By Taylor Knopf
It was a cold, wet, windy day as rural health advocates from North Carolina walked toward Capitol Hill earlier this month.
They had back-to-back meetings in the offices of six N.C. congressmen: Sens. Thom Tillis (R) and Richard Burr (R), and Reps. David Price (D), G.K. Butterfield (D), Alma Adams (D) and George Holding (R).
The group was in Washington D.C. for the annual National Rural Health Association conference, where the discussion centered around the health disparities and crumbling financial landscape in rural America. Few discussions about rural health ended without mention of opioid addiction and overdoses, and the ever-improving resource of telemedicine.
Every day on the Hill is advocacy day for some group or another. As the rural advocates wandered through the halls of Congressional office buildings, another group of blue-collared men wearing “save our pension” buttons passed by.
The rural health group from North Carolina was shepherded from one Congressional conference room to another (or rooms that were more nook between room dividers for some of the minority party representatives).
Meanwhile, each office television live-streamed the proceedings from the floor of the House of Representatives where Nancy Pelosi was giving a filibuster-style speech on the preservation of Deferred Action for Childhood Arrivals or DACA.
But most legislative aides were more concerned with what the latest budget agreement would hold.
By the time the group was on a plane headed back to North Carolina, the final spending deal included 10 years of funding for the Children’s Health Insurance Program (CHIP), money for community health centers, and $6 billion over two years for opioid addiction treatment and overdoses.
These are all big wins for the rural health community. At the same time, the budget for the Centers for Disease Control and Prevention was cut by 20 percent.[sponsor]
“As we met with harried, overworked staff and Congressmen during a budget negotiation that included funding for community health centers and CHIP, I was struck all over again [by] the extent to which advocacy matters,” said Deborah Owens with the Cary-based Foundation for Health Leadership & Innovation and a longtime rural health advocate.
The plight of a small rural hospital
For Laurel Molloy, it was her first time advocating on the Hill. Molloy is the chief nursing officer and vice president of Lenoir UNC Health Care, a hospital in Kinston. She came to explain to the state’s congressmen (or to their legislative assistants) just how difficult it can be to run a rural hospital.
There is high poverty and a disproportionately high share of patients who only have Medicare or Medicaid in the population around Kinston.
“The challenges are really socio-economic, and we are required to meet the same standards of care, but I can say it’s very challenging,” Molloy told Rachel Soclof, Burr’s health policy assistant. “We have operated at a negative margin for many years and the model of payment is really not sustainable.”
Molloy explained that the hospital reached a “crossroads” about five years ago when hospital leadership was told it needed to partner with UNC.
“But there are still lots of other things that affect that partnership in terms of growth than just the health and wellness of the community,” she explained.
“I think we rank 88th out of the 100 counties in terms of health outcomes, which is dreadful. That’s a very high disease burden. Even from Medicare, we have a really high percentage of those who are dual eligible [also eligible for Medicaid because of their low income]. We are really talking about a needy population.”
In addition to patients and community health outcomes, Molloy worries about her staff.
“But I feel like in my role as a senior leader that I also have a duty to the folks working in the hospital,” she said. “We offer higher wage employment. We are part of the health and wellness that is there.”
There are people who have worked at that hospital their whole lives and don’t know anything else.
“I’m in a position right now, as well as other senior team leaders, where we are talking about cuts again. Not huge, but the idea that we are losing money and have a negative margin year after year. It’s not sustainable,” Molloy said. “Not that I want anyone to lose their job, I really don’t. But we have to figure out how to do this differently.
“I don’t want folks to ever feel like the mainstay of the city, the hospital, that it would ever be in jeopardy,” she added.
What to do about the opioid problem
When talking about mental health needs in her community, Molloy segued right into the problem of opioid addiction.
“We are in distress,” she said. “I can tell you that just in our little emergency department, we often hold the sickest of the sick. So, patients that have serious mental illness, they have medical comorbidities, they have a propensity for violence. That’s a huge issue. These folks that are the most vulnerable are stuck in our emergency department for a long time waiting for a bed at Cherry [one of the state’s inpatient psychiatric facilities.]
“The point is that opioids can’t be discussed without looking at those economic drivers and without looking at what’s happened to mental health across the state,” Molloy said, adding that the state’s behavioral health management companies haven’t worked well in her community.
Soclof, Burr’s aide, said the multi-faceted issues surrounding opioid abuse and overdoses have consumed every committee in Congress.
“So part of all these hearings is to get a grasp of the issue before us,” she said. “Where can we most effectively target a response?
“That’s also part of why some legislation is taking time to come out, just trying to figure out the most effective way possible,” Soclof said.
She added that a lot of money has been thrown at the problem, through the 21st Century Cures Act and others.
“We don’t want to throw more money at a problem that we are not seeing an improvement on. So we’re trying to really understand what’s currently happening,” she concluded.
Influence in real time
Over the past few years, the National Rural Health Association’s annual conference in D.C. has focused a lot on the best ways to implement and preserve the Affordable Care Act, said Maggie Elehwany, NRHA’s vice president of government affairs and policy.
While that’s still a priority, as well as expanding Medicaid in states that haven’t done so, Elehwany said it’s finally time to stop playing defense and go on offense.
“[We want to] show the government these growing disparities,” she said. “If you want to try to address this, there is one kind of common denominator and that is the economic plight in rural America… That’s why we really try to focus on an offense message as we debate the infrastructure bill and what’s going to be a part of that.
“If you want to fix what’s broken in rural America, we can start from understanding that health care is part of infrastructure. That’s the theme. If you can have a healthy economic community, you can have a healthy population in rural America and vice versa,” Elehwany said.
The North Carolina state legislature has also heard some of the same arguments during its recently established rural health committee.
Jeff Spade, vice president of the NC Healthcare Association, was pleased the group from North Carolina could arrange visits with congressional leaders, calling the relationships “invaluable.”
“It was exciting to be on Capitol Hill while significant debate was occurring on the federal budget,” he said. “Many of the rural health issues and concepts that we discussed with our delegation were being actively considered in the budget process, both in the Senate and House.
“We had a remarkable ability to inform our legislative aides and congressional leaders as they were actually considering important rural health legislation, such as funding for [community health centers] and extending important rural health legislation, for instance, … CHIP funding, opioid crisis funding, and reversing Medicaid [disproportionate share hospital] cuts,” Spade said.