthermore, there is a lack of understanding of the importance of preventive care and lifestyle factors related to healthy living, as evidenced by the higher rates of obesity and smoking in rural areas.
NRHA Question: How would your administration promote geographic and economic access to and use of preventive services for rural America?
Senator Obama: Protecting and promoting health and wellness in this nation is a shared responsibility among individuals and families, school systems, employers, the medical and public health workforce, and federal, state and local governments. All parties must do their part, as well as collaborate with one another, to create the conditions and opportunities that will allow and encourage Americans to adopt healthy lifestyles. Some of the most important strategies that my administration would commit to are:
- Rewarding workplace efforts that involve health promotion programs, onsite clinical preventive services such as flu vaccinations, nutritious foods in cafeterias and vending machines, and exercise facilities.
- Working with schools to create more healthful environments for children, including grant support for school-based health screening programs and clinical services and increased support for physical education, and educational programs for students.
- Ensuring all Americans are empowered to monitor their health via electronic health records (EHR) and ensuring coverage of essential clinical preventive services in all federally supported health plans, including Medicare, Medicaid, SCHIP and the new public plan and use these technologies to assist providers to coordinate and integrate care.
- Increase funding to expand community based preventive interventions to help Americans make better choices to improve their health.
Primary care providers and public health practitioners are essential to leading efforts to protect and promote the nation's health. Yet, the numbers of both are dwindling. The existing workforce is further challenged by inadequate training for new health threats such as bioterrorism and avian flu, antiquated funding and reimbursement mechanisms, and limited access to real-time information and technical support. An Obama-Biden administration will expand funding to ensure a strong workforce that will champion prevention and public health activities in rural America, cognizant of the unique opportunities and challenges present in rural communities.
Finally, we must combat the scourge of methamphetamine in rural America. I have a long record of fighting this epidemic. When I was in the Illinois State Senate, I fought for and helped pass legislation to increase penalties against meth manufacturers, particularly in cases where a child was exposed. In the U.S. Senate, I supported the Combat Meth Act of 2005, major parts of which became law in 2006. The bill puts federal funds into the fight against methamphetamine, provides assistance to children affected by meth abuse, and places restrictions on the sale of the ingredients used to make the drug. As President, I will continue the fight to rid our communities of meth and offer support to help individuals fighting their addictions.
Reimbursement and Impact on Access
Background: The costs of Medicare and Medicaid are increasing rapidly. Despite the overall increase in Medicare and Medicaid spending, payments to rural providers are not keeping pace with the increase in costs. Rural providers of all types are suffering from inadequate payments from Medicare and Medicaid that often do not cover the true cost of care to their respective beneficiaries. In many cases rural providers are paid a lesser amount than their urban counterparts because of various limiting factors such as wage index, geographic adjustment factors or other artificial adjustments even though they incur equal or greater costs. This is especially problematic because rural areas have higher proportions of Medicare beneficiaries who are older, sicker and have a higher incidence of chronic disease requiring long-term care. Rural children are also disproportionately reliant on Medicaid and State Children's Health Insurance Programs. The inequitable payment structure also makes it more difficult for current providers to keep their doors open and for rural communities to recruit new providers. As long as rural providers do not receive adequate reimbursement, their communities will not have adequate access to the health care they need.
NRHA Question: How would your administration ensure adequate payment levels to rural providers in order to protect essential access in rural areas?
Senator Obama: This is a long-standing issue with rural providers that has never been adequately addressed. Although the issue is a complex one, my commitment is simple: Joe Biden and I will work hard to ensure equitable payment to clinical services provided to rural populations. This effort will start by building a more equitable Medicare and Medicaid reimbursement structure.
This summer, Joe Biden and I voted for a major protection of the Medicare program. The Medicare Improvements for Providers and Patients Act of 2008 (MIPPA) was an essential first step to assuring the continued strength of the Medicare program. Both Joe Biden and I were honored to assure that providers would not see the scheduled payment cuts that would have endangered their ability to offer care for seniors and disabled Americans. Further, we were proud to support provisions in MIPPA that continued to protect payments for rural providers and ensure a basic level of fairness in their payments. We understand that without equitable payment rates, many rural providers simply will not be able to continue to serve their communities.
But MIPPA was just a start. We must do more to ensure this equitable reimbursement structure. This fall, we supported efforts to increase the federal matching rate for Medicaid reimbursement as many states, due to the economic downturn, will have to either cut the number of beneficiaries on Medicaid or cut payments that are already too low to providers. We can and must do better by our health care providers. You have my assurances that an Obama-Biden administration would work to build stronger, fairer reimbursement structures.
Background: The expanded use of health information technology holds promise for improving the availability and quality of health care in rural America. Health information technology can support patient self-care, eliminate some of the costs associated with duplication of tests by consolidating an individual's health information, and improve patient safety. Health information technology promises to be especially useful in rural areas where patients and providers are separated from each other and other specialists by greater distance. All the costs of implementing and maintaining these technologies currently fall on the shoulders of the providers, while the benefits accrue to purchasers (employers, public payers), patients and insurers. Rural providers and rural health care institutions are the least able financially to bear these costs. Additional background.
