62. Big Bill and Huge Losses for Rural Health with Edwin Park, Shawn Martin and Nathan Baugh
Michelle Rathman: Hello one and all and welcome back to The Rural Impact. You know, we are the podcast that works hard. We really do to connect the dots between policy and rural everything. I am Michelle Rathman, and I am forever grateful. And I mean that, that you have carved out time and you're very busy schedule to join us.
And we're so appreciative for our growing community of listeners and subscribers. And listen real quick, if you have not yet subscribed. You can do that by visiting theruralimpact.com. It takes two seconds, and then you'll be sure to receive updates and information about upcoming shows and resources and all that good stuff right in your inbox.
Okay, so today it has been just over a week since the passing of H.R.1. And as you know, that is known as the One Big Beautiful Bill Act. And so, today's episode, we're gonna do a little bit of a shift from looking at what could happen, should it pass to what is and will happen and is anticipated to happen now that it has been signed into law.
Again, it's just been about a week or so. So, things are still being sorted out as you'll hear in this episode. But first, a really quick overview, in case you have not been following along in this 870 or so page, bill. It includes making permanent several provisions of the 2017 tax cuts, overhauls, understatement, overhauls of Medicaid eligibility, and increases funding for military and immigration enforcement, while also rolling back certain clean energy subsidies and adding an estimated 2.4 trillion to 3.1 trillion to the national deficit, something that's important for us to keep in mind.
So, for today's discussion, I'll note that the H.R.1 includes some of the harshest restrictions to Medicaid and SNAP ever, imposing stringent new work and reporting requirements on both Medicaid and SNAP recipients. And that includes children and for Medicaid, it reduces federal matching funds, for example.
Increases cost sharing for those above the federal poverty line and bottom line, it cuts roughly $863 billion from Medicaid and nearly $295 billion from SNAP over the next decade. and sometimes we are trying to just figure out how we're gonna get through tomorrow. So, it might be a little bit difficult to think about what's gonna happen 10 years from now, but down this course, this is the kind of cuts that we're looking at with really nowhere to look to see where that might be supplemented.
So, to help us sort through all of this I have invited quite the lineup of experts to include in this conversation because all of them much smarter than me, with a lot more detail to share. So, we've invited old friend of the podcast, Edwin Park, Research Professor at the Georgetown University McCort School of Public Policy.
I'm also thrilled to be joined by Shawn Martin. And Shawn Martin is the Executive Vice President and Chief Executive Officer for the American Academy of Family Physicians. Finally, we welcome Nathan Baugh, and Nathan is the Executive Director of the National Association of Rural Health Clinics. We have not had Nathan on before, but we're so glad that he is here to explain what all this means for those rural health clinics you might be served yourself by in your rural community.
So, with that, it is time, as I always do, invite you to tune out that background noise and put yourself in that podcast frame listening of mind, and listen to my first OBBA explainer conversation with the guy who knows more about Medicaid, Medicare and CHIP than anyone else I know. Mr. Edwin Park. Are you ready?
You know I always am, so let's go.
Michelle Rathman: Edwin Park Research Professor at Georgetown University, McCourt School of Public Policy, and my new phone a friend, which I really appreciate. Welcome back to the Rural Impact. We are very grateful that you're here today.
Edwin Park: Thank you, Michelle. Thank you for having me.
Michelle Rathman: All right, so before the passing and signing intol aw of H.R.1 one, we all know it as the One Big Beautiful Bill Act, there was an enormous effort put out by yourself, your colleagues, so many of us out here working in rural health. And the reason why we're talking about this is because it's just still so fresh.
You know, the wound is still very wide open, and we, we put out a lot of information to educate lawmakers about just how devastating, as you put it, so often these draconian cuts are going to be for rural America, rural you know, rural hospitals, rural providers, and people who live there who rely on Medicaid as their only source of insurance, you know, for health, for health coverage.
So now that it's law. I thought, Edwin, that you could help our listeners better understand the numbers even as we're still trying to figure that out because there are a lot of numbers out there, a lot of varying you know, X amount of million people will lose their coverage and so forth. So could you just kind of lay out what you know, and you know, a lot.
Edwin Park: Sure. So, there are many last minute changes made to the budget reconciliation bill and its Medicaid and chip provisions. So, despite being passed by Congress, signed by the president into law. We still don't have final numbers from the Congressional budget office in terms of the size of the cuts, how many more people will be uninsured?
We have a sense, a good sense of how large these cuts are. This will be the largest cut to the Medicaid program in history, the largest rollback in health coverage in history. It's probably going to be in the order of about a trillion dollars in, Medicaid cuts and 16, maybe 17 million more, uninsured by, the end of the decade, as a result of this legislation.
Michelle Rathman: And, and now I wonder, and this is something I was listening to this morning on Julie Rovners, What the Health Podcast, which I listen to all the time talking about some new provisions around removing legal immigrants who have legal status and completely eliminating them from all of this as well.
So I don't know if these numbers were included in this bill or not, or is this still kind of an ongoing process?
Edwin Park: Yeah. You know, we hope that all those numbers will be included in the final Congressional Budget Office Estimates, but this legislation takes away, not only Medicaid and CHIP coverage, also marketplace coverage, and Medicare coverage from many lawfully present immigrants. And this includes refugees, asylees, victims of develop domestic violence and human trafficking.
You know, a whole host of people who are, you know, very vulnerable, who've had access to various forms of federal, health coverage, including Medicaid for, for decades.
Michelle Rathman: And so, at the end of the day, we know with absolute certainty one thing, those who are uninsured will still need healthcare. Bottom line. And so, let's talk a little bit about what this means, just based on what you're seeing. I mean, we talk about rural hospitals being on the brink of closure. We've been doing it for a long time, but this takes it to a whole new level.
What do you foresee the impact just on the finances? Because less we forget, there was a provision that was thrown in kind of in the end about a $50 billion rural transformation fund. No one really understands how that's gonna work. What are you seeing in terms of like, first of all, will it even make a dent on now hospitals having to care for a whole new group of uninsured population and their finances being taken like double, triple hits.
