Democratic opposition to health reform linked to rural districts

The vast majority of Democratic opposition to the final health reform bill in the U.S. House came from members whose districts are more rural than the nation as a whole.

“Of the 39 Democrats who voted against the bill, 33 represent districts with higher-than-average rural populations,” report Julie Ardery and Bill Bishop of the Daily Yonder. “Six nay votes came from Democrats in the 20 most rural districts in the nation.”

A direct urban-rural comparison of votes within the Iowa delegation is not possible since lawmakers from the Hawkeye State split along party lines — there was no Democratic opposition.

Many of the Democratic legislators who did vote against the final reform bill voiced their concerns that provisions in the bill would have an adverse impact on the unique health care challenges facing rural America. In the build up to the weekend vote, however, several advocacy groups with ties to geographically rural areas applauded the move toward health care reform in a joint letter to Speaker of the House Nancy Pelosi. The groups noted certain aspects of the plan, such as the increase in Medicaid coverage to 150 percent of the poverty line and the addition of long-term care insurance programs for adults with disabilities, as key to drawing their support.

Rural experts aren’t ready to call the current health care reform bill a panacea for rural Americans, but support seems to be pulled between one camp that is willing to accept partial solutions and one that is not.

For instance, the bill does seek to stem provider drain in rural areas by offering incentives such as the National Health Service Corps, graduate medical education and other primary care initiatives. Such incentives, however, continue to be mostly tied to physicians and do not always include opportunities to increase rural workforces through support staff initiatives.

The bill also expands the 340B prescription drug discount drug program to programs that typically serve geographically rural areas, and provides new life for some Medicare programs that were slated to expire. Most importantly, the House bill restructures payments connected to the public option to allow for negotiated rates, an item that is considered key to providing a level reimbursement playing field between urban and rural providers.

Key provisions missing from the House bill, however, include incentives related to Critical Access Hospitals such as flexible bed counts, local control on identifying such facilities and a reconfiguration of stimulus monies that many rural providers felt provided an unfair advantage to urban or non-CAHs.

Perhaps the missing provision that has most angered rural advocates is a clause that would have provided for equal representation on the Medicare Payment Advisory Commission and the proposed health commission. Although an amendment to that effect was proposed by U.S. Rep. Greg Walden (R-OR) it was not included in the final bill, and the amendment was not brought up for a full vote before the final bill was passed.

Just like all other health care advocates throughout the nation, rural interests have now turned their attention toward the final Senate bill, expected to begin debate either late week or early next week.