Congress Picks up Pace as June turns to July
The House is back in session for the final week of June and is expected to meet throughout July. During the week of June 29, the House will vote on H.R. 1425, the Patient Protection and Affordable Care Enhancement Act. The bill will most likely pass on party lines and is not going to be taken up by the Senate. The legislation would expand the ACA’s tax credits, pressure states to expand Medicaid programs with the promise of more federal funding, and cap individual premiums at 8.5% of their income. The bill also allows immigrants living in the US under DACA to get access to subsidized insurance plans.
Beginning the week of July 6, the House will begin marking up Fiscal Year 2021 appropriation bills. The Labor-HHS bill, which sets the funding level for the SORH, FLEX and other rural health programs, is included in the HHS funding bill and is scheduled for markup July 7. The full House is expected to consider the bills on the floor the weeks of July 20 and July 27. The Senate will most likely not begin the markup process until September. Expect Congress to pass a continuing resolution through the November election.
Also beginning the week of July 6, the Senate is expected to begin negotiations with the White House on the next COVID-legislative package. During June, the Senate HELP Committee held a telehealth hearing that looked into which of the 30-plus temporary telehealth changes should be made permanent post-COVID-19 emergency. HELP Chairman Alexander (R-TN) called for Medicare to permanently lift restrictions on telehealth coverage for rural areas. Look for the next Senate COVID legislative package to include language making some of the temporary rural provisions permanent.
Rural Health-Related Bills Introduced in June
Rep. Sherrill (D-NJ) and Hern (R-OK) introduced the “protect Telehealth Access Act.” H.R. 7391 seeks to eliminate a requirement that someone receiving telehealth services must be located in a rural area or health professional shortage area, and that the person may only get telehealth services at home and in limited circumstances. Here is the press release.
Rep. Liz Cheney (R-WY) and Rep. Jason Smith (R-MO) introduced H.R.7338, the bill would amend title XVIII of the Social Security Act to allow HHS to waive requirements of telehealth services under Medicare. The bill would allow seniors to utilize CARES-related telehealth provisions after the national emergency period expires.
Senator Cindy Hyde-Smith (R-MS) introduced S.3998 to amend title XVIII of the Social Security Act to simplify payments for telehealth services furnished by Federally Qualified Health Centers or Rural Health Clinics under Medicare.
Rep. Guest (R-MS) introduced H.R.7208 to amend the Small Business Act to include hospitals serving rural areas or areas of persistent poverty in the Paycheck Protection Program.
Senator Mike Rounds (R-SD) introduced S.3917 to establish a home-based telemental health care demonstration program for purposes of increasing mental health services in rural medically underserved populations.
Rep. Norma Torres (D-NM) introduced H.R.7190 to amend the Public Health Service Act to provide for the establishment of a virtual health pilot program to facilitate utilization of remote patient monitoring technology to maintain or expand access to health care services for individuals in rural areas during the COVID-19 emergency period. Senator Martha McSally (R-AZ) introduced companion legislation in the Senate, S. 3951.
The NOSORH Grant Writing Institute features a series of nine online learning sessions covering every aspect of grant writing with a unique rural health focus. The series is intended for beginners seeking to gain the skills to research and draft winning proposals from various agencies.
Class size is limited to the first 50 registrants. Group discounts are available.
In response to the novel coronavirus (COVID-19) pandemic, NOSORH is hosting weekly listening sessions with the 50 State Offices of Rural Health to identify the challenges and opportunities that SORH are hearing from their constituents. These reports document the resulting identified rural challenges and concerns, innovative rural strategies, opportunities for collaboration, needed rural resources, and identified areas of concern or suggestions for SORH-managed federal programs.
Communications and Stakeholder Outreach
Rural Community-based Responses
Rural Health Care Infrastructure
Looking to share your rural successes, challenges or concerns? Rural stakeholders can send an email directly to HRSA at RuralCOVIDemail@example.com
On May 15, the House passed H.R. 6800, the Health and Economic Recovery Omnibus Emergency Solutions Act. The massive $3 trillion Coronavirus Relief bill is not going to be considered by the Senate, but does represent a starting point in the next virus-relief package. A few of the bill highlights include: an additional $100 billion to the Public Health and Social Services Emergency Fund; reduce the interest rate in Medicare Advanced Payment loans for all hospitals; include hazard pay for frontline healthcare workers; and a requirement for the promulgation of emergency OSHA standards for healthcare workers. Notably absent from the bill was a liability protection measure which Senate Republicans have said is a “red-line” for their support. The Senate will begin putting together their own COVID-relief package this month. The bill is expected to be much smaller in scope.