Edwin Park: Yeah, mean we, we know that some estimates of a slightly earlier version of the legislation from KFF is that federal Medicaid spending will probably fall by about $155 billion over 10 years. And separately, the Urban Institute estimates, estimates that rural hospitals will see revenue losses about $87 billion over 10 years, and an increase in uncompensated care costs by about $23 billion, so a total of $110 billion hit.
To give you a sense in comparison, this rural health transformation fund, which was touted, as a way to mitigate the harm to rural hospitals and rural health systems is really a fig leaf. You know, it's only $50 billion compared to the numbers I just gave you, so it's much smaller.
It's temporary. It's only for five years rather than permanent. These cuts are permanent. They're gonna get bigger over time and it's really poorly targeted. Half the money is divided equally across all states, irrespective of their need, their, the number of rural hospitals, rural residents in their states.
And then, the other half is really divvied up at the discretion of the secretary. It has to go to only at minimum a quarter of the states. The criteria are very vague. There’s no set formula for divvying up the dollars. And in fact, how the funds are allocated, is specifically exempted from judicial and administrative review.
And if you look at some, yeah, if you look at some of the, the purposes for these funds, some of them are about payments to, rural health systems helping rural health systems. But some of the permitted purposes have nothing to do with rural health systems. It's about chronic disease generally, which is one of Secretary Kennedy's priorities.
It's about technology, cybersecurity even. And so, even though the purpose that about paying providing payments to providers doesn't actually specify rural. It just says payments to providers. and we know from reporting that Dr. Oz, the CMS Administrator was telling House Republican members, don't worry.
Even if your district isn't a rural district, I'll still send you money from this fund. So, it's hard to see how this fund could, really make a big dent in the harm that, rural hospitals, rural health systems and rural communities will face under the legislation.
Michelle Rathman: And y'all will, forgive my skepticism in terms of transparency 'cause I don't think we're, we're really gonna know. I mean, if we don't know on the front end, we're certainly not gonna know on the back end. Edwin, I wanna talk to you a little bit about Medicaid expansion states. And this is something that really confused me to begin with.
You know, listen, I'm not as deep into this by any stretch of the imagination, but Medicaid expansion states are expected to fare far worse in this legislation which is confusing. So, I wanted to have you kind of explain to us kind of big picture of why this is so.
Edwin Park: Yeah, it's very clear that for Republican leaders in Congress and the Administration that one of the goals of the health cuts, in this legislation is to really undermine the Affordable Care Act Medicaid expansion. That, you know, this was something that was, ultimately unsuccessful back in 2017 in the first term of the Trump administration.
But according to KFF, roughly half the cuts are targeted specifically at the Medicaid expansion. So, this includes provisions that really scale back the ability of states to finance their share of the cost of Medicaid through so-called provider taxes. That specifically, one, one of one provision, related to provider tax is specifically targeted at expansion states. The work requirements, which we're gonna add a lot of red tape drive off eligible people off the program, even though they remain eligible, they're actually working, or they should be exempt, but they can't navigate the really complicated systems, as part of work requirements.
That's just for those eligible for the expansion. There are requirements that states have to more frequently renew coverage for those in the expansion six months rather than the 12 months that applies for everyone else, and we know from unwinding of the continuous coverage protection during the pandemic, if there's a lot of red tape, you have to go through renewals.
There's a bunch of people who get terminated from coverage for procedural reasons, again, not because they're no longer eligible because of paperwork problems, meeting deadlines complicated systems that they can't navigate in terms of reporting their paperwork, verifying that they're still eligible.
And so, you know, these are really all provisions targeted the Medicaid expansion as an attempt to really undermine it if they weren't able to go directly at the expansion. And so, you know, some of the proposals that were originally under consideration, what a cap federal funding, targeted the Medicaid expansion eliminated the, uh current 90% matching rate, which is the percentage of costs of the expansion that's picked up by a federal government, which would really force states to drop the expansion very soon.
They weren't able to get those provisions in this law but many of these other provisions in an attempt to move in that direction to really make it harder for states to continue their expansions and for those who are eligible for the expansion to be enrolled in the expansion.
Michelle Rathman: I read something yesterday and it's so true. This does not save anything. It just shifts the burden. So, let's talk about that for a moment because we're talking the federal piece of this, but what's it gonna look like for states that already are just, I mean, they've got hospitals closing left and right.
So, what is it gonna look like at the state level? Because you kind of have a theory we talked about before is that now, now will shift the burden, but the blame as well when, when it comes time to really unpack all this, who's gonna be to blame?
Edwin Park: I mean, I think, this set of cuts related to so-called provider taxes. These are taxes and assessments on hospitals, and other healthcare providers. it's used by states to finance a portion of the cost of, of Medicaid. You know, they draw an income taxes, sales taxes, other revenue sources. But this is one of those funding streams that supports existing Medicaid programs.
And if you make it much harder for states to use these taxes to finance Medicaid, then that's a big budget shortfall and states have to balance their budgets, unlike the federal government. So that means, you know, big Medicaid cuts, whether it's cutting eligibility, whether it's cutting optional benefits like, vision and dental for, for seniors and adults.
Whether it's cutting home and community based services for those with long-term care needs, whether it's slashing provider rates, including provider rates to rural hospitals that are already operate on under thinner operating margins, they're gonna have to make all these painful choices that are gonna result in, you know, harm to individuals who rely on Medicaid, the providers that serve them, as well as other parts of, of the state's budget because of all the pressures this is gonna create in terms of reduced federal funding.
And so, you know, that's part of the design of these type of proposals where the federal government can say, oh, we didn't directly cut these benefits or cut eligibility.
but it's the inevitable result of the, the kind of provisions, the kind of cuts that are included in the law.
