By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“On National Rural Health Day, we recommit to investing in rural communities and delivering affordable, quality health care so that generations of rural Americans can thrive.”

– Joe Biden
President of the United States of America

November 15 was National Rural Health Day, a time to reflect how health policy affects rural communities.

Much of the legislation and policy in California is written with an urban or suburban point of view. This is not surprising, as nearly 95% of all Californians live in an urban or suburban setting – this includes those who develop the regulations in various state departments.

From a health policy perspective, the Enhanced Care Management (ECM) program is a current example of an urban focus that creates challenges for rural communities. The Department of Health Care Services (DHCS) is directing Medi-Cal Health Plans to contract with non-traditional Medi-Cal providers and organizations for ECM Services, directing plans to contract with community- based organizations (CBOs). In urban communities, with hundreds or thousands of CBOs, this represents an attempt to direct resources to organizations who are working directly with communities in nimble ways, getting at the underlying social drivers of health status – this work is often more challenging for mega-Primary Care Physician (PCP) sites.

In rural areas, Health Centers are smaller and more deeply connected with the special needs of their communities, and sometimes, the only provider of social and medical services. Unfortunately, DHCS has shared that community health centers were not the provider types they had envisioned for this new benefit – although they may be the only ones in their community able to perform the work. The number of local, rural, CBOs interested in developing a business infrastructure to deliver Medi-Cal regulated services is small, certainly not enough to meet the need for care management in the first few years of the program.

A few other examples:

1. Medicare’s policy of paying rural providers less than urban providers.
2. Medi-Cal’s Pediatric Palliative Care Benefit, whose service requirements are not possible in rural areas.
3. Medi-Cal’s non-medical transportation benefit (NMT) which does not account for limited public transportation options, limited internet availability, limited public infrastructure such as passable roads, highways, etc. and challenges with time and distance for rural and remote communities.
4. Medi-Cal’s new Community Health Worker benefit, whose service delivery relies heavily on in-person outreach and engagement that will not have a quick update in rural communities due to rural and remote communities, along with a lack of readily available workforce.

Density accounts for the difference in the implementation of health policy in urban and rural settings: the density of clinicians, the density of patients, and the density of available support services.  Poverty exists in cities and rural areas, but higher-density provides larger urban areas with more governmental resources and economies to help address underlying economic inequities.

With advocacy, Partnership and other organizations representing rural health care providers, can request exceptions and workarounds for health policies that are not feasible in rural communities.  The energy needed to go through the exemption process takes away from other activities, like innovation, community engagement, and solidifying core management and operations.

It would be more efficient and equitable to have proposed health policies and regulations undergo a rural health analysis in the drafting stages.

Here are a few opportunities that can be implemented immediately:

1. In the policy development process, add a rural analysis that identifies any challenges in applying the policy equally and equitably in rural communities. This analysis should include direct feedback from key advisors and associations that represent rural communities.
2. If a difference is identified, the policy is amended to equitably affect rural areas. This may mean that a policy that is hard to operationalize in rural areas needs a higher level of funding than in urban areas, so that it can be applied equitably.
3. Department attests that this process has been followed.

A policy that is promulgated without accommodations for rural areas is inequitable and in fact creates risk for greater health disparities in rural communities.  Rural Native Americans face the largest health inequities in the state (and in the Partnership service area), any policy that is inequitable from a rural perspective, is also inequitable from a Native American perspective, with an effect that multiplies their historic trauma and inequities.

Health Policy that systematically, if unintentionally, disadvantages residents and health care providers in rural areas is a reflection of “Structural Urbanism.”  Just as intentionality is needed to address Structural Racism, so too is intentional policy analysis needed to ensure that health policy and regulations are not perpetuating inequities for rural Californians, including Native Americans.