Appropriations: Along with consideration of an additional COVID-relief bill, Congress will use June and July to attempt to advance the Fiscal Year 2021 appropriations bills, which are one of the few “must-pass” legislative items this year. House leadership has indicated they will not begin the markup process until Congress has reached an agreement on the next Coronavirus relief bill. The Senate has hinted they may hold markups before the July 4 recess, although a markup of the Labor-HHS package has traditionally been one of the later bills to move.
NOSORH will meet with lawmakers and their staff throughout the process and urge them to increase funding for the State Offices of Rural Health Program to $15 million annually. NOSORH has been in discussions and will continue to advocate for increased funding and reauthorization for the Medicare Rural Hospital Flexibility grant program.
Bills Introduced: A bipartisan group of senators introduced the Save our Rural Health Providers Act. Sens Lisa Murkowski (R-AK), Joe Manchin (D-WV), and Cindy Hyde Smith (R-MS) introduced the bill which seeks to create a new formula to ensure the provider relief fund has a dedicated set-aside amount directed towards rural areas of the U.S. The bill would create a 20 percent benchmark in the Provider Relief Fund which according to a press release would allocate more than $10 billion to rural states. The bill also grants priority for facilities that provide care for populations with limited access to health infrastructure. A companion bill was introduced in the House by Rep Small (D-MN) and Hagedorn (R-MN).
Also this month, Senators Schatz (D-Hawaii), Murkowski (R-AK), Boozman (R-AR) and Peters (D-MI) introduced the Health Care Broadband Expansion During COVID-19 Act. The bill directs $2 billion to help health care providers increase broadband capacity and expand telehealth services during the current public health crisis.
NOSORH and the fifty State Offices of Rural Health congratulate and appreciate the work of the National Rural Health Association team for their great work advocating for rural providers across the nation during this public health crisis. These are tough times for all. We value NRHA’s “rural voice louder” now more than ever. Thank you Alan Morgan, Maggie Elehwany, Mason Zeagler, Max Isaacoff, and the entire NRHA team for exemplary leadership and advocacy.
The Senate returns to Washington on May 4 for the first time since late March. The House will most likely return on May 11.
Putting together and passing a CARES 2.0 will be the main priority for Congress during the spring session. The legislation will likely include additional relief for hospitals, some form of liability protection, and funding for state and local governments to respond to COVID. Congress may consider a number of rural health-related provisions in the next recovery package including: increased flexibility for telehealth, supporting increased funding for broadband access, allowing CAHs to cost settle after the COVID pandemic, and updates to the Medicare Rural Hospital Flexibility Program.
Unlike the first three stimulus bills passed by Congress, members are considering including other non-COVID health priorities like surprise billing and drug pricing (H.R. 3/S. 2543) into CARES 2.0. The timeline for Congress moving a fourth stimulus is unclear, with Republican leadership indicating they would like to see how current virus funding impacts states and regions.
HHS Begins Distribution of Payments to Rural Hospitals, Providers with Elevated COVID Admissions: On May 1, HHS announced that $10 billion will be distributed to rural acute care general hospitals and Critical Access Hospitals, Rural Health Clinics, and Community Health Centers located in rural areas. Funds will be directly deposited, rural providers need not apply. Each RHC will receive a minimum of $100,000. CAHs will each receive a minimum of $1 million with the median receiving $3.6 million. HHS released a chart detailing the rural payment amount by State. Texas, Iowa, and Minnesota appear to receive the biggest share.
HHS also announced that $10 billion will be distributed to 395 hospitals who provided inpatient care for 100 or more COVID patients through April 10, 2020. $2 billion will be distributed to certain hospitals based on their Medicare and Medicaid disproportionate share and uncompensated care payments. HHS released a chart detailing the payment amounts by State.