Michelle Rathman: And I think it's really important for me to say this is that I don't care what color your state is, and people have heard me say this, I'm so tired of red and blue because at the end of the day, everyone's in the same pot where this one is concerned. It does not matter if you are a Republican or a Democratic led state.
The impacts will be felt regardless.
Edwin Park: Yes. I mean, if a rural hospital cuts staff, cuts services, has to close its doors entirely, you know, that affects everyone in the community, in terms of their access to needed healthcare, irrespective of who they voted for, their political affiliation. And they're gonna have to travel much farther to find the, the, the healthcare, they need, including labor and delivery services.
Services, whether it's for emergency care or for complex medical conditions. And if they have to go so far out of their way to get the care, it's gonna be much harder for them to avoid serious unnecessary health outcomes. You know, that could be potentially fatal.
Michelle Rathman: I had a conversation this morning with a, a gentleman from who was with an economic development commission in the state of Kansas. And we were talking about the fact that their, their critical access hospital closed their OB services. And we talked a little bit about some of the reasons why, and I said, well, how many births?
You know, it's like less than a hundred. And I said, well, that's one factor. Then how many of those births were Medicaid coverage? I mean, so people need to understand that financially it just doesn't it, it can't be sustainable. It's not sustainable. Alright, before I let you go, Edwin, I mean, right now we've, I said earlier everyone's been like, yeah, call your congress, call your member of congress, call your member of Congress.
And it just feels like even the smartest people, I mean the smartest people giving the best data, they, it, it wasn't being heard. At this point, I wonder now that it is, these cuts are written in stone and I know things can happen because there's this timeline for things. So, everything isn't by design not gonna happen all at once.
Are there any advice that you can give our listeners in terms of, first of all, just really understanding the impact in their own community and their state and what what else can be said? Is there anything left to say for your state local officials to help them understand, guide them through this process of not making it a bad situation worse, I'll say.
Edwin Park: I think two things. One is now that this has been signed into law. You know, these are provisions that are taking effect. Some, upon date of enactment, maybe some in a year or two. There are, you know, hospitals, other government officials at the state and local level. Now they're starting to run the numbers and they're estimating the, the direct harm, the direct hit on providers communities, and of course, individuals rely on Medicaid.
And, being able to promote that as a way to, to ensure accountability. Right? You know, members of Congress voted for this, and it passed, despite, you know, widespread opposition, both from the public generally, but from various stakeholders back home in their districts, and, you know, being able to really emphasize what this means in terms of, direct harm to communities, to health systems and so forth.
Separately, I think it's also critical, to push back against a lot of the misleading rhetoric, the falsehoods that are being issued by the administration, by members of Congress who voted for this bill. Many of these arguments, many of these claims are wholly inconsistent from each other.
So, there are no Medicaid cuts, no one will be harmed. Oh, but we are taking away coverage, but we're only taking away coverage from, you know, undocumented immigrants. But undocumented immigrants are not eligible for Medicaid. They never have been. This is all about fraud and abuse, even though this is really about taking away coverage from, you know, million, many, millions of people.
So it's, none of the arguments make sense. None of them hold up under even a couple minutes of scrutiny. But you know, being able to push back on that because, you know, those arguments are being made to try to inoculate those responsible for passing this legislation and all of its huge damaging Medicaid cuts.
Michelle Rathman: And as we're seeing so many people that didn't even know they were on Medicaid because of the fancy name that it was given to at the state level. Alright, so I'd imagine, Edwin, you're gonna keep writing about this because you're waiting for these numbers to come in. So where can folks follow you?
Because I really encourage them. 'em to do so. You've got some really good stuff out there.
Edwin Park: Yeah, it's ccf.georgetown.edu. So, I'm with the Center on Children and Families. We put out a lot of Medicaid and CHIP research. Once we do have final numbers from the Congressional Budget Office, we will be putting out a pretty lengthy detailed explainer of the Medicaid, CHIP and marketplace provisions in this legislation.
Michelle Rathman: Well, we will. Can't wait to get our hands on and I know you guys are great. We're, we're always keeping our eye out and we'll make sure that we share that with our listeners as well. And we'll put links on our website to make sure people know where to find you. Edwin Park, thank you so much for joining us.
I do appreciate your time.
Edwin Park: Thank you for inviting me.
Michelle Rathman: Okay. For the rest of you, do not go anywhere 'cause up next we are back with my conversation with Shawn Martin, Executive Vice President and Chief Executive Officer of the American Academy of Family Physicians for his take, as well as Nathan Baugh, Executive Director of the National Association of Rural Health Clinics.
They're each gonna share their perspectives about the One Big Beautiful Bill Act. We'll be right back. Sit tight.
Michelle Rathman: Hey, Shawn Martin, Executive Vice President and Chief Executive Officer of American Academy of Family Physicians and Nathan Baugh, Executive Director of the National Association of Rural Health Clinics welcome to you both to the Rural Impact. We are very grateful to have you here today.
Nathan Baugh: Thank you.
Michelle Rathman: That's great you guys.
Well listen there's some things going on I hear, so we have a lot to talk about. Shawn, I'm gonna start with you. I'm really, again, grateful because we don't really get to hear so much the, the physician perspective on all these matters. We hear a lot of organizational policy focused people and so forth.
And so I think, at the end of the day, I tell people, you know, nurses don't grow on trees, and doctors don't appear out of the, out of the woodwork. So there's a great deal of, of impact, if you will because of what we're gonna be talking about today. Among other things, the passage of and signing into law H.R.1 better known as the One Big Beautiful Bill Act and how it will impact family health physicians practicing in America's rural communities in all settings.
And Nathan will get into the settings that you're familiar with, but Shawn, can you just give us a big overview of what you're hearing from all of your members you know, where they were before and where they are now. And then maybe later on we'll talk about how we move forward.
