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Remarks to National Rural Health Association

Eric D. Hargan
February 11, 2020
Washington, D.C.

Better health is the fundamental goal of the vision President Trump has for our healthcare system. He understands the vital importance that health holds for every American, and he knows that access to the care we need to live long, healthy lives can be a special challenge for Americans who live in rural areas

As Prepared for Delivery

Good morning, and thank you for inviting me here to speak to all of you today.

Before I begin my remarks, I want to provide an update on the novel coronavirus and its spread, and talk a little bit about the extensive, decisive actions the President and HHS have taken to keep Americans safe and respond to the outbreak.

First, our sympathies go out to the people in the United States, in China, and elsewhere who have been sickened by the virus or seen loved ones fall ill. We were saddened to hear of the death of an American citizen recently, a 60-year-old woman in Wuhan. Our gratitude goes out to those responding to the outbreak in China and around the world.

We are working around the clock to learn more about the nature of this virus. So far, there have now been 13 cases of coronavirus confirmed in the United States, including two cases of transmission to people who had not recently been to China.

As we endeavor to learn more information, our assessment of the immediate risk to the American public from this virus remains the same as last week: Although the virus represents a potentially very serious public health threat, and we expect to continue seeing more cases here, in China, and elsewhere, the immediate risk to the American public at this time is low.

We have taken swift actions here in the U.S. to keep that risk to the American public low, and we're working on all fronts to do that.

The President takes his responsibility to the health and safety of the American people extremely seriously.

I'll mention just a few of the ongoing administration-wide actions we've taken: The State Department, HHS, and other agencies have been working to help Americans return to the United States from Wuhan if they so desire. The Department of Homeland Security and the Department of Transportation are working hard, in conjunction with the CDC, to screen passengers who are arriving in the United States who have been in China and could potentially represent a risk of spread.

Our longstanding offer to send world-class experts to China to assist with their response remains on the table, and this week the State Department helped deliver 17.8 tons of relief supplies to Hubei, the epicenter of the outbreak.

Meanwhile, we are working on the ground in countries around the world—in Africa, Asia, and elsewhere—to assist them with detection and prevention, through CDC offices, State Department personnel, and partnerships we've built through years of preparedness work.

Here at home, state and local public health departments are working with CDC to follow the playbook for an infectious disease response: identify, diagnose, isolate, treat, and contact trace.

Last week, the FDA issued an emergency use authorization for the diagnostic test developed by the CDC, and these test kits are now available for order for the 115 qualified laboratories in the United States, plus 191 international laboratories throughout the world.

Last week, our Biomedical Advanced Research and Development Authority, or BARDA, expanded its work with a pharmaceutical company around a candidate therapeutic for the coronavirus, while research on such countermeasures continues at NIH and elsewhere in the private sector.

The FDA is actively working to accelerate the development and availability of countermeasures and to assess the risks that the outbreak could present to American medical supply chains that involve China.

In all of this work, we've already benefited tremendously from the dedication of America's healthcare providers and public health workers: physicians, nurses, and other professionals throughout the country, including state and local health departments and rural healthcare providers.

This dedication is vital to the layered approach we have to protecting the American people, so thank you for the contributions many of you have already made.

Now, I'll turn to the topic that brought you all here: what we can do together to improve the health and well-being of the 60 million Americans living in rural areas.

I feel a certain kinship being here with all of you because I'm no stranger to rural healthcare.

It runs deep in my family—five generations deep, in fact.

My great-great-great grandfather was a doctor in rural Pulaski County in Illinois in the late 1800s. He traveled out in the elements to get to his patients, using everything from a horse and buggy to a rowboat to see his patients and provide them with care.

The rowboat, he needed to get across the river from southern Illinois, where I grew up, to Paducah, Kentucky, and the surrounding area.

Years ago, my sister called me and told me she had found a bill from our great-great-great grandfather's practice. As a lawyer, and someone who has worked in healthcare, I get unusually excited about paperwork and documents, so I was thrilled to see what one of his bills would look like.

It turns out that I misheard my sister. She said, "No, I have a bell from our great-great-great grandfather's horse and buggy."

As a lawyer, I'm less interested in a bell from a horse and buggy.

Many of you get to see the dedication it takes to provide care in rural settings firsthand, and I got to see the same through my mother's career.

She spent 58 years working at the same hospital, from 1952 to 2011. She started off as an X-ray tech, and ended up a "radiologic technologist"—isn't progress marvelous?

Today, that hospital is also a Federally Qualified Health Center, funded by the Health Resources and Services Administration at HHS.

Although the facility was technically a hospital, it was quite limited in the specialty care it provided.

So, when I was about to be born, my mom and dad had to drive two hours to Cape Girardeau, Missouri, to find a proper OB-GYN to deliver me.

