Special strategies may advance rural health

According to the National Rural Health Association (NRHA) in Kansas City, MO, the geographic and ethnic distribution of America’s uninsured varies widely as a function of employment patterns, poverty, the organization of medical care systems, and political differences among states.

Although numerous regulations, geographic definitions, special programs and reimbursements, and partial solutions have been tried to improve access for rural and frontier Americans, they appear to have had little success, according to data developed by the Urban Institute in Washington, DC. But in a May 1999 report, NRHA said it might be possible to improve on the incremental measures so they would have a greater impact.

The NRHA recommended taking these actions:

- creating new types of safety net providers for rural and frontier areas beyond the current community health centers, free clinics, and charity organizations;

- providing new grant funds or incentives for providers who supply a disproportionate amount of uncompensated care, or a subsidy for providers who see more than their share of Medicaid and Medicare patients;

- increasing state or federal resources to strengthen and adapt the emergency safety net;

- more broadly defining a "safety net provider" to include not only those who provide indigent care and have a sliding fee scale, but also those serving remote geographic areas, locations that serve culturally diverse populations, and areas with a limited number of providers where no patient can be turned away;

- undertaking a state-by-state effort to get state funds to subsidize care for the indigent, especially in rural and frontier areas;

- expanding tax options, including a broad-based national medical indigency tax or use of tobacco settlement funds to pay for indigent care;

- recognizing that certain populations, especially in rural and frontier areas, require special services including transportation, meeting sociocultural access issues, and improved access to specialists;

- creating community-based solutions for the uninsured aimed at covering entire communities and based on pilot projects;

- creating a more widespread use of local taxing districts to fund indigent care;

- expanding hospital- or organization-based programs to serve indigent populations;

- determining the effect, if any, on the uninsured of facilitating 1115 Medicaid waivers;

- requiring all providers, including health plans, to assume some reasonable responsibility for indigent care;

- adequately funding outreach efforts to educate and enroll rural and frontier people in programs such as CHIP and Medicaid for which they already may be eligible;

- obtaining better data on the uninsured and underinsured and how their care is provided;

- including provisions in new programs such as CHIP to improve access to care for the uninsured. n