Shawn Martin: Yeah. Well, thank you Michelle, so much. I, appreciate the opportunity to be here, and you know the practice of family medicine, primary care, generally speaking in the United States has been, you know, pretty tense over, you know, the last five or six years for a variety of reasons. One is, you know, relatively stagnant payment rates from both public and private payers and escalating administrative function that's being imposed upon practices from insurers and, and other entities.
But another downward pressure has really been, you know, the aging of the population and, and the prevalence of disease, particularly chronic disease and the population, which is what family physicians do. It's, it’s why they love family medicine. But it also, you know, takes more time to take care of those patients.
And time is a commodity that many of them just don't have these days. So, when we think about, you know, the provisions of the legislation that we're gonna discuss today a lot of it is you know, community focused for my members. I mean, they're, you know, we always like to say they're on Main Street.
They're not necessarily in the hospital. They're taking care of communities and families and things that put up barriers or make it harder. For individuals and families to access the healthcare system. You know, our members tend to view very negatively, and I think we just saw a series of those in this, this bill, just the, the, in the, you know, the barriers being erected to give people that already had a, a substantial number of barriers to accessing the healthcare system a, a few more obstacles to overcome.
And I think it's, it's not always known family medicine you know, is the largest contributor to the rural physician workforce. About 18% of our members practice in a truly defined rural community. They're not out there alone. There's a big team that takes place. The rural ecosystem is very much you know, centered and successful, when it's a team-based approach.
But a lot of our members do provide care to rural communities and, and rural patients. And you know, this is gonna make it harder.
Michelle Rathman: Hmm. You know, Shawn, in the circles that I travel, everyone knows I, I work in rural health for my day job. I mean, it's increasingly difficult for recruitment and so we'll talk about that a little bit later. But I I did read, I've been following your materials that you all have been putting out, and there was in the senate's version of the reconciliation bill, there was a, I would say a tiny step in, in improving access to primary care, but it's kind of like, I, I liken it to, dental floss for a lifeline dental, right?
So, it's like primary care through a one year increase to Medicare physician payment for 2026. What does that mean? What is the dent? Does it do anything?
Shawn Martin: Yeah, I mean it obviously more financing in the system is always better than less financing in the system. And I think, you know, that's kind of how we've approached this. But, you know, physician payments under the Medicare physician fee scheduler, about 30% behind inflation over the last two and a half decades.
Physicians of all specialties took about a 2.8% real dollar cut in 2025. So, you know, this puts a majority of that money back in, but it's still sliding further and further behind. You know, inflationary increases, increases in labor and, and, you know, practice expense. There was another provision maybe we can get into later.
There was a HSA provision that was specifically designed to help, you know, connect, individual patients and families with an HSA account to primary care, which we're pretty excited about. It's not necessarily a rural specific policy, but we do think it's an opportunity, to create a more meaningful connection between individuals and families in primary care.
And we're kind of curious how, you know, this will play out over time.
Michelle Rathman: Hmm. See, in my mind, I would hope that the infrastructure would be in place. It's like building the plane while you're trying to fly it. That's kind of the way I've been. I have a lot of analogies these days. I'm trying to keep it clean for a family show. So Nathan, I'm gonna jump to you because you are director of Government Affairs whom we've had on the podcast before, Sarah Holman has done a really excellent job, I'm sure, with the help of other team members kind of detailing the impacts to rural health clinics, which is a primary setting for, for family physicians in many ways.
And talking about, you know, these Medicaid cuts, which is cri critically important for you guys to continue doing.
But I wanna shift to the, kind of the how you guys are feeling about the Medicaid cuts and then talk about the Affordable Care Act reforms, which I think is unfortunately being kind of buried underneath the, the drumbeat of Medicaid cuts. Do you know what I mean? So talk about what those changes mean for rural health clinics.
But first I do not wanna assume all of our listeners understand the difference between, for example, a rural health clinic, FQHC and maybe a hospital based. So why don't you go there first and then to the next one.
Nathan Baugh: Okay, sure. So Rural Health Clinic is similar to an FQHC, but they are very different programs. we have similar reimbursement mechanisms on the Medicaid side, different reimbursements on the Medicare and Medicare Advantage side and FQHCs have, I would say, more requirements, but then they also get grant dollars.
RHCs have less requirements, but we don't, we're not as grant funded as FQHC. That's like the quickest summary there. Very different programs. Sometimes we're hand in hand 'cause we are written together in the law in many places. Other times we're kind of in different places. FQHCs can also be urban and rural.
Rural health clinics of course only could be rural. So that's the quickest summary there. Hosp like outpatient departments as you mentioned. I guess the way I think of it is just being a hospital outpatient department in a rural area or even just a doctor's office in a rural area, doesn't automatically mean you're a rural health clinic, even though you are, like an average person might call it a rural health clinic, and that would make sense.
It's, it's a formal program. So, a lot of rural health clinics are owned by hospitals. So, you could have like a hospital outpatient department that flips into a rural health clinic as an example.
So that's baseline understanding. In terms of how we're feeling about the bill I think we are concerned and, you know, obviously our, the biggest impact for us is going to be the anticipated rise in the uninsured patient, our uninsured patients. And that is going to hurt us in particularly because unlike the FQHCs who get grant dollars to help them cut care for uninsured, we don't really get any assistance.
So that is just a financial hit for our rural health clinics that we're gonna have to bear the brunt of. I am guiding and I, I'm trying to help the Rural Health Clinic community be on top of the Medicaid work requirement changes going forward. Just, I mean, at, at this point it's here. And so, I think the best thing our practices can do, our rural health clinics can do is help your patients not get caught up in this red tape that we know is coming to prove you or have community engagement.
You know, that means getting involved to the state level. It means getting involved with your patients and doing the best you can to help help your patients navigate the red tape that is coming.
And then finally the third question here on the Affordable Care Act. I think you're totally right. This is gonna be the major healthcare battle, in my opinion, heading into the end of the year. We, there were some people, myself included, who thought that they might address this issue as a part of the first reconciliation package, but we have, enhanced premium tax credits that are set to expire at the end of this year.