I wasn't this tall when I came out of the womb, but I guess I still presented a few challenges.

My experiences and the experiences of my family have given me a firsthand look into healthcare in rural America. As most of you know, about 60 million Americans are spread across 80 percent of the country's land mass—growing our crops, producing our minerals, and so much more. 

Further, as all of you know well, approximately 2,000 of the country's 5,000-plus acute care hospitals are located in rural America.

And, as all of you know even better, many of these hospitals are in crisis: The Government Accountability Office found that 64 rural hospitals closed from 2013 to 2017, representing about 3 percent of all the rural hospitals we had in the country in 2013.

These closures pose a real threat to rural access to care. But more importantly, they pose a threat to the actual health of Americans in rural areas.

Better health is the fundamental goal of the vision President Trump has for our healthcare system. He understands the vital importance that health holds for every American, and he knows that access to the care we need to live long, healthy lives can be a special challenge for Americans who live in rural areas.

He has a particular vision for healthcare: a system with affordable, personalized care, a system that puts you in control, provides peace of mind, and treats you like a human being, not a number.

Such a system will provide you with the affordability you need, the options and control you want, and the quality you deserve.

This vision doesn't only apply to densely populated cities; it applies to America's rural areas too, because, in many cases, they need this transformation the most.

There are three particular platforms for delivering this transformation: first, improving the ways Americans finance their care; second, delivering better value from the care they receive; and third, focusing on particular, impactable health challenges.

All three of these platforms pertain to rural healthcare, and outcomes and access to care in rural America is also a particular focus as impactable public health challenge.

Today, I want to discuss with you four particular areas where we think we can make an impact on rural health outcomes, and improve health for all rural Americans.

These areas are going to drive a lot of action from HHS, and they're identified as strategic priorities in the annual budget proposed yesterday by President Trump. The areas include first, a focus on preventing disease; second, creating sustainable models for financing; third, utilizing technology and innovation to improve patient access; and fourth, laying the groundwork for a strong rural health workforce.  I'll discuss each of these in turn.  

The President's healthcare vision seeks to tackle health challenges that we think can be mitigated if we focus more directed attention on them. Two specific areas of focus include the opioid crisis and maternal health.

One of the key focal points for both the opioid crisis and maternal health has been the Health Resources and Services Administration, which fund many rural community health centers but also is a fulcrum for much of HHS's rural health work in general.

Since FY 2018, $157 million has been invested by HRSA through the Rural Communities Opioid Response Initiative to prevent opioid abuse, provide treatment, and help Americans in recovery, with much of this funding going through community health centers, an indispensable player in providing quality healthcare in rural areas.

On the maternal health front, research has repeatedly shown that this is a particular challenge in rural communities. Last year, to tackle this challenge, HRSA created the Rural Maternity and Obstetric Management Strategy Program, or RMOMs, a pilot program that is investing nearly $9 million over the next four years to support rural health networks in order to improve the access to and continuity of maternal and obstetric care in rural communities.

We're also continuing to foster better partnerships between rural hospitals, health centers, state Medicaid offices, and Healthy Start and home visiting programs.

These efforts are designed to developing sustainable strategies at a regional level to better meet the local needs of patients by allowing best practices to be shared with other rural communities dealing with similar issues.

As I mentioned earlier, we are concerned about the closure of rural hospitals, and we're working to understand how we can support them.

But we also need to think broadly about what rural healthcare may look like in the future: the right sustainable model for healthcare in an area may not always be the traditional 1960s hospital model.

We do know there are some longstanding, structural challenges in payments for rural hospitals, including CMS's wage index formula.

We recognize that there's an important balance to strike here, but rural hospitals shouldn't be disadvantaged for not being located in a high populated area.

That's why, CMS finalized changes that will increase reimbursement to rural hospitals that would allow them to improve quality, put them on a more level playing field with their more urban counterparts, and attract more talent.

But only addressing something like the wage index isn't the endgame—we all know that. We need to be thinking about fundamental reforms to help rural hospitals drive better health in their communities.

That's why Secretary Azar has created a rural health taskforce at HHS, with key leaders and stakeholders from across the department, which has been hard at work for a number of months now.

The goal of the taskforce is to bring together disparate efforts across HHS and examine all aspects of our rural health policies, including looking closely at how payments are affecting rural hospitals and whether there may be models that can better serve rural communities.

One model of success for sustainable, low-cost, high-quality care in rural areas are HRSA's community health centers.

I visit all kinds of healthcare providers in the travel I do for HHS, including a lot of rural hospitals and urban teaching hospitals.

But, with more than 12,000 care delivery sites run by health centers across America, health centers are a very common stop for me.

