Episode 88. The Impact of H.R.1 - One Year In, Interview with Alan Morgan, Jed Hansen, PhD, APRN, FNP-C, and Kait Guild
Hello, one and all, and welcome back to a brand-new episode of "The Rural Impact." I'm Michelle Rathman, and as always, and I mean it when I say, thank you for joining us for another conversation that does work hard to connect the dots between policy and rural everything, or as we say often, rural quality of life. Well, today we are back with another episode in our series we're calling Tracking Transformation, and by that I mean Rural Health Transformation, which is the $50 billion fund that was introduced last year in 2025, at the last minute, if you will, during the, H.R.1 debate.
And, with that said, I just wanna make sure that everyone here is aware of where I stand on this, because I do work in the rural health profession as it is for 38 plus years. There's a lot of talk about how exciting it is to have this infusion of investment into rural health, and I really am glad to see that.
At the same time, I'm also very aware of what H.R.1 has done to cut access to health coverage, and we are talking about double-digit millions of people losing their health coverage, and on top of that, their nutrition assistance benefits. So, I am really pleased to bring to the table today three voices.
Those two have been on our podcast before, both of them very much in the know, and they're going to be able to lay out for us kind of where they see rural health transformation today. We are recording on July 27th, and you're going to hear this a little bit later on July 30th. And we're gonna keep our eyes on this because, of course, it's important for us to understand where this is concerned, that states how they're using that money, how they're being held accountable to make sure that it reaches the places and the people where it is needed most.
So, with that said, it is my pleasure to just go ahead and kick us off and introduce to you our guest for today's podcast. That is Alan Morgan, and he is the CEO of the National Rural Health Association. Always very insightful, and I'm always so pleased when he can join us outside of my time when I'm in DC recording from their policy conference.
And then after we hear from Alan, and we take a quick break to hear from our partners at the National Association of Rural Health Clinics, you're going to hear from Jed Hanson. Jed is one of the most informed, passionate, dedicated rural health advocates I know, and Jed leads as the Executive Director, the Nebraska Rural Health Association.
So, you're going to hear some straight talk from Jed, and then after that, before we close off the show, I am really excited to kind of introduce to you a new little segment we're calling Voices of Impact. Just a quick 10 minutes that you're gonna hear from Kait Guild. Kait is the Assistant Director for Mobile Health MAP and the Family Van at Harvard Medical School.
And we're gonna put some links on our website, theruralimpact.com, to an article that I read of Kait’s that really wanted me to have the conversation with her because she is talking about mobile health, which is, as you will hear, a significant portion of the investments that are being made in rural into mobile health.
But she's got a different perspective because mobile health is not new. It's been around for a while, and she's got some words of wisdom for us to keep in mind when making investments in that particular modality where rural health is concerned. So, we have got a jam-packed tracking transformation show ahead of you.
And with that, I invite you to sit back and tune out that background noise because it will be there, of course, when our time together is through, and hear my conversation with Alan, Jed, and Kait. Are you ready? You know I always am, so let's go.
=====
Michelle Rathman: Hey, as promised, everyone, we are joined by a phone-a-friend, Alan Morgan, CEO of the National Rural Health Association. It's always so great to have you back. We're really appreciative of your time.
Alan Morgan: Oh, Michelle, it's so great to be back and joining my favorite podcaster once again to talk about my favorite topic, rural health.
Michelle Rathman: You know, and I'm glad it's your favorite topic because right now it's, it's a little hard not to hold your nose because, you know, I'm talking with so many, you know, people who listen to this podcast know I work with rural hospitals, and I had a conversation, yesterday with a CFO of a rural hospital in the state of Washington, and every state's kind of addressing RHTP differently.
Of course, we're recording this as a part of our Tracking Transformation series. And so the news is, you know, depending on the way you look at it, what states, some, some hospitals are getting some money, some are quite unsure if they're going to get any money. But I wanna start here because we're just a year into the enactment of H.R.1, and it included several changes that absolutely, directly impact rural health on many fronts, from healthcare coverage and financing, food assistance, which we know absolutely contributes to health outcomes, as well as provisions focused on higher education.
Who knew we would be having conversations about that as well? And of course, the $50 billion Rural Health Transformation Fund. So, as someone who's very much in the know, I wonder if you could just kinda give us a rundown, a report card if you will, kind of an A through F, who's what, what's getting an A, what's still maybe a C minus, or a D, the issues impacting members.
And, what is the member- your members are what now? 21,000 members nationwide. That's a lot of constituents that you all serve. So, what are you hearing? What's the word?
Alan Morgan: Yeah. Well, we have a lot to talk about as we always do, but itI love the analogy of giving a report card where we're at and it, it... Just keeping along that theme, I honestly, it's NHI, not handed in. I feel like, you know, when the student doesn't quite get all the work done, and that's where we're at.
I think everyone, I'll say I expected us to be much further along by this time. And, we're gonna cover all this, but we've got the pending Medicaid cuts. We've got theTransformation Fund, and then we've just got the normal challenges of healthcare right now. And when it comes to the Transformation Fund, the feds have done their job.
They've got the money out to the states. The states have given broad outlines of how they're gonna spend this, so we have a concept. But Michelle, only now are the states starting to put the RFPs out, so we can see exactly in detail what they're gonna spend on. And a lot of states haven't gotten to that point yet.
They all have to get to that point, by I think it's September. The money has to be obligated by then. So, this is a mad dash at this point. And I'm gonna ask your expertise on, on guiding me to getting the, the information we need to know right now, 'cause there's so much to talk about when it comes to Transformation Fund.
Michelle Rathman: It is the conversation I was having and the context was this: We think we're gonna get about a million dollars a year for five years, and then we kind of did the scales, and then I said, I asked, "Are you, like, you know, know your numbers?" Like we wanna know our numbers about our cholesterol and what, and whatnot.