And these enhanced premium tax credits are credited for taking the ACA enrollment from about 12 million to over 24 million in the last couple of years. They, they were in put in during COVID. And so, if they expire, it's anticipated that that number's gonna come down by i've seen the CBO say I think 4.2 million. So, it's another 4.2 million folks that could lose their insurance.
And that's if they expire. The politics of this, I do have some numbers on this. 157% of that enrollment growth has been in red states, and only 36% of that enrollment growth has been in blue states since 2020. So, the politics of this are tricky and I don't know exactly where we're gonna land. I think a full, just letting all of the premium enhanced premium tax credits expire is, is maybe unlikely. And I think that, that perhaps they will, claw back some of those at the end of 2020, but perhaps not all.
Michelle Rathman: You know, you bring up a great point, Nathan and Shawn. I'm gonna go over to you because maybe the politics are tricky, but the policy is not, and everyone who listens to this podcast knows I say often, all roads to quality of life are paved by policy. I don't care what color, red or blue, I wake up every morning hoping someday that we can just erase all this ugliness because Shawn, at the end of the day, work requirements mean I just read something this morning that was just, it just breaks my heart every time. More patients will forego care.
Shawn Martin: Yeah. Yeah,
Michelle Rathman: And so what's that mean for your constituents?
Shawn Martin: yeah, I think
Michelle Rathman: don't want sicker patients.
Shawn Martin: I think it's twofold. I think I'll do the selfish one for my members first, which is, as Nathan said, you know physicians and other healthcare clinicians are going to have to help patients navigate this enrollment process that is going to be more and more difficult to do. And in, and in fact, there are certain provisions inside the work requirement eligibility, criteria that require some attestation from, you know, the healthcare entities that, see them.
So, the administrative function is going to increase. I think one of the things that I'm always most disappointed in work requirements is that it's never accompanied by continuous, you know, 12-month continuous enrollment. it's, you know, they still make them do this twice a year or states, I think now make, you know, three times a year.
And that's just challenging. It's challenging for the individual and the family, and it's also challenging for those that are advocating on their behalf. look, Michelle, I, you know, I always talk about barriers to care and, you know, in rural communities there's a lot of 'em. I mean, you know, you have distance, you have socioeconomic, a lot of times you have, you know, language or cultural barriers.
Like there, there are a number of barriers to care that just exist without us trying. So, I am always most disappointed when we try to put up other barriers and, and, you know, this bill does that in, in a, you know, a variety of, ways that are just going to cause people to forego going to see their family physician or going to see another clinician type in their communities.
Diseases will progress or go undiagnosed. Cancer screenings don't happen. ultimately the individual will have worse health outcomes and the healthcare system itself will experience a higher cost. And has been proven. This is not just Shawn saying this, it, you know, it's been proven over and over and over again in programs in the United States and around the world that, you know, continuous access to primary care, improves health outcomes and reduces on a per capita basis healthcare spending.
So the opposite of that is gonna happen. And that’s just too bad.
Michelle Rathman: In closing rural hospitals, I would say is one heck of a barrier to overcome. I mean, very few of them reopen and under these circumstances, I don't predict that that would be an option for so many of them. All right, let's, let's switch over to something else, because another thing that came out of this is this rural health transformation program, which is the number kept, fluctuating, went from 15 to 25 to 50, what is it billion dollars that are gonna go towards, you know, to help with things like, and I'm just gonna like kind of read off the, the list here. improve access to hospitals, healthcare providers and services. With all those other barriers, I'm not sure that will happen. It's supposed to improve health outcomes, prioritize the use of new emerging technologies and so on and so forth.
But the administration of the program is yet to be known. It's very subjective. Part of it will go here. A lot of people are saying it's not gonna go to the right places. I'd like for both of you to just kind of give me your sense of how this will impact, again, those who you're serving and, and really with all the unknowns, what can you tell us what you know about it?
Nathan Baugh: Do you want me to
Michelle Rathman: Go ahead, Nathan.
Nathan Baugh: Yeah, I mean, it's super vague. When I saw it you know, that was kind of the thing that I noticed. I also noticed that the states have to put together a plan and apply for this money by the end of this year.
Michelle Rathman: Oh yes,
Nathan Baugh: get to go, go forth and get your plan done, states, if you want access to this money, I don't know, that seems like a quick turnaround for state government to pull off.
Maybe they can impress me. I'm looking at those state plans for detail as to how this is going to eventually get spent. And then like I presume the secretary will approve or ask for edits in those state plans. And that's kind of when we're gonna see those details. But right now I think it's super vague, and I also think that this money is not necessarily hardwired to go to rural. So it's being called sometimes the rural hospital fund. and I don't think that that's right because our RHCs are, are defined in there as a rural facility. FQHCs are defined as a rural facility. so it's not just hospitals and, but the uses of the funds are, are don't even direct the funds to those rural f the defined rural facilities.
The, the, the use of that definition is just about how it's distributed across the states, not necessarily how the, the money must be spent on those end facility types. So, I it's something I'm watching. I don't have all the good answers.
I'm, I'm kind of waiting to I'm, I wanna take bets as to which state will be first to submit their plan which state will have their act together the most.
Michelle Rathman: Yeah, we'll, we'll be watching that too. And Shawn, there's no provision in this, from what I've seen, there's no provision that provides, support for the clinical services. So again, I ask, what are you hearing? And maybe what would you ask for? I mean, as we're out here advocating what needs to be considered.
Shawn Martin: I, I have very similar reactions to Nathan. I, I think, you know, one, I don't, I would've never designed this this way. I, I don't know that it's a good policy apparatus aimed at, you know, alleviating or mitigating the other provisions of the bill, which I think was kind of how it was presented.
But, you know, our general attitude is it now exists. So, you know, how are we going to work to shape both the design and distribution of these dollars? There's nothing in there that says it has to go to any provider type, you know, I mean, it's, it says it has to go to the provision of, you know promoting rural communities or helping rural communities.