NRHA Question: How would your administration propose to address the imbalance of costs and benefits such that health information technology is more available in rural America?
Senator Obama: HIT is one of the cornerstones of my Plan for a Healthy America and I fully agree with your view regarding the disconnect between those who pick up the tab and those who receive the benefits. That is why I plan to invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records. My administration will ensure that these systems are developed in coordination with providers and frontline workers, with particular attention to adoption in rural and underserved areas.
Background: A large number of veterans call rural America home, in fact, the rate of enlistment in rural areas is nearly double that of urban areas. Unfortunately, rural veterans are at a significant disadvantage compared to urban veterans when it comes to their health care. The death rate is 60% higher for rural troops and, for those who come home, rural veterans have to make the choice to travel to the free veterans clinic or hospital, which can often be over a hundred miles from home, or they can go to local providers and pay out of pocket. The same level of care that urban veterans count on is generally not available to rural veterans in their local communities and the health care demands of returning veterans cannot be met by the Veterans Administration system.
NRHA Question: How would your administration propose to remedy this inequity facing rural veterans?
Senator Obama: I am fully committed to the health and welfare of our veterans-rural and urban alike-who have served our country so bravely. Unfortunately, in many rural parts of the country, the nearest Department of Veterans' Affairs (VA) medical facility is hundreds of miles away. In my administration, we will push very hard to ensure that wherever they reside, rural veterans will be able to access high quality health care. Community based outreach clinics (CBOCs) are a key vehicle to extending this outreach as is ramped up application of high quality evidence based telemedicine interventions. Through the CBOCs and other means we will give the VA the tools and flexibility needed to contract with other providers in remote areas of the country where the VA determines there is inadequate access to a VA medical center or in which it is impractical to build one.
Background: Rural areas cannot attract the specialists needed to provide care to individuals with a variety of conditions, including chronic diseases and mental health problems, because of the relatively low volume of these patients. However, for individuals with these ailments, specialty care is crucial. For example, cancer patients may have to travel hundreds of miles on a regular basis to see an oncologist or receive chemotherapy that is not available in their local community.
NRHA Question: How would your administration propose to improve access to specialty care for rural Americans?
Senator Obama: Where we have successful models, broader dissemination and adaptation is necessary. For instance, some rural communities have local access to specialty series via visiting surgeons and other specialists and via telemedicine for services ranging from dermatology to mental health. Cleary, there is an important role for telemedicine and mobile clinics. But this may not be the only answer. With this and other challenges, I will welcome hearing the recommendations of people who are closest to both the problems, as well as developing the solutions, to help address this critical rural health issue.
Background: Rural health care facilities tend to be decades older than their urban counterparts. Under the Hill-Burton Act of 1946, the Federal Government committed to building the rural health infrastructure but today many of those facilities are in need of further attention. Aging facility infrastructure is a serious safety and quality issue and the latest medical advances are often incompatible with older facilities. Compounding the problem, older facilities tend to have high overhead costs and administrative burdens.
NRHA Question: How would your administration address the issue of aging rural health infrastructure?
Senator Obama: Aging rural infrastructure is a serious problem in this nation. When health care facilities are not fully up-to-date, they risk jeopardizing the safety of their patients or may lack the newest advances in medicine. This must change. An Obama-Biden administration will increase federal funds for the building and start-up costs of community health centers, many of which are in underserved rural areas. We will also seek to use existing programs, such as USDA Rural Development funding, and explore other options to address the issues of older health care facilities.
As we do so, I will remember that rural America also faces other serious infrastructure issues, such as transportation systems, water and sewer systems and lack of affordable broadband. Helping to support and modernize rural infrastructure will be a priority in my administration. Together, this lack of infrastructure jeopardizes both the financial wellbeing of rural America and the health of rural communities.
I will also insist that USDA Rural Development funding be targeted to truly rural areas. Since 2001, the USDA has distributed more than $70 billion in grants and loans through its Rural Development program with some of this funding in support of rural health care facilities. Unfortunately, less than half of the $70 billion has gone to truly rural areas. Instead, USDA has awarded the bulk of these benefits to metropolitan regions, recreational and retirement communities, and businesses that hardly qualify as contributing to the quality of life in rural America. In one particularly egregious example, USDA awarded $4.5 million to the Black Dog Tavern on Martha's Vineyard to refinance a mortgage and to expand its clothing stores. As President, I will rationalize USDA funding rules to ensure that these funds are provided to truly rural areas and with an emphasis on investments that are clearly in the public interest, such as health care facilities.
The NRHA does not endorse candidates for elected office. The questionnaire is for our members' benefit in assessing the impact of the candidates' plans on rural health .