Know your numbers. How many people in your service area will y- you project lose their coverage? So if you have a million dollars a year that we know, Alan, cannot be used for certain things, and I wonder if we could talk about that for a moment, because I still see things swirling around saying, yes, we can use it for, you know, facility, capital equipment, but you can't use it for this, that, and the other.
On the topic of RHTP, what do, what can you tell us about what you know, how the money, how... if it's making it to hospitals' hands, 'cause I know there's a lot of angry CEOs out there, hospital CEOs, because they're saying, "We're not going to see, we don't believe we're gonna see a dime of this." What are you hearing?
Alan Morgan: I hear that a lot from our members. So let me give you two examples of where we think this is going to go and one hard example where I've heard a CEO say it's showing up. In particular, I'm gonna pick out Tennessee and New York State. Tennessee has stated, they put in their grant application, they're going to be funding efforts to integrate and include behavioral health within the hospital walls.
So, they're going to be putting out RFPs to these rural hospitals of how they go forward with it. So that's great. It's a new service line, certainly addresses a huge need. Let's go up to New York. New York specifically said they're putting money in this to develop networks, ospital networks, to be able to connect up their rural hospitals, which is a huge transformation, one that needs to be done. I love that concept.
Those are two states in particular I'm gonna be following really closely, I think everyone should, to see how that actually transforms. To your point, talk of a rural hospital CEO from Kansas who said that he is receiving the money to deal with revenue cycle management. And in particular, for all your listeners out there, they're going to have technical assistance on how they can accurately report the health expenses to managed care firms to make sure that they're actually reimbursed for those services.
Now, I know you're thinking, "Well, what does that have to do with transformation?" Making sure that these hospitals are actually paid for meeting the needs of their community, and that they're set up both electronically and human, from a human capital perspective, to be able to do this, well, that is transformational for the hospitals.
And when it comes to looking at, you know, the top issues impacting rural hospital viability, that whole issue of how do you, how do you make sure the money comes back into your facility for the services given?
Michelle Rathman: Alan, this is a question I've been wanting to ask you, and whenever we can see each other in person, you're so busy. But I've been pondering this one. We're tracking transformation. We're looking at it state by state. No state is going to look the same. You know, we've seen, you've seen one rural hospital, you've seen one. If you could put your crystal ball out there five years from now, when this funding is a limited time, five years, will we see any continuity? Do you think we're gonna see any consistency across the board to say, "Hey, this was a best practice." You said Tennessee or New York. Are we gonna get to the point where people are gonna say, "Oh, we got this," and we'll be able to sustain it and continue?
I just wonder, you know, what's your, what's your opinion on that?
Alan Morgan: Yeah, that's the million-dollar question, and, it goes back to your opening statement. There's so many challenges right now. I keep repeating to myself the mantra that challenges, to rural health challenges drive innovation, and that's the way I can sleep at night. I don't know how you deal with it, but knowing that we're gonna have not just 50 different states, but multiple approaches at each state on dealing with this.
And to your point, it runs the gamut from food access to behavioral health to actually, ensuring that we have access to twenty-four/seven emergency room services. A huge focus on EMS in multiple states on this. So I no matter what, we are going to see the best practice come out of this. I'm encouraged that we're gonna have new best practices and ones that can then be replicated and implemented.
You know this. You're at all of our annual conferences. That's all we do: we share best practices at these conferences. I have to believe it's gonna be a little bit different with the federal government invested in these new models and new deliveries, that once they see them, they will be able to lock down and continue funding for these success stories as we move forward.
Michelle Rathman: Yes. I hope so too. I mean, I do sleep at night, you know, knowing that there are really dedicated people on the ground in every single state wanting so much, and their mission is to transform rural healthcare in their own communities. So, at the same time we've got this going on, of course, we, on this podcast, we connect the dots.
Let's talk about another, you know, kind of on one hand we got RHTP, but on the other hand, NRHA sent out a letter to CMS on July 21st that was focused on the Medicaid program, Medicaid Managed Care state-directed payments, and Medicaid fee for service targeted, all that good stuff. Break that down for us, 'cause I actually don't believe that most of us, I mean, I say I don't need to know what goes under the hood of my car, I just know how to put, you know, press the start key and drive it.
But this is a big one, andI thought it would be good for us to cover that today as well.
Alan Morgan: Oh, I can't thank you enough. Thank you, Michelle, for lifting this up and actually reading our comments. I really appreciate that too.
Michelle Rathman: Oh, yes.
Alan Morgan: We have been in it, as you know, this has been such a heavy lift this year with the regulatory changes coming through, most notably in Medicaid. Wow, that particular comment letter, and I would say for your listeners, you can go to our website.
I always do the easy, go on the website, policy, and then I do media, and then that's an easy way.
Michelle Rathman: We're gonna link it right on our resource page, and they'll go right to your website.
Alan Morgan: This particular comment letter, amazing job by our regulatory staff. Nine pages, nine pages of comment. There are more than 15 recommendations to the feds on this particular regulatory issue.
I'm gonna simplify this as much as I possibly can on this. This proposed regulation on how hospitals and clinics are gonna be paid for Medicaid, is exactly the type of regulation that, in the first Trump Administration, they would be eliminating because it's just nonsense. How's that for non-technical?
They overcomplicate the process by which clinicians will be paid for Medicaid going forward. Now, from a political standpoint, it's a win for them because they can say, "We're tightening up this system,” but there is a policy outcome that they are going to really reduce the Medicaid payments.
It makes it just unworkable, moving forward. It just, it can't go forward because normally CMS says, "Okay, here's what we're gonna pay for these services,” whether it's through, usually through PPS. This actually takes a retrospective look looking at the cost reports of hospitals, by some still unclear mechanism.
All of our comments boil down to this is not workable, it can't go forward, and you're going to adversely impact the health of rural communities.