And you know, I think the one thing that we were encouraged in the criteria is around the workforce. Like, do you know, are, do you have programs aimed at increasing the, you know, the rural healthcare workforce? I think, you know, that obviously is a place that we'll be interested. But you know, the challenge is, you know, always with grant programs when it goes to the states, is the states wanna negotiate with the fewest number of entities possible. And those fewest numbers of entities tend to be quite large. And they tend to maybe have a rural presence, but they tend to not be rural based.
And you know, and I don't blame them for that. It's easier to negotiate with one or two large entities than to negotiate with 500. So, you know, and I, I think we all have work to do to make sure that that money, you know, goes to where it has the highest impact.
And you know I think rural health clinics, rural primary care practices certainly are at the tip of the spear of impact as far as community, improving health outcomes in those communities.
Michelle Rathman: Mm. Yeah, you're right. And there's one little line here that says it's also can, can be used to recruit and train more healthcare clinicians. And before we move on, Shawn, I mean, I'm just curious you know, recruitment and retention is something, and Nathan. And you've heard this, like there's so many programs and so many formulas and so many people have answers about how you do that, but at the end of the day, they're human beings.
And I wonder what you're hearing, you know, from the human side of this, how all of this legislation might be impacting just the I mean, there's a will, there's a, there's a will for people to provide this amazing rural focused care. I wonder what all of this is doing to maybe detract those who want to do a rural career in Rural Health. They might say, man, this is just too hard.
Shawn Martin: Yeah, I, I think, you know, this one's tough because it's an individualized decision, but you know, our data would suggest to us that rural practice for a large number of family physicians is very attractive because it affords them things that are very value oriented to them. You know, it's, it's a connection with the community, it's a comprehensive practice environment. You get to have care across a, a longitudinal time period of a, of a lifespan. but the things that make it harder are isolation, you know, lack of other specialists to, you know, collaborate with and refer to, uncertain presence of other healthcare providers or entities in your community.
So, when the rural hospital closes, you know, that's really hard for rural primary care to stay. They lose a lot of you know, supporting services and, and other physicians. I, you know, the thing I always stress about those that go to rural communities and why losing access to care and increased number of uninsured and increased administrative burden is it, it gets harder to exist from a time perspective in that environment.
So, when you can move into a suburb practice or you know, a different type of location and someone does all that for you, um you know, that becomes more and more attractive as, as you know, the rural practice setting becomes more and more challenging.
Michelle Rathman: Yeah, I'm seeing more and more people say like the concierge kind of model where, where all of these things don't matter because you get paid a lump sum and you know, you get to choose, pick and choose which patient, uh base you want to, engage with, if you will.
I do want to shift over really quick to the provider attacks because I'm not gonna ask you both to like do the 101 on what it is.
But at the end of the day, this is another big topic that we're talking about. And Nathan, let's just start with you. I mean, in terms of the provider tax, I am quite frankly, full disclosure, not quite sure how the Rural Health Clinic kind of fit into this equation, but if you wouldn't mind just kind of sharing with us the impact of the provider tax provisions in that they'll be restricted, no new provider taxes.
What is that going to do to you all in the rural health clinics across this country? I.
Nathan Baugh: As far as I'm aware, there's gonna be no direct impacts, but money is fungible. Right? So, the, to the extent that it's gonna squeeze Medicaid program's ability to pay hospitals a certain amount of money you know, Medicaid programs might look to cut other provider types equally if they're gonna have to cut hospital payments.
As far as I'm aware, most, like I said, most RHCs don't, aren't directly tied to the provider tax the way perhaps some other provider types are. So it’s gonna be an indirect impact and for us at least, and that the states financing mechanism, it's just under greater pressure and that pressure will radiate throughout the system.
So even, and I would say that for anyone that's not directly you know. Getting a provider tax or something like that, the pressure will radiate through the entire system.
Michelle Rathman: Shawn, is there anything on your radar screen where this is concerned?
Shawn Martin: Yeah, I mean, I agree with that. I think just less money means that different choices have to be made and, and you know, most of the time those choices are pretty negative.
I think the other thing that, you know, when you talk about the juxtaposition of a bill like this, you know, many of the substance use disorder programs and rural outreach programs on opioid use disorder. And, you know, those types of things are all funded through this enhanced, you know, financing that states are able to achieve because of the provider tax. I mean, that money is a, a reinvested back into specific community needs or, you know, that are localized.
And I, I think that completely got lost, you know, in this debate around this bill. The, the mental and behavioral health services, the things that are helping, individuals in these communities really are a byproduct of, of that enhanced financing mechanism. And, and if that money goes away, I mean, it's just a logical step that some of those programs are.
Michelle Rathman: And we were making, I mean, strides. We were making strides in and addressing these things. And what strikes me so much is just the whole conversation around making America healthy. At the end of the day, you know, so much of this is the opposite of what we would think would do, achieve that.
So, kind of shifting before we, we close out. you know, there's a lot of information. I have been in healthcare for over 30 years, and I've never imagined my life, the changes coming out of HHS that what we're seeing for me, it's almost unrecognizable. And I've been to the, to the HRSA headquarters and work with a lot of folks in that agency.
And so, I would like to just kind of shift to that and talk about any concerns that each of you have. I mean, Nathan, yours is a bit, I'm sure different, but just related to some of these massive policy changes. You know, Shawn, there's been a lot of pushback from the physician community about things like child vaccination studies, access to COVID vaccines for children and pregnant people.
And I'm just wondering how the medical community you know, so many of the providers I talked to, like don't want to have a political conversation, and yet now this is so encroaching upon their expertise. How are your members addressing, you know being pushed to, you know, now we've got politicians telling us how, how to practice medicine and what's right and wrong. This has got to be a real thorn in some sides.
