People living in rural communities are more likely to be uninsured, to face barriers to accessing lifesaving health care, and to die from pregnancy-related complications than their nonrural counterparts, due to lack of insurance coverage, affordability, poor access to doctors and hospitals, and workforce shortages. Rural residents face limited insurer options, and in 10 percent of counties across the country – mostly rural counties – residents can only choose from one insurer. Ineligibility and fear of immigration enforcement are added challenges for rural Indigenous and Latino people and noncitizens.
Ensure Health Care Access for All
States that have taken advantage of the option to extend Medicaid coverage to adults living below 138 percent of the federal poverty level saw some of the largest health insurance coverage gains among rural adults – threefold faster than rural adults in nonexpansion states. Medicaid and other public programs, like the Children’s Health Insurance Program (CHIP), cover a larger share of people, including small business owners and solo entrepreneurs, in rural areas than in nonrural areas and play a critical role in keeping people healthy while buffering rural communities against hospital closures and provider shortages; these programs can be expanded to cover even more rural residents, including noncitizens.
Finally, the value of telehealth became clear to everyone during the COVID-19 pandemic; for many rural communities, telehealth is critical even without a pandemic. Although telehealth services are now covered through Medicaid in all 50 states and the District of Columbia, the way that states define telehealth services may continue to leave rural communities behind.
- Federal: Pass the Save Rural Hospitals Act, a bill that would preserve access to rural health care by ensuring fairness in Medicare hospital payments, creating opportunities for rural critical care facilities and investing in rural health care services.
- Federal: Expand, implement, and create rural reforms of Medicaid for poor and working-class families. Expanding Medicaid and increasing Medicare reimbursement rates have been identified by many rural health care advocates as the best way to deliver increased quality of care in rural communities. Additionally, reforms that give easier access to rural people should also be prioritized, such as making family, elder, and disability care reimbursable.
- Federal: Reduce cost and improve access to prescription drugs for rural people. This includes passing the Lower Drug Costs Now Act and reforming rural-specific programs like 340B to improve rural access, which is urgent.
The Inflation Reduction Act empowers Medicare to negotiate prescription drug prices and save taxpayers money.
- State: Expand and invest in Medicaid and CHIP, including opting in to cover lawfully present immigrant children and pregnant people and extending postpartum Medicaid coverage.
- State: Create a public health insurance option and/or expand who can participate in the state Medicaid program through a buy-in option.
- State: Extend coverage for telehealth service and also increase accessibility options to include audio-only telehealth services and translation services.
- State: Create prescription drug review boards to promote prescription drug affordability, and set allowable rates for certain high-cost drugs identified by the board.
- State: Expand mental health and addiction services for rural communities.
- State: Expand scope of practice for advanced practice clinicians, including nurses and physician assistants, to build out the pool of reproductive health care providers in rural areas.
- State: Remove unnecessary waiting periods and other restrictions on reproductive health services that disproportionately impact patients who are forced to travel long distances, often on multiple occasions, for time-sensitive care.
To date, 39 states have expanded Medicaid, while state lawmakers in the remaining states continue to consider expansion, most recently in Alabama (2021 AL HB 432), Kansas (2021 KS HB 2436), and Wyoming (2021 WY HB 162).
Thirteen states and the District of Columbia have enacted legislation to extend postpartum Medicaid coverage to address the maternal mortality crisis, which disproportionately affects Black, Indigenous, and rural people.
California (2019 CA SB 104) and Connecticut (2021 CT HB 6687) lawmakers approved legislation to extend 12 months of postpartum Medicaid coverage for persons regardless of immigration status.
Lawmakers in some states have extended coverage to certain immigrants regardless of immigration status. In California, children (2015 CA SB 75), young adults (2019 CA SB 104), and adults age 50 and over (2021 CA AB 133) are eligible for Medicaid regardless of immigration status, while a recently passed Oregon bill (2021 OR HB 3352) expanded eligibility to all people regardless of immigration status. Lawmakers in Illinois expanded eligibility to undocumented seniors age 65 and over in the state’s (IL FY 2021) budget, while Vermont legislators extended coverage to undocumented children and pregnant people (2021 VT H 430).
Lawmakers in Colorado (2021 CO HB 1232), Nevada (2021 NV SB 420), Oregon (2021 OR HB 2010), and Washington (2019 WA SB 5526) have approved legislation to create some version of a public health insurance option, while legislators in Hawaii (2019 HI SB 330) and New Jersey (2021 NJ S 3798) have enacted bills to allow more residents to participate in the state Medicaid program through a buy-in option.
Many states limit insurance reimbursement to video telehealth visits, which may be a barrier for rural communities with limited internet access, while interpreter services are not reimbursable through Medicaid in some states. Lawmakers in Arizona (2021 AZ HB 2454), Delaware (2021 DE HB 160), and Rhode Island (2021 RI H 6032) enacted legislation to allow for coverage of audio-only telehealth services. A bill introduced in Massachusetts (2021 MA S 678) aimed to require Medicaid reimbursement and private health insurance coverage of telehealth interpreter services for patients with limited English proficiency and those who are deaf or hard of hearing.
A growing number of states, including Oregon (2019 OR HB 2696) and Massachusetts (2019 MA H 1193), are considering legislation to create prescription drug affordability review boards.
In Minnesota, lawmakers enacted legislation (2021 MN SF 37/HF 33) that expanded eligibility for the state’s Health Professional Education Loan Forgiveness Program to include alcohol and drug counselors who agree to practice in designated rural areas or underserved urban communities. Legislation in New York (2021 NY AB 5220/SB 2664) would create a student loan forgiveness program for nurses working in rural psychiatric hospitals/units, addiction treatment centers, behavioral clinics, or county mental health programs. A bill introduced in New Mexico (2022 NM HB 17) would provide a $3,000 income tax credit to mental health professionals who work in a “rural health care underserved area.”
Lawmakers in California (2020 CA SB 855), Illinois (2021 IL HB 2595), and Oregon (2021 OR HB 3046) have passed legislation to expand the mental health or substance use disorders that health insurers must provide coverage for. In Colorado (2019 CO HB 1168), lawmakers enacted legislation creating a reinsurance program to encourage increased insurer participation in rural areas by offsetting high-cost insurance claims at a higher level in rural counties.
Legislation enacted in Kansas (2021 KS HB 2208) provides for the certification of community mental health centers as community behavioral health clinics and establishes a Medicaid-based payment system to fund these clinics. New Mexico (2021 NM SB 398) legislators introduced a bill to establish a mobile rural health units program to provide health services and substance use disorder recovery services in some rural counties.