Michelle Rathman: Do you have any anticipation about what the outcome might be from the outpouring of information going into CMS? Any, indication what, how they might decide?
Alan Morgan: I would love to be in those meetings because I honestly feel, and people may disagree, but I honestly feel that leadership in CMS feverantly cares about rural health and access in rural hospitals. I really do. They do care about that. But there is this other political issue where they just want to make sure that tthey're clamping down and removing Medicaid as much as they can.
And those two issues, as they play out, which one ultimately is going to win? Are they gonna keep rural hospitals and clinics open, or are they gonna succeed in just really, crashing the Medicaid program?
Michelle Rathman: Yeah. And then you wonder, you know, the, the $50 billion investment, you know, it's like let's make some logical sense here if we can out of it. And, you know, another issue around Medicaid is, you know, we're following, and Joan Alker is from the Georgetown Center for, University Center for Children and Families.
We've been following their work, sitting on their press calls as well, talking a lot about Medicaid work requirements, and later in this episode, we are gonna hear from someone I know that you know very well from Nebraska, and they were the first state to implement Medicaid work requirements. I'm really eager to hear how that's going, and that was way ahead of when it was prescribed by H.R.1.
What are you hearing about work requirements and how they are impacting rural hospitals and clinics? My folks are telling me that they are trying to find ways to acquire funding to hire, excuse me, navigators because they're so concerned about people b- dropping off. I mean, whether it's ACA plans or whether, you know, work requirements or what have you.
Are you hearing that that's putting a strain at this juncture, at this time already on, on rural health organizations?
Alan Morgan: The easy answer is yes. Yes, yes, yes. We've already heard it, and it's going to continue. And I get it. In the United States, we love great quality healthcare. We just want someone else to pay for it. And in this particular issue, the government is trying to ensure that it is not paying for it.
And, people still need healthcare. If they don't have healthcare, they're gonna, as we've talked multiple times, they're going to delay care until they end up in the emergency room. It's still not gonna be paid for by the government, and rural hospital clinicians and hospitals are stuck paying the bill, and that bad debt is driving hospital closures.
We've had two already this year, one up in Michigan and one in, I believe, Pennsylvania. Yep, I believe.
Michelle Rathman: Yes. Yep.
Alan Morgan: And the Michigan one, Sturgis, that was a rural emergency hospital. That's supposed to be the safety valve to keep healthcare local, and that's the first of my knowledge of a rural emergency hospital that's closed.
Michelle Rathman: And you know what? I think it's important for folks to know when we're talking in this context, you know, people ask, "Well, what about employer-based insurance?" And as we know, in rural places, you know, not just blanket rural America, in so many rural places, there are no employers who can provide insurance for their employees, and therefore they signed up for the ACA, Medicaid plans, and then here we go down this path.
Alan Morgan: Oh, 100%. Mom-and-pop Lee's Flower Shop is not gonna provide, you know, a comprehensive health insurance for its four or five employees. So, it-- that is the nature of it, and this is so, I can't stress how this is going to fall on the burden of our nation's farmers and ranchers in particular.
Michelle Rathman: Yes, and the finances for the hospitals as we know it is going to change exponentially if they are only caring for people in their emergency room and they leave without, you know... I mean, it's the, it, we call it charity care or bad debt, call it what you want, but still, it, some, it has to be paid for somewhere.
All right, before I let you go, there's gotta be some policy lifts. So, in the spirit of transformation, what are some of the things that NRHA is looking at right now, you know, that have gone well? Policy decisions that have, really helped lift rural?
Alan Morgan: Yeah. Let me, let me pick two. I could go all day, but let me pick two that I'm really happy about, and one is the announcement that just came out, the Federal Office of Rural Health Policy. They have just established, believe it or not, a new grant program that's intended to promote rural health networks, something we hear about within the Transformation Fund, but this is new grant money that's going to, hopefully, bring new hospital networks into the mix.
So incredibly important with this expansion, rapidly expanding, managed care that we're seeing, number one. So, I'm excited. There's something tangible. It's a policy move that's happening now. So that's good, number one. Number two, I'm gonna go back to the workforce, and I just am so encouraged about the support and the growth of rural residency training programs and that concept of let's get rural kids, let's put them with their peers in a training program, let's have them do their residency in rural, and let's place them in rural.
And the success of that program is unmatched. And, so I think there are definitely policy success stories we can hang our hat on and say, "You know, our movement has really made a difference, and this is going to help as we move forward."
Michelle Rathman: Yes, and I applaud, I really mean it, the work that you all did into recognizing how important it was to keep those professional degrees.
Alan Morgan: Yes
Michelle Rathman: And I really think that you, you all went to bat, you... And I appreciate that you did that. Could you just talk about that for a moment?
Alan Morgan: Yeah, absolutely. So we actually joined a lawsuit against the administration on professional degrees for nursing in particular. And, this is the first time that I believe we've done this since before I was on NRHA. Normally, we defer to other organizations to sue the federal government, but this is one that we felt just so strongly about.
We've heard so much, and you know, you've been in the meetings where you've heard the potential impact of, putting additional barriers up to getting, in many cases, our rural students, into these programs so they can come back into our communities. And by declaring many professionals now as, quote-unquote, "non-professional," it's just a huge barrier as we move forward.
Michelle Rathman: Yeah. Well, I really, it was the first time I had seen that you guys join a lawsuit, so I just, again, applaud that. Because sometimes we say courage is calling, and we hope that somebody answers. Okay, Alan, as usual, I am so thankful for you joining us. ou are the enlightening all the time on subjects that are not very light, and so we thank you, and I hope that we can call you back as we continue to track this transformation.
We'll see where this goes next year at the same time.
Alan Morgan: That's wonderful. Michelle, thanks again. I appreciate your voice when it comes to rural health
Michelle Rathman: It is my pleasure. All right, you guys, stick around. This dot connecting conversation is not over, but first we're gonna hear from our partners at the National Association of Rural Health Clinics. We'll be right back.