Shawn Martin: Yeah, I mean, it's frustrating. It's also, you know, counterproductive and I will tell you, you know, our association, the a FP, my job I take very seriously. Like our, our job is to, you know, do the best we can to deal with the environment in which they're practicing so that, you know, they can focus on the most important thing.
In their practice, which is the person in front of 'em, and, and I say this to our staff all the time, it's our job to deal with all the rest of the things to make the world better so that the person in front of them is really all that matters on a day-to-day basis.
Now with that said, healthcare is really hard in a status quo situation. You know, so when you start really disrupting large portions of that status quo from an operations perspective, you know, it gets even harder. And, and, and that's just where we are. There, there is not a single aspect of the practice of family medicine that's not being disrupted in some way either administratively, operationally, clinically, and, and I think, you know, I wish it wasn't this way, Michelle.
I really wish it wasn't this way. There, there are ways to make policy changes that are not as disruptive. But it's the world we're in and, and you know, we, we, all of us, you know, have to do the best we can to mitigate that disruption and make sure that we are putting people in a position to, pursue and achieve health.
And, and, you know, I don't know another way, I wish it was easier, but it's hard right now. But that goal remains the same.
Michelle Rathman: Yeah, absolutely. you know, Nathan and I work with a lot of rural health clinics and their staff and, you know, it's getting harder and harder for them. They get pushback. They don't have the support that they need. What, what are some of the things that you're hearing and that some sort of strategies that the rural health clinics are doing to kind of combat disinformation to, you know, patients have questions.
I mean, they're gonna be asked to answer a lot of questions that may be out of their wheelhouse 'cause they just wanna stick to patient care.
Nathan Baugh: Yeah, I’m gonna pass on the clinical side of it. Like I don't, I don't know what confusion some of the messaging is, is creating necessarily. I will say from the, sort of the financial end of, of things you know, we have concerns with some of the proposed HHS budget reducing, as an example, the number of, regional offices. It's unclear if it's gonna drop the number of CMS regional offices from 10 to five or just HHS.
That might be a distinction without a difference. But we already face really long enrollment times, like the process. If you said, Michelle, I'm opening a, you probably know this, if you're go, if you wanna open a RHC today, the process can take quite a bit of time to get properly enrolled in Medicare and Medicaid.
And that regional office does plays a big role in that. So, I we're concerned that there's gonna be a bigger bottleneck there and it could take upwards of a year, almost two years in order to formally enroll as a rural health clinic. So that is, that's a concern that we have with the reorg, which I know was not your last question.
It was part of your initial question. So, that's just one aspect we've seen, like I often get into like coding nuance stuff with CMS and I will say it hasn't felt more efficient at getting answers.
Michelle Rathman: Are so you're such diplomats, you two.
Nathan Baugh: Well, you know, there's always like CMS does the best that they can, and I, you know, the people I work with are, are great.
And I do think that sometimes they are held back by decision making timelines, above them. And it feels like, we had some changes that went into effect January one and some others that were supposed to go into effect July one. And it just doesn't feel like we have the same amount of guidance that we normally get from CMS when, when changes to this degree are made.
So that's been my experience thus far. So, hopefully the reorganization if it does happen, I hope that it leads to more efficiency down the line.
I'll, the last thing I'll say on this from the politics standpoint, the, a lot of the reorganization of like getting rid of HRSA and creating a AHA, I'm not a legal expert, but I believe Congress is gonna have to go along with that and that battle I'm expecting to play out certainly as a part of the appropriation cycle that we're heading into, you know, beginning October 1st. Will Congress pass a CR that blesses the restructure? I kind of doubt it.
And though I do have to say this other last thing as because it's in the budget that's a catastrophe. Rural health clinics are very reliant on their state offices of rural health. And so, we are really hoping that that doesn't happen. And that Congress you know, says, thank you for that recommendation, Mr. President, but we're gonna fund rural state offices of rural health. So that's, that's really one of the major things that we're, we're watching as part of this approaches.
Michelle Rathman: Sure, hope so. And maybe they'll do it in time for National Rural Health Day this year, which is always the third Thursday of November, because I, we, that is, that is catastrophic, really. I, I understand how much.
Okay. For both of you and Shawn, I'll start with you. At the end of the day, you know, there's, there's all sorts of sayings. It's not over, so it's over. I mean, this is pretty permanent. Everything they've ruled in here, I think has been done very deliberately to just put it all in one trunk, lock the key, and, you know, revisit it whenever someone gets that key back.
But advocacy also has to happen at the state level. One of the things that I wrote about yesterday was the fact that, you know, counties are gonna be impacted by this county finances, local economies.
You know, when a, when a rural hospital closes, or a rural health clinic, when a rural hospital closes, oftentimes the rural health clinic goes with it because it is part of it. So, there's a lot that can be done to bend the ear of other policymakers. Again, here's where we, we are, here's who we're appealing to. There's no other body responsible for this, but policymakers.
So with that said, for, for those who are in health professions, what is in your advocacy's toolkit that says, listen, there's a lot of damage that can be done from this. How do we start to kind of minimize some of that damage? What, what are some things that your members and others can really take with them to say, we have to keep talking. We can't just accept this and say, oh, we'll see what happens. That's my opinion.
Shawn Martin: Yeah, I, I think there's a one, I think we're still unpacking. But I think generally speaking, we're very concerned about the disconnecting people from healthcare coverage. even though there are some provisions of the bill I said at the top that are, you know, probably really favorable to primary care, the direct primary care and HSA, but you know, that's a marketplace that has to be developed over years and it may prove to be a very beneficial shift in creating greater access to primary care and time will tell. We're very supportive of that.
But I think, you know, what we're gonna start working with at the state level, especially if the ACA tax credits were to expire, you're gonna, you're gonna see a large number of uninsured that's gonna come with a incredible amount of economic burden on the healthcare systems in states, that's gonna make insurance premiums for just everybody else, including the employer market, fluctuate and go up.