Appropriations Update: With Congress returning in May, House and Senate appropriators will have limited time to pass their Fiscal Year (FY) 2021 funding bills. With Congress already approving trillions of dollars in stimulus funding this year, many programs are bracing to see how the committees write their FY 21 spending bills. Some of the house appropriations subcommittees are targeting late June as a date to move their bills.
COVID-19 has not only taught us more about social distancing, testing and the FDA approval process than we ever wanted to know, it has brought us hundreds of pages of new legislation leading to new funding, new service lines and new regulatory guidance. On April 30, yet another round of “sweeping changes” to support the healthcare community were announced. There are too many nuances to delve into all of them here, but the press release and other related guidance that has been released to date can be found on the NOSORH COVID-19 Resources web page. A couple of items of note:
When delving into these new guidelines, if using sources other than the agency providing oversight, ensure they are trusted and have established credibility. Rely on the official guidance from the oversight body when possible.
With guidance coming so quickly, there are more questions than answers in some topic areas. The NOSORH website houses two pages dedicated to COVID-19:
Looking to share your rural-specific questions, concerns, models, innovations, successes and challenges? The Federal Office of Rural Health Policy is now operating an email address for the general public. Send to firstname.lastname@example.org
As the COVID-19 pandemic swept across the country, NOSORH and the Association of State and Territorial Health Officials (ASTHO) were gearing up to host the 2020 Primary Care Office (PCO) Training Academy. The Academy includes a face-to-face meeting at the ASTHO offices in Arlington, VA, followed by site visits between each paired mentee and mentor.
Originally modeled upon NOSORH’s mentoring program, the Academy has been conducted for nearly 10 years and continues to grow in popularity with new PCO staff. When the health and safety of Americans became a concern, the decision was made to move the Academy to a virtual format.
Participants in the Academy overwhelming responded to the survey with positive reviews of their experience! Of the respondents to the survey, 100% indicated that the meeting was satisfactory or highly satisfactory. Though not quite the same experience as being face-to-face, the mentor and mentee pairs were able to break out into private chat rooms to have smaller conversations. Participants indicated that 100% found the virtual meeting useful in building working relationships and that the virtual meeting format was useful. In addition to specific mentor and mentee time, introductory presentations were delivered by the following partners: the Bureau of Health Workforce’s (BHW) Shortage Designation Branch, Loan Repayment Branch, Nurse Corps Loan Repayment Branch, Division of Participant Support and Compliance, and the Division of Regional Operations.
NOSORH would like to extend our thanks to all of the mentors that shared their expertise: Amber Myers (MI), Allison Mikuni (HI), Robert Martiniano (NY), Thomas Rauner (NE), Anna Riggan (VA), Cindy Ellis (TX), and Lynn Ann Bishop (KY).This year’s Academy included mentees representing PCO offices from Alaska, U.S. Virgin Islands, Iowa, Idaho, New Jersey, Tennessee, and the District of Columbia.
For more information on NOSORH’s collaborative efforts with the Primary Care Offices, please contact Beth Kolf, Project Coordinator, at email@example.com.
COVID-19 Spurs Passage of Landmark Spending Bills
With the spread of COVID-19 throughout the United States, Congress passed and the President signed into law three major funding bills addressing the COVID-19 crisis. Below is a look at the three bills and a preview of what’s next for Congress.
On March 6, President Trump signed into law H.R. 6074 – The Coronavirus Preparedness and Response Appropriations bill. This bill provides $950 million to the Centers for Disease Control and Prevention for grants to states. The bill also included $100 million to HRSA under the Health Centers Program as defined by section 330 of the Public Health Service Act.
On March 18, the President signed into law H.R. 6201 – the Families First Coronavirus Response Act. This multi-billion dollar spending bill largely addressed funding Unemployment Insurance and expanding the Emergency Family Medical Leave Act.
On March 27, the President signed into law H.R. 748 – the CARES Act. The Cares Act is the most significant of the three funding measures and includes billions of dollars in federal funding and many substantive rural provisions.