=====
Michelle Rathman: As promised, we are back from our break. With that, we have a new voice, a new face, a new influence at the table, and we, as we continue this conversation about tracking transformation. So, I am so pleased to welcome back to the podcast Jed Hanson, Executive Ddirector of the Nebraska Rural Health Association, although he has a national voice, and one of the most active rural health advocates I know.
Jed, welcome back to The Rural Impact. We are so pleased you could join us.
Jed Hansen: It's wonderful to be back, Michelle. Thanks for the invite
Michelle Rathman: Okay. I know you wear a lot of hats and on a lot of fronts. Again, you're so busy, but a few weeks ago, I followed you, as many do on LinkedIn, you write so many insightful things on the subjects that are not so light, to be sure. And a few weeks ago, you wrote these words, if I may just reflect them to you.
"The Nebraska Rural Health Association was founded on the belief that where you live should never determine the quality of healthcare you receive. 35 years later, we remain rooted to that mission. Yet as rural healthcare continues to transform, so must we. That means strengthening partnerships, embracing innovative technology, supporting local workforces, and advocating for smart policies, protecting essential services across the greater Nebraska."
You know, Jed, before we started, I mentioned to you that I spoke with someone you know very well, Alan Morgan, CEO of the, of the National Rural Health Association, and we talked about H.R.1. We're in the middle of our Tracking Transformation series. And with that, we kind of looked at RHTP using the analogy of a report card, and we did that from the big capital P policy perspective, if you will.
And while I know you do focus on federal policy, 'cause it definitely impacts what's happening there in Nebraska, as someone working on the front lines and on so many issues facing rural health providers, I'd like to get your perspective, have our listeners get your perspective on where health delivery systems are considering the crisis that has already been in Nebraska for a while.
Where are we a year later? What are you seeing, good, bad, ugly, and different?
Jed Hansen: Yeah. Really pertinent and, pertinent and, and timely question, Michelle, and appreciate it. You know, and RHTP, you know, if we're gonna use the report card, I think, I always try to find that silver lining in it, and I think that there are some, some initiatives and, and some, pieces of RHTP that, do deserve some, some praise. More than anything, RHTP has brought rural and the rural voice forward. And we're talking about rural, rural healthcare, rural healthcare delivery in a way and in a space that we really never have, at, at least in my professional history.
And so, the, the attention that we're getting in rural right now is, is phenomenal. And, you know, I guess if it's gonna be there, no press is bad press, that type of thing, I think with RHTP we can, we can definitely say that.
The other area, and this one may be a little bit more, more nuanced, but I also think that RHTP has given many of our healthcare professionals across the country permission to be more innovative.
I think that they're looking for solutions. They're wanting to find pathways forward in a way, and through conversations that I also haven't seen, in my time at the association before. And so the conversations are happening, and people are looking for solutions.
So that's where we're gonna, I don't know if we're talking elementary, report cards, and we'll give it a satisfactory, or if we're gonna go, go all out and give that, give those an A. You know, the challenges.
You know, the, an RHTP was floated, just over a year ago through H.R.1 and the One Big Beautiful Bill Act as a way to provide some funding as a transition for hospitals. It was going to be, you know, a hospital fund for hospitals where, you know, we're removing $1.1 trillion in Medicaid, and we're gonna give you this $50 billion, bridge fund, so that you can right-size the ship, on the hospital side.
Whether hospitals should have been the sole component of that conversation or not, they were. And I think in large part they were because that's where those headlines have been over the last fifteen years. We've seen those hospital closures across, across rural healthcare. A year later, I think when we look from state to state, very few of those dollars are going towards hospitals. And, my concern with all of this is that we're, at least in Nebraska, we are seeing the strains in the system already, and the out-the outcome of those strains in the system.
We've seen some high-level hospitals or some hospitals with some, really highly visible service lines, like dialysis and like hospice and home healthcare, that are where those hospitals have decided to close those, those service lines. We've seen some redesignation on trauma centers in our state already this year, and, we're looking at the financing for many of our hospitals, including our two rural emergency hospitals. And there a lot of concern, and that's where we're, that's where we're at now, understanding that we're going to have some significant change to Medicaid funding over the next ten years.
It's going to, to begin, really over the next two to three years with that phase in and, and earlier, as we're looking at changes to Medicaid enrollment. And so my concern in all of this is that if RHTP dollars aren't targeted in a very, very thoughtful way, to the tune of we have to be able to have every RHTP dollar needs to be able to counteract, you know, or it needs to find an eight to ten-fold, impact increase, downstream, that what we're going to be left with five years from now is something that's, that's in a much worse place than we are today.
And, gosh, all that work we've been fighting for, you know, over the last decade, last fifteen years, is just we're, we're gonna, we're gonna see tumbleweeds, and that's where my real concern is at.
Michelle Rathman: You know, one of the things I talked with Alan about was the fact that, you know, transformation, and I write about transformation all the time, and I think about transformation over a period of time, and transformation looks... It's, you know, there are small incremental steps, but at the end you should be able to see something really big, hence transformational, something very different than what.
And because every state is doing it differently, every state, well, you're gonna talk about your state in just a moment, it has different priorities. I will share with our listeners, I mean, it is, there's not a day that goes by, and I'm sure your inbox is full of them too, where I don't get an email from someone that does revenue cycle or technology that says, "Hey, we share the same passion. Can you tell me how a company like ours could get in the game?"
And I delete immediately, for those of you who are listening, I don't have any, I have no advice for you because at the end of the day, it is very much, it has been described as the Hunger Games of trying to get ahold of a piece of this money.