So, I think we're gonna talk a lot about what we talked about in 2006, seven and oh eight, which is, people being disconnected from healthcare coverage has rippling healthcare effects, but it also has pretty substantial economic impacts, on communities and states and in the country.
Another thing that we're gonna continue to talk about is, from healthcare coverage is not going to make people healthier. And there's a number of studies out there that shows there's really two things, as I said earlier. One is a continuous relationship with primary care, and the other one is continuous healthcare coverage.
Individuals that have those two things over prolonged periods of their life have better health and they spend less money on their healthcare. So, you know, we have a lot of work to do. The good news is from a wonky DC perspective, they gave us a lot of dials to turn in this bill. So we can turn 'em, you know, try to turn 'em down and, you know, I think there's opportunities to do that, but it's gonna be really challenging in the current political environment.
Michelle Rathman: And I want people to connect the dots too, because at the same time we're talking about this with the disinvestment and social drivers. And I talked to someone the other day that says we're not even allowed to say that anymore. You know, in our grant applications. So, when we, when we take away food assistance and nutrition assistance and we defund housing programs and we don't invest in transportation, all those things are indicators, as we all know, to health.
And then with that, the kind of the criminalization, if you will, of, the pen penalties for providing care for immigrant populations. That's another thing that we didn't have before. So, it's just compounded. I mean, I, I wish I had, I'm usually such a bright, sunny sunshine personality, but that's so much these days.
Nathan, what's your kind of takeaway for those who have it still within them, and I hope they do to advocate. Quite frankly, keep, you know, keep their skin in this game to make sure that we don't, you know, lose on every front.
Nathan Baugh: Well, as you both said, the action is moving to the States for sure, on, on Medicaid. But I would say the know your timelines many of these provisions kick in, over time. The work requirements don't begin until 2027. provider tax phase out stuff begins in like 2028 but some of the most aggressive savings and the most most of the pain is gonna be felt in 2032, 2033, 2034.
And that's a lifetime politically from now. So we did, we're not predestined to get there. I mean, when they passed the Affordable Care Act, they were all things in that bill that were passed initially, that never actually came to fruition because there were changes later on. And so you could take the same approach with this legislation just because it's something as scheduled to begin in '28 or and get worse by 20 33 doesn't mean that we have to just accept that there's a lot of politicking and policymaking that can happen between now and then. And you know, I do think a lot of this can be unraveled. And the other thing is just for us to retain our credibility. Um. I think it's important to really know those timelines because if someone's like, well, hey, I haven't really seen it yet.
It's like, well, yeah, that's 'cause it hasn't kicked in. So we have to educate the public and we can't forget about this in a couple of years and we have to be, 'Hey, remember because of the One Big Beautiful Bill, now this thing is happening 'cause we haven't reversed it or whatever.' So we have to make that connection.
I think.
Michelle Rathman: Yeah, I, and I say make the, you know, make sure that we keep the staffer engaged 'cause sometimes they outlast. And I think that's so important. I'm gonna just both read you guys something before we end. I read a blog today by a gentleman named Jim Baik. And Jim, I apologize if I said your name wrong, but this line really stuck out to me.
And he said, "whether Medicaid survives, this retrenchment will not be measured in abstract budget lines. It will be measured in real lives." And I hold that, I hold that very close to me every single day. Real people are going to be harmed by not having access to healthcare and nobody wants that in, in my circle anyway.
Shawn and Nathan, I'm so appreciative for your time to both of you. You are welcome back. I mean it anytime, we’ll be watching Nathan, you and I have some bets that we, we like before it was passed. Yeah. What states so we'll, we'll keep our eye on that. And again, thank you to you both for your work and the service that you do for your constituents.
It's greatly appreciated.
Nathan Baugh: Thanks so much, you, Michelle.
Michelle Rathman: You're welcome.
My sincere thanks to Edwin Park, who you heard first up, and also to Shawn Martin and Nathan Baugh for their time and certainly for their insights. You know, as you heard, there remains a great deal of uncertainty about the extent of the harms and the impact of this new legislation on America's rural communities.
But we do know with all certainty, there will be considerable challenges moving forward. this bill does not remove roadblocks, as you've heard. It certainly does place new ones in front of us that we need to continue to have these conversations about. But before closing, I, today’s show, I want, to make sure that I extend this very serious invitation to you.
I've been thinking about this a lot and talking to our whole team here at The Rural Impact over these next six to 12 months. we are going to be really taking a look at the impacts of these policies from a state and county level, so a rural county level. And that means we want to hear from you directly, those of you who are working to balance your own budgets and figure out ways to make sure your rural communities can continue to be served for those life, lifeline programs, if you will.
So, if you are a county or a city government official, if you work in the area of economic development, housing, healthcare, food security, nonprofit, faith-based organization. again, if you're serving a rural community, send us a note. We really do wanna understand, in just a few sentences about how these policy shifts are impacting your rural community and your ability to do the important work that you do.
And you can reach out to us by simply emailing us at, [email protected]. Again, that's [email protected]. And if you would prefer, please go ahead and follow us on social media. You will find us on Blue Sky, LinkedIn and Facebook. That's where we're spending, most. All of our social media time at this point in time, and we'd be happy if you would send us a direct message or tag us and we will be sure to respond to you.
As long as you're being nice and not using profanity, I'm gonna put that out there for you. So. Some days you feel like you wanna use it, but not on this show. And if you are interested in partnering with us, like our new partners at the National Association of Rural Health Clinics, and you're gonna be hearing more about that coming soon, just visit again,theruralimpact.com, click on the link for partners and learn all the ways that we can help you expand your rural reach.
As always, we do appreciate the feedback that you sent us through notes. I just cannot tell you how much it means to me to get your messages through LinkedIn and other platforms. And of course, we do appreciate those donations that are coming in because they do help us continue to produce these dot connecting conversations.
So again, I am Michelle Rathman, until I see you again, I'm always gonna say this, please take the best care of yourself as you possibly can, and those around you. We will see you soon on a new episode of The Rural Impact.