Fourth Stimulus Bill on the Horizon
A fourth stimulus bill is already being worked on by House Democrats. The bill is expected to address shoring up health systems, creating protective standards for frontline healthcare workers, and boost infrastructure along with some other priorities. With Congress working remotely until at least April 21, Senate Republicans have indicated they would prefer to wait and see how CARES funding impacts the virus before committing to a fourth funding bill.
By Beth Blevins
Public health students at Oklahoma State University (OSU) are tackling real-life problems at Critical Access Hospitals (CAHs) in the state. In collaboration with the Oklahoma Office of Rural Health (OORH), Master of Public Health (MPH) students enrolled in the Designing Public Health Programs course are creating projects that address challenges faced by the hospitals.
“The programs that the students create are in direct response to priorities identified in the hospitals’ Community Health Needs Assessments (CHNAs),” said Lara Brooks, OORH Rural Health Analyst. “The students are divided into groups of two to four during the semester, and they then work on a priority from one of the previous year’s CHNAs.”
The program focuses on CAHs that do CHNAs (particularly nonprofit CAHs, which are required by the IRS to do a CHNA every three years). “Every fall I make a spreadsheet pulling out the priorities identified in the CHNAs and share that with the course instructor, who goes through and weeds it down according to what could be applicable to students in the course,” said Brooks.
This year’s topics addressed sexual health and education for adolescents, smoking cessation, opioid prevention for young adult males, physical activity, healthy lifestyles, and adolescent and parent counseling as prevention for future drug and alcohol abuse. Past programs have included mental health first aid, the creation of a Narcotics Anonymous (NA) group, and a dental hygiene program for nursing home residents.
“The really interesting part is the creativity in the projects,” Brooks said. For example, one group that was assigned “physical activity” as a priority utilized the state parks as an opportunity to get outside. “They went to that community and looked around and saw that the sidewalks aren’t great so they thought outside the box. They visited the nearby state park, got maps, and created a program around being active using the state park.”
Another year, a group from the class created a program on healthy eating that included grocery store tours, working with the local grocery store to host events and to highlight healthy products. “The fresh set of eyes and ideas are what make the collaboration so interesting,” Brooks said.
Brooks visits the students on the first day of class giving them an overview of OORH and its grant programs, describing a CHNA, and talking about common themes and priorities across the state. She then returns on the last day of class when students give their presentations. Brooks also acts as an intermediary between the students and the hospitals since the students do not have time to visit them themselves. She delivers their projects to the hospitals’ CEOs, “making sure they know they can ask follow-up questions,” Brooks said. “At the end, they will have a binder of the program the student group created, along with implementation steps, a budget overview, an evaluation plan, and the students’ own needs assessment.”
The collaboration between OORH and the course creates a three-fold opportunity—for the students, the hospitals, and for OORH. “From the hospital’s perspective, they have the opportunity to have a group of students creating a program just for them,” Brooks explained. “From the student’s perspective, they have the chance to create a real program for a real community to address a real need. And at OORH, we get the opportunity to introduce rural areas of the state to a group of students each spring.”
Stephany Parker, who taught the course this spring, said that the collaboration “brings students and communities closer together in an applied way and opens up communication channels with OORH as an essential resource for public health professionals.” Parker continued, “OORH is our connection to those real-life settings, circumstances and community leaders. The programs and materials students develop are creative, comprehensive, and provide clinic partners with a plan for implementation consideration.”
Andrew O’Neil, a recent student in the course, concurs. “(The course) gave me an understanding of health outcomes, determinants of health, and resources available to implement programming in rural communities, which will be useful as I continue my studies and research addressing rural-urban health disparities,” he said.
So far about 80 students have participated in this coursework/collaboration since its inception in 2016. OORH’s work with this collaboration requires no special funding. “When I deliver the binders to the hospital CEOs, it’s in conjunction with a site visit to the CAH, something that would normally be funded under the Flex program,” Brooks said.
Because OORH is part of the OSU Center for Rural Health, it probably makes a collaboration like this easier, Brooks said. “A program like this is probably easier to replicate with the university-based State Offices of Rural Health since they have that relationship on campus.”
“Nonetheless,” she added, “I know that a lot of folks who work for their state health departments are alumni of public health programs in their states, so if anyone wanted to replicate this it would be fairly simple, just by making a relationship with that program.”