But Nebraska's RHTP, like everybody else, as I said, has something different. What I'm reading is that Nebraska, you guys over the five years, got about $218.5, million in the first year, and it's looking at things like food is medicine, which I think is great, school kitchen modernization, regionalized rural access to navigation, kind of abstract for people what they don't really understand what that means, rural workforce acceleration, chronic disease management navigation, behavioral health.
Those are some really big chunks of where that will be spent. What are you hearing? What are you seeing in terms of how this will finally get to a place where communities in your state, and you are in large part pretty much as rural as it c- gets really, where do you see this happening in you know, what, in that first year into five years?
You know, what are some of the practical conversations you're having to, to see implementation?
Jed Hansen: Yeah. You know, what's fascinating about, you know, both Nebraska's application and as you look out ac- across the country, it shows you just how great the need is, right? You know, when we, when we talk food is medicine, transportation, EMS, maternal care, mental health, workforce development, workforce retention, it...
There isn't a bad, I guess, application line really across the country. There are all- there's a need across the board, and all of these ideas deserve their time in the sun.
With RHTP, I'm gonna go back to we're going to have to find what, what, what we need to be able to do is find those programs that can generate a 10 times plus improvement in, in health outcomes in, in health finance over the next five years, and that's where I think a lot of these programs are really going to struggle. You know, things like, like Food is Medicine, School Kitchen Modernization, I love the idea of that. Is a five-year runway for a program like that enough to net a difference?
Michelle Rathman: It needs perpetual funding after it's stand up,
Jed Hansen: Right. And, and so sustainability of that funding, and when we look at funding in those, in those areas, absolutely, right? Food security, healthy foods on, on tables and on
plates and in...
Michelle Rathman: food
Jed Hansen: vitally important.
Was RHTP, does-- was it allocated out for those funds?
And, will those programs and those dollars make the difference five years from now? And, I don't know. I don't know. And unfortunately, I'm skeptical.
The areas that we have been advocating for, really from the onset, have been in, in a couple of different buckets. Workforce. We don't have healthcare if you don't have a workforce. And we know that there-- we have an aging population, we have an aging workforce. And in healthcare, more so than most other professions, the lead time to get that highly skilled professional is significant.
And so every dollar that we invest now can, be that dollar of where we see a return a decade from now. Technology. You also can't have healthcare without technology, and so looking at technology modernization, this was one where, in our state, we really advocated to take that at the community level. Our communities and our community hospitals, our clinicians, our community healthcare professionals, they know better than I do when I'm looking at the state level, and certainly better than what the state can do or at the federal level. They're, they're able to know what technology is needed in their community now and what technology will net in the future.
I think there have been some challenges, in how our application was written as well as many other states, and being able to appropriately allocate those dollars out and make sure that from a technology standpoint, that those dollars are going in, in, in the most impactful way at the community level, and provide that level of flexibility from community to community. Where one community may need remote patient monitoring technology, another one may need a, you know, may need a, a mobile imaging. They may need an MRI, you know, truck. Another community may need something completely different. Maybe, it is EHR modernization. And so that was an area that we advocated for. We think our... that the state was looking, you know, I think that there was good intent, in that for, for Nebraska as well as other states, but I think challenges exist there. And then at the, at the, with, along with workforce and along with technology, really looking at, you know, shoring up those essential services.
We can't get so far out ahead of ourselves that, that we're forgetting that we have a significant need today. And so, what are those areas for maternal care, mental health, for, you know, pediatric, you know, care, for, for geriatric care, where we need to make sure that, that not 10 years from now we're looking at, at where our communities are gonna be at, but where's that need today?
And, that's an area that I think, there's an area for improvement, really from the applications that I've seen across the country. And so that's what it comes down. Those three buckets, and if RHTP can be thoughtfully deployed in those three areas, I think we could see a lot of wins. Do I think that that's what's gonna happen? I don't know.
Michelle Rathman: And at the same time, we have to keep our eye on the other conditions that are really, as I say, muddying the water. But before we move on real quick on the technology piece, what I'm hearing from others about the fact that technology, yes, we need it. What we don't need are a bunch of fragmented systems.
What we don't need are for hospitals and clinics to have to take on the weight of hundreds of different new licenses that require all sorts of maintenance and technical support, and so forth down the road. Because again, if it, if, if it can't be adaptable, accessible, sustainable, why make the investment?
It's a question that comes up in my circles quite often. I'm sure you've heard it too.
Jed Hansen: Yeah, and, you know, technology is one of the... It's ever-changing. And so we wanna be really careful with RHTP dollars that we're not investing too much in, in that hardwired technology that is going to be out of date three, five years from now when we're not going to have RHTP dollars. We need to be able to create those ecosystems that allow for rural communities to be able to invest in a way that, that allows them to, to bring that technology for tomorrow, tomorrow, and not just, and not just looking at, at that patchwork that you're that, yeah. I think that we're seeing a lot of today
Michelle Rathman: If we only looked at its infrastructure, I mean,I really have been thinking about this a lot. If we could see it as health, rural health infrastructure that could be deployed, you know, because I know we've seen one rural community, we've seen one, but the health needs, if we are able to put buckets into older, sicker, poorer, chronic disease and so forth, we ought to be able to come up with something that can be sustained across, but that's another whole story.
All right, I wanna move on with you a little bit because it is, again, as we do here, connecting the dots. I would like to just talk a little bit about the shift in work requirements, because Nebraska was the first state that has been out of the gate, to press the lever, if you will, on work requirements.
And I wonder what it, you have been seeing with your constituents, the members of your organization, how have they prepared? What are they doing to help prepare patients to help navigate? I mean, I was telling Alan yesterday, we're talking to hospital CFOs saying like, "We gotta hire another full-time position just to have a navigator to make sure that people understand," because it's not that easy, especially when states have had to, your state even before they had the, their infrastructure in place, just pressed go, and it almost felt like we'll just see where the chips land where they may.