In nearly every city I visit to learn about some issue for HHS, I end up getting the privilege of visiting a health center.

At this point, honestly, it's kind of like how some baseball fans try to visit a new Major League baseball park every time they take a trip. I'm a health center fan, so if I'm on the road, I want to see a health center.

Most health centers are located in rural areas or urban areas with other challenges, and yet they have shown success in beating the national averages with their patients' results in blood pressure control, diabetes treatment, and more.

We know that community health centers are just a piece of the picture of access to care, alongside critical access hospitals, other rural hospitals, and rural health clinics.

Ultimately, a truly sustainable model for rural healthcare is going to require thinking about these parties can better work together. In some cases, we've seen mergers between health centers and hospitals.

As part of the rural task force, we're thinking hard about how to make these kinds of collaborations more feasible.

Thinking about this kind of innovation leads me to the next area of focus: improving access to care through innovation and technology.

New technology can be a game changer for improving healthcare in rural areas. Technologies like telehealth are helping bridge the gap for rural patients, giving many access to care they haven't had before.

However, for all the benefits and promise of telehealth, we know that there are a number of regulatory and payment barriers that have held back this technology from reaching its full potential.

For instance, the Medicare fee-for-service system currently pays for telehealth services only in a limited range of circumstances—typically, rural areas with a shortage of healthcare professionals.

We believe that can sometimes be a penny-wise, pound-foolish restriction, and we want to continue searching out areas where technology, including telehealth, can increase access to care and decrease costs.

Late last year, for instance, we created two new ways for Medicare to pay providers specifically for forms of "virtual care," delivered remotely.

Providers can now be reimbursed for remote patient monitoring visits and for assessments of electronically transmitted images.

Previously, a physician's phone or video check-in with a patient was not payable by Medicare separately from an in-person visit.

We've started paying separately for physicians to consult with their patients remotely, using technology, without the patient being in a doctor's office or other health facility. 

In many circumstances, patients can just now check-in with their doctors from home. For someone in a city or suburb, that's convenient; for a patient in a rural area, it could be life-changing.

In addition, we have continued to conduct an annual review to identify services we can remove from statutory limits on telehealth so that these services can be reimbursed by Medicare regardless of whether they originate in areas that are designated as rural shortage areas.

We also know that the technical definitions of which communities are rural and which communities face provider shortages can sometimes be a confusing barrier in and of themselves.

As part of our rural health task force, we're looking hard at how these definitions work and whether they need to be adjusted or refined.

The final area I want to touch on is building a strong rural health workforce.

As some of you may know, earlier in the administration, various components of the Trump Administration released a report on choice and competition in American healthcare.

It laid out a number of places where existing regulations, from the federal to the local level, may be raising the cost of healthcare and reducing the supply of practitioners, and many of these issues are especially relevant to rural areas that face provider shortages.

I'll give you just one example: There's a category of nurses technically known as advanced practice nurses, which includes nurse anesthetists, nurse midwives, clinical specialist nurses, and nurse practitioners. They are explicitly trained to offer primary care and certain specialized care.

Yet, as the administration's report noted, more than half of states impose on them either supervision requirements or "collaborative practice" requirements, which can have the same cost and inconvenience.

These nurses are qualified, capable and ready to serve, but these regulations make it costly or even impossible to practice to the top of their license. And of course, there's potential not just to empower advanced practice nurses, but also physician assistants and other health professionals.

Some rural providers, like rural health clinics, have been pioneering a team-based approach to care that wisely utilizes advanced practice nurses, physician assistances, and certified nurse midwives. This is an example we shouldn't be afraid to follow, and I encourage you to explore how you can use qualified practitioners throughout the medical field and use their skills and talents to help patients in underserved areas.

It's not only a matter of getting the best value from the care we pay for and being good stewards of financial resources; increased access to care will directly improve the health of the American people, and it can also mean new economic opportunities for members of your communities to work in rural hospitals.

I want to close by encouraging all of you to explore the opportunities presented by the ideas I've laid out today—and to come to us, at HHS, with your own ideas about how to improve rural healthcare.

There is a lot of action coming, because it's not just a really big rural health task force and I who are focused on rural health as an area of opportunity—that commitment runs up through Secretary Azar, straight up to President Trump.

We still have a lot of work to do to ensure that every American, whether living in the heart of a big city, or in a small rural town like Mounds, Illinois, where I grew up, has a chance at better healthcare and, ultimately, better health.

As HHS works to deliver on the President's vision of better health for every American, I look forward to more collaboration with many of you along the way.

So thank you all again for being here, and let's get to work on improving the health of all Americans.

Content created by Speechwriting and Editorial Division 
Content last reviewed on February 11, 2020