Jed Hansen: Yeah, Nebraska was the first state in the country on, on May first to implement H.R.1 workforce requirements.
I guess the fortunate thing is we're probably still a little bit too early to see what the true impact of that is going to be. Now, the concerns are certainly there. You know, that one, we're going to see a, a drop-off in, in coverage for individuals that would otherwise qualify, that they may not, be able to effectively navigate, you know, those workforce requirements along with kinda that, that biannual, just enrollment or, re-verification, redetermination, excuse me.
So, there's that challenge, and then, you know, there's also that waterfall effect that takes place. So, if they are no longer-- if-- so we're going to... we know. We know that we are going to, that individuals that have coverage today are not going to have coverage six runs-- six months and a year from now.
That’s, that's a fact. w- we know that we're going to have individuals who could and should retain coverage that are, but are not going to have that. So what happens? Well, those individuals still have healthcare needs, and they're still ultimately going to, to present to a clinic or a hospital, except now it's going to be, in a, in, you know, maybe a, a man- instead of being in a manageable chronic state or an early acute state, it’s, it's gonna be a crisis.
And cris-healthcare crises in healthcare are expensive. And if they don't have coverage and aren't eligible for coverage, now all of a sudden we're-- we've created additional financial burden for that patient and their family, and we've created additional healthcare financial burden for that clinic and that hospital. So that's the reality of what we're looking at.
What are we doing? Well, one, we're continuing to have conversations with our, with our hospital leaders. You know, we're trying to, to look at what are going to be best practices in this, and making sure that they are prepared to understand where their populations are going to be. We're also exploring some really innovative, technologies, utilizing AI, and we're considering a statewide rollout of an AI-enabled technology that would allow, hospitals, clinics, and importantly, patients, to be able to track and help with an automated approach towards, towards Medicaid enrollment, where we could deploy some, some AI agentic technology, to help those individuals through that process and help them understand when they need to go through redetermination and what may be a qualifier and what may not be.
So that's where we're at. We've been having some ongoing conversations, looking at some different, technology groups to be able to, to look at, at that type of a, of a solution. 'Cause it, we think at this point, unfortunately, maybe fortunately, I don't know, but, we're going to have to look for private market solutions to, to help us through this, through some of these, Medicaid issues.
Michelle Rathman: Yeah. And on, on that same note, I mean, as I take a look at this, I was on the Georgetown University Center for Children and Families call about the new federal Medicaid work reporting requirement rules. It says, "Rule threatens coverage for vulnerable Americans," an explainer of the interim final rule.
And, and in that, of course, we've also been hearing about, people in positions of clinical decision-making having to make that determination and now putting a, not just a financial burden, but then there's this ethical, I would imagine, like, you know, writing an excuse saying, "This person does qualify, this doesn't, person doesn't qualify," what have you.
Jed Hansen: Right. Medical hardship is one of those areas that, that can qualify an individual and, you know, hospitalization would be a pretty easy determination for that qualification. Along with, you know, looking at some other, you know, chronic diseases and looking at disease burden. And yeah, that creates, it's an area where you wish politics could stay out of the
Michelle Rathman: of the exam room,
Jed Hansen: Out of the exam room, and we need to make sure that what, we're ultimately doing is in the best interest of the, of the patient. But yeah, you don't want to get medical providers into that space where they're having to, to try to navigate, you know, the health and wellness of that individual.
We already have to do that.
Michelle Rathman: Be a part of litigation that challenges that. Jed, before we go, I know this is a subject that's so near and dear to your heart, and `we cannot have this conversation about rural health transformation if we do not include our nation's veterans. You know, we are recording this on the 24th of July.
I would be remiss if I didn't say, listen, we're gonna have a new group of veterans coming back, at some point, hopefully safe. But we have to make sure that we care for our veterans who disproportionately live in rural America, where so many of our veterans come from. Tell us a little bit about your advocacy work, where this is concerned, to make sure that they are not left behind, that they receive what they need without fear or favor.
Jed Hansen: Yes. Yeah, and thank you for this question. Yes, our veteran work is, is truly, truly near and dear to me and something that very passionate about. Yeah, this is an area where some of our early advocacy efforts, our current advocacy work, and then RHTP have aligned. And what we've been, strongly advocating for is the digitization of the VA’s, scheduling grid and, really looking for ways to modernize and automate that so that we can look at, care coverage both within the VA and then out in the community.
So, one of our initiatives in Nebraska, through RHTP, that our association is leading is working on the modernization of the external provider scheduling grid for the VA. And, by the end of the RHTP program, Nebraska's Rural Healthcare grid should effectively be connected with the VA, meaning that a veteran anywhere in the state, when they call into the VA, will be able to receive care anywhere that they choose in the state. And so, this is an area where we think that there's a smart deployment of a digital technology where an investment in the digital side can net a greater good than in the physical space. Instead of looking to build, you know, five or ten or however many new, VA buildings, well, we already have really good healthcare and really good infrastructure, across our state and across this country. So we're looking to, kind of be the leader on, on this one and really get out and show other states how they can effectively deploy this technology so that hopefully wherever a veteran is in this country, when they have a medical need, they can, they can, they can get that care, where it makes most sense for them.
Just doesn't make sense to have a veteran having to, to travel, you know, you know, two hours, three hours for a qualifying C&P exam in the same way that it doesn't make sense for them to, to travel two or three hours in the middle of the winter for an audiology appointment.
Definitely neither one of those makes sense when they could receive care, you know, within, within their own community or within a five or ten-minute drive.
So that's...You know, there's been a lot of really good work, our own, Senator, Deb Fisher has been, has been really leading in this space. And then on the House side, it's been, you know, really wonderful working with representatives of the VA, Technology Subcommittee. I had some... had a chance to go up to Central Michigan a couple of weeks ago, and testify up there.
And so there's a lot of really good work being done. And this is an area that I also think the VA administration should really be applauded for. I think that they're looking at all of the solutions that are out there to really improve access to care.
And, you know, hats off to Secretary Collins and his team on, on really looking at really keeping every door open, in how to explore and improve, veteran healthcare.
Michelle Rathman: Yeah, and I hope this, I, if you ask me, Jed, this is what would be a true testament to transformation because as long as I've been in this space, that was just ludicrous to me that a veteran could live in a community with an amazing critical access hospital or rural health clinic or FQHC and still not be able to go there because of, say it with me everyone, policy.
And so, if we could change this and some of those payment models, then we've done our job. I think that's a good way to, to close as a lift up because that is such important work, and we wanna make sure that we hear back from you when you see progress happen anywhere. You're welcome back anytime.
Jed Hansen: Well, II sure appreciate that, and I'm looking forward to it, I'm confident that in particular with this veteran initiative, that we're going to be able to report some positive results back here, very soon.
Michelle Rathman: Yeah. We, we need some good news to be sure. Oh my goodness. Well, Jed, thank you so much again for your time. We're so appreciative.
Jed Hansen: Absolutely. Thanks again for the invite, Michelle
Michelle Rathman: Thank you. All right, so you guys, I know we have to say goodbye to Jed, but I want you to stay with us because before we close out today's show, you are gonna hear just a little bit of my conversation, which is what we're gonna call voices who are making an impact in this RHTP space right now.
Next, you're gonna hear just a little bit of my conversation with Kait Guild, Assistant Director of the Family Van and Mobile Health MAP at Harvard Medical School, and we're gonna talk about how, why mobile health must be factored into this important conversation, including research on how mobile clinics expand access to preventative services, improve chronic disease management, reduce avoidable emergency department use, all things that we know are truly essential, truly essential for lasting transformation.
So, stay with us. Here's my conversation with Kait.
=====
Michelle Rathman: Kait, why is mobile health critically important to improving access and outcomes in rural and remote places across the US? We should know this answer, but you know it better.
Kait Guild: Yeah. So rural and remote communities face particularly complex and intersecting barriers to care, especially considering long distances to healthcare entities, limited public transportation, workforce shortages, and rural hospital closures. And it can make it incredibly challenging for folks to access care, often leading individuals to delay care until it becomes an emergency or forego care completely.
Mobile healthcare brings healthcare services directly to these communities, overcoming a lot of those logistical barriers. It brings care to trusted spaces where people live, gather, and work. But in addition to bringing care to folks, mobile healthcare also helps build trust. A lot of programs are co-created with the community, have partnerships with community leaders, and through doing this, mobile clinics are able to engage folks who may be disconnected or disenfranchised from the healthcare system, bringing them back into the healthcare system.
And when we're thinking through H.R.1 and shifts to Medicaid, mobile healthcare is particularly important for rural and remote communities. We anticipate that many individuals will lose access to healthcare coverage or insurance coverage. We also anticipate that additional requirements for reporting will create new barriers for folks.
And mobile clinics employ professionals like community health workers and patient navigators. And by bringing these folks directly into the community, not only are mobile clinics able to identify folks who might lose coverage and provide free, low-cost care to these individuals, but mobile clinics can also educate and support folks in recertification and navigating those new administrative processes that are required.
It’s crucial I make it clear that mobile healthcare cannot undo or replace Medicaid cuts. However, it can help ensure that lost coverage doesn't mean becoming completely disconnected from the healthcare system, which is incredibly important for
Michelle Rathman: It, it is. And when you say losing healthcare coverage, I mean, really, that is spot on because without insurance in this country, you know, it doesn't really exist unless you have millions of dollars and you can pay by cash. One of the things I really appreciate about learning about your work, is that it is very strategically aligned.
I am a strategist by trade. So, let's talk for a few moments about what the Mobile Health Map. What is the Mobile Health Map and what its purpose is. Because it is strategic
Kait Guild: Yes. So, Mobile Health Map is a national program of Harvard Medical School. We work to support, sustain, and strengthen the mobile healthcare sector. Our work is grounded in the local direct service of our sister program, the Family Van, which has been around for 34 years, providing care in Boston.
And this grounding really enables us to provide technical assistance, capacity building assistance to, and free tools to mobile clinics across the country. We particularly focus on measuring, evaluating, and helping clinics share their outcomes and economic impact with stakeholders. And then on a national scale, we engage in research and maintain a mobile clinic registry, and an impact tracker through which we measure, evaluate, and communicate the sector's impact, reach, and value.
Our goal is not simply to count mobile clinics. As you said, we really bring strategy into this work. We aim to help the field demonstrate its value, learn from one another, and build mobile healthcare into the broader health system in a sustainable way. That sustainability really is key. We work closely with health systems, states, funders, and policymakers to help them think strategically about mobile health expansion and how to integrate mobile healthcare sustainably.
It's an exciting time. We are experiencing a shift in how we approach research and evaluation in the sector. We're no longer simply making the case for mobile. We know it works. We know decision-makers are starting to understand the value of mobile healthcare and the potential impact. We estimate that there are roughly 3,600 mobile clinics nationally providing over 10 million visits annually.
We also know that 48 states included mobile health in some capacity in their Rural Health Transformation Plans. Our goal now is to ensure that mobile health is implemented with sustainability in mind, so new programs and existing programs can continue to provide care in the community long-term and sustainably.
So, this is really where our interest and engagement in research around policy and sustainability is coming from.
Michelle Rathman: Yeah. You know, I appreciate that you brought up that states have got this in their plans. I'm reviewing a lot of state plans, and we're having conversations with state influencers who are part of their RHT programs. But alas, there are some missing pieces, if you will. We're all about connecting dots on this podcast.
What are states missing, as you see it, in their implementation plans? Because there are a few holes, if you will
Kait Guild: Absolutely. It's an incredible opportunity, but as you said, there are some holes, and I think that connective tissue between purchasing a mobile unit and actually delivering sustainable long-term care in the community is what's missing. I think three pieces of the puzzle are missing.
You know, oftentimes we're seeing through RHTP states wanting to immediately look to expansion through the deployment and purchase of new units. Now, expansion is part of this solution; we know that, to reach communities that aren't, aren't being reached. However, many programs-- many states across the country have really robust, vibrant mobile health ecosystems.
These programs have trusted relationships. They have established routes and partnerships in the community, but those programs may be underfunded or poorly connected to the rest of the healthcare system. They will be impacted by the shifts in Medicaid. And so, if we don't think through how to sustain the existing programs, we're gonna lose care. Folks are gonna lose care that they are already accessing care through mobile health.
So, I think that piece of acknowledging and understanding the existing challenges of mobile clinics is missing. And then again, purchasing a vehicle is not necessarily the same as building a mobile health program.
States need to think critically about those programs and how programs will get buy-in. If the community doesn't understand, want, need, or trust the mobile program, there's nothing to sustain, right? So, thinking about how community plays in the implementation and development of new mobile programs really is key, and I think that community piece is missing from a lot of state proposals and plans.
And then finally, the question everyone has: the logistics. In many state plans, again, we see funding for new units, but we don't see a lot of conversation around how it will be maintained operationally. So, who will operate the unit? Who's gonna drive it, right? Who's gonna staff it? Where will it go?
How will patients be referred to and from the clinic? What does that data sharing look like? Because it needs to be integrated into the healthcare system. And then one of the trickiest, yet most important questions really is: how will the program be financed and funded long term after those-- that initial investment?
So, you know, I strongly believe that we need to stabilize and expand what already exists. And, states need to include funding for the development of implementation plans that really account for the importance of community engagement and sustainability planning, and I think that's missing from most states' proposals.
Michelle Rathman: I would agree. I've read a few, and I would agree with you because it's like, "Yay, units," you know, "Hit the road." But it's not, it's not like you know, we, we talked earlier about, you get a unit, and now all of a sudden we have a lot of expensive, mobile units sitting in garages somewhere and not being utilized, and that would be the least of what we want.
All right, so before we let you go, as we always do, we always wanna look at the policy perspectives. You write about the policy change that would matter the most when it comes to mobile health and the RHT program. So what is that?
Kait Guild: If I could recommend one policy change, it would be to stop thinking, this is a big one, but to stop thinking about mobile healthcare as temporary grant-funded gap fillers and really treat it as essential healthcare infrastructure. We've spent decades demonstrating the value of mobile health. We know it works.
The question is no longer whether we should invest in mobile healthcare. The question is how can we invest in mobile healthcare in a way that is gonna sustain those services and community five, 10 years down the line? So, I believe that every rural health transformation, investment in mobile health, should include funding for development of a long-term sustainability plan, covering things like reimbursement, workforce, referral pathways, data integration, and financing beyond the initial grant period.
And from a reimbursement perspective, we need policies ideally both at the federal and state level that support care delivered through mobile clinics. We need reimbursement policies that recognize and support the high-quality care that these clinics are providing while also addressing the unique operational care coordination and outreach costs that make these programs successful, like the coverage of community health worker services, for example.
You know, quickly connecting it back to H.R.1, as rural communities experience changes in Medicaid coverage and continued strain on local healthcare resources, it's even more important than ever that we don't build mobile clinics that disappear when the grant ends, and you mentioned that that's already a challenge we're facing.
Rural communities really need and deserve lasting access that they can trust and count on, not temporary access that will disappear after the grant term.
Michelle Rathman: And I would say along with that, a stipend for education, because again, to your point, we need, we need the medical community to embrace it. We need the counties, the cities, the communities to embrace it and not just seen as something that's specifically for the under, in quote, underserved or under-resourced, because this could be a game changer for everybody who accesses healthcare.
Oh my gosh. Kait Guild, I have to tell you, I'm so glad that we found you. I'm gonna make sure that we put your links to the papers that you wrote, a link to your map, and all the great work that you guys are doing there. And, for the rest of you, I just wanna say, make sure that you check out Kait's work.
Where can people find you if they wanna follow you, real quick?
Kait Guild: They can find me on LinkedIn, Kait Guild on LinkedIn. I love cold outreach. I love to connect, so please reach out.
Michelle Rathman: Absolutely. Thank you so much. And for your voice, your voice of impact, you are making a rural health difference. And we also wanna make sure that we thank Alan Morgan for joining us for this episode. Always great to hear from him, and Jed Hansen, of course, a champion for rural health to be sure. We are always grateful for their candidness and the context that they bring to these ongoing tracking transformation conversations.
A few more closing thank you notes. First, I just wanna make sure that we thank our partners at the National Association of Rural Health Clinics. Check out their website at NARHC, that's N-A-R-H-C, dot org, to learn how you can join them at their fall institute in Louisville. And in a few short months from now, you're going to be able to do that.
We also wanna make sure that we thank Sarah Garvin and Brea Corsaro, whose support makes everything we're doing here possible. Thank you to you as well. And don't forget to follow us on social at LinkedIn, Blue Sky, Facebook, and of course, anywhere you can find us on social. We are so happy that you do. And please be sure to visit theruralimpact.com.
That's where you're gonna find our resource page, where you're gonna see Kait's work, and so many others of those conversations we had today. And when you do, you can also stop by our merch store, where you can also help us support these conversations and, you know, do it in style with a water bottle in your hand, a baseball cap on your thinker, or a reusable Shop Rural swag bag.
But, you know, as I said, you're helping to make a small and generous contribution to help us continue these dot-connecting conversations. Until the next time we are together, you know I'm gonna say it, please take the best possible care of yourself, and to the best of your ability, all those around you.
We'll see you in a brand-new episode coming at you soon on The Rural Impact.
